ABDOMINALE CHIRURGIE

CENTRUM ABDOMINALE CHIRURGIE

ARTIKELS

ABSTRACT 1

Laparoscopic liver resection for liver tumours in proximity to major vasculature: a single-center comparative study.

D'Hondt M, Vansteenkiste F, Parmentier I, et al. European Journal of Surgical Oncology, 2020, 46(4 Pt A), 539-547

INTRODUCTION With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs).

OBJECTIVE The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs.

MATERIALS/METHODS This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs.

RESULTS Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140-210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12).

CONCLUSION In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results. ABSTRACT 2

Outcomes after minimally-invasive versus open pancreatoduodenectomy: a pan-European propensity score matched study.

Klompmaker S, van Hilst J, D'Hondt M, et al. Annals of Surgery, 2020, 271(2), 356-363

INTRODUCTION Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking.

OBJECTIVE To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers.

MATERIALS/METHODS Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3).

RESULTS Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001).

CONCLUSION In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and

OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.

ABSTRACT 3

Hepatopancreatoduodenectomy – a controversial treatment for bile duct and gallbladder cancer from a European perspective.

D'Souza M, Valdimarsson V, D'Hondt M, et al. The Official Journal of the International Hepato Pancreato Biliary Association, 2020, 22(9), 1339-1348

INTRODUCTION Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers.

MATERIALS/METHODS Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed.

RESULTS In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival.

CONCLUSION HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome. ABSTRACT 4

International multicenter propensity score matched study on laparoscopic versus open left lateral sectionectomy.

van der Poel M, Fichtinger R, D'Hondt M, et al. The Official Journal of the International Hepato Pancreato Biliary Association, 2020, Oct 7, DOI: 10.1016/j. hpb.2020.09.006

INTRODUCTION Despite a lack of high-level evidence, current guidelines recommend laparoscopic left lateral sectionectomy (LLLS) as the routine approach over open LLS (OLLS). Randomized studies and propensity score matched studies on LLLS vs OLLS for all indications, including malignancy, are lacking.

MATERIALS/METHODS This international multicenter propensity score matched retrospective cohort study included consecutive patients undergoing LLLS or OLLS in six centers from three European countries (January 2000-December 2016). Propensity scores were calculated based on nine preoperative variables and LLLS and OLLS were matched in a 1:1 ratio. Short-term operative outcomes were compared using paired tests.

RESULTS A total of 560 patients were included. Out of 200 LLLS, 139 could be matched to 139 OLLS. After matching, baseline characteristics were well balanced. LLLS was associated with shorter operative time (144 (110-200) vs 199 (138283) minutes, P < 0.001), less blood loss (100 (50-300) vs 350 (100-750) mL, P = 0.005) and a 3-day shorter postoperative hospital stay (4 (3-7) vs 7 (5-9) days, P < 0.001).

CONCLUSION This international multicenter propensity score matched study confirms the superiority of LLLS over OLLS based on shorter postoperative hospital stay, operative time, and less blood loss thus validating current guideline advice.

ABSTRACT 5

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.

van der Heijde N, Ratti F, D'Hondt M, et al. Surgical Endoscopy, 2020, 2, DOI: 10.1007/ s00464-020-08109-y

INTRODUCTION Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS).

MATERIALS/METHODS An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007-December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS.

RESULTS Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195-285) vs. 247 min (195-315) p = 0.004], less blood loss [260 (188-400) vs. 400 mL (280-550) p = 0.009] and a shorter LOS [5 (4-7) vs. 8 days (6-10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.

CONCLUSION This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate. ABSTRACT 6

Resections for tumors in the posterosuperior segments: a single-center experience of 174 consecutive cases.

Kirmizi S, De Meyere C, Parmentier I, D'Hondt M Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2020, 30(6), 518-521

INTRODUCTION Laparoscopic posterosuperior liver resection is a technically difficult and complex surgery. These patients are seen as poor candidates for laparoscopic surgery. This study aimed to show the safe and effective applicability of the posterosuperior segment resections by experienced surgeons in advanced centers.

MATERIALS/METHODS Patients who underwent laparoscopic posterosuperior liver resection between October 2011 and October 2019 at the Groeninge Hospital were evaluated retrospectively. Demographic and perioperative data were obtained from the prospectively maintained database. Resection of at least 3 consecutive Couinaud segments was accepted as a major surgery (trisegmentectomy). Postoperative complications were registered according to the Clavien-Dindo classification.

RESULTS The median age of the 174 patients was 68 years [interquartile range (IQR): 60 to 75]. The semiprone position was used in the majority of operations (82.2%). Nonanatomic resection was performed in more than half of the operations (55.1%). A total of 5 patients underwent major hepatic resection. The median time of surgery was 150 (IQR: 120 to 190) minutes. Median blood loss was determined to be 150 (IQR: 50 to 300) mL. Malignancy was detected in 95% of the cases. The surgical margin was reported to be R0 in 93.3% of the specimens. The median hospitalization time was 4 (IQR: 3 to 6) days. The major complication rate was 1.7%, and only 1 patient died. Overall survival rates for patients who underwent a resection for colorectal liver metastases in the first and fifth years were 97.5% and 62.2%, and disease-free survival rates were 69.8% and 35.5%, respectively.

CONCLUSION Laparoscopic resections in the posterosuperior segments can be performed safely in experienced hands with good short and long term (oncologial) outcomes.

ABSTRACT 7

Pure laparoscopic versus open hemihepatectomy: a cri- tical assessment and realistic expectations - a propensity score-based analysis of right and left hemihepatectomies from nine European tertiary referral centers.

Cipriani F, Alzoubi M, Fuks D, D'Hondt M, et al. Journal of Hepato-Biliary-Pancreatic Sciences, 2020, 27(1), 3-15

INTRODUCTION A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies.

MATERIALS/METHODS Laparoscopic and open hemihepatectomies from nine European referral centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub-analyses).

RESULTS Five hundred and forty-five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P < 0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001).

CONCLUSION This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated. ABSTRACT 8

Risk factors of positive resection margin in laparoscopic and open liver surgery for colorectal liver metastases: a new perspective in the perioperative assessment: a European multicenter study.

Cacciaguerra AB, Görgec B, Cipriani F, D'Hondt M, et al. Annals of Surgery, 2020, Jul 9, DOI: 10.1097/ SLA.0000000000004077

INTRODUCTION The clinical impact of R1 resection in liver surgery for CRLMs has been continuously appraised, but R1 risk factors have not been clearly defined yet.

OBJECTIVE To assess the risk factors associated with R1 resection in patients undergoing OLS and LLS for CRLMs.

MATERIALS/METHODS A cohort study of patients who underwent OLS and LLS for CRLMs in 9 European high-volume referral centers was performed. A multivariate analysis and the receiver operating characteristic curves were used to investigate the risk factors for R1 resection. A model predicting the likelihood of R1 resection was developed.

RESULTS Overall, 3387 consecutive liver resections for CRLMs were included. OLS was performed in 1792 cases whereas LLS in 1595; the R1 resection rate was 14% and 14.2%, respectively. The risk factors for R1 resection were: the type of resection (nonanatomic and anatomic/nonanatomic), the number of nodules and the size of tumor. In the LLS group only, blood loss was a risk factor, whereas the Pringle maneuver had a protective effect. The predictive size of tumor for R1 resection was >45 mm in OLS and >30 mm in LLS > 2 lesions was significative in both groups and blood loss >350 cc in LLS. The model was able to predict R1 resection in OLS (area under curve 0.712; 95% confidence interval 0.665-0.739) and in LLS (area under curve 0.724; 95% confidence interval 0.671-0.745).

CONCLUSION The study describes the risk factors for R1 resection after liver surgery for CRLMs, which may be used to plan better the perioperative strategies to reduce the incidence of R1 resection during OLS and LLS.

ABSTRACT 9

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection.

Cappelle M, Aghayan D, van der Poel M, D'Hondt M, et al. Langenbeck's Archives of Surgery, 2020, 405(2), 181-189

INTRODUCTION Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and singlecenter cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

MATERIALS/METHODS A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained. ABSTRACT 10

Foreign body granuloma reaction following SIRT mimicking peritoneal metastases: a word of caution.

Willems E, Smet B, Dedeurwaerdere F, D'Hondt M Acta Chirurgica Belgica, 2020, 120(1), 47-49

ABSTRACT Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver malignancy with poor survival rates. Surgical resection is the only curative treatment option, yet only a small portion of cases are resectable. In unresectable situations, suggested therapy consists of a systemic chemotherapy regimen with cisplatinum and gemcitabine. Selective internal radiation therapy (SIRT) has been proposed as an alternative treatment option and may lead to downstaging of unresectable iCCA to surgery. We present a case of a female patient diagnosed with an unresectable iCCA treated with SIRT in order to obtain downstaging. Explorative laparoscopy three months later showed multiple peritoneal lesions in the left upper quadrant, mimicking peritoneal metastases. Anatomopathological investigation showed a foreign body granuloma surrounding the SIRT resin particles. These findings have important consequences, as the presence of peritoneal metastases implies a palliative situation. Anatomopathological confirmation of any intra-abdominal lesion mimicking peritoneal metastases should be carried out.

ABSTRACT 11

Reply to: is there a place for microwave ablation under Pringle maneuver for perivascular colorectal liver metastases?: Response to "laparoscopic liver resection for liver tumours in proximity to major vasculature: a single-center comparative study".

Willems E, D'Hondt M European Journal of Surgical Oncology, 46(9), 2020, 1768-1769

Er is geen abstract beschikbaar.

ABSTRACT 12

Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome.

De Meyere C, Nuytens F, Parmentier I, D'Hondt M

Techniques in Coloproctology, 2020, 24(9), 947-958

INTRODUCTION Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up.

MATERIALS/METHODS A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS.

RESULTS Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings.

CONCLUSION SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.

ABSTRACT 13

One-stage laparoscopic parenchymal sparing liver resection for bilobar colorectal surgical.

D’Hondt M, Parmentier I, De Meyere C, Pironet Z, Vansteenkiste F, et al. Endoscopy, 2021, Mar 8, DOI: 10.1007/ s00464-021-08366-5

INTRODUCTION Laparoscopic liver resections (LLR) of bilobar colorectal liver metastases (CRLM) are challenging and the safety and longterm outcomes are unclear. In this study, the short- and long-term outcomes and recurrence patterns of one-stage LLR for bilobar CRLM were compared to single laparoscopic resection for CRLM.

MATERIALS/METHODS This single-center study consisted of all patients who underwent a parenchymal sparing LLR for CRLM between October 2011 and December 2018. Demographics, perioperative outcomes, short-term outcomes, oncologic outcomes and recurrence patterns were compared. Data were retrieved from a prospectively maintained database.

RESULTS Thirty six patients underwent a LLR for bilobar CRLM and ninety patients underwent a single LLR. Demographics were similar among groups. More patients received neoadjuvant chemotherapy in the bilobar group (55.6% vs 34.4%, P = 0.03). There was no difference in conversion rate, R0 resection and transfusion rate. Blood loss and operative time were higher in the bilobar group (250 ml (IQR 150-450) vs 100 ml (IQR 50-250), P < 0.001 and 200 min (IQR 170-230) vs 130 min (IQR 100-165), P < 0.001) and hospital stay was longer (5 days (IQR 4-7) vs 4 days (IQR 3-6), P = 0.015). The bilobar group had more technically major resections (88.9% vs 56.7%, P < 0.001). Mortality was nil in both groups and major morbidity was similar (2.8% vs 3.3%, P = 1.0). There was no difference in recurrence pattern. Overall survival (OS) was similar (1 yr: 96% in both groups and 5 yr 76% vs 66%, P = 0.49), as was recurrence-free survival (RFS) (1 yr: 64% vs 73%, 3 yr: 38 vs 42%, 5 yr: 38% vs 28%, P = 0.62).

CONCLUSION In experienced hands, LLR for bilobar CRLM can be performed safely with similar oncologic outcomes as patients who underwent a single LLR for CRLM.

ABSTRACT 14

Oesophageal-pericardial fistula: a rare complication of radiation-induced oesophagitis.

Denglos P, Nuytens F, Piessen G, et al. European Journal of Cardio-Thoracic Surgery, 2020, 58(5), 1097-1099

ABSTRACT Oesophageal-pericardial fistula after radiation therapy for lung cancer is a rare complication associated with a high mortality. In this casereport, we present the case of 52-year-old women with late radiation-induced oesophagitis after chemoradiotherapy for a pulmonary adenocarcinoma, complicated by an oesophageal-pericardial fistula for which a transthoracic oesophagectomy with pericardial drainagewas performed. The postoperative course was complicated by a fatal hypovolaemic shock due to a perforation of the descending aortanear the initial fistula track. In this case report, we illustrate the importance of thorough inspection of diagnostic images in this context andemphasize the role of endovascular repair in case an associated aortic perforation is suspected.

PRESENTATIES

ABSTRACT 15

Laparoscopic liver surgery through day-case surgery: initial single centre experience.

Baekelandt L, De Meyere C, Parmentier I, D'Hondt M November 2020, Belgian Surgical Week, Antwerpen - België

ABSTRACT 16

Five year single center experience of sacral neuromodulation for low anterior resection syndrome.

De Meyere C, Pironet Z, Parmentier I, D'Hondt M November 2020, Belgian Surgical Week, Antwerpen - België

ABSTRACT 17

Combined ablation and resection (care) for colorectal liver metastasis in the era of minimal invasive surgery.

Lutin B, De Meyere C, Parementier I, D'Hondt M, et al. November 2020, Belgian Surgical Week, Antwerpen - België

ABSTRACT 18

The role of the laparoscopic approach in two-stage hepatectomy for bilobar colorectal liver metastases: a single-center five year experience.

D'Hondt M, Taillieu E, De Meyere C, Parmentier I November 2020, Belgian Surgical Week, Antwerpen - België INTRODUCTION Laparoscopic liver resection (LLR) as a treatment for colorectal liver metastases (CRLM) has proven to be feasible and safe in selected patients. The role of LLR in two stage hepatectomy (TSH) is poorly documented.

MATERIALS/METHODS A single-center retrospective study was performed in which the role of LLR in the first and second stage of TSH was evaluated.

CONCLUSION The already proven advantages of LLR in the treatment of CRLM favor the role of a laparoscopic approach in TSH for CRLM. In first-stage minor hepatectomy, LLR is progressively becoming the gold standard. Laparoscopic second stage major hepatectomy is feasible in experienced hands, but should be limited to selected cases and should be performed in expert centers.

ABSTRACT 19

The laparoscopic approach for two stage hepatectomy: a single center five year experience.

D'Hondt M, Taillieu E, De Meyere C, Parmentier I March 2020, Americas Hepato-Pancreato-Biliary Association (AHPBA) 2020 Annual Meeting, Miami Beach, Florida - USA

ABSTRACT 20

One stage laparoscopic parenchymal sparing liver resection for bilobar colorectal liver metatases: safety, recurrence patterns and oncologic outcomes.

D'Hondt M, Parmentier I, De Meyere C, Vansteenkiste F, et al. March 2020, Americas Hepato-Pancreato-Biliary Association (AHPBA) 2020, Miami Beach, Florida - USA

INTRODUCTION Laparoscopic resections (LLR) of bilobar colorectal liver metastases (bCRLM) are challenging and the safety and long term outcomes of these procedures are unclear.In this study the short and long term outcomes and recurrence patterns of one stage LLR for bCRLM were compared to patients who underwent a single laparoscopic resection for CRLM.

MATERIALS/METHODS This single center study consisted of all patients who underwent a parenchymal sparing LLR for CRLM between October 2011 and December 2018. Data were retrieved from a prospectively maintained electronic database.

RESULTS Thirty six patients underwent a LLR for bCRLM and 90 patients underwent a single LLR. Demographic characteristics were similar among groups. More patients received neoadjuvant chemotherapy in the bilobar group (55.6% vs 34.4%, p=0.03). There was no difference in conversion rate, R0 resection rate, and transfusion rate when comparing the bilobar group with the control group. Blood loss and operative time were higher in the bilobar group (250cc(150450) vs 100cc(50-300), p<0.001 and 200min(170-230) vs 130min(120-190), p<0.001) and hospital stay was longer (5days(4-7) vs 4days(3-6), p<0.001). More patients in the bilobar group underwent a technically major laparoscopic resection (88.9 vs 56.7%, p<0.001). Mortality was nil in both groups and major morbidity was similar (2.8% vs 3.1%). There was no difference in recurrence pattern (hepatic/ extrahepatic) or interval to chemotherapy. Overall survival was similar when comparing the bilobar group to the control group (1year: 96% in both groups and 5year 76%bilobar vs 66%, p=0.80) and disease free survival was similar (1year: 64% vs 73%, 3year: 38 vs 42%, 5year: 38% vs 28%).

CONCLUSION In experienced hands LLR for bCRLM can be performed safely with similar oncologic outcomes as patients who underwent a single laparoscopic resection for CRLM.

ABSTRACT 21

Laparoscopic alpps procedure after failed portal vein embolization.

D'Hondt M, Baekelandt L March 2020, Americas Hepato-Pancreato-Biliary Association (AHPBA) 2020, Miami Beach, Florida - USA

INTRODUCTION Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is a relatively new surgical technique for the resection of colorectal liver metastases (CRLMs) with insufficient future liver remnant (FLR). Only 27 cases of laparoscopic ALPPS have been reported in literature. This video aims to demonstrate our first experience with this minimally invasive approach. MATERIALS/METHODS In January 2016 a 51 year old male patient presented with massive bilobar colorectal liver metastases. There was one CRLM in the left hemiliver and numerous CRLMs in the right hemiliver. The primary tumor was asymptomatic and the patient received 4 cycles of chemotherapy (Folfox/ Panitumumab). Since the left hemiliver (=FLR) was only 16% of total liver volume (TLV) a right PVE (portal vein embolization) was performed. However, PVE failed and 4 weeks after PVE the FLR-volume was only 18% of TLV. Chemotherapy was continued till 12 cycles. The option of performing an ALPPS procedure was discussed with the patient and the patient agreed. First, a laparoscopic sigmoid resection was performed in October 2016. On December 12 2016 the first step of the ALPPS procedure was performed. During the first stage a metastasectomy in the left hemiliver was performed and the liver parenchyma between the left and right hemiliver was transected. Intraoperative ultrasound reveiled residual portal flow in the right hemiliver after PVE. The right portal vein was isolated an transected using a vascular stapler. Eight days postoperatively the volume of the left hemiliver was 30%. The second stage of ALPPS was performed 1 day later (9 days after the first stage).

RESULTS Operative time of stage one was 300 minutes an blood loss was 150 ml. Postoperative course was uneventful and hospital stay was 4 days. Operative time of stage two was 90 minutes and blood loss was 150 ml. Postoperatively the patient developed grade A liver failure. The patient was discharged on postoperative day 8. At 20 months postoperatively there was no evidence of disease recurrence.

CONCLUSION Laparoscopic ALPPS appears to be feasable in experienced hands. The well-recognized advantages of laparoscopy may play a favorable role in the management of patients with bilobar CRLMs candidate for an ALPPS procedure.

ABSTRACT 22

Hybrid minimally invasive esophagectomy for esophageal cancer: five-year survival results of the MIRO trial.

Nuytens F

October 2020, Virtually the best of the ISDE 2020 (International Society for Diseases of the Esophagus), Online

ABSTRACT 23

The use of intraoperative ultrasound in minimally invasive hepatic and pancreatic surgery.

D’Hondt M, Aroori S October 2020, Webinar: Clinical Value of Intraoperative Ultrasound in HPB Surgery, Online