Introduction: Pre-operative assessment of liver function using liver function tests, 99m Tc-Mebrofinate SPECT-CT scan, and HVPG measurements could identify patients at higher risk of post hepatectomy liver failure (PHLF), allowing them to be selected for an appropriate management pathway. This study aimed to evaluate the effects of the novel pre-operative liver function assessment pathway on post-operative outcomes following liver resection. Methods: Liver functional assessment was included in the pre-operative pathway in January 2018. All the patients undergoing liver resection between January 2016 and November 2020 were included. Comparisons were made between the cohorts before (Group I) and after (Group II) implementation of the pathway. Post-operative biochemical parameters (POD 1,3,5,10), post-operative complication rates and 90-day mortality rate were compared between the groups. Results: A total of 1216 patients were included (Group I: 507 patients and Group II: 709 patients). Post-operative platelet counts on Day 1 (p=0.021), INR on Day 1, 3, 5 (p<0.001), albumin on Day1, 3, 5 (<0.001), sodium levels on Day 1, 3, 5 (p<0.001) were significantly better in Group II. White cell count and neutrophil counts decreased (p=0.001) with no significant reduction in the post-operative infective complication rates. PHLF rates decreased from 4.1% to 2.1% [Grade A], 0.6% to 0.4% [Grade B], and 1.0% to 0.7% [Grade C] respectively (p=0.175). Overall, 90-day mortality rate has decreased from 3 to 2.4% (p=0.588). Discussion: Pre-operative planning based on the assessment of liver parenchymal function using 99m Tc-Mebrofinate SPECT-CT scan and portal hypertension by wedge pressures, appears to improve post-hepatectomy outcomes.

Introduction: Risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) are well established. However, an ability to differentiate between biochemical leak (BL) and CR-POPF in the early postoperative period may be beneficial. The aim of this study was to identify early postoperative variables associated with CR-POPF. Methods: All consecutive patients diagnosed with BL and CR-POPF after PD were identified from a prospective database (2009-2019). Demographics, intraoperative parameters, postoperative drain fluid amylase (DFA) and C-reactive protein (CRP) on the first five postoperative days were retrospectively collected. Preoperative, intraoperative and early postoperative (POD1-5) factors were compared between groups. Cut-off values for DFA and CRP were calculated using ROC analysis. Results: 210/830 patients (25.3%) developed a POPF (104 BL, 106 CR-POPF). DFA1 (p=0.006), DFA3 (p=0.006), DFA5 (p<0.001), CRP2 (p=0.014), CRP3 (p<0.001), CRP4 (p<0.001) and CRP5 (p<0.001) were all significantly higher in patients with CR-POPF compared to BL. There was no significant difference in body mass index (27 v 26; p=0.150), Birmingham fistula score (p=0.05), pancreatic duct width (p=0.216) or soft gland consistency (p=1.00) between groups. CRP4 (AUC 0.677, 95%CI 0.588-0.765; p<0.001) and DFA5 (AUC 0.712, 95%CI 0.628-0.795; p<0.001) outperformed other variables in differentiating between BL and CR-POPF. Conclusion: In patients with a confirmed pancreatic fistula after pancreaticoduodenectomy, it may be possible to differentiate between a biochemical leak and a clinically relevant fistula using early postoperative variables, particularly drain fluid amylase and C-reactive protein values.

Purpose: Hepatic Echinococcus Granulosus disease (HEGD) requiring surgery is uncommon in the United Kingdom. The annual disease incidence in England and Wales is 10 cases. The aim of this study was to assess the surgical management of HEGD at a tertiary liver surgery uni in England. Methods: Retrospective review of an electronically maintained database of all patients' undergone liver surgery for HEGD, between 2006 and 2019, was performed. Details of patient demography, perioperative medical management, investigations, post-operative morbidity, and presence of live scolices on histology were reported. Perioperative medical management was compared with available local and regional guidelines. Results: 30 patients underwent liver surgery for HEGD (17male:13female). Mean age was 44 yrs(17-76). Right lobe disease was predominant (27/30patients). Average diameter of the cysts was 9.5cm at the time of surgery. Surgical procedures performed were deroofing of liver cysts: 16, Non-anatomical liver resection: 5, Pericystectomy:7, major liver resection:2. Bile leaks encountered (≥Grade IIIa):3 patients. Live scolices were present in 8 histological specimens. There were two perioperative medical management protocols available, and compliance to these was only 55%. There were no drug therapy related complications. Two patients (6%) had recurrent disease. Conclusion: The number of patients requiring surgical intervention for HEGD remains low (two cases/year in this series). Standardisation and compliance with perioperative medical management needs ensured with support from local infection diseases teams.

Purpose: Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden) is increasingly used to assess the hepatic uptake of Technetium Mebrofenate for preoperative liver function assessment. The workstation also allows assessment of anatomical and functional liver volumes on SPECT-CT scan. The aim of the current study is to compare the agreement of the semiautomated liver segmentation for the assessment of total and segmental liver volumes with post resection liver specimen volumes using Hermes workstation. Methods: A retrospective analysis was carried out using a prospectively maintained database. A total of 144 patients underwent standard right or left hepatectomy (Brisbane 2000 nomenclature) between January 2015 and December 2016 were included. Total, resection and remnant anatomical liver volumes were measured retrospectively using Hermes workstation. Postresection volumes measured by assessment of dry weight of pathological specimen were compared with the resection volumes. The Pearson's correlation coefficient (r) was used to calculate the linear correlation using SPSS. Results: Right hepatectomy was performed in 79% and left hepatectomy in 21% of the included patients. There was no significant inter reader variability (AO,BD) as assessed on 15 initial consecutive scans (+/-15ml). The mean TLV calculated with the Hermes Software was 1688.41±582.86. The mean specimen weight measured during the histopathological analysis was 880.4±469.38. The volume of the resection segments calculated with the Hermes software significantly correlated with the weight of the specimen, with the Pearson correlation coefficient being 0.84 (p<0.001) (Figure 1). Conclusion: Hermes workstation is a reliable, and efficient tool to measure liver anatomical segmental volumes.

Background: Refractory ascites following orthotropic liver transplantation (LT) is multifactorial in causation. It can be due to graft failure, hepatic microvascular resistance or surgical technical issues. Transjugular hepatic venography(TJHV) allows assessment of hepatic venous outflow as well as the portal pressures. This study is aimed at assessing the causes and outcomes of conservative and radiological intervention in patients with post-transplant ascites from a large DDLT programme in the United Kingdom. Methods: Adult(≥18yrs) LT recipients(between 2006-2019) who were investigated with TJHV for management of persistent ascites, were included. Outcomes were compared between those that received medical treatment vs. endovascular intervention, and also between those with normal(≤10mmHg) vs. elevated(>10mmHg) hepatic venous wedge pressure gradient (HVWPG). Results: Thirty patients underwent TJHV to investigate post-transplant ascites, and 29/30 had a peri-procedural graft biopsy. The median age (range) was 46 (34-71) and 12/30 (40%) were female. Overall, six patients received a graft from a deceased circulatory death donor. The median (range) cold ischaemic time of the whole cohort, medical and interventional group was 362 (286-693), 438 (274-624) and 490 (252-734) respectively. Ascites was present pre-operatively in 17/30 (55%), 6/12 (50%) and 11/18 (61%) of the whole cohort, medical and interventional groups respectively. Table 1 demonstrates the transplant characteristics of the cohort. 18/30(62%) patients underwent one or more of the following interventions: angioplasty(3), hepatic vein stenting(9) or transjugular intrahepatic portosystemic shunt(TIPS) procedure(8). Median time from transplant to TJHV was 77days(range 7-1878). The median HVWPG for the medical and interventional groups were 12mmHg(3-19) and 14mmHg(2-35) respectively. After 6 months follow-up, ascites had resolved on ultrasound in 10/18(56%) and 7/12(58%) in the medical management and interventional groups respectively. Overall, 17/30(56%) had resolution of ascites at 6 months. Conclusions: Biopsy findings and venographic pressure studies should be carefully integrated and evaluated in the management of post-DDLT ascites. Complete radiological resolution is achieved in up to 60% of patients with refractory ascites.TP04.07_Table 1Total cohort (N=30)Medical management (N=12)Endovascular intervention (N=18)Classical piggybackModified piggyback8/30 (27%)22/31 (71%)3/12 (25%)9/12 (75%)5/18 (28%)13/18 (72%)IVC pressure10 (4-22)9 (4-14)11 (4-22)Hepatic vein wedge pressure24 (7-44)24 (7-29)30 (13-44)HVWPG, median (range)Normal HVWPG (<10mmHg)Elevated HVWPG (≥10mmHg)12 (2-35)13 (43%)7 (57%)12 (3-19)6 (50%)6 (50%)14(2-35)7 (39%)11(61%)IVC-HV gradient2(0-14)1(0-4)3(0-14)HVWPG= Hepatic vein wedge pressure gradient, HVWP= hepatic venous wedge pressure, HVP= Hepatic vein pressure, Open table in a new tab HVWPG= Hepatic vein wedge pressure gradient, HVWP= hepatic venous wedge pressure, HVP= Hepatic vein pressure,

Introduction: Evidence from sepsis literature, and growing evidence in trauma suggest hyperlactataemia is prognostic of poor outcome. Some evidence suggests a similar relationship following liver resection.The current study is aimed at assessing the relationship between lactate kinetics and post hepatectomy liver failure (PHLF). Methods: A dataset was collated of up to 50 sequential serum lactate concentrations in all patients who underwent major hepatic resection from 2015-2019. Lactate values were taken from the start of surgery. Data were analysed using 'R' (R-Studio v1.2.5001). Values were split into 24h epochs, and means were compared using Mann-Whitney U tests. Results: A total of 1275 patients were included (58.4% male). Scatterplots with best fit lines (generalised additive model) of lactate concentration against time were produced and were compared between subgroups (Figure 1). For patients undergoing major liver resection, postoperative day 1-3 lactate was significantly elevated in those who developed PHLF(A-C) compared to those with no PHLF (Table 1) and subsequent kinetic profile was different. Conclusion: These data suggest that early and sustained hyperlactatemia may predict subsequent PHLF. We plan further analysis to characterise individual patients' lactate trajectories via machine learning, using this data to build and ratify a model predicting patients´ risk of PHLF and other adverse outcomes based on their lactate dynamics and other factors influencing the post hepatic resection outcomes.Tabled 1Table 1No PHLF (mmol/L)PHLF A-C (mmol/L)No PHLF vs PHLF A-CPHLF C (mmol/L)No PHLF vs PHLF CDay 1 mean peak lactate3.444.67p<0.000015.424p<0.00001Day 2 mean peak lactate2.694.92p<0.000015.68p<0.00001Day 3 mean peak lactate2.042.86p<0.000013.70p<0.00001 Open table in a new tab

Background: Preoperative evaluation of future liver remnant (FLR) is traditionally assessed using standardised anatomical liver volumes to prevent post-hepatectomy liver failure. 99m Technetium -Mebrofinate scan is emerging as a promising pre-operative investigation to assess the global, lobar and the dynamic liver function. With a combination of 99m Technetium -Mebrofinate and SPECT-CT anatomical liver volumes can also be assessed. Aim: The study is aimed to investigate if there is a difference in the percentage distribution of scintigraphy within the given anatomical volume of the planned future liver remnant. Methods: All patients who underwent 99m Tc-Mebrofenin SPECT-CT scan in the unit since 2018 were included. Data were processed on a workstation (MultiModality; Hermes Medical Solutions) to assess the anatomical volumes, global liver function and lobar liver function assessed as scintigraphy as well as dynamic liver function. Data was collated from a prospectively maintained database. Results: Fifty-two 99m Tc-Mebrofenin SPECT-CT scans were included of which three patients had the scan prior to the second stage liver resection. Nine scans during the initial learning curve where all the above parameters were not assessed were excluded. Median global sum count was 8257858/voxel. Median global dynamic uptake /min was 12.35 (4.66-20.85). Median anatomical remnant volume was 506ml (range: 312-1453ml). Percentages of the anatomical remnant volume vs functional distribution were shown in Figure 1 (r=0.69; p<0.001). There was a no variation in 7/43 scans (16.2%), up to 5% variation in 24 scans (55.8%), between 5 and 10% variation in 5 scans (11.4%), and of more than 10% in 7/ 43 patients (16.2%) Conclusion: Based on the non-homogeneous distribution of liver function, we recommend functional imaging (99m Tc-Mebrofenin SPECT-CT or equivalent) to be included in the pre-operative assessment of patients undergoing major liver resections.

Background: Pancreaticoduodenectomy is increasingly being offered as treatment for periampullary tumours in patients 80 years and older. Our aim was to evaluate clinical outcomes of pancreaticoduodenectomy in octogenarians from two high-volume tertiary HPB centres. Materials and Methods: A retrospective case-control analysis of a prospectively-maintained database, between January 2008 and December 2017, was performed. Octogenarians who underwent pancreaticoduodenectomy were matched with consecutively-operated younger patients with 1:1 ratio, based on extent of surgery (venous, arterial or additional resection). Pre-operative comorbidities, intra-operative variables, post-operative complications and mortality were compared, with statistical significance at p<0.05. Results: 88 octogenarians (median age 81 years,range:80-90) who underwent pancreaticoduodenectomy (either classical or pylorus-preserving) were compared to similar number of controls (median age 66 years,range:16-79). Gender, ASA (octogenarians median grade 2 [range:1-4] versus median grade 2 [range:1-3] for controls) and performance status (median score 0 [range:0-2] for both groups) were comparable (p=1.00,p=0.18 and p=0.11 respectively). Charlson Comorbidity Index scores were higher overall for octogenarians (median 7 [range:6-10] versus 5 [range2-9],p=0.001). Median LOS was comparable, 15 days (range:5-69) for octogenarians and 12 days (range:5-78) for controls (p=0.12), as was median ICU stay, 2 days (range:0-58) for octogenarians versus 2 days (range:0-25) (p=0.40). Negative resection margin (R0) rates were 64% for octogenarians and 59% for controls (p=0.53), with no significant difference in lymph node status (p=0.53). Overall post-operative complication rate was higher in octogenarians (60% versus 49%); however this was not statistically significant (p=0.17). Similarly, complication rates across the Clavien-Dindo classification categories were not statistically significant. 30-day and 90-day mortality were 2.3% and 8% for octogenarians versus 1.1% and 3.4% for controls (p=1.0 and p=0.33 respectively). Conclusion: Despite higher 90-day mortality, pancreaticoduodenectomy outcomes in octogenarians are comparable to their younger counterparts. Pancreaticoduodenectomy should therefore be offered as a curative surgical option in this cohort, in specialised centres after meticulous pre-operative assessment.

Introduction: Intrahepatic cholangiocarcinoma (iCCA) is an aggressive cancer with dismal long-term survival despite surgical extirpation. Majority of patients (approximately 60% - 80%) are not amenable to surgical resection due to advanced disease at presentation. Neoadjuvant therapy (NAT) has gained interest for downstaging iCCA for resectability in the management of locally advanced hepatobiliary and pancreatic cancers but is not fully ascertained for iCCA. This systematic review aims at assessing the role of NAT in the management of iCCA Methods: A systematic review and pooled analysis were performed of published studies between January 2000 and December 2018. Eligible studies were those where chemotherapy or radiotherapy was used in patients with non-metastatic locally advanced iCCA. The primary outcome measure was overall survival. The secondary outcomes were the tolerance rates and completion of NAT, and margin-negative resections post NAT. Results: Seventeen cohort studies (prospective, n=2; retrospective, n=15) reporting NAT for locally advanced iCCA in 1687 patients were included. Of these, 83% received NAT consisting of chemotherapy (n=11 studies), chemoradiotherapy (n=3 studies) and radiotherapy (n=1 study). Whilst majority of patients receiving chemotherapy consisted of gemcitabine or capecitabine-based regimens, there was inconsistency in the reporting of the number of cycles given. Median overall survival in all patients was 14 months (7 - 18 months). Patients with NAT undergoing resection had significantly longer survival than NAT only or no NAT (median: 29 vs 12 vs 8 months, p<0.001). Overall the resectability rate was 6% (83/1687), of which 46% had margin-negative resections (38/83). Conclusion: This review appears to support NAT to improve long-term survival compared in locally advanced iCCA. There is a need to obtain consensus on the definition of borderline resectable iCCA and the appropriate chemo regimen. Fit patients deemed unresectable upfront should be considered for downstaging chemotherapy.

Background: Post hepatectomy liver failure (PHLF) is multifactorial and is a serious complication in patients undergoing hepatectomy. Pre-operative identification of patients at higher risk of PHLF might allow for the selection of patients for two-stage liver resections and, if suitable, extreme parenchymal preserving surgery with further down staging chemotherapy. This study hypothesized that pre-operative integrated functional assessment pathway including liver function tests, indocyanine green test (ICG), 99m Technetium -Mebrofinate scan, elastography and HVPG measurements could identify patients at higher risk of PHLF, allowing them to be selected for appropriate management pathway. Methods: Patients who underwent 99m Tc-Mebrofenin SPECT-CT scan in the unit and those who have been through the pathway were included. 99m Tc-Mebrofenin SPECT-CT scan data were processed to assess the anatomical volumes, global liver function and lobar liver function assessed as scintigraphy as well as dynamic liver function. Amsterdam criteria of FRLF was taken as the cut-off for patients at risk of PHLF (2.69%/min/m2). LiMON-ICG module was used to assess the ICG PDR and R15 and Elastography were performed using Fibroscan 502 (EchoSens). HVPG was measured in patients with HCC planned for major resection. All the investigations were performed on an outpatient basis. ISGLS definition of PHLF was used. Results: Patients planned for major liver resection or a minor resection in patients with suspected or confirmed Background liver disease were included in this group (17 CRLM, 11 HCCs, 7 Hilar cholangiocarcinomas, 5 others). Three patients had the scan performed prior to second stage liver resection. Of the 34 patients who progressed to resectional surgery, no one developed PHLF. One patient had ascites (prior local ablation resulting in the hepatic vein thrombosis), and one patient had hyperbilirubinemia. Conclusion: Early Results of this novel integrated functional assessment pathway demonstrates its feasibility and the ability to reduce the incidence of PHLF.

Background: Treatment for colorectal liver metastasis (CRLM) involves sparing liver parenchyma surgical techniques. Hence, the impact of subcentimetric resection margins (RM) needs to be investigated. Methods: 682 patients were analysed from 2005 to 2015. They were allocated in four groups according with the width of RM: <1 mm (R1 resection), ≥1mm-4mm, 5-9mm and ≥10mm. Results: Survival rate was 66.3% in a follow up period of 20.58 months. Survival rates (p=0.027) and overall survival (p=0.001) increased steadily with the increment of width in RM. The disease and liver recurrence rates were 57.3% and 36.1%, respectively, both higher for groups with narrower RM (p<0.001). R1 resection was an independent risk factor for mortality (HR:23.73; p=0.008), hepatic recurrence (HR:1.265; p=0.015) and R0 resection protective for disease recurrence (HR:0.836; p=0.009). Lack of adjuvant chemotherapy following CRLM resection was a risk factor for hepatic (HR:1.229; p=0.003) and disease recurrence (HR:1.143; p=0.013). Although, adjuvant chemotherapy isolated was a protective factor for mortality (HR:0.276; p=0.004) in synchronous presentation, this was not significant for the subgroup with R1 resection (p=0.392) or metachronous disease. Conclusion: Survival and recurrence were progressively affected with larger subcentimetric histological margins. Adjuvant chemotherapy brought benefits but not for all subgroups, reinforcing the importance of a histologically free RM and a target of 10mm, even in the era of modern treatments.

Background: A recently published nomogram, the Blood Use Risk Score (BURS) [1], predicts packed red cell (PRC) use following surgery. Post-pancreatectomy haemorrhage has been defined as early or late (under or over 24 hours after surgery) [2]. This study assessed the BURS among patients exclusively undergoing pancreatoduodenectomy to predict early and late need for PRC. Methods: Risk factors for early or late PRC use were identified in uni- and multivariable analyses. Results: Among 628 patients, 99 (16%) and 144 (23%) received early and late PRC. The BURS was associated with early (AUROC 0.700, p<0.001) but not late use of PRC (AUROC 0.525, p=0.360). In multivariable analysis, preoperative haemoglobin and need for venous resection were related to early PRC use. Late PRC use was related with a Whipple resection, lack of biliary stent and narrow pancreatic duct. After accounting for these factors, late PRC usage was associated with post-operative pancreatic fistula (POPF) and increasing severity (OR 2.00, 3.06 and 9.96 for grade A, B and C POPF respectively). Conclusion: Two largely different sets of variables are related to early and late PRC use following pancreatoduodenectomy. The BURS identified early but not late PRC use. An understanding of POPF risk allows assessment of the need for late PRC use. References [1] Kim Y, Bagante F, Gani F, Ejaz A, Xu L, Wasey JO, et al., (2016), Nomogram to predict perioperative blood transfusion for hepatopancreaticobiliary and colorectal surgery, Br J Surg [2] Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al., (2007), Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition, Surgery

Background: Post-hepatectomy liver insufficiency (PHLI) after elective liver surgery is primarily influenced by the extent of resection in addition to several other modifiable and non-modifiable factors. Preoperative use of statins is known to improve the postoperative outcomes following cardiac, and non-cardiovascular surgery. There is evidence that statins may increase hepatic angiogenesis and increased liver regeneration response. This study investigated if the use of statins would have reduced incidence of PHLI. Methods: Patients who underwent hepatectomy between January 2013 and January 2017 were included. ISGLF definition was used to identify patients with PHLI. The extent of liver resection was categorised as minor, major (right and left hepatectomy) and extra major hepatectomy. Univariate and multivariate (Binary logistic regression model) analyses were performed to identify predictors of PHLI. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p< 0.05 being statistically significant. Results: A total of 890 patients underwent liver resection during the study period. Of these, 18% patients were on statins in the peri-operative period. PHLF (Grades A,B,C) was encountered in 19% of the patients. On univariate analysis, use of statins(p< 0.01) had a protective effect on the incidence of PHLI. Extent of resection(p< 0.001), post-operative septic complications (bile leak, intra-abdominal collections) and renal impairment, were also significant. Statins remained as a significant(p< 0.01) variable on multivariate analysis. Conclusion: Peri-operative use of statins were shown to have a protective effect on the incidence of PHLI in this observational study. Its role as a modifiable factor of PHLI needs further investigation.

Background: Posthepatectomy liver failure (PLF) is one of the most feared complications in major hepatectomies. Elevated portal venous pressures (PVP) and flow (PVF) after resection are associated with development of PLF. Splenic artery ligation (SAL) is a potential strategy to modulate the portal venous inflow. The aim of our study is therefore to investigate the course of portal pressure and flows during major hepatectomy and the impact of SAL. Methods: All patients undergoing major hepatectomy on a non-cirrhotic liver were included in this prospective study since October 2017. Measurement of PVP and PVF were performed before and after liver resection a using Transit Time Flow Measurement (Medistim, Oslo, Norway). SAL was performed in patients with a Liver-remnant-to-Bodyweight-ratio (LR/BW-ratio) < 1%, or a PVP >5mmHg and/or suboptimal macroscopic liver parenchyma appearance, due to previous chemotherapy. Results: Sixteen cases were analysed with a median LR/BW-ratio of 1.2% (range 0.7-1.8%). Median PVP increased from 4 to 7 mmHg after resection, while PVF decreased from 851 to 710 ml/min. The peak lactate was higher in patients with an increase in PVP of >5mmHg (Figure 1). SAL effectively decreased the median PVP and PVF of 3 mmHg and 100 ml/min, respectively. Conclusion: Elevated pressures in the portal system have a negative impact on the initial function of the liver remnant after major hepatectomy. Splenic artery ligation appears easy to modulate the portal inflow. This study is currently recruiting further patients and the entire data set will be available at the conference.