AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 73. TRAVEL DISTANCE IS ASSOCIATED WITH IMPROVED SURVIVAL IN HEPATOCELLULAR CARCINOMA C Hester, N Rich, M Augustine, J Mansour, M Porembka, S Wang, H Zeh III, A Singal, A Yopp Presenter: Caitlin Hester MD | University of Texas Southwestern Medical Center Background: An association between travel distance and survival measures has been been demonstrated across gastrointestinal malignancies but thus far has not been examined in patients newly diagnosed with hepatocellular carcinoma (HCC). We aimed to determine the association of travel distance with time to treatment (TTT) and overall survival (OS) in patients newly diagnosed with HCC. Methods: Newly diagnosed HCC patients who received treatment were identified in the Texas Cancer Registry from 2004 to 2015. We compared system- and patient-level factors among patients who traveled short (<12.5 miles), intermediate (12.5-49.9 miles), and long (≥50 miles) travel distances for initial treatment. Anova and Chi-square analyses were used to compare clinicopathologic variables, and Kaplan-Meier with log rank and cox regression models were used to compare survival. Results: 4,329 patients were identified: 2,136 (49.3%) short, 1,380 (31.9%) intermediate, and 813 (18.9%) long distance patients. Patients who traveled intermediate and long distances were more likely to be Non-Hispanic White (59% for intermediate and 60% for long vs 33% for short, p<0.001) and a higher proportion of privately insured patients (29% for intermediate and 24% for long vs 16% for short,p<0.001). Short distance patients were more often Hispanic White (43% vs 24% for intermediate and 31% for long) or Non-Hispanic Black (18% vs 8% for intermediate and long,p<0.001). Long distance travelers were more often initially treated at ACS accredited hospitals (95% vs 73% for short and 89% for intermediate, p<0.001), non-safety net hospitals (53% vs 40% for short and 52% for intermediate,p<0.001), academic centers (80% vs 57% for short and 73% for intermediate,p<0.001), and high volume hospitals (85% vs 63% for short and 78% for intermediate,p<0.001). Long distance travelers had smaller tumors, more localized disease, and were more likely to undergo ablation. Patients who traveled short distances were more likely to undergo surgical resection or transplantation. Long distance travelers had the shortest median TTT (4 weeks vs 5 weeks for short and intermediate,p=0.003). Non-Hispanic Black and Hispanic White races were independently associated with decreased odds of intermediate (OR 0.27, 95%CI 0.2-0.4, and OR 0.40, 95%CI 0.3-0.5) and long (0.27, 95%CI 0.2-0.4, and OR 0.58, 95%CI 0.5-0.7) driving distance compared to short distance. Intermediate distance was associated with the highest median OS of 32 months vs 31 (long) and 22 months (short) (p<0.001). Intermediate distance was independently associated with improved OS (HR 0.89, 95%CI 0.81-0.98) compared to short, but long distance was associated with similar survival. Conclusion: Racial/ethnic minority patients have decreased odds of traveling longer distances for HCC care. Intermediate travel distance (12.5-49.9 miles) is associated with decreased TTT and improved OS compared to other travel distances.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 74. VALUE OF ROUTINE DOPPLER ULTRASOUND SCREENING FOR HEPATIC ARTERY THROMBOSIS AFTER LIVER TRANSPLANTATION LK Winer, AR Cortez, TC Lee, MC Morris, A Kassam, F Paterno, TS Diwan, MC Cuffy, RC Quillin III, SA Shah Presenter: Leah Winer MD | University of Cincinnati Background: Hepatic artery thrombosis (HAT) is the most common arterial complication after orthotopic liver transplantation (OLT) and can lead to graft failure and death. Protocoled Doppler ultrasound screening (DUS) is an inexpensive and noninvasive method to detect HAT, but definitive guidelines regarding the optimal timing and frequency of DUS are lacking. The objective of this study was to evaluate a high-volume center’s experience with routine postoperative ultrasound in the detection and management of HAT after OLT. Methods: This is a retrospective review of a prospectively maintained database of patients who underwent deceased donor OLT between January 2013 and June 2018 at a single center. Our institutional protocol was to perform DUS on postoperative days (POD) 1 and 5 unless clinical suspicion or provider preference warranted additional evaluations. HAT was defined as the absence of blood flow in the main, right, and/or left hepatic arteries. Patients were stratified into HAT and non-HAT groups, and donor and recipient demographics, perioperative variables, and outcomes were compared with chi-square and Wilcoxon rank-sum tests. Descriptive statistics were reported as medians and interquartile ranges (IQR), and p-values <0.05 were considered statistically significant. Results: During the study period, 485 OLTs were performed on 470 patients with a median follow-up of 26.0 months (11.6-42.9 months). The rate of HAT was 2.7% (n=13). HAT was associated with higher MELD, older donor age, and the use of aortoiliac jump grafts (all p 0.05). All patients received their first DUS on POD 1 according to protocol, but HAT patients had their second DUS significantly earlier than non-HAT patients (POD 2 vs POD 5, p 0.05). Conclusion: HAT is a devastating complication after OLT and necessitates swift diagnosis to prevent graft loss and death. Routine DUS on POD 1 and 5 was associated with reliable and early detection of HAT, which allowed for prompt surgical intervention and attempt at graft salvage usually without the need for retransplantation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 75. HEPATECTOMY FOR MALIGNANCY IN THE AGED POPULATION: A COMPARATIVE STUDY F Gryspeerdt, F Vandenbroucke-Menu, R Lapointe, S Turcotte, M Dagenais, M Plasse, R Letourneau, A Roy Presenter: Filip Gryspeerdt MD | Centre Hospitalier de l'Université de Montréal Background: Worldwide, there is an increase in life expectancy. With increasing age, comorbidities rise and physical reserves decline. The population of patients older than 70 year diagnosed with cancer are expected to rise substantially. Advanced age is sometimes considered as a contra-indication for surgery. However, chronological age does not always correlate with physiologic age and a large proportion of this patients will benefit from surgery. By analysing our experience in a comparative study, we want to justify major surgery in the elderly population. Methods: All records from a prospectively collected database were retrospectively analysed. Benign pathology was excluded. Patients aged 70y or older (OP) at the time of liver surgery for malignancy were compared to patients between 18 and 65y (YP). The primary endpoints for this study were defined as postoperative 90D-morbidity and 90D-mortality. Morbidity was reported according to the modified Clavien-Dindo classification of surgical complications and the Comprehensive Complication Index [CCI]. Major complications were reported as Clavien-Dindo III or greater. The most frequently affected organ system and specific complications were analysed in each group. Results: From 2010 until 2016, 385 patients were identified matching our criteria. Of these patients, 155 in the OP group were compared to 230 patients in the YP group. There were significantly more major hepatectomies in the OP group (58,7% VS 45,2%; p=0,009). The 90-day mortality for the OP group was 3.2% (n=5) VS 1.3% (n=3) for the YP group (p=0.195). Major complications (Dindo-Clavien III and IV) were not significantly more frequent in the OP group (16.1% VS 11.5%; p=0.199). In the OP group, there were significantly more patients who suffered from one or more complications (54.2% VS 39.7%; p=0.006) resulting in a mean CCI-score of 16.62 VS 10.16 (p 75y showed a not significant increase in major complications (respectively 17.6% and 18.2%), but CCI scores (17.97 and 17.428 respectively) remained significantly higher in the elderly compared to younger group. Conclusion: Age should not be a contra-indication for liver surgery for malignancy. When well selected, hepatectomy and even major hepatectomy are safe in the aged population. Nevertheless, elderly patients are more prone to having one or more complications and to having more infectious complications compared to the younger population.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 76. RE-APPRAISAL OF THE BLUMGART STAGING SYSTEM FOR HILAR CHOLANGIOCARCINOMA A Crown, K Skorohodova, NR Conti, AA Alseidi, TR Biehl, WS Helton, FG Rocha Presenter: Angelena Crown MD | Virginia Mason Medical Center Background: Hilar cholangiocarcinoma is one of the most challenging malignancies to treat given its aggressive nature, propensity for local involvement and distant spread precluding resection for cure. In 1998, the Blumgart staging system was proposed in order to predict resectability, metastases and survival based on preoperative imaging factors. This system has been confirmed in an expanded series. We sought to validate its utility in an external patient cohort. Methods: Consecutive patients referred for the management of hilar cholangiocarcinoma at our institution between 2004-2017 were included in the study. Those with adequate preoperative cross-sectional imaging had their images independently re-reviewed by an independent body radiologist blinded to clinical outcome. Patients were stratified according to the Blumgart staging system as T1, T2 or T3. Clinicopathologic information was obtained from the electronic medical record and correlated to T-stage. Chi-square test, Kaplan-Meier estimates, logistic and Cox regression were used to compare groups. Results: Of 119 eligible patients, there were 31 with T1 tumors, 28 with T2 tumors and 57 with T3 tumors; 3 were not able to be classified. The average age was 68 years and 54% were male. Seventy-one patients (60%) were found to be unresectable at presentation due to locally advanced disease (33), metastatic spread (18) and medical unfitness for surgery (20). Of the remaining 48 patients who were explored surgically, 27 were ultimately resected (18 R0, 9 R1). When grouped by T stage, 11 (35%) T1, 10 (35%) T2, and 6 (10%) T3 patients were able to undergo curative intent surgery, p <0.004. Metastases were found in 9 (29%) T1 patients, 4 (14%) T2 patients, and 13 (23%) T3 patients. Perioperative mortality at 30 days was 2.5%. Median overall survival was 35 months, 40 months and 20 months in patients with T1, T2 and T3 tumors respectively, p < 0.05. R0 resection was associated with the best survival, p = 0.0015 (See Figure). Conclusion: The majority of patients with hilar cholangiocarcinoma are not candidates for curative therapy. With modern imaging, the Blumgart preoperative staging system was able to predict worse resectability and survival in patients with T3 tumors, however it was unable to distinguish between those with T1 and T2 tumors. This may be due to the higher incidence of metastases in T1 lesions and preponderance of T3 tumors in the study population. Further validation with a larger cohort is warranted to confirm these findings.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 77. IMPLEMENTATION OF A PATIENT-CENTERED TUMOR BOARD-BASED MULTIDISCIPLINARY PROGRAM TO IMPROVE QUALITY AND EXPEDITE CARE FOR HEPATOBILIARY TUMORS J Ehab, B Powers, A Chin, C Zambrano, R Kim, B Kis, J Frakes, D Coppola, J Choi, G El-Haddad, N Parikh, B Biebel, J Sweeney, DA Anaya Presenter: Jasmina Ehab MS2 | Moffitt Cancer Center Background: The standard of care for management of patients with hepatobiliary malignancies is within a multidisciplinary framework, often accomplished within a tumor board setting. Despite widespread use of tumor boards, coordination of care for complex cancer cases is challenging. Studies have shown that appropriate and timely evaluation of patients with hepatobiliary tumors is uncommon, and often lead to delays in care in this population. The goal of our study was to examine the impact of implementing a structured hepatobiliary tumor board-based multidisciplinary program on the process and quality of care. Methods: A retrospective cohort study using a prospectively collected database was performed to compare the process of care for new patients with hepatobiliary malignancies receiving treatment at our institution before (BP: July1, 2014 – June30, 2015) and after the implementation of the program [AP: July 1 2017 – June 30, 2018); a hepatobiliary-specific weekly tumor board was implemented on November 2015, centered around patient measures of efficiency and standardized and structured to provide high-quality care based on established standards. The primary outcome of interest was time to treatment initiation (TTI), defined as the time from first visit to treatment initiation (days), and the number of clinic visits from first visit to treatment initiation. Secondary outcomes included completion of multidisciplinary evaluation and measures of tumor board implementation. Results: A total of 1,154 patients were presented during 109 tumor board conferences (Nov 2015 – June 2018), with a median number of 11 cases presented per conference, and a median number of 11 healthcare providers attending per conference – representing all disciplines involved with care for hepatobiliary tumors. Among the 1,154 patients presented, 657 (57%) were new patients; with 354 (54%) presented at the tumor board as the entry-point to the hepatobiliary program and the remaining 303 (46%) presented after their initial visit. The study cohort included 259 patients: 131 in the BP group and 129 in the AP group. The majority of patients were treated for HCC (40%), followed by bile duct/gallbladder cancers (22%), colorectal liver metastasis (19%), neuroendocrine liver metastasis (7%), other liver metastasis (7%), and other pathologies (5%). Multidisciplinary evaluation was accomplished more frequently in the AP group as compared to the BP group (100% vs. 42%; p<0.01). Median TTI was significantly lower for the AP as compared to the BP (17 days vs. 24 days; p<0.01), and the median number of clinic visits was also significantly lower for the AP group (1 vs. 2; p<0.01). Conclusion: The implementation of a structured, tumor board-based and patient-centered hepatobiliary multidisciplinary program is feasible and sustainable, and associated with improved quality of the process of care – including higher multidisciplinary evaluation, a more efficient process of care and expedited and timely treatment initiation. This model represents a viable, real-life intervention to improve care for patients with hepatobiliary malignancies within a hospital and/or across healthcare networks.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 78. OUTCOMES IN SQUAMOUS VARIANTS OF GALLBLADDER CARCINOMA: IS RESECTION FUTILE? NL DeNicola, D Solomon, B Sullivan, U Sarpel, DM Labow, DR Magge, BJ Golas Presenter: Natasha DeNicola MD | Icahn School of Medicine at Mount Sinai Background: Although gallbladder adenocarcinoma (GBA) is potentially curable with surgical resection, the influence of the squamous histological subtype upon outcomes is not well described. Methods: We retrospectively analyzed all patients with gallbladder cancer (GBC) who underwent surgical resection with curative intent in our health system from 2007 to 2017. We compared clinicopathologic, perioperative, and oncologic outcomes of adenocarcinoma (GBA) to histologic subtypes of adenosquamous (GBAS) and pure squamous cell (GBS). Results: 91 patients met criteria; 3 GBS, 12 GBAS, 76 GBA. The three cohorts had similar preoperative profiles. Patients with any squamous histology had larger primary tumors (60mm GBS, 48mm GBAS vs. 28mm GBA, p<0.001), requiring adjacent organ resection (33%, 42% vs. 7%, p=0.003), and were higher stage (stage 3/4 66%, 75% vs. 52%, p=0.039) with more frequent LVI (67%, 58% vs. 36%, p=0.200) and G3 disease (67%, 75% vs. 43%, p=0.382). R0 resection rates and use of adjuvant therapy were similar in all cohorts. Median OS was similar between GBA and GBAS (26 and 23 months), but significantly worse in pure GBS (<5 months) with no patients alive at 1 year (vs. 68% GBAS 71% GBA, p=0.502). PFS was significantly worse in squamous variants (GBAS 8 months, GBS 1 month) than GBA (15 months), p=0.001. On multivariate analysis, R1 resection, higher grade disease and recurrence were significant independent predictors of shorter OS (p<0.05). Although R0 improved OS in GBAS/GBS (24 vs. 14 months R1), it was still extremely poor. Conclusion: Squamous cell variants of gallbladder cancer confer more aggressive disease. Even with R0 resection and adjuvant therapy, surgical resection is not superior to best supportive care. Our data suggest that preoperative identification of a squamous variant may identify patients who could be spared from unnecessary surgery.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 79. THE SHORT-TERM OUTCOMES OF PRIMARY TUMOR RESECTION WITH SYNCHRONOUS METASTASES FROM PANCREAS NEUROENDOCRINE TUMORS: AN ANALYSIS OF THE ACS-NSQIP REGISTRY N Latchana, L Davis, CHL Law, JR Howe, R Pommier, J Hallet Presenter: Nicholas Latchana MD, MSc | University of Toronto Background: The incidence of pancreatic neuroendocrine tumors (PNET) is rising worldwide, with many patients developing metastatic disease. Resection of the primary tumor despite of unresectable metastases is suggested to improve long-term oncologic outcomes. Assessments of the morbidity of this approach are scarce and limited to small, single-institutional studies. We sought to determine the patient characteristics and short-term outcomes of pancreatectomy for metastatic (M1) PNET, and compare them to non-metastatic (M0) PNET. The comparison was undertaken to provide a reference with which providers are familiar – i.e. outcomes of pancreatectomy for M0 disease, to better appreciate the burden of complications with M1. Methods: We conducted a retrospective cohort study using the ACS-NSQIP targeted pancreatectomy registry. We included all adults undergoing pancreatectomy for PNET between 2014-2016, with complete staging information. M1 and M0 PNET groups were created. Primary outcomes were 30-day major morbidity, mortality, and prolonged length of stay (>75th percentile). The characteristics and outcomes of M1 and M0 groups were compared using Pearson Chi square, Fisher exact test, and Student t test, as appropriate. A propensity score was created with the following potential confounders defined a priori: age, sex, body mass index, ASA classification, T and N stage, surgical procedure, open approach, and functional histology. The association between M1 and outcomes was adjusted for the propensity score using logistic binomial regression. Results: Of 1,381 included patients, 148 (12%) had M1 disease. Patients with M1 were more likely to be younger, have lower hematocrit, higher ASA class, lower body mass index, and have pre-operative weight loss, than M0 patients (all p<0.05). T1/2 (75.7% vs. 28.8%, p<0.01), node positive (72.3% vs. 25.9%, p<0.01), and functional (29.7% vs. 22.1%, p=0.04) tumors were more common in the M1 group. There were no differences in the type of pancreatectomy (distal pancreatectomy 60.1% Vs. 57.3%, p=0.46), but there were more open resections (78.4% vs. 55.5%, p<0.01) and longer median operating time (322.5 vs. 261 minutes, p<0.01) for M1. No significant difference was detected in overall 30-day major morbidity (38.5% vs. 39.7%, p=0.77) and mortality (2.7% vs. 1.0%, p=0.06) between groups. Prolonged length of stay was more common with M1 (35.1% vs. 25.8%, p=0.01). Adjusted regression analysis revealed no independent association between M1 and 30-day morbidity (relative risk 0.90, 95% confidence interval: 0.71 -1.14), or prolonged length of stay (relative risk 2.89, 95% confidence interval: 0.78-10.7). Regression was not conducted on mortality due to too few events. Conclusion: In a multi-institutional analysis of prospectively collected data, resection of the primary tumor for M1 PNET was not associated with different post-operative morbidity and mortality than for M0 disease. The knowledge of short-term outcomes provided herein is important to weigh perioperative risks against the potential benefits of PNET primary tumor resection in the setting of M1 disease. This can support both decision-making and patient counselling.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 80. EVALUATING THE PROGNOSTIC NUTRITION INDEX IN PANCREATIC NEUROENDOCRINE TUMOR: RESULTS FROM THE NEUROENDOCRINE TUMOR STUDY GROUP EW Beal, F Bagante, AG Lopez-Aguiar, G Poultsides, E Makris, F Rocha, Z Kanji, SR Kelley, JR Barrett, RC Fields, BA Krasnick, K Idrees, P Marincola Smith, CS Cho, MV Beems, SK Maithel, CR Schmidt, TM Pawlik, M Dillhoff Presenter: Eliza Beal MD, MS | The Ohio State University Background: The prognostic nutritional index (PNI), which incorporates total lymphocyte count and albumin, has been shown to provide an accurate, quantitative estimate of operative risk. The objective of this study was to evaluate the impact of PNI on complications, recurrence and overall survival for patient with pancreatic neuroendocrine tumor. Methods: Patients with PNET who underwent curative-intent resection from 2000-2016 were identified using a multi-institutional database comprised of data from 8 academic medical centers. The PNI was calculated using serum total lymphocytes in count/mm3 and serum albumin in grams/100 ml. Patients with PNI>40 were considered to have a normal PNI. Preoperative clinicopathologic variables and complications were compared between groups. Overall and recurrence free survival were evaluated using Kaplan-Meier curves with log rank tests. Results: 380 patients who underwent curative-intent resection for PNET were included. Forty-six (12%) had a PNI less than 40. One hundred ninety (50%) were male, with a median age of 57 years. Patients with PNI less than 40 were older (61 years vs. 55 years, p 40 had significantly improved overall (p<0.01) and recurrence-free survival (p<0.01). Conclusion: The prognostic nutrition index predicted some complications and both overall and recurrence free survival in patients who underwent curative-intent, complete resection for pancreatic neuroendocrine tumor. This measure can be easily calculated preoperatively and may help identify patients who would benefit from preoperative nutritional supplementation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 82. RETROSPECTIVE REVIEW OF MALIGNANCY IN LIVER TRANSPLANT RECIPIENTS WR Johnston, N Vachharajani, AS Khan, Y Lin, JR Wellen, S Shenoy, WC Chapman, MB Majella Doyle Presenter: William Johnston BS | Washington University, St. Louis Background: Multiple studies demonstrate an increased incidence of malignancy following solid organ transplantation. Due to steady improvements in post-transplant survival, the proportion of recipient deaths secondary to these malignancies is increasing. While cancer in kidney recipients is well researched, studies of cancer in liver recipients are relatively few and limited by small numbers of patients. In this study, we analyze the frequencies, treatments, and outcomes of different malignancies in adult liver transplant recipients from a single high-volume transplant center and suggest appropriate management strategies. Methods: A retrospective review was performed of all adult liver transplant recipients at a single liver transplant center between January 2002 and December 2016. Data regarding treatment, outcome, and survival was collected and analyzed from a previously established institutional database. Results: We identified 1221 adult liver transplants, of which 108 developed at least one post-transplant malignancy, with 45 cases of cutaneous malignancy and 67 cases of solid organ malignancy. Three patients developed recurrent hepatocellular carcinoma and one developed de novo hepatocellular carcinoma. A history of cancer prior to transplant was positive in 85/1061 (8.0%) patients that did not develop cancer and 14/108 (13.0%) patients that did (p=0.10). Overall 1-, 3- and 5- and 10-year survival were 96.3%, 87.9%, 80.1% and 50.7% for the patients who developed cancer and 90.1%, 83.5%, 77.7% and 67.2% for those who did not (p=0.0209). For patients who developed cutaneous cancer only, corresponding survival was 100%, 100%, 97.1% and 86.4% compared to 94.3%, 81.4%, 71.0% and 32.1% for patients developing other cancers. (p<0.0001). 24 (22.2%) patients that developed cancer experienced biopsy-proven rejection, compared to 227 (21.4%) for patients without cancer (p=NS). 41 patients with cutaneous malignancy received local excision, while four developed local invasion and required invasive surgery or radiation. Only one of these patients developed metastatic disease. 50 patients with solid organ tumors received surgery, chemotherapy, radiation, hormone therapy, and/or targeted therapy while the rest received hospice, surveillance, or were lost to follow up. Lung, colorectal, and hematologic cancer patients that received chemotherapy (n=17) tolerated treatment poorly with 14/17 (82.4%) regimens reduced or stopped due to toxicity and progression. Those with other cancers (n=7) tolerated chemotherapy well and completed their prescribed courses. One patient treated with surgery required re-operation for a hematoma, one with radiation developed a bleeding ulcer, and one with targeted therapy developed a GI bleed. Conclusion: Outcomes varied based on the type of malignancy and degree of systemic involvement. Cancer patients demonstrated significantly worse 10-year survival relative to those without cancer but comparable 1-, 3-, and 5-year rates, indicating risk of mortality due to cancer does not increase until well after transplantation. As expected, patients with solid organ cancers had significantly worse survival than those with cutaneous cancer, whose survival was similar to those without cancer. There were no differences in rates of rejection, suggesting a judicious reduction of immunosuppression is an appropriate component of oncologic treatment. Patients with non-metastatic disease amenable to local surgery or radiation tolerated treatment well, while patients with hematologic, lung, and colorectal cancer requiring chemotherapy developed higher rates of toxicity than patients with other cancers.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 83. THE IMORTANT ROLE OF ADJUVANT TREATMENT IN ADVANCED GALLBLADER CANCER EY Bekhor, B Sullivan, D Solomon, N DeNicola, M Hofstedt, BJ Golas, U Sarpel, DR Magge, DM Labow, N Bolton Presenter: Eliahu Bekhor MD | Icahn School of Medicine at Mount Sinai Background: The role of adjuvant treatment has been well established in cholangiocarcinoma, Gallbladder cancer (GC) is a rare and less studied tumor Methods: We retrospectively analyzed all patients with gallbladder malignancy that underwent surgical removal of the gallbladder in our health system from 2007 to 2017. We compared clinical and oncological outcomes for two groups of patients: a group that received adjuvant treatment and a group that did not receive adjuvant treatment . The adjuvant treatment group was composed of patients who received either chemotherapy alone (19 patients) or chemo-radiation (21 patients). Results: Overall 69 patients with advanced (TNM stage III/IVa) gallbladder cancer (GBC) underwent resection for curative purposes. Among them, 40 patients (58%) were in the adjuvant treatment group and 29 patients (42%) were in the NO adjuvant treatment group. Gender (female, 58% vs 60%), ASA score (%) (I – 22 vs. 24, II- 39 vs. 37, III- 32 vs. 39, IV, 7 vs. 0), TNM stage IV (%, 17 vs. 10), and neoadjuvant chemotherapy administration (10% vs. 12%) were comparable (p=NS). The patients in theadjuvant treatment group were significantly younger (mean, years, 63 vs. 70, p=0.03). Intraoperatively, surgical approach (laparoscopic, %, 28 vs. 25), incidental finding (%, 52 vs. 48), and tumor max dimension (mean, mm, 44 vs. 45) were all similar. Significantly more patients in the adjuvant treatment group underwent radical cholecystectomy (%, 69 vs. 98, p=0.01). At median follow-up of 20 months, 43 patients recurred. Patients in adjuvant treatment group had significantly better survival (months, 25 vs. 10, p=0.01). Similarly, the median disease-free survival was improved for patients in adjuvant treatment group (months, 18 vs. 8), although this didn’t reach statistical significance (p=0.16). Conclusion: Adjuvant treatment has significant survival benefits for patients with advanced GBC and should be offered to patients with acceptable performance status. Despite these data, the application of adjuvant therapy after resection is not universally applied

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 84. SURGICAL DRAINS DO NOT ALTER THE SPECTRUM OF COMPLICATIONS IN DISTAL PANCREATECTOMY. AN ANALYSIS OF THE NSQIP PANCREATECTOMY DATABASE ES Tang, AM Schneider, PH Newell, SC Chang, L Wang, PD Hansen Presenter: Ephraim Tang MD, MSc, FRCSC | London Health Sciences Centre Background: Distal pancreatectomy remains the procedure of choice for masses within the body and tail of the pancreas however post-operative pancreatic fistulas (POPF) continue to be the major source of morbidity. While we reasoned that drains may not reduce POPF, some evidence suggests they may reduce the frequency of related severe complications. We sought to evaluate the role of surgical drains in mitigating the frequency of severe complications related to POPF in distal pancreatectomy. Methods: We performed a retrospective cohort study of the procedure targeted, Pancreatectomy NSQIP database from 2014-2016. We included all patients who underwent non-emergent, distal pancreatectomy for any reason. We excluded patients with sepsis, or clinical instability. The primary endpoint was a modified clinically relevant POPF (mCR-POPF). This included any POPF that resulted in the need for percutaneous drainage, or was associated with sepsis, organ failure, reoperation, or death. We also looked at multiple secondary endpoints including percutaneous drainage, sepsis, septic shock, acute renal failure, re-operation, cardiac arrest, organ space infection and mortality. Multivariable logistic regression models were built for the primary and each secondary endpoint. Results: Based on our criteria, we identified 5,055 distal pancreatectomies eligible for analysis. Of these, 4679 had no mCR-POPF, while 376 did. In addition, drains were left in 4334 patients (85.7%). On multivariable logistic regression, surgical drain placement was not associated with mCR-POPF (OR 0.86, 95% CI 0.637-1.161, P = 0.325). Additionally, for each of the secondary endpoints evaluated, there was no evidence that surgical drain placement was associated with either an increase or a decrease in any of the outcomes (Percutaneous drainage OR 1.151, 95% CI 0.875-1.514, p 0.3143, Septic Shock OR 1.240, 95% CI 0.888-1.941, p = 0172, mortality OR 1.503, 95% CI 0.456 – 4.955, p = 0.503). Conclusion: Based on this analysis of the NSQIP procedure targeted pancreatectomy database, we did not find any evidence that surgical drains alter the frequency of mCR-POPF, or with related moderate to severe complications. As a result, the practice of standard drainage in the setting of distal pancreatectomy should be critically evaluated.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 Table 2: Final adjusted odds ratios for the effect of surgical drain placement on each outcome based on

multivariable logistic regression models

Outcomes OR 95% CI p-value Risk factors controlled for

mCR-POPF 0.86 0.63 1.16 0.33 Age, CHF hx, OP time, BMI, reconstruction, ASA

Percutaneous drain 1.15 0.88 1.51 0.31

COPD hx, CHF hx, Chemo, OP time, BMI, ASA, reconstruction

Sepsis (including septic shock) 1.31 0.89 1.94 0.17 Sex, COPD hx, OP time, ASA Septic shock 1.24 0.56 2.75 0.60 Age, dialysis, OP time, ASA Renal failure (very few events, 0.4%) 3.24 0.43 24.26 0.25 ASA Transfusion 1.58 0.90 2.758 0.11 Dialysis, steroid, OP time, BMI, ASA Return to OR 0.98 0.64 1.514 0.94 COPD hx, OP time, ASA 30-day mortality 1.50 0.46 4.955 0.50 Age, steroid, OP time Cardiac arrest 1.84 0.43 7.820 0.41 Age, OP time Organ space infection 1.02 0.77 1.342 0.89

Sex, smoking, dialysis, steroid, OP time, BMI, ASA, reconstruct

>=30 day admission 0.64 0.28 1.474 0.29 COPD hx, OP time, ASA 30-day mortality 1.57 0.47 5.198 0.46 OP time, logit of predicted mortality

Odds ratios for the effect of surgical drains on each outcome when adjusted for the indicated

confounders. mCR-POPF (modified clinically relevant POPF), CHF (Congestive heart failure), OP time

(operative time), BMI (Body Mass Index), COPD (Chronic Obstructive Pulmonary Disease), ASA

(American Society of Anesthesiologist Class)

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 85. PANCREATODUODENECTOMY IN THE GERMAN DGAV STUDOQ|PANCREAS AND DUTCH PANCREATIC CANCER AUDIT: DIFFERENCES IN PATIENTS, INDICATIONS, SURGERY, CENTRALIZATION AND OUTCOME TM Mackay, UF Wellner, LB van Rijssen, TF Stoop, OR Busch, B Groot Koerkamp, D Bausch, E Petrova, MG Besselink, T Keck Presenter: Tara Mackay MD | Academic Medical Center Background: Nationwide audits facilitate quality and outcome assessment of pancreatic surgery. Differences may exist between countries but studies comparing nationwide outcomes of pancreatic surgery based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation. Methods: Anonymised data from patients undergoing pancreatoduodenectomy (2014-2016) were extracted from the German DGAV StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit. Results: Overall, 4495 patients (2489 German, 2006 Dutch) were included. In the Netherlands, adenocarcinoma was more often the indication for pancreatic resection. German patients had higher ASA class but Dutch patients had more pulmonary comorbidity. Dutch patients underwent more minimally invasive surgery and venous resection, but less multivisceral resection. No difference was found in rates of postoperative pancreatic fistula grade B/C, post-pancreatectomy haemorrhage grade C and in-hospital mortality. There was more centralization in the Netherlands (1% versus 13% PD in very low volume centres, P = 0.001). After multivariable analysis, both hospital stay (2.5 days difference, 95% CI 1.17-3.80) and the odds of reoperation (OR 1.55, 95% CI 1.21-1.95) were higher in the German audit, whereas the odds of postoperative pneumonia (OR 0.57, 95% CI 0.37-0.86) and readmission (OR 0.38, 95% CI 0.31-0.49) were lower, see Table. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality. Conclusion: Although in-hospital mortality, and rates of pancreatic fistula and haemorrhage are similar, noteworthy differences exist between patients, indications, surgical technique and centralization for pancreatoduodenectomy between Germany and the Netherlands.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 86. SOLID PSEUDOPAPILLARY NEOPLASMS OF THE PANCREAS: AN EXTENDED ANALYSIS OF A SINGLE INSTITUTION SERIES AFTER PANCREATIC RESECTION J Yu, YY Zhu, T Saunders, LD Yin, J Griffin, N Pu, HJ Hu, RA Burkhart, MA Makary, JL Cameron, MJ Weiss, CL Wolfgang, J He Presenter: Yayun Zhu MD | Johns Hopkins University School of Medicine Background: Solid pseudopapillary neoplasms (SPNs) of the pancreas often put both patients and clinicians at a surgical dilemma. Few articles are currently available for surgeons to resort to for a convincing evaluation of the value of long-term postoperative follow-up which has been designated for more survival benefits. Methods: Data concerning relevant demographic, clinical, operative, and pathology were retrospectively collected for all patients with SPN who received surgical resection at the Johns Hopkins Hospital from July 1970 to July 2015. All data collected for this study, including long term survival information, came from the patient medical records and the US Social Security Death index. Perioperative surgical complications and mortalities and post-operative pancreatic were recorded. Statistical analysis was conducted using Standard Student t-test, and chi-squared analysis with IBM SPSS Statistics. A two-sided p < 0.05 were considered statistically significant. Results: A total number of seventy-nine patients with SPN, comprising 66 females (84%) and 13 males (16%) (p=0.00). The median age for the total cohort was 33 years (Range: 6-75 years), 31 years and 35 years for females and males respectively. Thirty-two (41%) patients had complications, the most common of which were pancreatitis (n=11, 14%), pancreatic fistula/leak (n=6, 8%), delayed gastric emptying (DGE) (n=6, 8%), abscess formation (n=3, 4%), and wound infection (n=5, 7%). Malignant characteristics were observed in 11 patients (five in the 13 male patients and six in the 66 female patients, p=0.018). Two of the patients presented with liver metastasis, one of which passed away one year after diagnosis and the other survived for 5.6 years. Perineurial invasion was found in six, perivascular invasion in two, and lymph node involvement in three patients. All patients underwent a R0 resection except for three, two of which had R1 resections. The other patient underwent an R2 resection that ended up becoming a complete pancreatectomy. Three patients had lymphatic spread to regional lymph nodes. the median follow-up for the 79 patients is 6 years. Five patients died in the series, two of which died of liver metastasis, one died from Stage IV colorectal cancer at 1.5 years, and two died of unknown causes at 6.8 and 9.7 years respectively. The remaining 74 patients are alive including two patients with R1 resections who have been alive for 15.7 and 27 years respectively. Conclusion: SPNs are rare pancreas tumors that show predominance in females but are more likely to have malignant characteristics in males. Survival and outcome had no correlations to any preoperative, operative, or postoperative characteristics. This extensive follow up for patients with surgically resected SPNs supports the treatment of surgical resection and gives more insights into the follow up of patients with SPN, especially in males.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 87. MINIMALLY INVASIVE DISTAL PANCREATECTOMY FOR PANCREATIC CYSTIC NEOPLAMS AND LOCALIZED SOLID TUMORS: VARIATION IN UTILIZATION AND POTENTIAL AS A QUALITY MEASURE RJ Ellis, L Zhang, CY Ko, DJ Bentrem, KY Bilimoria, AD Yang, RP Merkow Presenter: Ryan Ellis MD, MS | American College of Surgeons Background: Minimally invasive distal pancreatectomy (MIDP) has been demonstrated to be a technically feasible and oncologically sound alternative to open distal pancreatectomy (ODP) for pancreatic cystic neoplasms and localized solid tumors, including pancreatic adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (PNET). However, it is unknown which patients are being selected for MIDP or the extent to which hospitals are adopting this approach. The objectives of this study were to (1) identify patient-level factors associated with utilization of MIDP, (2) describe hospital-level variation in utilization of MIDP, and (3) compare outcomes between ODP and MIDP for cystic lesions and early stage solid tumors. Methods: The American College of Surgeons National Surgical Quality Improvement Program Pancreas Targeted Data File was used to identify patients from 2014-2017 who underwent distal pancreatectomy for pancreatic cysts (serous cystadenomas, mucinous cystadenomas, and intraductal papillary mucinous neoplasms), Stage I PDAC, or Stage I PNET. Surgical approach was categorized as OPD or MIDP (laparoscopic or robotic). Outcomes of interest included unplanned conversion of MIDP to OPD, postoperative length of stay, and a composite outcome of death or serious morbidity (DSM). Associations between patient factors, surgical approach, and postoperative complications were assessed by risk-adjusted hierarchical multivariable logistic regression. Hospital-level utilization of MIDP was calculated to assess institutional variability in surgical approach. Results: Analysis identified 3,276 patients undergoing distal pancreatectomy at 141 hospitals. Overall, 55.1% of patients had pancreatic cysts, 12.0% had Stage I PDAC, and 32.9% had Stage I PNET. ODP was performed in 37.3% of cases (35.6% of cyst cases, 61.6% of PDAC cases, and 31.4% of PNET cases), while 62.7% were MIDP (of which 76.1% were laparoscopic and 23.9% were robotic). The rate of unplanned conversion to open during MIDP was 11.8% (12.1% laparoscopic, 10.8% robotic, p=0.700). Patients were more likely to undergo MIDP if they were <55 years old (66.6% vs 56.4% if ≥75; aOR 1.34, 95%CI [1.08-1.67]) or had a BMI≥30 (67.1% vs 57.8%, aOR 1.34, 95%CI [1.11-1.62]). Patients were less likely to undergo MIDP if they had PDAC pathology (38.4% vs 66.0% for PNET; aOR 0.33, 95%CI [0.25-0.44]). There was significant variation in hospital-level MIDP utilization (range: 0% to 100% of cases, Figure). Only 36.9% of hospitals attempted MIPD on at least 75% of patients with localized neoplasms. Similar to previous studies, length of stay was significantly shorter following MIDP (5.4 vs 7.2 days, p<0.001), and patients were significantly less likely to experience DSM following MIDP (16.2% vs 20.1%; aOR 0.74, 95%CI [0.62-0.89]). There was no difference in DSM between cystic neoplasms (DSM 17.2%), PDAC (DSM 18.0%), and PNET (DSM 18.0%; p=0.519). Conclusion: Despite being a safe alternative to ODP with fewer complications and shorter length of stay, MIDP is still underutilized even in cases of cystic neoplasms and localized solid pancreatic tumors. While some patient-level factors are associated with use of MIDP, hospital variation in adoption of MIPD appears to be the principal driver of utilization and should be the primary focus of strategies to increase its uptake. In addition to short-term and oncologic outcome measures, hospital-level MIPD rates in appropriate patients could be utilized as a measure of hospital quality to both improve patient outcomes and encourage adoption of minimally invasive techniques.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 88. ASSOCIATION OF TRAVEL DISTANCE, HOSPITAL VOLUME AND PERI-OPERATIVE OUTCOMES FOLLOWING RESECTION OF GALLBLADDER ADENOCARCINOMA EW Beal, R Mehta, JM Hyer, A Paredes, K Merath, ME Dillhoff, J Cloyd, A Ejaz, A Tsung, TM Pawlik Presenter: Eliza Wright Beal MD, MS | The Ohio State University Background: The effect of hospital/surgeon volume and travel distance on patient outcomes after major abdominal surgery remains poorly defined. We characterized the relationship among travel distance, hospital volume and long-term outcomes after resection of gallbladder adenocarcinoma. Methods: The 2004-2015 National Cancer Database was used to identify patients who underwent resection of gallbladder adenocarcinoma. Patients were stratified according to travel distance and hospital volume quartiles and multivariable Cox regression models were utilized to examine the impact of travel distance, hospital volume and travel distance/hospital volume on overall survival. Results: Among 11,559 patients identified with gallbladder adenocarcinoma, the most commonly performed procedure was total removal of the primary site (N=7,605, 65.7%). Median patient age was 71 years (IQR 62-80); most patients were female (N=8,081, 69.9%) and white (N=9,301, 80.4%). Stratifying data into quartiles, travel distance to surgical care was: ≤3.6 miles, >3.6-8.1 miles, >8.1-21.3 miles, and ≥21.3 miles. Overall hospital quartile volumes were 1-9 cases/year, 5-9 cases/year, 10-22 cases/year, and ≥ 23 cases/year. White patients who had private insurance, as well as patients with more advanced pathological T and N stage disease, were more likely to travel further for surgical care (all p<0.001). On multivariable analysis, after controlling for factors except hospital volume, a longer travel distance was associated with a lower risk of death long-term (HR 0.91, 95% CI 0.84-0.98, p<0.001). The association of travel distance with overall survival was mediated through hospital volume as only hospital volume was associated with survival (HR 1.15, 95% CI 1.04-1.27, p=0.007) after controlling for both travel distance and hospital volume. Conclusion: Roughly 1 in 5 patients with gallbladder cancer travelled more than 20 miles for surgical care. Longer travel distance was more common among white patients with private insurance. Increased travel distance was associated with improved overall survival with the association likely mediated through the effect of hospital volume.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 89. WEIGHT LOSS FOLLOWING HEPATOPANCREATOBILIARY SURGERY. HOW MUCH IS TOO MUCH? B Zhang, SG Faisal, L Ruo, M Simunovic, MI Sanchez, PE Serrano Presenter: Pablo Serrano MD | McMaster University Background: Postoperative weight loss commonly occurs in patients who undergo major hepato-pancreato-biliary (HPB) surgery. Many surgeons and patients are unaware of the extent of weight loss that is regularly seen after HPB surgery. We aimed to assess the median decrease in percent weight loss among all patients following HPB surgery and in those who experienced postoperative complications. We also evaluated the degree of weight loss that should be considered clinically relevant and may warrant nutritional assessment and treatment. Methods: We analyzed a retrospective cohort study of 398 consecutive patients undergoing HPB surgery from 2011-2016 at a single institution (50% pancreaticoduodenectomies, 40% hepatectomies and 10% biliary surgery). We determined: a) the percent change in postoperative weight, b) the incidence of postoperative complications (as defined by Clavien-Dindo), and c) correlation with nutritional clinical markers (i.e. albumin, hemoglobin) at three, and six months postoperatively compared to baseline. Percent and median weight loss from baseline were compared using Kruskal-Wallis and paired-sample Wilcoxon test when appropriate. Multivariable analysis using logistic regression was performed to evaluate risk factors (age, preoperative weight loss, postoperative complications, type of surgery, comorbidities) associated with clinically relevant postoperative weight loss (defined as weight loss >10% compared to baseline) at three months from surgery. Results: There was a significant decrease in percent weight loss at three months from surgery for the entire cohort (median 76Kg at baseline vs. 72Kg at three months, p<0.001). Patients did not recover their weight by six months (median 72Kg, p<0.001). Patients who experienced major complications had a greater decrease in percent weight loss at three months compared to those without major complications (median 10.6%, interquartile-range (IQR), 15.3 to 5.9 vs. median 4.3%, IQR, 8.9 to 0.3, p<0.001); respectively. There was no significant difference in weight at baseline among patients who experienced major complications after surgery. Patients who experienced major complications had a significantly lower albumin and hemoglobin and did not tend to recover their weight as much when compared to patients without major complications (median percent weight loss at six months: 8.6 vs. 3.1%, p<0.001). Predictors for clinically relevant weight loss at three months were: pancreaticoduodenectomy (odds ratio (OR) 4.7; 95% confidence interval (CI), 4.4-5.1), major complications (OR 3.39; 95% CI, 1.4-8.3), and minor complications (OR 2.53; 95% CI, 1.2-5.3). Conclusion: Patients undergoing HPB surgery experience substantial weight loss at three months from surgery, and their weight is not recovered by six months. Patients who experience major complications after surgery have increased risk of weight loss at three and six months when compared to patients without major complications. Clinically relevant weight loss is associated with postoperative complications and pancreaticoduodenectomies; which highlights the importance of nutritional assessment at baseline and at follow up for these patients.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 90. INVASIVE CENTRAL VENOUS MONITORING DURING HEPATIC RESECTION:UNNECESSARY FOR MOST CASES DC O'Connor, M Gonen, PJ McCormick, C Correa-Gallego, VP Balachandran, RP Dematteo, MI D'Angelica, TP Kingham, PJ Allen, JA Drebin, WR Jarnagin, ME Fischer Presenter: David O'Connor PhD, DNAP, CRNA | Memorial Sloan Kettering Cancer Center Background: Low central venous pressure (LCVP) improves outcome after hepatic resection and is the standard anesthetic management technique. Historically, this approach required a central venous catheter (CVC), but non-invasive assessment of CVP has evolved and is now routine. This study evaluates the impact of this change in practice and patient outcome after liver resection. Methods: A non-randomized, retrospective, cohort design was conducted using a prospectively maintained database of hepatic resections at our institution from 2007-2016. Infection, major morbidity, and 90-day mortality were compared between the group that received CVC and the group without CVC. Multivariable logistic regression was used for each outcome. CVC was forced into each model to assess association while controlling for other significant factors. Results: During the study period, 2518 hepatic resections were assessed and analyzed over three time periods (2007-2010, 2011-2013 and 2014-2016). CVCs were placed in 16.3% of the patients. The use of CVC was significant for 90-day mortality, 3.40% with CVC verses 1.0% without CVC (p 0.008). Presence of CVC was not significantly related to superficial wound infections (p 0.644), deep wound infections (p 0.389), or major complications (p 0.166) while controlling for other significant factors in the multivariable analysis. In patients submitted to a major resection (≥3 segments), CVC was not used in 75.8% of the cases. The results remained constant over the three time periods analyzed. Conclusion: The evolution to non-invasive assessment of fluid management for patients undergoing partial hepatectomy has not resulted in adverse outcomes.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 92. BILE DUCT INJURY REPAIRS: PROGRESSIVE OUTCOMES IN A TERTIARY REFERRAL CENTER PJ McLaren, HS Khadra, JE Crowther, M Darden, GG Parker, JF Buell Presenter: Patrick McLaren MD | Louisiana State University Health Science Center Background: Bile duct injury associated with cholecystectomy persists as a significant problem in general surgery. There exist concerns over referral for definitive management of complex injuries in order to minimize complications, including re-stricture. Methods: Our group analyzed our experience in bile duct repairs at a tertiary referral center over two eras 1987-2001 (n=59) and 2002-2016 (n=51) using regression analysis to evaluate re-stricture rates. Results: Patient demographics and presentation were similar between the two eras with respect to age, gender, race, BMI, incidence of arterial injury and Bismuth grade. The latter era demonstrated a lower incidence of attempted outside repairs (47% vs. 68%; p=0.046), a higher incidence of cholecystitis (51% vs. 32%; p=0.038), PTC placement (59% vs. 27%; p=0.022), and more complex repairs (47% vs. 19%; p=0.001) The latter era exhibited an increased length of stay (9.6 vs 8.3 days; p =0.026), equivalent complications (16% vs. 14%; p=0.07) and mortality (5% vs. 2%; p = 0.13), but a lower re-stricture rate (8% vs. 29%; p=0.005). Regression analysis identified: higher Bismuth grade (p=0.026), cholecystitis, (p=0.007), and PTC (p=0.009) were associated with increased of length of stay. Advanced age (p=0.043) was associated with complications. Higher injury (p=0.005), and earlier era of repair (p=0.020) were associated with recurrent stricture. High injuries (Bismuth III-V) required more complex repairs and resulted in overall higher complication rates (29% vs. 24%; p=0.07), but a lower re-stricture rate was noted in the latter era (11% vs. 21%; p=0.060). Conclusion: Our data identified there were no significant changes in the demographics or clinical presentation of bile duct injury over the two eras. However, the second era realized an increased use of complex reconstructions resulting in a significantly lower incidence of re-stricture. Regression confirmed surgical experience rather than complex repairs were the etiology, reaffirming the benefits to referral of bile duct injuries to a specialty center.

Variable Coefficient Std Err z-value p-value

Age at repair 0.0090212 0.0158508 0.569 0.5693

Male Gender -0.1340934 0.6476022 -0.207 0.836

Caucasian 0.0051218 0.6186416 0.008 0.9934

BMI 0.0549109 0.049467 1.11 0.267

Bismuth Grade -0.1948929 0.2567286 -0.759 0.4478

Arterial injury 0.3005449 0.7726327 0.389 0.6973

PTC placed 0.0832391 0.571197 0.146 0.8841

Prior repair 0.8438829 0.6063344 1.392 0.164

Repair date -0.0004393 0.000189 -2.325 0.0201

Complex Repair -0.2453447 0.761525 -0.322 0.7473

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 93. LIVER FUNCTIONAL RESERVE AND PRE-TREATMENT IMMUNE TOLERANCE IN WAITLIST TREATMENT NAÏVE HCC PATIENTS IS ASSOCIATED WITH POOR TUMOR RESPONSE TO LOCOREGIONAL THERAPY KG Nunez, T Sandow, S Robertson, AJ Cohen, PT Thevenot Presenter: Kelley Nunez PhD | Ochsner Health System Background: Locoregional therapy is used for downstaging or bridge to transplant in hepatocellular carcinoma (HCC) patients. Resistance to doxorubincin-eluting bead transarterial chemoembolization (DEB-TACE) increases recurrence risk following orthotopic liver transplantation. However, strategies to predict treatment response are lacking. In this study, we investigated the role of synthetic liver function and tolerogenic immune populations in response to DEB-TACE. Methods: HCC patients listed for transplantation and undergoing DEB-TACE were prospectively enrolled. Blood was collected before DEB-TACE. Tumor response was evaluated by mRECIST 30-60 days after treatment. Regulatory T cells (Tregs) and myeloid derived-suppressor cells (MDSCs) were quantified by flow cytometry. Results: The cohort consisted of 65 patients with median age of 61, 66% male, 77% hepatitis C, 78% within Milan with median AFP of 13 ng/mL, and MELD-Na of 10. Forty-seven percent of patients had a complete response to DEB-TACE. Patients with incomplete response had significantly lower albumin (p 35 had complete tumor necrosis following DEB-TACE. PNI was negatively correlated with bilirubin (p<0.001, R2=0.24). ALC was found to negatively correlate with immunotolerogenic populations, specifically Tregs (p<0.01, R2=0.23) and MDSCs (p<0.01, R2=0.26). After stratifying patients on the basis of lymphocyte status (ALC<1.2 K/L) revelaed lymphopenia was associated with incompete treatment response (p<0.05) and strongly associated with elevated Tregs (p<0.001) and MDSCs (p<0.01). Conclusion: Treatment naïve HCC patients not responsive to locoregional therapy had impaired liver synthetic function and ALC. This was accompanied by increased immunosuppressive cell populations which may play in role in resistance to DEB-TACE.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 94. PERIOPERATIVE NSAIDS DO NOT INCREASE THE RATE OF POST-OPERATIVE PANCREATIC FISTULA AFTER PANCREATECTOMY P Horning, A Manilchuk, CR Schmidt, TM Pawlik, M Dillhoff Presenter: Paul Horning BS | The Ohio State University Background: Enhanced recovery after surgery (ERAS) protocols are becoming increasingly common, and as a result, the use of opioid sparing medications, such as NSAIDs, are increasing in the postoperative period. There is limited data on the effect of NSAIDs on post-operative pancreatic fistula (POPF) following pancreas resection. Methods: The ACS NSQIP database was used to identify pancreas resections at Ohio State Medical Center between 2013 and 2017. Demographic and outcome data from NSQIP was combined with chart review for type of NSAID, dosage, and timing within the first 30 days. POPF was defined as a drain amylase >300 U/L on postoperative day 3 or later, or a “yes” value in the postoperative pancreatic fistula variable of NSQIP. A clinically relevant POPF (CR-POPF) was defined as a POPF in addition to percutaneous drainage, reoperation, drain in place >21 days, a hospital length of stay ≥14 days, organ/space surgical site infection, postoperative percutaneous drain placement, sepsis, shock, or single or multisystem organ failure. Univariate and multivariate logistic regression was used to identify predictors of POPF. Results: Three hundred ninety five patients were identified, 266 undergoing pancreaticoduodenectomy (PD) and 129 distal pancreatectomy (DP). For patients undergoing PD- BMI, pancreatic duct diameter, and pancreatic gland texture were significant predictors of development of any POPF by univariate analysis. For DP, pancreatic gland texture was the only significant predictor by univariate analysis for any POPF. On multivariate analysis, pancreatic gland texture and pancreatic duct diameter were significant predictors of any POPF following PD. When examining CR-POPF following PD, pancreatic gland texture, duct diameter, and BMI were significant predictors. (Figure) There was no significant association between NSAID use (ketorolac, aspirin, or ibuprofen) or NSAID timing (administration within POD5 vs. POD30) on development of POPF. On univariate analysis, there was a significant relationship between aspirin administration within postoperative day 30 and development of any NSQIP complication for both PD and DP. Conclusion: There is no significant association between NSAID use and development of any post-operative or clinically relevant pancreatic fistula for patients undergoing pancreas resection. This is important as the use of NSAIDS may rise with the implantation of ERAS protocols across the country.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 95. VARIATION IN PERIOPERATIVE OUTCOMES AMONG HIGH VOLUME HOSPITALS ME Smith, U Nuliyalu, JB Dimick, H Nathan Presenter: Margaret Smith MD, MS | University of Michigan Background: Minimum volume standards for complex surgery have been advocated as a means to reduce surgical mortality. However, surgical volume correlates poorly with occurrence of complications. Serious complications having significant repercussions for patients even if they do not result in mortality. As such, volume-based referral alone may be insufficient to ensure high-quality care. We sought to assess variation in perioperative outcomes and spending among high-volume hospitals for pancreas and liver resection. Methods: We identified patients age >65 undergoing pancreatectomy and liver resection in 2012-2014 Medicare claims data. Hospital volume was established from all-payer claims. Based on the 2018 Leapfrog Group pancreatectomy volume standards, high-volume hospitals (HVHs) were defined as hospitals performing an average of >20 operations per year. The same volume threshold was used to define HVHs for liver resection. Postoperative outcomes following elective procedures were ascertained from inpatient and outpatient Medicare claims. Adjusted hospital rates of serious complications and mortality were assessed using a hierarchical logistic regression model. Price-standardized, risk-adjusted Medicare payments were calculated for the entire surgical episode from index admission through 30 days after discharge. HVHs were stratified into quintiles of serious complications, mortality, and episode spending to assess variation. Results: One quarter of hospitals performing pancreatectomy and liver resection were HVHs (pancreas n=289 (28%); liver n=234 (23%)). Despite the low proportion of HVHs, over 80% of patients undergoing elective operations received care at a HVH (pancreatectomy 85% and liver resection 81%). As expected, high-volume pancreatectomy hospitals had lower mortality rates than low-volume hospitals (LVHs) (3.8% vs 3.5%; p<0.001). For liver resection, HVHs and LVHs had no significant difference in mortality (3.74% vs 3.72%; p=0.15). Among only HVHs, significant variation in serious complications and surgical episode spending was present. Pancreatectomy serious complication rates ranged from 6.9% in the lowest complication quintile of HVHs to 17.0% in the highest quintile. Comparable variation was present among liver resection HVHs where serious complication rates ranged from 8.3% to 16.9% among HVH quintiles (all p<0.001) (Figure). Substantial variation in serious complications among pancreatectomy and liver resection HVHs remained after accounting for individual hospital volume. Surgical episode spending also significantly varied among HVHs with the highest quintile spending $13,000 more than the lowest quintile ($37,123 vs. $24,172; p<0.001) for pancreatectomy and $10,500 for liver resection ($32,872 vs. $22,325; p<0.001). Notably, the bottom 40% of pancreatectomy and liver resection HVHs for serious complications and spending had worse outcomes than the average LVH. For example, pancreatectomy serious complications in the lowest two HVH quintiles were 12.7% and 17.0%, compared to a serious complication rate of 11.8% in LVHs. Conclusion: Significant variation in perioperative outcomes exist among high-volume hospitals with a large proportion of high-volume hospitals having higher rates of serious complications and surgical episode spending than the average low-volume hospital. Given a strong volume-mortality relationship for many complex operations, avoiding low-volume surgery is necessary to reduce perioperative mortality. However, referral strategies based solely on volume may be insufficient given the substantial variation in perioperative outcomes among high-volume centers. Future efforts to identify high-quality centers for complex operations should incorporate hospital volume as well as perioperative outcomes to optimize surgical care and value.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 96. EFFECT OF REGIONAL LYMPHADENECTOMY AFTER NEOADJUVANT CHEMOTHERAPY ON SURVIVAL OUTCOMES IN PANCREATIC CANCER FI Macedo, SH Cass, K Kelly, CJ Allen, D Yakoub, V Dudeja, AS Livingstone, D Franceschi, NB Merchant Presenter: Francisco Igor Macedo MD | University of Miami Miller School of Medicine Background: Neoadjuvant chemotherapy (NAC) has been advocated to enhance the outcomes of patients with resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC), however its benefits are yet unknown. We sought to assess the role of lymph node (LN) dissection and staging in outcomes of patients with resected PDAC who underwent NAC. Methods: National Cancer Database (NCDB) was queried for patients with stage I-III PDAC diagnosed from 2004 to 2014. Actuarial estimates for overall survival (OS) were calculated using Kaplan-Meier methods. Cox proportional hazards models were performed to evaluate associations of number of positive nodes (NPN), total number of LN examined (TNE), and lymph node ratio (LNR) with OS. Results: Of 35,599 patients with PDAC, 3,395 (9%) underwent NAC, 19,865 (56%) received AC and 12,299 (35%) had surgery alone. Cox regression showed superior OS in NAC compared to AC and surgery alone (26 vs. 23 vs. 14 months, p< 0.001). Of NAC patients, OS was significantly higher in N0 than N1 (29.4 vs. 22.6 months, p< 0.001). LNR > 0.2 had worse prognosis than those with LNR < 0.2 (median OS 19.4 vs. 24.4 months, p < 0.001). Minimum TNE affecting OS after NAC was 8 LNs (23.8 vs. 26.6 months, p=0.029), whereas minimum TNE in patients undergoing AC was 12 LNs (22 vs. 23.1 months, p=0.028). Conclusion: LN yield (TNE, NPN, and LNR) remains a significant prognostic factor in patients with PDAC who undergo NAC. NAC is associated with improved local control and OS compared with patients undergoing surgery upfront. The minimum number of harvested LNs associated with sufficient staging and survival is decreased after NAC.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 97. SUCCESSFUL USE OF SALVAGE PORTAL VEIN STENT IN ACUTE PORTAL VEIN THROMBOSIS S Maithel, NK Kabutey, RM Fujitani, D Fernando, K Nelson, B Sheehan, B Gambhir, DK Imagawa Presenter: Shelley Maithel MD | University of California, Irvine Background: Acute portal vein (PV) thrombosis associated with pancreatic surgery is a rare complication associated with potential catastrophic consequences. PV stenting is an option typically provided in cases of longstanding malignant PV stenosis and chronic thrombosis. We review the utility and outcomes of salvage PV stent use in acute PV thrombosis in two patients following pancreatic surgery Methods: 60-year-old female with pancreatic adenocarcinoma invasion into the porta hepatis underwent NanoKnife ablation. She developed immediate intraoperative bowel engorgement attributed to PV thrombosis. Open venorrhaphy and embolectomy could not be performed due to PV stenosis from the encroaching tumor. Successful intraoperative salvage PV stent (Bard LifeStent 4cmx8mm) was deployed using direct needle access of the PV. 65-year-old male with pancreatic adenocarcinoma invasion into the PV necessitating resection of the PV with primary repair developed large volume ascites on post-operative day 3. CT scan demonstrated thickened bowel with mesenteric edema with near occlusion of the PV on duplex ultrasound. Transhepatic PV thrombectomy and stent placement (Cordis S.M.A.R.T.-Flex stent 8cmx12mm) was performed successfully. Results: Both patients had recanalization of portal vein flow in the perioperative period with resolution of signs of portal hypertension. Follow up CT scans demonstrated patent PV stent at 2 months in our first patient, who died at 6 months due to progression of cancer, and at 1 year in our second patient, who continues to do well clinically. Conclusion: PV stenting is an adjunctive salvage maneuver in acute PV thrombosis in patients undergoing pancreatic tumor resection.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 98. UTILIZATION OF DEHYDRATED HUMAN AMNION/CHORION MEMBRANE (DHACM) FOR PANCREATIC ANASTOMOSIS DURING PANCREATICODUODENECTOMY KT Watkins Presenter: Kevin Watkins MD | Cancer Treatment Centers of America - Atlanta Background: With changes in care for patients undergoing pancreaticoduodenectomy there has been significant improvements in surgical outcomes. The main driver of morbidity continues to be pancreatic anastomotic leaks. Recent evidence shows improvements in intra-thoracic esophageal anastomotic leaks utilizing dehydrated human amnion/chorion membrane (dHACM) reinforcement of the anastomosis. Since that information became available dHACM has been used to reinforce the pancreatic anastomosis at our institution. The purpose of this study was to evaluate if the use of dHACM showed similar improvements in pancreatic anastomotic leak. Methods: A retrospective chart review was performed on all patients undergoing pancreaticoduodenectomy with a pancreatic anastomosis from August 2013 through August 2018. Charts were reviewed for operative details and postoperative outcomes. Comparison was made between 55 patients without use of dHACM (Control) and 8 with dHACM. Results: All grade pancreatic leak occurred in 12.7% of the entire group. The overall incidence of grade B/C leak was 9.5%. There was no difference in all grade leaks between the Control and dHACM (12.7% vs. 12.5%). However, there was a statistically significant difference in grade B/C leak between the control and dHACM (10.9% vs. 0%, p<0.01). There was only one leak in the dHACM group which only required maintaining the operative drain for 15 days. Conclusion: It is difficult to draw any definitive conclusion since there are already recognized factors that influence pancreatic anastomotic leak that cannot be adequately controlled for in this small sample size. Further investigation is warranted to see if dHACM is effective at helping to prevent the more catastrophic pancreatic anastomotic leaks.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 99. INTRODUCTION OF LAPAROSCOPIC HEMIHEPATECTOMY AND EVALUATION OF THE SHORT-TERM OUTCOMES K Hayashi, S Yamada, H Kusanagi Presenter: Ken Hayashi MD, PhD | Kameda Medial Center Background: Ever since laparoscopic hemihepatectomy began to be covered by the national health insurance system in Japan in April 2016, we have performed it regularly at our department. On the basis of the short-term outcomes, we evaluated the safety and efficacy of this procedure. Methods: A total of 17 patients who underwent laparoscopic hemihepatectomy at our department between April 2016 and September 2018 (L Group) were included in the study, and the perioperative outcomes of these subjects were compared with those of 25 patients who underwent hemihepatectomy by open surgery between April 2011 and March 2016 (O Group). Results: The background characteristics of the patients were as follows (L Group vs. O Group): age (70 vs. 67 years), gender (male/female ratio, 11/6 vs. 16/9), BMI (22.7 vs. 23.41), ASA-PS (1,2/3 ratio, 13/4 vs. 18/7), ICGR15 (10.3 vs. 7.7%), and diagnosis (HCC/others, 7/10 vs. 11/14), with no significant differences between the two groups. Among the perioperative factors, there was no significant difference in the type of surgery performed between the two groups (right/left 11/6 vs. 13/12); however, the operative duration was shorter in the O group than in the L Group (436 vs. 346 minutes, P = 0.021), and the blood loss was lower in the L Group than in the O group (310 vs. 610 g, P = 0.007). There was also no significant difference in the postoperative complication rate (C-D Grade 1/Grade 2 or higher, 15/2 vs. 18/7) or duration of hospitalization (9 vs. 11 days) between the two groups. Conclusion: Laparoscopic hemihepatectomy tends to take a longer time as compared to open surgery, but is associated with significantly less bleeding. On the other hand, the rate of complications and other factors were similar between the open surgery and laparoscopic surgery groups, indicating that laparoscopic surgery can be performed safely.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 101. SURVIVAL IN PANCREATIC CANCER: A RETROSPECTIVE COHORT STUDY IN A LATIN AMERICAN POPULATION JA Ramirez, LM Barrera, FA Vergara, MF Duque, MA Ortiz Presenter: Jaime Ramirez MD | IPS Universidad de Antioquia, Clinica Leon XIII Background: Pancreatic cancer is the fourth leading cause of death among all types of cancer. The prognosis of patients with this type of cancer is very poor, with a 5-year survival rate of only 6%. Only 10%-20% of the patients with pancreatic cancer could be candidates for surgical resection which is the only curative therapy. The incidence of pancreatic cancer varies across different regions with higher incidence rates in Northern America (7.4 per 100 000) . In the Latin American population there is not much information available about the incidence and survival rate of this disease. Methods: A retrospective cohort study from March 2011 to June 2018 of patients diagnosed with pancreatic cancer while under the care of HPB diseases and transplants of the IPS Universitaria, Leon XIII Clinic in Medellin-Colombia.We made a comparison of the patients who received surgery with curative intent with those who received palliative treatment We first analyzed the clinicopathological characteristics of the 203 patients. We then assessed the prognostic factors and survival rates using Kaplan-Meir curves. The Cox-Hazard model was used for the multivariate analysis, and P values less than 0.05 were considered significant. Results: The 203 patients consisted of 79 males and 129 females mean age 66 ± 12.5 years at the time of the diagnosis (Table 1). Median and interquartile range of tumor marker concentrations were arcinoembryonic antigen (CEA) 4 (2 - 9) ng/mL, carbohydrate antigen 19-9 (CA19-9) 179 (29 - 4715) U/mL. There were a few patients who didn’t undergo examination of tumor marker, and their data of tumor markers were missing. The union for International Cancer Control (UICC) pathological stage was ⅠA in 3 patients (2.4%); Ⅰ B in 16 patients (12.9%); ⅡA in 11 patients (8.8%); ⅡB in 10 patients (8.06%); Ⅲ in 19 patients (15.3%) and Ⅳ in 64 patients (52.4%).Of the 43 patients who received surgical treatment, 13 had lymph node metastases, 30 had R0 resection, 13 R1 resection, 40 Whipple procedure and 3 distal pancreatectomy. The median overall survival was 241 days, and the median survival was 250 days for palliative treatment and 1000 days for surgical treatment. Table 2 shows the results of from the multivariate analysis. Age>65 (HR= 1.02; 95%CI: 1.002-1.046) and surgical treatment (HR = 0.39; 95%CI: 0.20-0.72) were the only independent prognostic factors. Conclusion: Pancreatic cancer is an aggressive disease with high mortality rates.Only a small proportion of patients become treated with surgery with curative intent. The behavior of this desease in this small Latin American population is very similar to that described in other populations. Age less than 65 years and surgical treatment are favorable prognostic factors in achieving long-term survival.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

Table 1. Clinicalpathological Characteristics of all patients

Variables Value (n=203) Age, mean +/- SD 66.52 +/- 12.17 Gender Male 79 Female 124 Tumor Marker (IQR) CEA (ng/ml) 4 (2-9) CA19-9(U/ml) 179 (19 - 4715) Operative procedures n Pancreaticoduodenectomy 40 Distal pancreatectomy 3 UICC T clasification, n T1 4 T2 24 T3 25 T4 72 Surgical margin status, n R0 30 R1 13 Lynph node metastasis, n Si 13 No 30 Portal ivasion, n Si 97 No 106 UICC stage, n IA 3 IB 16 IIA 11 IIB 10 III 19 IV 65

Table 2. Multivariate analysis of factor prognostic for survival

Variables HR 95% CI Age >65 1.02 1.002-1.046 Ca 19-9>200 1.56 0.96-2.55 Surgical treatment 0.39 0.20-0.72 Tumor size >2 2.01 0.73-5.53

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 102. ACUTE LIVER FAILURE DUE TO TORSION AND INFARCTION OF ACCESSORY LIVER LOBE IN A YOUNG MAN CE Cornejo, LS Saavedra, OG Salinas, VH Medina, RJ Ricse, PF Dongo Presenter: Consuelo Elsa Cornejo Carrasco MD | Clinica San Pablo Background: An accessory liver is a rare anomaly and in most cases, it is an incidental finding at laparotomy, but we diagnosed it before surgery. It can cause serious complications such as acute abdominal pain and impaired liver function that can lead to acute liver failure. Methods: Male patient of 16 years old with history of omphalocele and cryptorchidism surgery. He entered in the Emergency Room after that 2 days of acute abdominal pain in the flank and right iliac fossa, abdominal distension, vomiting and progressive jaundice. On admission, he had tachycardia of 110 X', bradypsychic, jaundice, painful palpable mass in mesogastrium, flank and right iliac fossa and mild abdominal distension. Laboratory tests were: creatinine 1.47 mg/dL, ALT 6060 U/L, AST 6540 U/L, total bilirubin 8.8, alkaline phosphatase 517 U/L, GGT 104 U/L, albumin 3.6 g/dL, Hb: 12.2 g / dL, white blood cell count of 20.1 K / uL, platelets 90,000, lactate 3.4 mmol / L, INR 2.67 S/U, DHL: 5731 U/L; so he was transferred to the Intensive Care Unit. Results: The next day the platelets decreased to 69 000, the bilirubin increased to 15.1, oliguria, tachycardia of 130 X ', tachypnea, desaturation and somnolency. Abdominal doppler ultrasound found normal-sized liver has continuity with an intraabdominal mesogastrium mass with similar echogenicity, without presence of vascularity to probable thrombosis, portal vein without flow and moderate ascites. Tomography showed ascites, a liver with diminished of its volume with ischemic areas in lower segments, associated with voluminous solid mass intraabdominal of 16 x 10 x 18 cm occupying the right flank with hypoperfusion, which corresponds to the large accessory hepatic lobe twisted and dependent on the hepatic hilum. Urgent laparotomy was undertaken because of a sudden worsening of liver, renal and respiratory function and the findings in the images described, with the preoperative diagnosis of ischemic liver failure due to liver lobe torsion. Laparotomy revealed free turbid serohematic fluid in the peritoneal cavity (2 litres), main liver with slightly violet colour and a accessory lobe twisted was completely infarcted with and gangrenous gallbladder; this accessory lobe, corresponding to a right hepatic lobe isolated with own mesentery and vasculature, this pedicle was connected to the hepatic hilum and also cause its torsion and decrease its vascular supply to the main liver that when the twisted pedicle is devolved the vascular flow of the main liver is returned. Resections of the necrotic accessory liver, cholangiography reconstruction bile duct (hepatic-jejunoanastomosis in Y of Roux) were performed. Histological examination showed a diffuse hemorrhagic infarction of the liver parenchyma. The patient had a favourable evolution, with normalization of hepatic, haematological and renal function. Until the fifth month of follow-up, he didn´t present any complication. Conclusion: The torsion of the accessory lobe of the liver is a rare finding but may cause severe problems and should therefore be kept in mind when patients present acute abdominal pain and impaired liver function, as well as medical history of omphalocele surgery. So, with the help of an ultrasound and a tomography, it can be diagnosed in the pre-operative. The recommended treatment is the resection of accessory liver lobe.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 103. MANEJO PERCUTÁNEO DE LAS ESTENOSIS DE LAS ANASTOMOSIS BILIODIGESTIVAS G Parquet, RI Sánchez, ML Sánchez, FJ Heiberger Presenter: Guido Parquet MD | Instituto de Previsión Social Background: Previous to percutaneous intervention, biliodigestive anastomosis stricture (BDS) was treated with surgical re-anastomosis, with a rates of re-stenosis of 10 to 30%, with the corresponding difficulties. There are treatment options for BDS such as endoscopy, and transhepatic percutaneous balloon dilation. The endoscopic procedures are difficult, inaccessible after iRoux-en-Y bilioenteroanastomosis. The first report of the percutaneous treatment by BDS was in 1978 by Molnar and Stockum, the first large series was reported by Nueller et al., In 1986. We report the result in 24 patients treated percutaneously, analyzing technical aspects Methods: This is cross sectional, retrospective study, of patients with bilio-digestive anastomosis, with symptoms of biliary obstruction due to its stenosis, studied during the period from June of 008 to April of 2016, in the Service of Minimally Invasive Surgery - Hospital Central, IPS, and Private practice managed by the same medical team. Patients with malignant stenoses and with a history of primary sclerosed cholangitis were excluded. The technique used was: 1- Drainage of the exclusive bile duct, guided by fluoroscopy to determine conduct 2- Drainage + 1 to 8 sessions of balloon dilation every 3 weeks. Results: 15 female patients (62.5%) and 9 males (37.5%), average age 49.6 years. Out of a total of 23 patients, 12 had IBDI, 7 (29%) after LC, and 5 (21%) with open cholecystectomy; 3 patients with pancreatic cancer, 1 (4%) Hepatic-jejunal anastomosis, 2 (8%) DPC; 2 (8%) Cholangiocarcinomas, 1 (4%) after trauma, 1 (4%) resection of colecoccal cyst, and 5 (21%) unknown causes.It was performed, only drainage in 3 patients (12%), drainage + dilatation in 20 pctes (80%). Morbidity 10 patiens, output of the catheter 4 patiens. (17%), Fever 3 patiens. (13%), Hemobilia 2 patiens. (8%), jejunal fistula 1 patien. (4 %). They presented calculations 5 patients (21%). Mortality 0%. Conclusion: Percutaneous balloon dilation of biliodigestive stenoses is an effective alternative with small morbidity and mortality. The results are worse in patients with a neoplastic history. Biliary drainage with dilation appears as the best option for exclusive drainage. The multidisciplinary management (endoscopist, surgeon and percutaneous management) is fundamental for the success in the management of these complex patients

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 104. HEPATIC INTRAVASCULAR DIFFUSE LARGE B-CELL LYMPHOMA WITH SYNCHRONOUS METASTATIC COLORECTAL ADENOCARCINOMA FS Elgammal, H Wei, G Grimberg, R Tilani, T Proverbs-Singh, DA McCain Presenter: Fatima Elgammal MD | Rutgers University Background: Hepatic intravascular large B-cell hepatic lymphoma (IVLBCL) is a rare extra-nodal non-Hodgkin malignancy, characterized by the proliferation of clonal lymphocytes within microvasculature. The incidence of IVLBCL is less than 0.0001%, with tumor cells found in a variety of visceral organs. The presentation of IVLBCL is non-specific, and manifests in one of two variants classified by organ involvement and syndromic presentation. We present a patient with a pathologically confirmed diffuse large B-cell lymphoma of the liver with concurrent metastatic disease from a primary colorectal adenocarcinoma. Methods: A 79-year-old diabetic man, former smoker with extensive cardiac history, who presented with iron deficiency anemia, underwent a colonoscopy, revealing an ascending colonic mass, the biopsy of which and subsequent right colectomy revealed moderately differentiated invasive colonic adenocarcinoma. PET demonstrated a presumably oligometastatic disease of the liver. The methods we describe include preoperative evaluation with hematologic studies, tumor markers, staging imaging with a PET, details of the robot-assisted laparoscopic hepatectomy, and pathologic analysis for adjuvant chemotherapy. Results: The pathology of the patient’s index right colectomy was significant for pT3N0M1 tumor measuring 4 cm. PET revealed a focal area of metastatic disease in the left hepatic lobe, warranting a metastectomy, however intraoperative evaluation revealed multiple hepatic lesions, necessitating left hepatectomy. Pathology of the resected liver was significant for an intravascular diffuse large B-cell lymphoma co-expressing BCL2 and c-MYC, with non-double-hit FISH, Ki > 95%, and normal p53. Histology additionally revealed concurrent metastatic colon adenocarcinoma. The patient is receiving adjuvant chemotherapy with R-CHOP with VCR, and at the time of third cycle of adjuvant therapy, is alive and well, only complaining of occasional fatigue. Conclusion: While non-Hodgkin lymphoma is a common malignancy, IVLBCL is a rare form of extranodal lymphoma. Preoperative diagnosis is difficult, with resultant delay in diagnosis, due to non-specific symptomatology, biochemical markers, and imaging. Despite poor prognosis, patients with confirmed IVLBCL diagnosis should be started on adjuvant chemotherapy with CHOP-based agents.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 105. PRIMARY PANCREATIC PARAGANGLIOMA; CASE REPORT AND LITERATURE REVIEW SJ Fruchter Presenter: Shani Fruchter DO | Florida Hospital Background: Paragangliomas represent a rare tumor comprised of neuroendocrine cells with only 21 reported cases of primary pancreatic paraganlioma found in the English language literature. We present a case of primary pancreatic paraganglioma and a literature review. Methods: Our patient is a 74 year old lady with a 2.5 x 2.2 x 1.9 cm pancreatic head mass found on computed tomography during an evaluation for frequent diarrhea. She underwent an endoscopic ultrasound with fine needle aspiration which indicated a low grade neuroendocrine tumor. Chromogranin A was 80. The day prior to her scheduled surgery, she suffered a transient ischemic attack with no residual symptoms. Surgery was delayed three months. We were then able to perform an enucleation of the tumor with immunohistochemical examination showing the tumor cells positive for synaptophysin and negative for cytokeratin AE 1/3 immunostains, confirming the diagnosis of pancreratic paraganglioma. Results: Twenty one cases found representing 16 females and 5 males, ranging in age from 19 to 74 with a median age of 55 years. Only two out of 19 cases were found to be malignant and all but one patient was treated with surgery. One patient was found to have a functional tumor and became unstable during surgery. He was subsequently treated with chemotherapy. Conclusion: Primary pancreatic paragangliomas are an extremely rare pathology, with the diagnosis confirmed with histopathological and immunohistochemical examination. Primary treatment is surgical excision. We conclude that enucleation rather than radical excision should be attempted when feasible.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 106. PANCREATICODUODENECTOMY IN A PATIENT WITH JEJUNOILEAL BYPASS NM Handy, L Harmon, FG Rocha Presenter: Nicketti Handy MD | Virginia Mason Medical Center Background: A 77yo F with a history of a remote jejunoileal bypass (JIB) for morbid obesity presented with obstructive jaundice, diarrhea and weight loss. Abdominal and pelvic CT showed biliary dilation and a poorly defined mass in the distal bile duct without evidence of metastatic disease as well as several loops of atretic small bowel consistent with JIB. Endoscopy with ERCP revealed a stricture of the common bile duct which was stented and brushings were consistent with adenocarcinoma. On exploration, a dilated proximal jejunum was found anastomosed end to side to the terminal ileum. Following an uncomplicated resection, the pancreatic remnant and common hepatic duct were anastomosed to the dilated, functional jejunal limb. Reversal of JIB and conversion to biliopancreatic diversion were considered. Instead, a duodenojejunostomy was constructed to the previously defunctionalized intestine and a jejunojejunostomy was constructed between the pancreatobiliary limb and the alimentary limb. (See Figure) Final pathology revealed a T3N0 poorly-differentiated adenocarcinoma of the bile duct. Postoperative recovery was prolonged requiring supplemental tube feeding for one month but the patient was eventually nutritionally intact on oral intake alone. Upper gastrointestinal series demonstrated patency of the jejunojejunostomy with anterograde flow through both limbs as well as reflux into the proximal atretic ileum. Resection of pancreatobiliary malignancy following bariatric surgery can be challenging due to restricted reconstruction options. This is particularly true after JIB where most of the functional jejunum is not suitable for an anastomosis. To our knowledge, this is the first description of a successful pancreaticoduodenectomy in a patient with an intact JIB.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 107. TREATMENT OF GIANT ADENOMA THROUGH A CENTRAL HEPATECTOMY APPROACH KT Nguyen, M Sinkler Presenter: Margaret Sinkler | Medical College of Georgia Background: Hepatic adenomas (HA) are benign liver masses with a yearly incidence of 1-4 per 100,000 adults. We present a 22 year old female with a 9 year history of contraceptive use presented asymptomatically with a giant (14.2 x 11.4 cm) HA. HAs are surgically treated once they exceed 5 cm in diameter to prevent hemorrhage or malignant transformation. An MRI identified a giant, centrally located liver mass stretching the inferior vena cava, hepatic veins, and portal vein. Due to the size and location of the mass, the tumor was initially inoperable. Methods: The patient underwent an trans-arterial embolization (TAE) , which has been shown in select cases to reduce the size of HAs. The TAE resulted in a successful reduction of the HA to 10.6 x 5.5 cm with a core of central necrosis. A second embolization was performed to attempt to further shrink the mass but was not successful in producing further significant change. Results: The HA measured 7.7 x 8.3 x 8.2 cm prior to surgery. The location of the patient’s mass meant traditional anatomic hepatic resections, including a right extended hepatectomy, were not an option as it would remove significant normal liver parenchyma. To achieve the complete removal of the large centrally located tumor, a central hepatectomy approach was performed. The resulting procedure was an open central liver resection with removal of segments I, IVA, V, and VIII. The operation was completed through a right subcostal incision with upper midline extension with the patient in supine position. The entire liver was mobilized in order to posteriorly free the mass from the IVC. Following the dissection off the IVC, the liver was divided right next to the right and middle hepatic veins before freeing the mass inferiorly from the portal plate. The right hepatic vein was skeletonized laterally and the middle hepatic vein was skeletonized medially. After careful dissection off the major hepatic vessels, the entire identified HA was completely freed. Ultrasound of the residual liver showed proper inflow and outflow. The patient followed up with a MRI one month after operation which showed mild operative related inflammation and no other complications. Conclusion: Due to the location of the presenting mass, a central hepatectomy approach was selected to remove the entirety of the mass and preserve the maximum functional liver tissue. The approach resulted in removal of the tumor and preservation of more functional tissue then the traditional hepatic resections. The traditional resection approaches would result in significant loss of functional liver mass. The central hepatectomy approach taken in this case limited the removal of functional liver tissue to approximately 25%. Overall, the case illustrates the consideration of TAE and a central hepatectomy approach with careful dissection of vascular and biliary structures to expand the range of initially inoperable giant, central hepatic tumors.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 108. AN UNUSUAL HEPATIC PSEUDOTUMOR DUE TO NODULAR ELASTOSIS OF THE LIVER MJ Minarich, M Yan, RE Schwarz Presenter: Michael Minarich MD | Goshen Center for Cancer Care Background: Standard evaluation of a liver mass includes dedicated hepatic imaging and appropriate tumor markers. After complete workup, strong clinical suspicion of a malignant process in a patient with resectable disease may make a preoperative biopsy unnecessary. Methods: We report the resection of a 3.1 cm mass in segment 5/6 whose appearance on preoperative imaging, along with a significantly elevated CA 19-9, was strongly suspected to represent an intrahepatic cholangiocarcinoma. The literature was reviewed to characterize similar cases. Results: A 73 year old female initially presented with complaints of bloating and abdominal distention. A CT of the abdomen and subsequent MR of the liver demonstrated a 3.1 x 2.7 cm minimally T1 hypointense, minimally T2 hyperintense mass which demonstrates mild arterial enhancement with increased enhancement on delayed phase imaging. Surrounding liver parenchyma was atrophied, c/w a local biliary obstructive process. Further preoperative workup included a serum CA 19-9 of 6966, CEA of 6.2, normal LFTs and AFP, and a normal colonoscopy. The diagnosis was most likely consistent with intrahepatic cholangiocarcinoma, and thus the patient underwent resection of segment 5/6 with cholecystectomy. Pathologic evaluation showed markedly increased fibrosis surrounding large and small branches of hepatic artery and portal vein with surrounding atrophic hepatocytes, inflammation, and bile duct proliferation consistent with segmental liver atrophy with nodular elastosis. No malignant component was identified within the mass. The patient recovered well and has been symptom-free for more than 2 years. Her postoperative CA 19-9 normalized to 31. Literature review confirmed this is a rare clinical entity, similarly presenting as a hepatic mass that may be confused on imaging with cholangiocarcinoma preoperatively. This is the first description including an elevated preoperative serum CA 19-9 that normalized after resection. Conclusion: Segmental liver atrophy with nodular elastosis is an atypical hepatic pseudotumor that can be confused preoperatively with malignancy, including cholangiocarcinoma based on preoperative imaging and biochemical testing. Since pathologic clarification likely requires analysis of the entire process, a resection will not be avoidable in most similar scenarios.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 109. ECTOPIC ACTH SYNDROME FROM A NEUROENDOCRINE TUMOR OF THE PANCREAS Y Lin, V Krishnan, M Debot, R Schulick, K Kiseljak-Vassiliades, M Del Chiaro Presenter: Vishnupriya Krishnan MS3 | University of Colorado Background: Ectopic ACTH syndrome is a potentially fatal clinical entity that results in excess cortisol production. Rarely, these syndromes originate from tumors in the pancreas. We discuss a case report of a patient with pancreatic ectopic ACTH syndrome who ultimately required surgical treatment of her disease. Methods: A 70 year-old female presented with rapid onset of insomnia, anxiety, weight loss, and proximal muscle weakness over 6 months. A thorough laboratory work up revealed ACTH-dependent hypercortisolism, with an ACTH level of 284. Imaging studies showed a negative pituitary MRI, and inferior petrosal sinus sampling was consistent with ectopic ACTH tumor. A CT of the chest, abdomen and pelvis performed at an outside hospital did not identify any potential culprit lesions. A DOTATE scan was unable to be completed initially due to insurance limitations. The patient was therefore initiated on medical therapy with Ketoconazole, pending further imaging. Following three days on medical therapy, the patient presented to our emergency department with malaise, hypotension, and hypoxia. She was admitted to the medical ICU and intubated for respiratory failure. A CT scan done to rule out a pulmonary embolism (PE) found no evidence of PE but a diagnosis of multifocal pneumonia. A review of her prior CT scan at the outside hospital revealed a lesion in the distal pancreas, suspected to be the source of ACTH producing tumor. She underwent endoscopic ultrasound with biopsy. Pathology results were suspicious for neuroendocrine tumor with faint staining of ACTH. Therefore, the decision was made to perform an open distal pancreatectomy and splenectomy. The procedure was done without any complications. This led to an immediate decrease in the patient’s ACTH level to 18, as well as an improvement in her clinical status. She did well post operatively and was discharged to home on post op day 9. Final pathology revealed a well-differentiated neuroendocrine tumor at 3.4 cm, with clean margins and no evidence of metastasis to the lymph nodes. Conclusion: We report on the clinical management of a pancreatic ACTH producing tumor. It is important to note that on first evaluation at the outside hospital, this mass was not identified as the source of the ACTH syndrome. This is likely due to the uncommon diagnosis of a pancreatic ACTH producing tumor. It is, therefore, important to consider pancreatic neuroendocrine tumor, as well as other uncommon locations as part of the differential diagnosis when evaluating patients with ectopic ACTH syndrome. Figure legend: CT abdomen reveals a solid mass in the pancreas (arrow) enhancing on arterial phase of CT.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 110. VICTORY BY A NARROW MARGIN – IS A HIGHER RATE OF R0 RESECTION ASSOCIATED WITH ROBOTIC WHIPPLE OPERATIONS? AN OBSERVATION IN ROBOTIC AND CONVERTED-TO-OPEN CASES R Borscheid, E Cho, F Lewis, H Osman, J Kurtz, DR Jeyarajah Presenter: Rene Borscheid MD | Methodist Richardson Medical Center Background: Robotic Whipple operations, like other minimally invasive approaches to pancreaticoduodenectomy (PD) have a lesser amount of blood loss, less postoperative pain, a faster recovery time and may decrease the time to adjuvant therapy. The risk of major complications and death are not elevated compared to open pancreaticoduodenectomy. In terms of lymph node retrieval and the rate of R0 resections, robotic PD is considered equivalent to open procedures in the current literature. Methods: We performed a retrospective chart review on patients undergoing robotic Whipple operations between 2/2014 and 5/2018 at the Methodist Dallas and Richardson hospitals. All patients considered for robotic procedures had preoperative imaging suggesting resectability without doubt. We obtained data relating to patient demographics, diagnosis, details of the operation, postoperative hospital course and histological data from the electronic medical record. Consent of the patients and IRB approval had been granted prior to chart review. Results are given as percentages of the total case numbers. Results: 61 patients underwent a robotically-assisted Whipple operation. The age range was from 24 to 87, 42.6% of the patients were female. 17 procedures were converted to open (27.9%). Blood loss was lower in the robotically completed patients (311.8 ml vs 838.2 ml) and their transfusion requirement was less (15.9% vs 41.2%). The average length of stay was more than 3 days higher in the converted group. Malignancy was the indication of the majority of cases and tumor size did not vary between the two groups (3.1 cm for robotically completed vs 2.8 cm for converted cases). The rate of positive margins (R1 resection) was higher in the converted group (36.1% vs 50%). Conclusion: All patients in our study had similar tumor characteristics, such as preoperative imaging suggesting resectability and a comparable average size of tumors; yet patients who underwent conversion-to-open had a higher rate of R1 resection than cases completed robotically. Although further studies are needed to delineate all possible causes for this observation, robotic Whipple surgery may offer a higher rate of margin clearance compared to open PD.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 111. ISOLATED INTRAHEPATIC MASS: WHO WOULD BIOPSY, WHO WOULD RESECT? MJ Minarich, M Yan, E Kio, RE Schwarz Presenter: Michael Minarich MD | Goshen Center for Cancer Care Background: For patients with symptomatic liver lesions, preoperative imaging characteristics and elevated tumor markers can sometimes obviate the need for preoperative biopsy in a patient that is otherwise resectable. We present a case where preoperative clinical evaluation was consistent with cholangiocarcinoma, but postoperative pathologic review revealed a rare, unconsidered tumor. Methods: We report a resection of a symptomatic 12 cm right-sided liver mass that on final pathology was found to be a small cell carcinoma of the liver, as well as the post operative treatment and 1 year post operative course. A literature review was conducted to categorize similar cases. Results: A 58 year old female presented initially to the hospital with complaints of right upper quadrant pain and was found on CT and subsequent MR imaging to have a 9.9 cm right hepatic mass that centrally was T2 hyperintense, T1 hypodense with a peripheral rim that demonstrated slight T2 hyperintense, T1 hypointense signaling. Synthetic liver function parameters, AFP and CA 19-9 were normal. Resection was offered without preoperative biopsy given its symptomatic nature and resectability. The patient underwent a R-0 open right hepatectomy. Pathology revealed a high-grade neuroendocrine carcinoma with high N/C ratio and positive immunohistochemical stains for neuroendocrine and epithelial markers, consistent with primary small cell carcinoma of the liver. Postoperatively, she recovered well and received etoposide and cisplatin for 6 months. Eleven months postoperatively she presented with a new metastatic pontine lesion that was treated with radiation therapy for improved symptoms. A literature review revealed that most patients previously described with small cell cancer of the liver were not candidates for operative resection due to poor underlying liver function or performance status. For those who underwent operative resection, intrahepatic recurrence was the most commonly described recurrence pattern. Conclusion: Small cell carcinoma of the liver is a rare malignancy, with few documented cases of the natural progression after R-0 resection. This appears to be the first description of a patient with R-0 resection and isolated intracranial recurrence.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 112. CASE REPORT OF HEMORRHAGIC SHOCK FROM SPONTANEOUS GALLBLADDER RUPTURE IN A PATIENT WITH ADVANCED LIVER DISEASE AWAITING LIVER TRANSPLANT H Aziz, SM Zielsdorf, J Emamaullee, LS Sher, Y Genyk Presenter: Hassan Aziz MD | Keck Hospital of USC Background: Rupture cholecystitis is a rare entity with high morbidity and mortality, especially in cirrhotic patients. Here, we presented a case report of perforated hemorrhagic cholecystitis in a patient with cirrhosis awaiting liver transplant. Results: A 60 yo male with a history of alcoholic cirrhosis was admitted from hepatology clinic for worsening encephalopathy. His past medical history was significant for hypothyroidism, recurrent ascites, chronic portal vein thrombosis, and spontaneous bacterial peritonitis. His management on the ward included diuretics, paracentesis and lactulose. On post-admission day 9, the patient was found to be hypotensive with a hemoglobin 4 g/dl. His abdomen was tense and distended. He was transferred to the ICU for resuscitation and evaluation. He required massive transfusion protocol and vasopressors. CT angiography of the abdomen revealed perforated cholecystitis with active extravasation from the cystic artery and large volume hemoperitoneum. His Na-MELD was 30. The decision was made to proceed with open cholecystectomy. The patient was optimized for surgery with renal replacement therapy and involvement of our liver transplant anesthesiologist. He was found to have a perforated, hemorrhagic cholecystitis with significant bleeding from the liver bed, which was controlled with suture and hemostatic agents. He stabilized post-operatively, but his Na-MELD worsened to 40. On post-operative day 7, he underwent a successful liver transplant. He subsequently had an unremarkable post-transplant course. Conclusion: Ruptured cholecystitis, though a rare entity, should be considered in the setting of hemorrhagic shock in patients with advanced liver disease. These patients benefit from urgent surgical intervention, and delay or missed diagnosis may result in death and adverse outcomes.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 113. A RARE CASE OF PANCREATIC CARCINOMA WITH OSTEOCLAST‐LIKE GIANT CELLS REPORTED IN A YOUNG FEMALE L Shi, K Grooms, J Clanton Presenter: Lindsay Shi DO | West Virginia University, Charleston Background: Undifferentiated carcinoma with osteoclast‐like giant cells of the pancreas is a rare diagnosis with few cases reported in the literature and many unanswered questions regarding treatment and prognosis. A case of this rare tumor in a young patient is presented and the literature surrounding this type of tumor is reviewed. Methods: A 34-year-old woman with a history of type 1 diabetes and nephrolithiasis presented with complaints of weakness, fatigue, and concern for recurrent UTI. A non-contrast CT scan was done which suggested a possible perinephric mass vs abscess, but follow-up MRI revealed a 5.5x5.1x4.7 cm mixed cystic and solid mass within the tail of the pancreas. On review, CT scan done one year prior for kidney stones demonstrated a present but much smaller mass in this location, which was not noted by the radiologist. Chest CT did not demonstrate any metastatic disease and all tumor markers including CA19-9 and CEA were normal. Results: She underwent laparoscopic distal pancreatectomy and splenectomy. Pathology revealed a mixed solid and cystic tumor with features of undifferentiated carcinoma as well as high grade spindle cell sarcoma and numerous osteoclast-like giant cells. The mass had two distinct staining patterns, with the epithelium of the cystic component positive for CK 7, CK 8/18, CEA, mucin, and pankeratin whereas the spindle and osteoclast-like giant cells were positive for vimentin, factor XIIIa, CD 68, and CD 163. All cells were negative for desmin, S-100, and CD 45. All resection margins were free of tumor and 18 peripancreatic lymph nodes were negative. The patient had an uneventful recovery, discharged on postoperative day 5 and is doing well 3 months out from surgery. Per patient request, the pathology was sent to several other institutions for further examination, and given a final diagnosis of undifferentiated carcinoma with osteoclast-like giant cells in a background of intraductal papillary mucinous neoplasm. The patient was seen by oncology and underwent a PET/CT scan which was negative. At this time she is currently receiving adjuvant chemotherapy with FOLFIRINOX. Conclusion: This case demonstrates a very rare form of pancreatic cancer comprising less than 1% of cases with many different subtypes. They occur most often in the body and tail of the pancreas and are most often large. This case is unique due to the young age (34) of the patient whereas previously reported cases occur in the later decades of life. Mean survival is typically fewer than five months although cases of long term survival are reported in particular histological subgroups. The role of chemotherapy and radiation are still relatively unknown but cis-platin, paclitaxel and gemcitabine have all been used with some success. Radiation has been attempted due to some success in giant cell tumors in bone also with some good results.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #4 P 114. PERCUTANEOUS DRAINAGE AND HYDATID CYST ALCOHOLIZATION A PREGNANT PATIENT G Parquet, A Gimenez, R Sanchez, ML Sanchez, F Heiberger, R Rojas Presenter: María Liz Sánchez MD | Hospital de Clínicas de Asunción Background: Hydatidosis is an endemic parasitosis, caused by Echinococcus, which usually affects the liver (50-70%) and the lung. The symptomatology is variable depending on the location and size of the cyst. The ultrasound detects 90-96% of the cysts. The absence of positive serology does not rule out the disease. The standard treatment is surgical and in recent decades new minimally invasive procedures such as percutaneous drainage and videolaparoscopy have emerged, with excellent results Methods: We present the case of a 16-year-old patient who was admitted with a liver hydatid cyst diagnosis + 1st trimester gestation, after receiving treatment with albendazole for 2 months. In the ultrasound, a cyst image of 12.4 x 9 mm in segment 6 of the liver is shown, rounded, with defined walls, heterogeneous, with septa, fine echoes and image that protrudes in the suggestive light of the daughter vesicle. A single gestation, topical, heartbeats + is observed, corresponding to 9 weeks. Percutaneous drainage of the cyst was performed with a 8.5 Fr multipurpose catheter, using the Seldinger technique. Results: At the placement of the catheter it drains 1000cc of dark liquid + 700cc in later days. 20cc of absolute alcohol was instilled on the 11th day of the drainage and 10cc on the 18th day. The control ultrasound showed a decrease of 3.5 cm in diameter after the 1st alcoholization, no longer a cystic cavity was observed after the 2nd, so who is discharged without a catheter. Percutaneous drainage with aspiration of the content and instillation of scolicide agents has proven to be a technique, with little invasiveness, with excellent results in patients in whom surgery is not possible or at high risk. Absolute alcohol is the sclerotherapy agent against the wall of the hydatid cyst. Conclusion: This patient has shown that percutaneous drainage is a feasible alternative to surgery, even in large cysts, and in patients with surgical contraindication, with low risk of complications

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 115. PREVALENCE OF ACUTE PANCREATITIS AMONG CANNABIS USERS: REVIEW OF THE NATIONAL INPATIENT SAMPLE DATABASE I Enofe, O Igenoza, O Osaghae, M Rai, A Aluko, H Laird-Fick Presenter: Oluwatosin Igenoza MBChB, MPH | University of Texas Southwestern Medical Center Background: Cannabinoid, a derivative of cannabis, is purported to have health benefits. With the recent push to decriminalize recreational marijuana, its actual risks and benefits remain largely unknown. Our aim is to explore the correlation between cannabis use and hospitalization for acute pancreatitis. Methods: We used data from the National Inpatient Sample to identify patients admitted to the hospital in 2014. We identified users of cannabis and categorized them as dependent or non-dependent. Primary outcome was prevalence of acute pancreatitis in cannabis users. Inpatient mortality and length of stay was assessed using multivariable analysis. Other risk factors for acute pancreatitis including alcohol use, gallstones, gall bladder disease, viral, fungal and bacterial infections, and congenital abnormality of the pancreas were adjusted for using multivariable analysis. Results: Of the 7,071,762 patients included, 98.42 % (6,960,328) were non-cannabis users and 1.58% (n=111434) cannabis users. Amongst cannabis users, 89.05 % (n = 99,233) were classified as non-dependent users and 10.94% (12,2201) were dependent users. 1.22% (n = 86856) of total discharges had a diagnosis of acute pancreatitis, while 98.77% (n = 6,984,906) did not. Overall, cannabis users were 23 % less likely (AOR 0.77, CI 0.73 -0.81) to have a diagnosis of acute pancreatitis compared to non-cannabis users. A greater reduction in odds was observed amongst dependent cannabis users suggesting a dose dependent response to cannabis use. Dependent users were 66% less likely (AOR 0.34, 95% CI 0.27 – 0.43) and non-dependent users were 18 % less likely (AOR 0.82, 95% CI 0.78 – 0.86) to have pancreatitis compared to non-cannabis users. Ingroup comparison to examine dose related response showed that dependent users were 58% less likely (AOR 0.42, 95% CI 0.33 - 0.53) to develop acute pancreatitis compared to non-dependent users. Overall, gallstones (AOR 18.33.74, CI 17.91-18.76), anomaly of the pancreas (AOR 12.62, CI 10.51-15.14.77), alcohol (AOR 4.61 CI 4.48-4.74), hypercalcemia (AOR 1.81, CI 1.67-1.96), and tobacco (AOR 1.26, CI 1.23 - 1.28) were associated with higher prevalence of acute pancreatitis. Conclusion: Cannabis users have lower odds of hospitalization for acute pancreatitis after controlling for alcohol and tobacco use. The reasons for this are unclear. Cannabis use might moderate the amount of alcohol consumed. Previous analysis by Subbaraman and Kerr found that adults who simultaneously used both substances had a higher average daily number of drinks. Alternatively, marijuana use may alter health-seeking behavior. Finally, cannabinoid may have biological effects that reduce the occurrence of pancreatitis. Endocannabionoid receptors have been identified in exocrine and endocrine pancreatic cells, supporting this hypothesis. Further translational studies are needed to explore their function and potential relationship to acute pancreatitis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 116. SURGEON-DIRECTED HPB ULTRASOUND: CLINICAL PRACTICE, CERTIFICATION, AND BEYOND EJ Hagopian, RB Adams, J Machi Presenter: Ellen Hagopian MD | Hackensack University Medical Center Background: Ultrasound (US) in hepato-pancreato-biliary (HPB) surgery is inarguably an indispensable tool. In 2012, HPB ultrasound training was established through the Americas Hepato-Pancreato-Biliary Association (AHPBA). At the AHPBA annual meetings, a formal day-long post-graduate HPB US course has been offered to up to 30 practicing surgeons and surgical trainees. The purpose of this work was to identify why and how North American surgeons’ use of US has changed since the completion of the AHPBA HPB US course, while identifying challenges encountered to incorporate US into practice. Methods: To explore surgeon’s practices, experiences, and perceptions of the use of operative ultrasound, a qualitative research design was chosen using a survey method of open-ended questions. An anonymous on-line survey was sent to the previous participants of the AHPBA HPB US course to collect responses to questions in addition to surgeon demographics. Survey responses were collected between August and September 2018. Qualitative data were analyzed from the responses received from the North American (United States and Canada) practicing surgeons, using a grounded theory approach. A content analysis was conducted to identify common themes and sub-themes. Summary and descriptive statistics were applied. Results: Between 2010 and 2018, a total of 69 surgeons from the United States (91.3%) and Canada (8.7%) took the HPB US course. Fifteen (15) of the 69 surgeons (21.7%) returned the on-line survey. The area of clinical specialty of the respondents included transplantation (26.7%), surgical oncology (40%), HPB (20%), and general surgery (13.3%). Two dominant themes were identified regarding the surgeons’ motivations to take the HPB US course, which included issues related to training/experience (77.4%) and issues related to US certification (16.1%). Most surgeons (80%) reported a change in their practice as a result of the HPB US course, including an improvement in knowledge or skills (64.3%) and/or a change in the use of ultrasound (35.7%). Most surgeons (80%) also reported challenges in incorporating US into practice. The most common theme was issues related to US system (73.3%), and sub-themes reflecting cost issues were dominant (64%). (Figure) Conclusion: Costs of the US system are among the most important challenges to incorporating US into an HPB surgical practice. Importantly, this study has found that although HPB surgeons are motivated to seek US training to enhance knowledge and skills in US, they are also interested in obtaining certification in surgical US, a finding which has not been previously reported. A certification process in HPB surgical US is currently under development, which will be a step forward as there is a clear desire for US certification on the behalf of the HPB surgical community.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 117. TREATMENT OF FIBROLAMELLAR HEPATOCELLULAR CARCINOMA WITH DISULFIRAM AND COPPER INDUCES APOPTOSIS AND IS EQUIVALENT TO TRADITIONAL CHEMOTHERAPIES IN VITRO JL Leiting, MC Hernandez, L Yang, MJ Truty Presenter: Jennifer Leiting MD | Mayo Clinic, Rochester Background: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare subtype of hepatocellular carcinoma. Surgical resection is the only cure, however, most patients succumb to distant metastases despite curative intent with overall survival at five years of only 30-45%. There are no consensus systemic therapeutic options for FL-HCC given its rarity and lack of data. Disulfiram (DSF), an aldehyde dehydrogenase inhibitor, with the co-administration of copper gluconate (Cu), has been investigated as an anti-cancer agent and has been found to be effective against a number of solid malignancies. Our aim was to assess the efficacy of disulfiram and copper on patient-derived FL-HCC tissue. Methods: With IRB approval, resected patient FL-HCC tumor was dissociated into a single cell suspension and plated on a 96-well plate. Cells were treated with increasing concentrations of DSF/Cu, Gemcitabine and Oxaliplatin, or FOLFIRINOX. After 24 hours, cells were assessed for viability. Light microscopy was used to assess cell structure and morphology. Dissociated cells were then plated onto a 6-well plate and treated with vehicle or 1 uM of DSF/Cu. After 24 hours, cells were harvested and assessed for apoptotic proteins by western blot. Results: Patient-derived FL-HCC cells treated with traditional chemotherapeutic agents, including a combination of Gemcitabine and Oxaliplatin or FOLFIRINOX, had significantly reduced cell viability at 0.01 uM (p < 0.01) with DSF/Cu having a significant reduction by 0.1 uM (p > 0.01) (Figure 1A). With 1 uM of treatment, only 1.3% of Gemcitabine and Oxaliplatin treated cells, 6.7% of FOLFIRINOX treated cells, and 3.4% of DSF/Cu treated cells were viable (Figure 1A). Light microscopy showed a loss of cell structure and cell number at 0.1 uM and 1.0 uM in the cells treated with DSF/Cu (Figure 1B). Cells treated with DSF/Cu were assessed for protein expression by western blot. There were increased levels of activated apoptotic proteins in the cells treated with DSF/Cu, including cleaved caspase 3, cleaved caspase 7, cleaved caspase 9, and cleaved PARP (Figure 1C). Conclusion: The combination of DSF and Cu has a significant treatment effect on patient-derived FL-HCC tumor cells and that effect is equivalent to the effect seen by treatment with traditional chemotherapeutic agents. The process of apoptosis appears to be part of its mechanism of action given the increased levels of activated apoptotic proteins in treated cells. Additional experiments are underway to assess the effect of this treatment regimen in a patient-derived xenograft model. DSF has already been shown to be safe in humans given its use in the treatment of alcoholism, and may be a useful treatment or treatment adjunct in patients with this rare tumor type.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 118. PATHOLOGY REMAINS THE MOST IMPORTANT PREDICTOR OF LONG-TERM SURVIVAL USING A MODERN PROGNOSTIC NOMOGRAM FOR RESECTED PANCREATIC DUCTAL ADENOCARCINOMA ME Lidsky, K Seier, M Gonen, TP Kingham, MI D'Angelica, VP Balachandran, JA Drebin, WR Jarnagin, MF Brennan, PJ Allen Presenter: Michael Lidsky MD | Memorial Sloan Kettering Cancer Center Background: Our group previously published a prognostic nomogram generated from data on 555 patients resected between 1983 and 2000. Improvements in perioperative outcomes, and application of modern chemotherapy regimens, may have influenced the importance of certain prognostic variables. The purpose of this study was to re-evaluate prognostic variables for patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) using a contemporary dataset, and generate a predictive model for long-term survival. Methods: A prospectively maintained pancreas registry at Memorial Sloan Kettering was analyzed from 2000-2016, identifying patients that underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma. Patients with mortality within 90 days of resection were excluded. Patient, tumor, and treatment related variables were analyzed for their association with the primary endpoint of overall survival (OS). A nomogram was generated using univariate and multivariate regression, and cubic splines were used for continuous variables. Survival was predicted at 1, 3, and 5 years after resection. Results: 1,322 patients met inclusion criteria, from which 927 patients were used to build the model and 395 patients were used for validation. Median patient age was 69 years (range = 30-91 years) with equal gender distribution (51% male, 49% female). Pancreaticoduodenectomy was performed in 1,052 (80%) patients and 270 (20%) underwent distal pancreatectomy. Positive margins were found in 26% of patients, and 68% had positive lymph nodes. Median estimated blood loss (EBL) was 500 mL (range = 20-8,500 mL), length of stay was 8 days (range = 3-162 days), and the overall grade 3 or 4 complication rate was 22% (23% after PD and 18% after DP). Univariate analysis revealed increasing age (HR 1.02), increasing tumor size (HR 1.01), positive margins (HR 1.48), positive lymph nodes (HR 1.79), increasing number of positive lymph nodes (HR 1.07 per node), and EBL (HR 1.02 per 100 mL) to be associated with OS. Multivariate analysis concluded that age, tumor size, margin status, the number of positive lymph nodes, and EBL were predictive of OS, and were included in the nomogram (Figure), for which the concordance index was 0.62. Conclusion: Using a large, prospectively maintained registry of patients undergoing resection for PDAC, a nomogram prognostic of 1-, 3-, and 5-year survival was generated. Criteria for pathologic staging, namely tumor size and nodal burden, remain the most important predictors of long-term survival.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 120. IMPACT OF SURGICAL WAIT TIME ON POSTOPERATIVE AND ONCOLOGICAL OUTCOMES IN RESECTABLE PANCREAS ADENOCARCINOMA E Vasilyeva, J Li, S Desai, S Khaola, AK Buczkowski, SW Chung, CH Scudamore, M Segedi, PTW Kim Presenter: Elizaveta Vasilyeva MD, Ms, MHSc | University of British Columbia Background: Upfront resection with adjuvant chemotherapy is the optimal treatment for resectable pancreas adenocarcinoma. It is unclear what an acceptable surgical wait time is from oncologic perspective. The aim of this study was to evaluate the effect of surgical wait time on postoperative complications, short-term, and long-term oncologic outcomes. We hypothesized that longer surgical wait time was associated with higher rate of palliative bypass, increased postoperative complications, and decreased survival. Methods: An 8-year retrospective cohort study of 144 patients with proven or suspected resectable adenocarcinoma of the head of pancreas was performed. Patient demographics, preoperative and intraoperative clinical parameters, postoperative complications, pathologic stage, and survival were analysed in four groups according to the wait time as defined by time elapsed between diagnosis and surgery ( 12 weeks). Cox regression analysis adjusted for confounders was performed to analyse survival between groups. Results: Patients in the shortest wait time group (<4 weeks) were less likely to receive preoperative biliary drainage (p<0.001), tend to be younger (p=0.055) with a lower Charlson comorbidity index (p=0.01), and had the most recent cross sectional imaging (p<0.001). A strong trend towards a higher rate of successful resection was observed in the shortest wait group (89.7%) compared to a combined rate of the other three groups (71.3%) (p=0.072). There was no difference in length of stay (p=0.906) or postoperative complications (p=0.984), tumour size (p=0.672), lymph node involvement (p=0.396), or the rate of R0 resection (p=0.204) between the groups. There was no difference in oncologic outcomes such as the proportion of patients who initiated adjuvant chemotherapy (p=0.442), or had disease recurrence (p=0.219). Median survival for the full cohort was 22.8 months, and 5-year survival was 18.3%. Adjusted Cox regression analysis found that the longest wait time group had a significant reduction in the risk of death during the study period (HR 0.28-0.85). Conclusion: Patients with shorter surgical wait time were on average younger, less likely to have comorbidities, undergo preoperative biliary drainage, or have a palliative bypass. Of the patients who underwent resection, surgical wait time over 12 weeks was associated with better long-term survival, even after adjustment for potential confounders. Longer wait time did not appear to have an impact on intraoperative or postoperative complications.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 121. LARGE CELL AND SMALL CELL PANCREATIC CANCER: LONG-TERM OUTCOMES FROM A NATIONWIDE COHORT FI Macedo, SH Cass, N Song, K Kelly, D Franceschi, D Yakoub, V Dudeja, AS Livingstone, NB Merchant Presenter: Francisco Macedo MD | University of Miami Miller School of Medicine Background: Large (pLCC) and small cell (pSCC) carcinomas are extremely rare and highly malignant subtypes of pancreatic cancer. Due to their rarity, current management of these entities are limited to case report series. We sought to examine the long-term outcomes and practice patterns of patients with pLCC and pSCC in a large nationwide cohort. Methods: National Cancer Data Base (NCDB) was queried for patients with pLCC and pSCC diagnosed from 2010 to 2014. Actuarial estimates for overall survival (OS) were calculated using Kaplan-Meier methods. Log-rank and Cox multivariable regression analysis were performed to compare the outcomes of patients with pancreatic pLCC and pSCC. Results: A total of 986 patients with pLCC (44.2%) and pSCC (55.8%) were included in the analysis. Median age was 67 years; 85.8% of patients were Caucasians and 59.4% were male. 631 (64%) presented with metastasis at diagnosis. Adjuvant chemotherapy was used in only 6.2% and only 10.9% of patients underwent pancreatectomy. OS was 3.7 vs. 5.8 months (p=0.415) in pLCC and pSCC, respectively. Of patients who underwent resection, median OS was 35.9 vs. 17.3 months (pLCC vs. pSCC, p=0.026). Adjuvant chemotherapy was associated with improved OS [20.9 vs. 4.6 months, p<0.001 (chemo: pLCC 34.1 vs. pSCC 12.8 months, p=0.003)]. After controlling for patient and disease-related factors, age [HR 1.023, 95% CI 1.012-1.034], metastasis at presentation [HR 0.710, 95% CI 0.56-0.959], N1 [HR 0.143, 95% CI 0.043-0.469] negatively impacted OS, while pancreatectomy [HR 4.083, 95% CI 2.361-7.060] and pLCC [HR 1.335, 95% CI 1.006-1.772] were independently associated with superior outcomes. Conclusion: This is the first series assessing the long-term outcomes among patients with pancreatic pLCC and pSCC. Most patients presented with metastatic disease and outcomes are dismal. Only a minority of patients undergo conventional multimodal therapy. In patients undergoing resection and/or chemotherapy, pancreatic LCC was associated with better prognosis than pancreatic SCC.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 122. HEPATOPANCREATODUODENECTOMY IN NORTH AMERICA: ARE THE OUTCOMES ACCEPTABLE? J Welch, E Gleeson, A Karachristos, HA Pitt Presenter: Jonathan Welch MD | Lewis Katz School of Medicine at Temple University Hospital Background: Major hepatectomy and pancreatoduodenectomy have become safe operations in developed Eastern and Western countries. Most reports of hepatopancreatoduodenectomy (HPD) come from Asia. Historically, the morbidity and mortality of HPD were very high, but recent single institution Asian reports suggest improvement. To date, no Western data with HPB-specific complications have been available to assess the outcomes of HPD. The aim of this analysis was to compare the outcomes of HPD to those of major hepatectomy and pancreatoduodenectomy in North America. Methods: The 2014-16 ACS-NSQIP Procedure-Targeted Participant Use Files were queried for major hepatectomy, pancreatoduodenectomy (PD) and HPD. For major hepatectomy (MH), only right hepatectomy, left hepatectomy and trisegmentectomy (CPT code) procedures were included. For HPD, the MG and PD operations had to be performed concurrently. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to compare HPD procedures with MH (4:1) and PD (6:1) operations. Matching included 33 general demographic, comorbidity, laboratory, operative and pathologic variables. Multiple surgical outcomes were compared by Wilcoxon rank-sum, chi-squared and Fisher’s exact tests where appropriate Results: Over a three-year period, only 23 HPD procedures were performed. During the same time, 3,893 MHs and 10,583 PDs were available for comparison. With the extensive matching process, 92 MHs and 138 PDs were chosen for comparison. The four most frequent indications for surgery were cholangiocarcinomas, pancreatic malignancies, benign disorders and neuroendocrine tumors. The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p<0.01) compared to MH, PD or both (Table). Similarly, serious morbidity, including organ space infections, septic shock, prolonged ventilation and renal failure, was significantly (p< 0.01) greater in patients undergoing HPD. Liver failure also was more common (p<0.01) in HPD patients, but pancreatic fistula rates were similar. Median length of stay was more than twice as long (p<0.01) in patients undergoing HPD. Conclusion: Hepatopancreatoduodenectomy (HPD) is rarely performed in North America. During a three year period, only 23 HPDs were undertaken compared to thousands of major hepatectomies (MHs) and pancreatoduodenectomies (PDs). Overall and serious morbidity were more than 80% for HPD, and one-quarter of the patients died after this operation. Major infections and multiple organ failure are the complications which lead to death. These outcomes are unacceptably high and help to explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 123. RADIOGRAPHIC CHARACTERISTICS OF NEUROENDOCRINE LIVER METASTASES ARE NOT ASSOCIATED WITH CLINICAL OUTCOMES FOLLOWING LIVER RESECTION EW Beal, EA Armstrong, M Shah, B Konda, S Abdel-Misih, A Ejaz, ME Dillhoff, TM Pawlik, J Cloyd Presenter: Eliza Beal MD, MS | The Ohio State University Background: Previous research has demonstrated that specific radiographic criteria, including the presence of calcifications and the enhancement pattern on computed tomography (CT) imaging, correlates with clinicopathologic features and outcomes of patients with gastroenteropancreatic neuroendocrine tumors. We sought to investigate whether these radiographic characteristics were prognostic among patients with neuroendocrine liver metastases (NELM) undergoing surgical resection. Methods: The preoperative contrast-enhanced CT scans of all patients who underwent resection of NELM at a single institution between 2000-2015 were retrospectively reviewed. The presence of calcifications was determined on non-contrast phase imaging. Enhancement on the arterial phase scan was categorized as hyperenhancing, hypoenhancing, or mixed. Relevant clinicopathologic characteristics as well as recurrence-free (RFS) and overall-survival (OS) were compared between groups. Results: Among 82 patients who underwent resection of NELM, 56 had available data on calcifications while 50 had data available on arterial enhancement patterns. Among all patients, median age was 58 (IQR 47-63) and the majority were female (N=48, 58%). The most common primary tumor locations were pancreas (N=25, 30%) and small bowel (N=27, 33%). The most commonly performed procedures were right hepatectomy (N=21, 28%) and bisegmentectomy (N=14, 19%). Median tumor number was 3 (IQR 1-5), median Ki-67 was 5% (IQR 2%-10%), and median size of the largest liver metastases was 4.5 cm (IQR 2.8-7.7). Twelve (21%) patients had tumor calcifications. Among patients with and without calcifications there were no differences in demographics, clinicopathologic characteristics, RFS (p=0.917) or OS (p=0.104). Arterial enhancement was hypoenhancing in 23 (47%), hyperenhancing in 9 (19%), and mixed in 16 (34%). Similarly, there were no differences between arterial enhancement groups in demographics, clinicopathologic characteristics, RFS (p=0.303) or OS (p=0.258). Conclusion: Radiographic characteristics on contrast-enhanced CT are not associated with the outcomes of patients undergoing resection of NELM. Future investigations should evaluate the prognostic impact of functional neuroendocrine imaging.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 124. PRE-TRANSPLANT ALBI GRADE 3 IS ASSOCIATED TO INCREASED MORTALITY AFTER LIVER TRANSPLANTATION N Bernardi, CRP Kruel, MF Chedid, TJM Grezzana-Filho, AD Chedid, MA Pinto, I Leipnitz, JE Prediger, C Prediger, AN Backes, TO Hammes, LT Guerra, A Araujo, MR Alvares-da-Silva Presenter: Cleber RP Kruel MD, PhD | Hospital de Clinicas de Porto Alegre Background: Although MELD score is a reliable tool for estimating mortality in the waiting list, criteria for preoperative prediction of survival after liver transplantation (LT) are lacking. ALBI score was validated as a prognostic marker for hepatocellular carcinoma (HCC) patients undergoing transarterial chemoembolization, hepatic resection and sorafenib treatment but not for LT outcomes yet. This study aimed to evaluate ALBI score as a prognostic factor in LT. Methods: Single center analysis of patients undergoing LT between October 2001 and June 2017. Primary endpoint was overall post-LT mortality. Secondary endpoint was 90th day mortality. Results: Of all 301 patients included in this study, 185 (61.5%) were males. The mean age was 54.1±11.3 years. Univariate and multivariate analyses revealed that ALBI grade 3 (HR=1.836, 95%CI [IQR=1.154–2.921], p=0.010), low serum albumin (HR=0.628, 95%CI=0.441-0.893, p=0.010), black race (HR=2.431, 95% CI [IQR=1.160–5.092], p=0.019) and elevated body mass index (HR=1.061, 95% CI [IQR=1.022-1.102], p=0.002) all were associated to decreased overall survival following LT. Receiver operating characteristics (ROC) for ALBI grade had the highest AUC (0.629). MELD score had no prognostic association to post-LT mortality in any of the multivariate models. Comparison among all 3 ALBI grades revealed a significant difference in overall survival (p=0.015) (Figure 1). ALBI grade 3 was associated to the lowest survival (1-year=70.4%, 3-year=62.4%, 5-year=54.1%, 7-year=47%). ALBI grade 1 was associated to a 1-year survival=92.3%, 3-,5-year and 7-year survivals of 76.8%. ALBI grade 2 had 1-year survival of 81.1%, 3-year=74%, 5-year=66.7% and 7-year=63.4%. Conclusion: ALBI grade 3 was related to lower post-LT survival, and can be utilized as a tool for risk stratification in LT.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 125. OUTCOMES OF DIFFERENT ADJUVANT TREATMENT APPROACHES IN RESECTABLE PANCREATIC CANCER: A NATIONAL CANCER DATABASE STUDY O Moaven, CJ Clark, GB Russell, R Howerton, KI Votanopoulos, EA Levine, P Shen Presenter: Omeed Moaven MD | Wake Forest University Background: The optimal adjuvant treatment approach for resected pancreatic cancer patients remains controversial. The aim of this study was to identify the survival benefit of different adjuvant approaches and factors influencing survival in the subgroup of patients who received adjuvant therapy. Methods: In this study of the National Cancer Database of the American College of Surgeons, patients who underwent pancreatic cancer resection between 2010 and 2014 and did not receive neoadjuvant treatment, were analyzed to determine clinical outcomes stratified according to different adjuvant treatments approaches. Kaplan-Meier method was used to calculate and generate survival curves. Results: Included in the study were 15,270 patients. Of those, 3857 (25.3%) patients received adjuvant radiation and 8745 (57.2%) patients received postoperative chemotherapy, comprising a total of 8937 (58.5%) receiving adjuvant treatment. The most common adjuvant approach was chemotherapy only (5193; 58.1%), followed by chemotherapy with subsequent radiation (2675; 17.5%), radiation with subsequent chemotherapy (877; 9.8%), and radiation only (192; 2.2%). Median follow up was 42.9 months and median survival was 22.2 months with 1-year survival of 71.3% and 2-year survival of 47.2%. On multivariable analysis, tumor size (p=0.004, HR 1.021; 95% CI 1.01-1.04 per 10 mm increase) and number of days chemotherapy was started after radiation (p=0.016, HR 1.02; 95%CI 1.01-1.05, for each 10 days) were associated with worse survival. Lower tumor grade (p<0.001, HR 0.65; 95%CI 0.54-0.78 for grade 1 vs 3/4 and HR 0.82; 95%CI 0.74-0.90 for grade 2 vs 3/4), negative margin (p<0.001, HR 0.73; 95%CI 0.66-0.81), negative nodal involvement (p<0.001, HR 0.62; 95%CI 0.54-0.70) and duration of radiation (p=0.003, HR 0.93; 95%CI 0.88-0.97 per each 10 days with maximum at 62 days) were predictors for improved survival. Most survival benefit was observed in patients who received chemotherapy with subsequent radiation, followed by chemotherapy only, chemotherapy after radiation, and radiation only (P<0.001). Conclusion: In resectable pancreatic cancer patients who do not receive neoadjuvant treatment, increased survival benefit was observed with adjuvant chemotherapy followed by radiation. Sequence of treatment has significant impact on overall survival and delaying chemotherapy after radiation is associated with worse outcome.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 126. RESECTION OF PRIMARY PANCREATIC NEUROENDOCRINE TUMORS WITH CONCOMITANT LIVER RESECTION: REASONABLE AND SAFE KJ Lafaro, AM Blakely, J Kessler, D Li , PHG Ituarte, B Lee, G Singh Presenter: Kelly Lafaro MD | City of Hope Cancer Center Background: Pancreatic neuroendocrine tumors (PNETs) are increasing in incidence. Resection of liver metastases and the ideal timing of resection is a matter of debate. Combination pancreatic and liver surgery raises the concern of increased morbidity and mortality, however there is little data. The objective of this study was to determine whether or not there were differences in morbidity between resection of PNET primary alone versus concomitant resection of liver metastases. Methods: California Cancer Registry (CCR) was queried for patients with a confirmed histologic diagnosis of PNET with liver metastases who underwent resection from 2000 to 2012. The group was then divided into those who underwent resection of primary PNET alone with either a distal pancreatectomy (DP) alone, Whipple procedure (WP) alone, distal pancreatectomy with liver resection (DPLR), and Whipple procedure and liver resection (WPLR). Demographic, clinical, treatment characteristics, and hospital length of stay (LOS) were assessed with Cox proportional hazards. Complications were assessed using Fisher’s exact test. Results: 113 patients with PNET metastatic to the liver underwent resection with or without liver resection between 2000 and 2012. Of these 113 patients, 39 (34.5%) underwent DP alone, 40 (35.4%) underwent DPLR, 18 (15.9%) underwent WP alone and 16 (14.1%) underwent WPLR. There was no significant difference in demographics or disease characteristics between the groups who underwent primary resection alone vs. combined liver resection, including age, gender, race, comorbidities, primary tumor size, grade, or lymph node positivity. There was an increased LOS for those who had a combination DPLR compared to DP alone (7.48 days vs. 10.4 days, p=0.02) but there was no difference in LOS between those who underwent WP vs. WPLR (19.6 days vs. 16.2 days, p=0.64). There was no difference in overall complication rate between the groups. When broken down by complication type, there was no difference in intra-abdominal abscess rates between those who underwent DP vs. DPLR (p=0.116) or those who underwent WP vs. WPLR (p= 0.900). There was also no difference in pancreatic fistula rates between those who underwent DP vs. DPLR (p=0.494) or WP vs. WPLR (p=1.00). Conclusion: PNETs are increasing in frequency, and current standard of care is to resect metastatic disease if complete resection is possible. Debulking surgeries are also noted as a consideration in NCCN guidelines with some evidence already published that debulking may improve survival. Using the CCR database, there was no difference noted in complication rates between removal of the primary alone versus concomitant liver resection; however, there were increased LOS with combination DPLR compared to DP alone.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 127. ARE OLD DONOR`S GRAFTS A LIMITATION FOR RECIPIENTS DUE TO HIGH RISK? M Poupard, E Quiñonez, RM Vergara Sandoval, JPS Duran Azurduy, M Chahdi Beltrame, M Lenz, FJ Mattera Presenter: Emilio Gaston Quiñonez MD | Hospital el Cruce Background: Liver transplantation continues to be the only treatment for terminal liver disease. The growing increase in the number of patients on the waiting list, in line with the low rate of donors in our country, has produced a negative disproportion to meet the demands. The time on the waiting list has increased as also did the drop out due to progression or deterioration of liver function. The use of suboptimal grafts is an alternative to reduce this gap. However, there are multiples studies that report increase number of complications with them. Methods: Patients with liver transplant were analyzed from January 2013 to December 2017. They were stratified into 4 groups according to the age of the donors: Group 1 ( 60 years). Donors, patients and procidure variables were analized. Primary graft dysfunction, overall patient survival and graft loss were evaluated. Results: In this period, 196 patients were transplanted. 55% were male, with an average age of 46 years. There were 31 emergencies, without significant differences between the groups. The use of Split was greater in groups 1 and 2 (p<0.001), as well as the hepatorenal transplants, where only donors of group 1 were used (p<0.001). Regarding the grafts, there were no significant differences between the presence of macroesteatosis, increase liver transaminases or the sodium level of the donor. The time of cold ischemia was greater in group 1 (minutes = 500), group 2 (471), group 3 (428) and group 4 (417) with a statistically significant difference (p0.01). Regarding the postoperative period, no significant differences were observed in the peak of AST, days of hospitalization, mortality or primary graft failure (p0,127), although, there were no cases of this latter complication with donors under 40 years old. The analysis of long-term survival and loss of the graft also did not yield significant results. Conclusion: In our series, no statistically significant differences were observed with the use of grafts from elderly donors. We consider a primordial and extremely beneficial strategy when used with a careful choice of the recipient.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 128. ROBOTIC APPROACH MITIGATES THE EFFECT OF MAJOR COMPLICATIONS ON SURVIVAL AFTER PANCREATICODUODENECTOMY FOR PERIAMPULLARY CANCER GC Wilson, MS Zenati, AI Al Abbas, CJ Buccholz, E Perrone, ME Hogg, HJ Zeh, AH Zureikat Presenter: Gregory Wilson MD | University of Pittsburgh Medical Center Background: Major complications (MC) after pancreaticoduodenectomy (PD) have been shown to be an independent predictor of worse oncologic outcomes. There is limited data on the effect of major complications on long-term outcomes after robotic PD (RPD). The aim of this current study is to compare the effect of MC on overall and disease-free survival (DFS) after RPD and open PD (OPD). Methods: This is a single-center, retrospective review of a prospectively maintained database of all patients undergoing PD for periampullary cancer including duodenal adenocarcinoma, ampullary carcinoma and distal cholangiocarcinoma from January 1, 2011 through November 30, 2017. Univariate analysis was performed on all clinical, pathologic and treatment factors. MC were defined as Clavien-Dindo grade 3 or higher complications. Kaplan-Meier survival analysis was performed with log-rank test for group comparison. Multivariate cox regression analysis was used to identify factors associated with overall survival (OS) in both the OPD and RPD groups. Results: A total of 190 patients with ampullary carcinoma (n=98), cholangiocarcinoma (n=55), duodenal adenocarcinoma (n=37) were examined over the study period with 61.1% (n=116) undergoing RPD and 38.9% (n=74) undergoing OPD. Patient demographics were similar between the RPD and OPD cohorts regarding patient age (67.3±10.3 vs 69.8±10.2 yrs, p=0.11), body-mass index (27.7±5.7 vs 29.5±7.1, p=0.06) and age-adjusted Charlson Comorbidity Index (aCCI) (5.0±1.6 vs 5.2±1.5, p=0.33). R0 resection rates were similar between the RPD (94.0%, n=109) and OPD cohorts (93.2%, n=69, p=0.84). Tumor size (2.8±1.8cm vs 2.9±1.8cm, p=0.70) and lymph node involvement (lymph node positivity = 67.3% vs 66.2%, p=0.88) were also similar between the two cohorts. OPD had higher rate of MC (40.5% vs 28.3% in RPD, p=0.011) including clinically-significant pancreatic fistula (25.7% vs 8.6%, p=0.001) and wound infection (34.5% vs 13.8%, p<0.001). Completion of adjuvant chemotherapy was higher in the RPD cohort (46.2% vs 28.6%, p=0.048). OS and DFS for each cohort by MC status are depicted in Figure 1. Factors associated with OS on multivariate analysis in the OPD cohort included postoperative MC (hazard ratio (HR) = 2.18, 95%CI 1.04-4.55, p=0.038), aCCI (HR=1.50, 95%CI 1.16-1.93, p=0.002), tumor grade (HR=2.24, 95%CI 1.08-4.62, p=0.03), tumor perineural invasion (HR=4.84, 95%CI 1.84-12.73, p=0.001) and number of adjuvant therapy cycles (HR=0.84, 95%CI 0.72-.98, p=0.03). Factors associated with OS on multivariate analysis in RPD cohort included T stage (HR=1.58, 95%CI 1.10-2.28, p=0.014), lymph node involvement (HR=1.10. 95%CI 1.03-1.17, p=0.004), lymphovascular invasion (HR=2.77, 95%CI 1.08-7.11, p=0.035), transfusion requirement (H=2.62, 95%CI 1.34-5.13, p=0.005), reoperation (HR=3.23, 95%CI 1.18-8.81, p=0.022), and completion of adjuvant therapy (HR=0.34, 95%CI 0.17-0.68, p=0.002). MC was not associated with OS in the RPD cohort (HR=1.55, 95%CI 0.87-2.76, p=0.14). Conclusion: MC are associated with worse patient outcomes after OPD but not after RPD. Robotic approach abrogates the negative effects of MC on patient outcomes after PD for malignancy and is associated with improved adjuvant chemotherapy completion rates.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 129. COJOINED TWINS THORACOONFALOPHAGUS SEPARATION AND LIVER BIPARTITION (CASE REPORT) VH Torres, E Anchante, CM Yeren, JJ Nuñez, R Cruzalegui, A Fuentes Rivera, W Ludeña, M Arboleda, F Chavarry, L Palma, S Chumpitazi, L Cabana, W Cabrera, J Mucha, M Villegas, A Castañeda, L Morales, G Morales, V Casquero Presenter: Victor Hugo Torres-Cueva MD | Hospital Nacional Guillermo Almenara Irigoyen Background: Cojoined twins are a rare phenomenon of monochorionic and monoamniotic twins. The incidence varies from 1 in 50,000 to 1 in 200,000 live births. Female fetuses are more commonly affected, with a ratio of men to women being 1:3, particularly in the thoracic type. The thoraco onfalophagus twins are joined and can share body part as the respiratory, cardiovascular and gastrointestinal systems, besides of thoracoabdominal wall. in the present case shared thoracoabdominal wall and livers and one of the twins has congenital complex cardiac malformation. These types of twins have better chances of survival if they are separated successfully. Methods: We present a rare case of male thoraco onfalóphagus twins successfully separated at 28 days old. We reviewed the postnatal study, the surgical technical aspects of the separation and the postoperative evolution of both twins. These twins are the product of primigesta of 22 years (G1P1001), without significant antecedents, with prenatal diagnosis of double gestation type Siameses thoraco onfalóphagus, the delivery was by caesarean section at 34 weeks of gestation for acute fetal distress. and we confirm that the Siameses are joined by the thoracoabdominal wall; Ultrasound studies and AngioCtScan showed that shared the visceras: heart and liver, the separation surgery was successfully performed with a multidisciplinary team of anesthesiologists, hepatobiliary surgeons, pediatric cardiovascular surgeons, plastic surgeons, pediatric surgeons, Results: The intraoperative findings, hearts and independent great vessels were seen, the pericardium, diaphragm and costal arches were shared, absence of sternum, the livers were joined by a bridge with an area of approximately 7 cm2 of parenchyma and maintained independence from the portal systems, A left portal branch coming from siamese 2 was common, veins cavas and suprahepatic veins as well as the biliary system were independent, there was a complex cardiac malformation in the Siames 1 (double exit route from the right ventricle, subvalvular and pulmonary valve stenosis, double-related ventricular septal defect) and malformation cardiac failure in the Siamese 2 (interatrial communication without hemodynamic repercussion), intestinal malrotation in the Siamese 1. Successful separation of the Cojoined twins was achieved through hepatic transection with ultrasonic dissector (CUSA), in addition to the use of monopolar and bipolar electrocautery, the shared portal vein was sutured; The separation of the thoracic and abdominal wall components described was carried out. In siamese 1 the total closure of the chest wall was not achieved and it was covered with a dermal patch that guarantees the posterior reconstruction, the abdominal wall was closed satisfactorily with lateral incisions of discharge. In siamese 2, satisfactory closure of the chest wall and abdominal wall with lateral discharge incisions was achieved. Conclusion: The management of cojoined twins together remains a medical challenge, due to multiple congenital anomalies associated, as in this case they lead to low success rate. The specialized and multidisciplinary integral management of these cojoined twins is necessary to guarantee success in terms of reducing complications and increasing survival. In this particular case, we performed the separation of thoracoonfalophagus and liver Bipartition succesfully and the current evolution is satisfactory, with emphasis on the subsequent correction of chest wall defects and associated cardiac congenital malformations.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 130. EXTERNAL PANCREATIC STENTS AFTER PANCREATICODUODENECTOMY REDUCE PANCREATIC FISTULA RATES AND SEVERITY JA Reza, C Canavan, M Uwah, K Wissinger, P Veldhuis, S Patel, Y Du, JP Arnoletti Presenter: Joseph Reza MD | Florida Hospital Background: Postoperative pancreatic fistula (PF) is a common complication after pancreaticoduodenectomy (PD). Additional interventions to decrease incidence of PF may add cost and procedural risk to patients with variable results. The purpose of this study is to evaluate the impact of routine pancreatico-jejunostomy reconstruction over external pancreatic stent on PF rates and severity after PD. Methods: We retrospectively reviewed the medical records of 148 consecutive patients undergoing open pylorus-preserving PD between March 2014 and April 2018. All patients had a temporary trans-anastomotic external pancreatic stent placed. Octreotide was not utilized. Outcomes in 49 patients with PDAC were compared to the remaining group of 99 patients with non-PDAC pathologies. PF risk score was calculated for each patient. Continuous and categorical variables were analyzed by chi square, Fisher's exact tests, Student t-test and Mann-Whitely Rank test. Results: Overall postoperative PF incidence rate was 3.4%. Among patients with PDAC, the average risk score for pancreatic fistula was 2.4 vs 4.4 in the non-PDAC group (p=< 0.001). There were 5 Type B PF in the non-PDAC patients and 0 Type C in the entire patient group as defined by 2017 ISGPS guidelines. No patients in the PDAC group required intervention to address PF where 5 patients required postoperative percutaneous drainage in the non-PDAC cohort. PDAC patients received more crystalloid during PD (4.3 liters vs 3.6 liters; p=0.01). Significantly more PDAC patients underwent pre-operative chemotherapy (p= 2 major comorbidities, BMI, volume of crystalloid received, peripancreatic inflammation and wound infection could not account for the difference observed in the need for postoperative percutaneous drainage after PF. Conclusion: During PD, reconstruction over an external pancreatic stent led to very low PF incidence with no significant difference observed in severity between patients with PDAC and other high fistula risk pathologies. Routine external pancreatic stent placement after PD, regardless of PF risk, may reduce incidence of PF and need for additional interventions.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 131. EARLY VS. LATE PANCREATIC FISTULA PRESENTATION: ANALYSIS OF A DIAGNOSTIC DILEMMA AND IT’S OUTCOMES MT LeCompte, GA Williams, KE Dougherty, E Lu, RC Fields Presenter: Michael LeCompte MD | Washington University, St. Louis Background: Pancreatic fistula (PF) is a major cause of morbidity and adverse outcomes after pancreaticoduodenectomy. Post-operative care of the pancreaticoduodenectomy patient is centered on recognition and prevention of complications. Few studies have evaluated the timing of fistula presentation, yet the clinical experience at our institution has been associated with a high variability in the timing and presentation of PF. The purpose of this study is to evaluate whether there is a chronological association for PF and to assess the effects on clinical outcomes. Methods: A retrospective, single center study was conducted evaluating our experience with pancreaticoduodenectomies from 2011 to 2018 using a prospectively collected database. Patients with PF were identified, evaluated and graded based on the 2016 International Pancreatic Study Group of Pancreatic Fistula grading system. The cutoff for early and late PF was determined at 7 days based on our median LOS after pancreaticoduodenectomy. Factors associated with Early vs. Late presentation of PF were evaluated using a combination of univariate and multivariate logistic regression. Readmission rates, complication grades and length of stay were analyzed between the two groups. All statistical tests were two-sided using an α = 0.05 level of significance. SAS Version 9.4 (Cary, NC) was used to perform statistical analyses. Results: A total of 664 patients undergoing pancreaticoduodenectomy for both benign and malignant disease from 2011 to July 2018 were included in the study. A total of 109 patients (16.3%) were diagnosed with PF. Sixty-one patients (56%) were categorized as Early PF and diagnosed within 7 days of surgery. Demographic, pathologic, surgical and comorbid factors were analyzed in multivariate analysis. Diabetes was found to be the most significant factor in Late PF (p=.019). No significant differences in blood loss, malignancy, pancreatic gland consistency, duct size, ASA class, BMI, smoking or drain amylase levels were associated with Early vs. Late PF. Late PF was associated with increased hospital readmission rates (64% vs. 23.5% p=0.00). However, there was no statistical difference in PF grade (65% vs. 75% grade B/C p=0.564) or severity of associated complications (p=0.539). Fifteen patients (31%) were diagnosed with PF after hospital discharge in the Late PF group. Length of stay was significantly higher in PF patients compared to non-PF (p=0.00). Total 30-day length of stay (initial LOS + readmission LOS) was significantly higher in the Late PF group with an average hospital stay of 19.7 vs. 15.5 days in Late v. Early PF respectively. Conclusion: Pancreatic fistula is a complex post-operative problem after pancreaticoduodenectomy associated with adverse outcomes. This study demonstrates a chronologic difference in presentation and clinical determination of PF. Late PF is associated with insidious presentation and consequently, results in higher readmission rates. Few criteria are available to predict Early vs. Late presentation. Diabetes was the only factor strongly associated with later presentation while other well describes risk factors for PF such as drain amylase were not helpful in predicting later occurrence. Late PF affects outcomes such as increased readmission rates and 30-day total length of stay. Further study is needed to characterize the cause and predictors of this phenomenon to help guide clinical practice, improve diagnostic accuracy and prevent unnecessary readmission and interventions.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 132. BLOOD GROUP HAS NO BEARING ON OVERALL SURVIVAL OF PATIENTS WITH PANCREATIC DUCTAL ADENOCARCINOMA H Williams, MR Jajja, S Hashmi, K Cardona, SK Maithel, MC Russell, JM Sarmiento, JH Winer, DA Kooby Presenter: Hannah Williams BA | Emory University Background: Evidence suggests patients with blood group O are less likely to develop pancreatic ductal adenocarcinoma (PDAC) and survive longer compared to patients of other blood groups. We evaluated our pathologically proven PDAC patients who underwent pancreatoduodenectomy (PD) for their underlying blood type and survival to determine if this relationship was observed in our cohort. Methods: Demographic, operative, chemotherapy and survival data for patients undergoing PD in one healthcare system from 2010-2017 were reviewed. ABO blood group and Rhesus factor were documented for each patient. Due to small sample size of blood groups B and AB, analysis was limited to blood types A and O. Kaplan-Meier survival curves were constructed to analyze patient survival and a cox-proportional hazard regression model was used to calculate hazard ratios for associated variables (p-value cutoff <0.05 for significance). Results: 477 consecutive PDAC patients were analyzed of whom 204 (42.1%) were blood group A, 185 (38.8%) group O, 60 (12.6%) group B and 28 (5.9%) group AB. Patients in blood groups A and O differed by mean age (66.7 vs 64.7, t=2.065; p=0.039), but did not differ significantly by ethnicity, gender, pathologic stage or in treatment with chemotherapy (neo-adjuvant and adjuvant). Median survival for blood group A was 28.2 (±3.9) months compared to 24.9 (±1.8) for type O (p=0.896). On cox-regression analysis (including age, ethnicity, gender, blood group, T and N stage, LVI, PNI, tumor grade and differentiation) blood group A (HR 0.852; p=0.437) and O (HR 0.803; p=0.289) did not influence survival outcomes (Figure 1). However, lymph node positivity (HR=1.518; p=0.0206) and increasing age (HR= 1.026, p=0.002) were associated with decreased survival. Conclusion: Blood group did not impact overall survival among patients undergoing PD for PDAC in our study. Our results contrast with those of recent studies, which have found blood group A to be associated with lower survival rates.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 133. NEUTROPHIL TO LYMPHOCYTE RATIO IS PREDICTIVE OF PATIENT SURVIVAL AFTER RESECTION OF PANCREATIC ADENOCARCINOMA DT Pointer Jr., D Roife, BD Powers, G Murimwa, S Elessawy, PJ Hodul, J Pimiento, JB Fleming, MP Malafa Presenter: David Pointer MD | Moffitt Cancer Center Background: White blood cell ratios (neutrophil-to-lymphocyte [NLR] and platelet-to-lymphocyte [PLR] and more recently the lymphocyte-to-monocyte ratio [LMR]) have been associated with pancreatic adenocarcinoma (PDAC) survival. Few studies have examined these inflammatory markers in US surgical cohorts. We sought to evaluate if these ratios predict outcomes and survival in a large US cohort of surgical PDAC patients. Methods: We used a single institution database of patients who underwent upfront resection for PDAC between 2007 and 2015. This identified 307 patients of whom 277 patients had preoperative lab values to calculate NLR, PLR, and LMR ratios based on prior literature values (NLR, PLR and LMR cutoffs of 5, 150 and 3 respectively). We used Chi squared and Wilcoxon rank sum for statistical analysis. Survival was assessed with univariate and multivariate Cox regression. Results: Elevated NLR, PLR, and decreased LMR represented 13.7%, 46.9% and 56.3% of the cohort, respectively. Univariate survival analysis showed that high NLR was associated with increased mortality however, high PLR and low LMR were not. On multivariable analysis, after adjusting for sex, comorbidity, insurance, receipt of neoadjuvant and/or adjuvant therapy, node status, margin, lymphovascular invasion, and Clavien grade 3/4 complication, high NLR remained a significant predictor of mortality (See Table). Additionally, more patients with high PLR (46.5%) and NLR (48.7%) and low LMR (47.7%) had borderline resectable PDACs than the total cohort (36.5%). Conclusion: Our findings confirm, using multivariable analysis, that a high NLR is a significant predictor of overall survival. However, in contrast to other studies, LMR did not predict survival. The underlying mechanism of inflammatory cells in the tumor microenvironment needs further elucidation to better clarify the role of predictive biomarkers.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 134. PANCREATECTOMIES ASSOCIATED TO VEIN RESECTION: TWO LARGE INSTITUTIONS EXPERIENCE OF EAST AND WEST K Tanaka, A Oba, R Valente, E Rangelova, U Arnelo, Y Inoue, Y Mise, H Ito, Y Takahashi, A Saiura, M Del Chiaro Presenter: Kimitaka Tanaka MD, PhD | Hokkaido University Faculty of Medicine Background: Pancreatic tumors frequently involve the superior mesenteric/portal vein (SMVPV). Vein resections are considered the standard of care in these cases, in some Centres. However, potential benefits of pancreatectomies associated to vein resection (PAVR) are still contradictory in literature and the timing of surgery debatable. The aim of this study is to analyze short- and long-term outcomes and prognostic factors of PAVR Methods: All consecutive patients with pancreatic cancer or invasive intraductal papillary mucinous neoplasm who underwent PAVR at 2 tertiary centers in Sweden and Japan from January 2008 to August 2017 were included. Pancreatectomies with arterial resection was excluded in this series. Overall 428 patients were analyzed (245 patients from Cancer institute hospital, Japanese foundation of cancer research: JFCR and 183 from Karolinska University Hospital: KU). Patient characteristic, short-term outcome, and histological outcome were compared between the two Centers. Overall survival was analyzed using the Kaplan-Meier method and comparison was performed using the log-rank test and Cox progression analysis. Results: The mean age was 66.8 years, 220 patients were males and 208 were female. Neoadjuvant and adjuvant therapy were received in 14.9% and 71.8%. Pancreaticoduodenectomy was performed in 381 patients (89.0%), Total pancreatectomy was in 37 patients (8.6%), and distal pancreatectomy was in 10 patients (2.3%). The median operation time was 480 minutes (interquartile range [IQR], 404-553), median intraoperative blood loss was 650ml (IQR, 400-1050). Segmental resection of SMV-PV was performed on 320 patients (74.8%), and wedge resection was on 91 patients (21.3%). Severe post-operative complications were observed in 7.3%. Mortality was 1.2%. The median hospital stay was 20 days (IQR, 11-30). The patients with ASA score 3 were significantly higher in KU (21.3%) than in JFCR (11.0%) (P 200 U/ml [hazard ratio (HR):1.633, 95% confidence interval (95%CI): 1.257-2.123, P<0.01], without adjuvant therapy [HR:2.313, 95%CI: 1.769-3.004, P<0.01] and with pM (+) [HR:1.974, 95%CI: 1.372-2.778, P<0.01] were significantly associated with shorter survival. Conclusion: In this 2 Institution retrospective study, PAVR seems to be safe and feasible, although patient’ s characteristics were different between two hospitals. Long-term survival after PAVR are similar to the one reported for conventional pancreatectomies. The selection criteria for resection play a key role for the improvement of long-term outcome. Postoperative chemotherapy is confirmed as one of the most important prognostic factors. Preoperative levels of serum CA 19-9 could be used for selecting good candidates for neo-adjuvant treatment.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 135. ROBOTIC LONGITUDINAL PANCREATICOJEJUNOSTOMY FOR CHRONIC PANCREATITIS BM Motz, RC Pickens, JK Sulzer, AR Cochran, DA Iannitti, JB Martinie, EH Baker, LM Ocuin, D Vrochides Presenter: Benjamin Motz MD | Atrium Health Background: Longitudinal pancreaticojejunostomy (LPJ) is a critical tool in the armamentarium for the surgical treatment of chronic pancreatitis with pancreatic ductal dilatation. Most LPJ procedures are still performed via laparotomy. Though laparoscopic techniques have been described, technical complexity has limited their adoption. Our objective is to report our experience with robotic-assisted laparoscopic techniques for LPJ and to compare outcomes from this series with open LPJ procedures performed during the same time period. Methods: A retrospective review was conducted of patients who underwent LPJ from 2008 to 2017 at Carolinas Medical Center, a major regional quaternary care facility with hepatopancreatobiliary surgical subspecialty care within the Atrium Health System. Patients were identified from medical records containing the International Classification of Disease (ICD)-9 and 10 codes for chronic pancreatitis and the current procedural terminology (CPT) code for LPJ. Patients who underwent a modified LPJ such as a Frey or Beger procedure were excluded. Retrospective chart review was used to identify demographic data, perioperative clinical data such as laboratory values, and postoperative clinical outcomes data. Data were then analyzed using STATA. Results: 32 Puestow-type LPJ procedures were performed for chronic pancreatitis from 2008–2017 (9 robotic, 23 open). No differences in patient characteristics were found between the two groups. Both groups had similar preoperative serum albumin levels as well as preoperative hemoglobin. There was no statistically significant difference in median operative time between the robotic and open groups (309.5min vs. 240.5min, p=0.165), or in estimated blood loss (100cc vs 150cc, p=0.100). Three patients (33%) undergoing robotic LPJ required conversion to an open procedure. Total length of stay (5 vs 7 days, p=0.034) was significantly shorter in the robotic group. 30-day readmissions did not differ significantly between the robotic and open groups (13.0% vs 11.1%, p=0.882). One anastomotic leak at the pancreaticojejunostomy occurred following robotic LPJ and two occurred in the open group (11.1% vs 8.7%, p=0.833). Only one patient in our series required reoperation following open LPJ for pancreaticojejunostomy leak, as the other two leaks in our series were managed nonoperatively. No patients died in the immediate postoperative period, however there was one mortality within 41 days following an open LPJ. Conclusion: Numerous studies have demonstrated decreased length of stay and lower morbidity in patients undergoing minimally invasive surgery. In our institutional experience, incorporating a robot-assisted approach to LPJ decreased hospital length of stay without sacrificing patient safety. Additionally, operative efficiency and feasibility of the robotic approach is equivalent to that of the open approach, with similar operative times and EBL, though it does require a high level of competence with the robotic system. Further studies to examine the potential financial implications of this approach and patient-centered metrics such as postoperative pain scores will help to clarify the role of what we certainly believe is a beneficial tool in the complex surgical care of patients requiring LPJ.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 137. PANCREATICODUODENECTOMY WITH IRREVERSIBLE ELECTROPORATION (IRE) MARGIN ENHANCEMENT FOR BORDERLINE RESECTABLE PANCREATIC CANCER JK Sulzer, RC Pickens, M Passeri, K Murphy, JB Martinie, EH Baker, L Ocuin, DA Iannitti, D Vrochides Presenter: Jesse Sulzer MD, PhD | Atrium Health Background: Borderline resectable pancreatic adenocarcinoma (BRPC) remains a challenging surgical problem. Recently, irreversible electroporation (IRE) has shown promise as a safe adjunct to surgical resection in attempts to improve local control. Here we present a case-matched cohort of patients with BRPC undergoing pancreaticoduodenectomy with and without IRE margin enhancement to evaluate local recurrence and survival. Methods: A retrospective cohort analysis was performed on patients with BRPC. Patients who underwent pancreaticoduodenectomy and concurrent IRE (S-IRE) for margin enhancement were compared to a case-matched cohort who underwent pancreaticoduodenectomy alone (SR) based on demographic, tumor staging and resection margin status. Primary outcome measures included disease recurrence and overall survival. Results: Forty-one patients were included from 2013 to 2018, with 21 in the S-IRE group and 20 case-matched in the SR group. Recurrence-free survival was numerically better for the S-IRE group between 6 and 12 months but overall survival equilibrated by two years (26% vs 34%). There was no statistical difference between S-IRE and SR for medial overall survival (17.5 months vs 19 months) or median recurrence-free survival (15 vs 14.1 months). There was, however, a trend towards a decrease in local recurrence in the S-IRE group (29% vs 54%). Conclusion: This study demonstrated trends towards improvements in short-term recurrence-free survival and decreased local recurrence following margin enhancement with IRE. Results demonstrating a difference in overall survival were limited by loss to follow-up and restricted case matching. Ongoing accruement and continued surveillance will build on the promising trends presented here.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 138. PORTOMESENTERIC VENOUS COMPLICATIONS FOLLOWING PANCREATIC RESECTION: TOWARD DEVELOPMENT OF A CLINICAL SCORING SYSTEM TO PREDICT INCIDENCE, SEQUELAE AND MANAGEMENT L Yohanathan, SM Thompson, WS Harmsen, RL Smoot, MJ Truty, TE Grotz, SP Cleary, DM Nagorney, JC Andrews, ML Kendrick Presenter: Lavanya Yohanathan MD | Mayo Clinic, Rochester Background: Borderline resectable and locally advanced pancreatic adenocarcinomas are commonly encountered in our practice. This leads to increasing utilization of neoadjuvant chemoradiotherapy and need for vascular (arterial and venous) resection and reconstruction. The occurrence of portomesenteric venous complications after pancreatic resection appears to be increasing. However, factors predicting the incidence of venous complications such as portal vein thrombosis/occlusion or superior mesenteric vein thrombosis/occlusion are not well established. We sought out to evaluate the incidence, natural history and identification of potential risk factors that lead to portomesenteric venous complications following a Whipple procedure. Methods: Single site, retrospective review of patients who underwent a Whipple operation between 2015-2017. Clinical data, including patient demographics, preoperative therapy details (upfront resection, versus neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy), operative details, pathology details and postoperative portomesenteric venous complications were recorded based on retrospective data analysis. All imaging studies were independently reviewed by a radiologist to assess the incidence of portomesenteric venous narrowing as well as portomesenteric venous thrombosis following operation over the time period that each patient underwent imaging at our institution Results: 105 patients that underwent pancreaticoduodenectomy were identified. Mean age was 64 yrs. 51 patients (48.6%) underwent neoadjuvant chemotherapy,42 patients (40%) underwent neoadjuvant radiation. At surgery 24 patients (23%) underwent vein resection and 5 patients (5%) underwent arterial resection. 46 patients (49%) had a postoperative fluid collection of which 12.5% were pancreatic fistula. On postoperative surveillance, portal vein (PV) narrowing was present in 18 patients (19.1%), 8 of which resolved, and 4 required stenting. Superior mesenteric vein (SMV) narrowing was present in 38 patients (40%), 15 of which resolved and 4 required stenting. PV thrombosis was associated with presence of a postoperative fluid collection (p<0.03). SMV narrowing was associated with postoperative fluid collection (p<0.001), neoadjuvant radiation (p<0.02) and vein resection (p<0.0001). Stenting of the PV and SMV were associated with vein resection (p<0.01 and p<0.05). In a univariate model patients who received neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy alone were at a significantly higher risk of postoperative PV narrowing (p<0.001) with a HR=11.4, 95% CI 2.7-48.9. A patient who had upfront resection, relative to a patient with neoadjuvant chemotherapy alone was at a non-significant increased risk of postoperative PV narrowing (p=0.13) with a HR=3.3, 95% CI 0.7-15.6. In the same model, patients undergoing portal vein resection had a significantly increased risk of post-operative narrowing (p<0.001) with more than 3-fold increased risk, HR=3.3, 95% CI 1.9-5.9. Conclusion: Preliminary data suggest that neoadjuvant radiation, vein resection and postoperative fluid collection may be risk factors for portomesenteric venous complications following pancreaticoduodenectomy. The need to define and identify these patients is of utmost significance to evaluate the natural history of PV narrowing and thrombosis, to assist in our understanding of which patients benefit from stenting and the timing to stent.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 139. DEFINITIVE TREATMENT OF WALLED OFF NECROSIS - CASE REPORT P Vanerio, MC González, V Zubiaurre, A Taullard, G Andreoli Presenter: Patricio Vanerio MD | Hospital de Clinicas Montevideo Background: Walled off necrosis (WON) is defined as a mature collection of pancreatic or peripancreatic necrosis with a well defined wall. Diagnosis is made after 4 weeks to the onset of necrotising pancreatitis. Minimally invasive approaches currently are reported to be associated with less morbidity and mortality with similar success rates than surgery alone. We report a case of a walled of necrosis which was treated through an endoscopic approach. Methods: We report the case of a 48 year old woman, admitted on May 2017 with severe acute pancreatitis (respiratory and renal disfunction). Admission computed tomography (CT) - pancreatic and peri pancreatic necrosis compromising pancreatic body and tail (Figure 1). Patient had a good response to initial intensive care treatment. On first month of follow up patient begun with epigastric pain and fullness postprandial sensation. Magnetic resonance (MRI) - pancreatic collection of approximately 5 inches occupying body and tail with a thin wall. Interior is liquid and has detritus. (Figure 2) Medical treatment is proposed and patient is discharged. Symptoms do not decrease and 3 months after onset of pancreatitis, a trans gastric endoscopic approach of the WON is performed. (Figure 3). Results: Endoscopic cystogastrostomy was performed to manage WON. A yo-yo stent to maintain its lumen for programmed endoscopic drainages. Endoscopic trans gastric necrosectomy was done in three opportunities. Symptoms decreased and a new CT scan was made 2 months after treatment, this showed no elements of WON nor pancreatic tissue alterations. (Figure 4) Laparoscopic cholecystectomy was done 2 months after to complete integral treatment of this pathology. No complications were registered during or after both procedures. Conclusion: WON is an evolutive complication of necrotising pancreatitis. Minimally invasive approaches, particularly endoscopic access has shown to be the procedure with less morbidity and mortality than other procedures. Laparoscopic cholecystectomy completes treatment, avoiding new complications.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 140. UTILITY OF THE HUTSON-RUSSELL LOOP FOR THE MANAGEMENT OF BILIODIGESTIVE ANASTOMOSIS STENOSIS G Parquet, ML Sánchez, RI Sánchez, FJ Heiberger Presenter: Guido Parquet MD | Instituto de Previsión Social Background: The biliodigestive derivations, usually performed by the classical technique of Roux-en-Y loop, reppresent a technical difficulty or impossibility for endoscopic procedures The Hutson-Russell loop is a modification of the Roux-en-Y loop, where the proximal end is left longer (15cm) which is fixed to the abdominal wall in a subcutaneous position to allow direct endoscopic access to the bile duct, to treat residual lithiasis or stenosis. Duane G Hutson et al. described this technique in 1984 when they performed choledochojejunal anastomosis in patients with sclerosing cholangitis. Methods: We present a case of a 17-year-old patient with a stenosis of the hepaticojejunostomy, with history of a hepaticojejunostomy with Hutson-Russell handle during a resection of a choledoc cyst 1-The external transparietohepatic drainage of the bile duct is performed accesing the right hepatic lobe, with no progress of contrast or any guidewire to the jejunal loop 2-The Hutson-Russell loop is accessed endoscopically. Identification, puncture and radiological verification of the anastomosis site. Cannulation with guidance and dilation of it. Progress is made with the endoscope to the common hepatic, the percutaneous drainage catheter is identified, with traction of it to the jejunal loop. 3-Change under external catheter guidewire by a biliary catheter 4-Percutaneous treatment of the stenosis, 6 balloon dilations 5-Closure of the jejunal fistula Results: 17 year-old female patient, Previous history: a week of jaundice, acholia, choluria and progressive pruritus, fever and chills in 2 opportunities that improved after antibiotic treatment. Refers similar episodes in 3 opportunities that subsided with medical treatment - History of choledochal cyst resection a year before with hepaticojejunal recosnstruction with the Hutson – Russell loop. Physical Examination: jaundice, mid-supra, transinfraumbilical median scar with jejunal port closed at upper end. No abdominal pail. Rectal examination: acholia -Laboratory test: WB 9600 / mm3, with 89% N, TB 12.3 mg / dl, CB 11.2 mg / dl, Alkaline phosphatase 1820 mg/dl. External transparietohepatic drainage of the bile duct is performed by access in the right hepatic, without progress of the contrast or any guidance to the jejunal loop -The endoscope of the Hutson-Russell loop is accessed endoscopically. Identification, puncture and radiological verification of the anastomosis site. Cannulation with guidance and dilation of it. Progress is made with the endoscope to the common hepatic, the percutaneous drainage catheter is identified, traction of it to the jejunal loop. Change under guides of the external catheter by a biliary catheter. Percutaneous treatment of the stenosis 3 weeks later, 6 dilatations with high pressure balloon of 10 mm * 6cm at a pressure of 5 atm, with intervals of 1 month. In the last sessions the anastomosis and the opening of the left liver were dilated -After 10 months the catheter was removed - Alow-outputt jejunal fistula remained that was treated surgically. Conclusion: Simple modifications of convectional surgical techniques such as Hutson-Russell´s loop; allow the combination of surgery, radiology and endoscopy to improve medical management. The endoscopic approach of the subcutaneous loop may be sufficient for the treatment of residual lithiasis or biliodigestive anastomosis stenosis. In young patients we recommend the repair of major lesions with HJ and Hutson Russell's loop, which allows endoscopic therapy in the future avoiding new surgeries.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 141. A RESECTED CASE OF GALLBLADDER CANCER BY THE LEFT HEPATECTOMY, CAUDATE LOBECTOMY COMBINED RESECTION AND RECONSTRUCTION OF THE RIGHT HEPATIC ARTERY T Sano, K Komaya, T Osawa, T Saito, T Arikawa, S Komatsu, K Kaneko Presenter: Tsuyoshi Sano MD, PhD | Aichi Medical University Background: Although the right-sided hepatobiliary resection has been indicated for advanced gallbladder cancer as a curative treatment, the functional deficiency of future remnant liver is a critical issue. Methods: A 66-year-old man was diagnosed with an advanced gallbladder neck cancer potentially involving the right hepatic artery (RHA). CT-volumetry showed a future remnant liver volume as 220ml, 19.1% of the whole liver in terms of the right side hepatobiliary resection, which carries the potential risk of postoperative mortality even after preoperative portal vein embolization (PVE). Therefore,the tumor was curatively resected by left hepatectomy with caudate lobectomy and combined hepatic arterial resection and reconstruction with negative surgical margins. The plural hepatic arterial reconstructions between the anterior branch of the RHA and proper RHA, the posterior branch of the RHA and medial branch of the left hepatic artery were performed under the microscopic technique, respectively. Results: The operation time was 1011 minutes and intraoperative blood loss was 642g, no transfusion was required. Histologically, a well-differentiated adenocarcinoma of the gallbladder invaded the bile duct and liver parenchyma, and pericholedocal lymph node (pT3N1M0, stage IIIB, UICC 7th). The tumor invasion was observed cross to RHA. Although the direct tumor invasion to RHA was absent, reservation of RHA possibly caused the tumor exposure on the dissected plane (R1 resection). The postoperative course was unventful, and the patient discharged on the 17th postoperative day and is alive 41 months after surgery without tumor recurrence. Conclusion: The left hepatectomy combined resection and reconstruction of the right hepatic artery can be an alternative for patients with advanced gallbladder cancer as a curative treatment in terms of a tumor extension and the left liver volume.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 143. PANCREATIC ADENOCARCINOMA WITH ISOLATED GALLBLADDER METASTASIS AND 2 YEAR DISEASE FREE SURVIVAL: A RARE CASE REPORT MA Tabbal, AI Mahozi, MS Qahtani Presenter: Mahmoud Tabbal MD | King Fahad Specialist Hospital Background: Pancreatic cancer is one of the most lethal malignancies, and carries the worst prognosis of all solid tumors. Majority of these tumors are ductal adenocarcinoma, and most patients present with metastatic or locally-advanced, unresectable disease. Metastasis to the gallbladder is an extremely rare entity. The present case is the first single case reported in English literature for a patient presenting with pancreatic ductal adenocarcinoma with gallbladder metastasis. Methods: A 44-year-old woman presented with obstructive jaundice and right upper quadrant abdominal pain, and was found to have a lesion in the head of the pancreas, with a suspicious nodule in the gallbladder. The patient underwent a pancreaticoduodenectomy, followed by a gemcitabine-based adjuvant chemotherapy. Histological examination revealed poorly differentiated adenocarcinoma of the pancreatic head, and metastatic pancreatic poorly differentiated adenocarcinoma involving the gallbladder. Results: Surgical resection offers the best chance of potential cure when the disease is limited to the pancreas. For patients with unresectable disease, the recommended treatment is usually palliative chemotherapy, which is reported to result in a mean survival time of approximately 6 months. In our case, the patient benefited from surgical resection despite distant metastases, and died of a cerebrovascular accident 22 months after the procedure. Conclusion: Surgical resection may benefit highly selected patients. Further research is needed to determine the value of surgical resection in patients with oligometastatic disease, particularly with regards to survival.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 144. MANAGEMENT OF GIANT HEPATIC ADENOMA IN A 32-WEEK PREGNANT WOMAN. RG Vaghjiani, G Doulaveris, C Muoser, A Mazur, J Bernstein, NE Judge, JP Rocca Presenter: Raj Vaghjiani MD | Montefiore Medical Center Background: The prevalence of hepatic adenomas is estimated at 30-40 cases per million women endorsing long term use of hormonal contraception. Historical descriptions of ruptured hepatic adenomas during pregnancy note a high maternal and fetal mortality (59% and 62% respectively), thus leading in part to the modern practice of surgical resection in child-bearing age women whose tumors exceed 5cm in diameter. Furthermore, the highest risk of adenoma rupture is conferred to those with tumors >10cm and in women who are in their third trimester of pregnancy, yet the optimal management of such patients, especially those with both risk factors, is unknown. Methods: Herein we describe our management of a 24 year-old primipara woman at 32 weeks gestation. Her medical history is only significant for celiac disease. At approximately 24 weeks gestation, she experienced severe epigastric pain which was originally thought to represent a celiac flare; a work-up initiated by her gastroenterologist included an abdominal sonography which revealed a large hepatic mass. A subsequent non-contrast MRI was performed and revealed a 16x10x10cm mass with an area of central heterogeneity. The mass was located in a subcapsular position in the left hepatic lobe. Her images were reviewed at our tertiary referral center and the radiographic characteristics were consistent with hepatocellular adenoma. In the setting of this large, symptomatic adenoma, she was admitted to the high-risk obstetrics service. Results: A multi-disciplinary meeting including maternal-fetal medicine, neonatology, anesthesiology, interventional radiology, and hepatobiliary surgery sought to determine the optimal balance between prematurity and the ongoing risk of devastating adenoma hemorrhage. After dosing antenatal corticosteroids for fetal lung maturity, a cesarean birth was carried out utilizing spinal anesthesia at week 33. A contingency plan of emergent interventional embolization was established in the event of symptom development or hemorrhage prior to or during delivery. Delivery was uneventful, repeat MRI with Gadolinium post-partum day 2 confirmed a highly vascularized adenoma with a central area of prior hemorrhage. On post-partum day 6, transarterial bland-embolization of the mass was performed and a post-procedure CT 2 days later demonstrated 60% necrosis of the mass. She was re-admitted 3 weeks after discharge due to a post-necrotic hepatic collection managed with percutaneous drainage. The current therapeutic plan is to proceed with laparoscopic resection of remnant viable adenoma 12 weeks after delivery in order to prevent complications from future from oral contraception or in future pregnancies. Conclusion: The management of giant hepatic adenomas during pregnancy is challenging due to the uncertainty of spontaneous rupture with an unacceptably high fetal and maternal mortality. There is very scarce published data on the occurrence of complications and optimal management in such situations. Hepatic treatment options during pregnancy, either surgical or interventional, can lead to complications affecting the pregnancy, while anticipating fetal delivery before week 34 can lead to short- and long-term complications in the newborn. This case report illustrates successful multidisciplinary management which weighed the risks of ruptured adenoma versus the risks associated with premature delivery. It also outlines the creation of a contingency plan in the case of peri-natal rupture and deferral of the definitive treatment of the adenoma once past the puerperal phase.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 145. FINDING THE NEEDLE IN THE HAYSTACK: MINIMALLY-INVASIVE REMOVAL OF INGESTED FOREIGN BODY FROM THE NECK OF THE PANCREAS A Crown, EJ Scott, FG Rocha Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 40yF presented to the emergency room with several episodes of acute pancreatitis. She described her symptoms as a sharp, stabbing pain in her epigastrium radiating to her back. Computed tomography (CT) scan showed an oblong, dense object projecting from the antrum to the stomach through the neck of the pancreas and abutting both the superior mesenteric vein and artery. (See Figure) The patient denied ingesting any foreign objects but admitted to keeping sewing needles above her microwave oven. An upper endoscopy did not reveal evidence of any intraluminal objects; however on endoscopic ultrasound, a metallic object could be visualized in the muscular wall of the stomach but unable to be removed. Given her symptoms, repeated pancreatitis and potential for development of vascular injury, operative extraction of the foreign body was recommended. Laparoscopic exploration began by dividing the gastrocolic ligament but inspection of the lesser sac did not reveal the foreign body. The surface of the pancreas was exposed and intraoperative ultrasound located the object that buried inside the pancreatic parenchyma. Given the concern for transmission of current with cautery to the mesenteric vasculature, decision was made to place an epigastric handport to palpate the pancreas. The distal end of the needle could be felt upon squeezing the gland and it was removed in its entirety. There was no bleeding or pancreatic leak and the patient was discharged on POD#3. A follow-up CT scan showed no evidence of a pseudoaneurysm and the patient is currently doing well without further episodes of pancreatitis. Ingested foreign bodies lodged in the pancreas can cause complications and should be removed minimally-invasively if possible.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 146. SQUAMOUS CELL CANCER OF THE TONGUE WITH METASTATIC DISEASE TO THE LIVER K Schaefer, H Aziz, R Harland, T Jie Presenter: Kenzie Schaefer BS | Banner University Medical Center Background: Two years ago, a 64-year-old man with a history of squamous cell cancer at the base of his tongue developed a metastatic lesion on segment 4 of his liver. Initially, the lesion was treated with radiofrequency ablation. However, he underwent a left hepatectomy when it recurred a year later Results: There was a large mass at the left lobe of the liver extended into segment 4. The middle hepatic vein was intimately involved but not invading into it. An ultrasound demonstrated that the cancer was not in the 1 branch of the middle hepatic vein. The right portal vein and hepatic artery were protected. The left hepatic artery and the left portal vein were divided right at the hila. We used the ERBE waterjet system to complete the parenchymal transection, and we used a staple to control the portal vein and the left hepatic vein. The surgical margin was negative. The pathology revealed metastatic squamous cell carcinoma with necrosis. Margins were negative. Conclusion: We point out that distant metastases of SCCs of the head and neck region can manifest in the liver. Therefore, when performing a tumor staging and during aftercare, this possible localization of metastases should be taken into consideration.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 147. GASTRIC CANCER IN A POST PANCREATICODUODENECTOMY PATIENT WITH ATM MUTATION - INTERESTING CASE I Siddiqui, E Lewis Presenter: Imran Siddiqui MD | St. Vincents Medical Center Background: 50 y old female with past history of ampullary cancer diagnosed 10 years prior. Patient underwent a pancreaticoduodenectomy and pathology was consistent with a poorly differentiated T4 lesion which was node negative and margin negative with lymphovascular and perineural invasion. Patient underwent adjuvant chemotherapy followed by chemo-radiation. She was found to have ATM mutation on genetic panel analysis. She was lost to follow up after completing surveillance for 5 years. She presented with anemia several years later and underwent an endoscopy which revealed an ulcerated mass in the stomach just proximal to the gastrojejunal anastomosis. Methods: She underwent endoscopic ultrasound which revealed a T2 lesion and no significant regional lymphadenopathy. Patient underwent staging scans including a PET-CT which did not demonstrate metastatic disease. She underwent oncologic surveillance with mammography and pap smear and gynecologic examination. She was started on perioperative regimen of FLOT (5-FU/leucovorin/oxaliplatin/docetaxel) and was taken to the operating room after restaging scans. Results: She underwent an exploratory laparotomy, extensive lysis of adhesions, subtotal gastrectomy and roux-en-y reconstruction of the biliopancreatic limb and the alimentary limb as well as completion celiac, hepatic and splenic lymphadenectomy with feeding jejunostomy tube placement. Patient was discharged home with an uneventful postoperative recovery. Conclusion: Final pathology demonstrated poorly differentiated diffuse type gastric adenocarcinoma with submucosal invasion( T1N0) with negative margins . Patient to complete perioperative chemotherapy with FLOT and then proceed with surveillance.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 148. DEVELOPMENT OF PANCREATO-PLEURAL FISTULA IN RECURRENT ACUTE ALCOHOLIC PANCREATITIS NA Royall, K Swanson, HV Tran, G Chow Presenter: Kerry Swanson BS | The University of Oklahoma Background: Pancreato-Pleural Fistula (PPF) is a rare complication of pancreatitis, reported to occur in approximately 0.4% of episodes of pancreatitis. PPF often presents in the setting of progressive respiratory distress following transient clinical improvement. Diagnosis is made using a combination of imaging demonstrating pleural effusion and characteristic elevation of pleural fluid:serum amylase ratio on paracentesis. Methods: A 62-year-old female with history of severe acute alcoholic pancreatitis, hypertension, non-oxygen dependent COPD, and anxiety presented with recurrent severe acute alcoholic pancreatitis with elevated lipase and abdominal pain. Initial CT scan revealed a 1.7 cm acute necrotic collection in the body and uncinate process of the pancreas. On hospital day eight, worsening symptoms led to transfer for a higher level of care. Repeat CT revealed development of a large acute peripancreatic fluid collection and left-sided pleural effusion. With persistent leukocytosis and worsening symptoms, she was started on antibiotics and percutaneous retroperitoneal drains were placed by interventional radiology (IR) for suspected infected pancreatitis. Serial pancreatic fluid and blood were negative. Results: The patient developed recurrent respiratory failure requiring intubation. A thoracentesis was performed, and pleural fluid amylase was markedly elevated compared to serum amylase, consistent with PPF. She was treated with conservative management using octreotide and a tunneled thoracostomy tube for intermittent drainage. The thoracostomy tube output decreased significantly and she demonstrated clinical improvement with eventual extubation. She was discharged to a skilled nursing facility for continued recovery with planned follow-up and non-operative management. On follow-up her PPF was found to have resolved evidenced by resolution of the effusion and pleural fluid without measurable lipase. Conclusion: PPF is a rare complication of acute pancreatitis and there should be a high index of suspicion in patients with persistent or recurrent respiratory failure. Early diagnosis using pleural:serum amylase ratios and referral to Hepato-Pancreato-Biliary Surgery may improve the associated morbidity and mortality. Conservative therapy using octreotide and intermittent pleural drainage may facilitate resolution. Refractory PPF requires pancreatic ductal imaging and interventional therapy using either endoscopic or surgical therapies.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 149. SMALL BOWEL ADENOMYOMA: AN INCIDENTAL INTRAOPERATIVE FINDING DURING HEPATECOJEJUNOSTOMY FOR CBD INJURY MA Tabbal, HA Omran, NK Mansi, MS Qahtani Presenter: Mahmoud Tabbal MD | King Fahad Specialist Hospital Background: Adenomyoma is a benign lesion that’s most commonly seen in the gallbladder, however, rare cases have been reported where this pathology was encountered in the vicinity of the gastrointestinal tract; most frequently in the pyloric region of the stomach, followed by the periampullary area of the small intestine, and only 26 cases reported to occur in the jejunum and the ileum. The pathogenesis of this lesion is still a controversy, with the previous reports suggesting it to be either a form of hamartoma or incomplete heterotopic pancreas Methods: Hereby we report a case of a 58 year-old gentleman who was referred to our HPB facility with CBD injury post laparoscopic cholecystectomy for hepatecojejunostomy. Intraoperatively, an intralumenal, jejunal mass was found measuring 2x2 cm and about 95 cm from the DJ junction. The lesion was resected with safety margins, and primary anastomosis was done. The final histopathology of the specimen was consistent with adenomyoma, and all of the surgical margins we free. Results: The patient was found incidentally to have a mass in the small bowel that was resected and confirmed to be adenomyoma. The usual clinical presentation is variable depending on the location of the lesion, with the periampullary lesions presenting with obstructive jaundice, while jejunal and ileal lesions may present with intussusception, GI bleeding, or can be an incidental finding during surgery or autopsy [2-6]. Although there is no specified management guidelines for this pathology due to the low incidence, the prognosis is all in all good, and simple surgical resection is all what is needed, however, aggressive surgical approaches, such as pancreaticoduodenectomy for periampullary adenomyoma, were done in the previous reports due to the misdiagnosis with carcinoma preoperatively; hence knowledge of the nature of the lesion is important to avoid unnecessary extensive surgery Conclusion: Adenomyoma of the small bowel is a rare entity, it's worth reporting this finding to norish the litrature. The diagnosis was confirmed by histopathology and the patient needed no more treatment for this lesion after the resection.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 150. EXPRESSION LEVEL OF NRP1 AND SMAD2 IN CORRELATION TO MUTATIONAL STATUS OF RAS (BRAF) IN PANCREATIC CANCER L Stanek, R Gurlich, J Hrudka, J Hajer, L Havlů, Z Musil, J Neuzil, M Oliverius, R Soumarova Presenter: Robert Gürlich MD | Charles University and University Hospital Kralovske Vinohrady Background: Pancreatic cancer is the second leading cause of death in tumor diseases worldwide. There are more than 300 thousands of newly diagnosed patients and majority of them die eventually. In the pathogenesis, several genes play important role. These include oncogenes, tumor suppressor genes and its related proteins of signal pathways of VEGF and EGFR with a RAS domain. It appears that the gene neuropilin NRP-1 coding for one of the two neuropilins, that bind many ligands, affect cell survival and migration ability. Methods: Retrospective study is based on analysis of 50 FFPE bioptical samples (40 resections, 8 punctures, 2 thin-needle biopsies); histology verified all as adenocarcinomas. The expression level of NRP1 and SMAD2 is measured by IHC by mice monoclonal antibodies Anti-Neuropilin 1 and Anti-SMAD2 (Abcan) on the device BenchMark ULTRA (Ventana Medical Systems), Roche. DNA isolation is executed by QIAamp® DNA Mini Kit. We used Codon Specific Mutation Detection Kit (Diatech pharmacogenetics) for detection of somatic point mutations in codons 12, 13, 61 and 146 of KRAS and NRAS genes. BRAF mutational status was revealed by direct sequencing on ABI Prism 3130. We monitor the level of expression of NRP1 and SMAD2 and correlate it to the mutational status of RAS and BRAF, and disease prognosis. Conclusion: We assume that causal relationship exists between inactive NRP1 and wild-type KRAS, and that these should cause decrease of the rate of tumor growth. These characteristics, which are achievable simultaneously during the histological verification, may serve as a potential prognostic marker for subsequent decision of how radical surgical resection should be. Acknowledgement This work was supported by the research programme of Charles University PROGRES Q28 (Oncology) and the research programme AZV 17-30138A.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 151. HEPATOBILIARY CYSTADENOMAS WIHT AND WITHOUT BILIARY LEAK MJ Zeoli, G Andreoli, P Vanerio, R Valiñas Presenter: Mariana Zeoli MD | Hospital de Clínicas Background: The incidence of benign tumors such as biliary cystadenoma is very low, its finding is generally incidental. The definitive diagnosis is anatomopathological. Histologically, 3 types of cystadenomas are defined, the first with mesenchymal stroma similar to ovarian tissue, it is the most frequent in women. The second with absence of mesenchymal is more frequent in men. The third and rarer type also has no mesenchymal stroma and instead has eosinophilic epithelial cells. Despite the improvement in imaging tests, differential diagnosis is sometimes difficult and may be confused, as in the first case, with simple cysts or with hydatid cystst. Methods: Clinical Case 1 - Female, 41 years old. Multiple consultations for pain in HD, Fever, coluria in the last 8 months. Physical examination without particularities. Functional Hepatic: only the increase in Gammaglutamyltranspeptidase (GGT) stands out. Clinical case 2 - Female, 54 years old, recurrent vesicular colic, echo of abdomen: vesicular lithiasis, polylobulated cyst, segment VI. Tomography: segment VI well defined cystic lesion, with polylobulated contours, measures 31 x 41 x 41 mm. Results: Case 1: Ultrasound: Vesicle without lithiasis, no dilation of the bile duct. Tomography: right lobe, cystic image 60 mm, echogenic walls with sediment slope. Serology for positive hydatidosis. Initial diagnosis: hepatic echinococcosis The surgery: Cyst 5 - 6 cm. Sectors in communication with posterolateral bile duct. Walls 3-4 mm not calcified. Endothelium coating. Biliary purulent content + microlithiasis. Case 2: In its interior multiple septa that seem to converge towards its center, no nodular sectors or calcium are visualized inside. Fine bile way. Initial diagnosis: Symptomatic cystic tumor Surgery: Segmentectomy VI. In these two cases the pathological anatomy certifies: mucinous cystadenomas Conclusion: The suspicion of hepatic cystadenoma is fundamental in the therapeutic, are infrequent tumors less than 5%, and its malignant potential makes this surgery indicated. Normality in tumor markers such as CA19-9 and carcinoembryonic antigen does not exclude the diagnosis. Rule out differential diagnoses as in our first case, hepatic echinococcosis. Major hepatectomies or lobectomies should be taken into consideration depending on the tumor location and resulting hepatic reserve. Not indicating another type of minor surgical treatment, such as drainage or unroofing of the lesion, due to the high probability of recurrence or to that it is a malignant lesion after the complete histological study of the piece.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 152. LONG TERM OPIATE ABUSE AND COMMON BILIARY DUCT DILATATION S Tuler, N Sayedy, P Srivastava, A McEvoy, N Khimitch, J Singh Presenter: Shahaf Tuler MS4 | Nassau University Medical Center Background: Acalculous common bile duct dilation secondary to chronic opioid use is a rare event that has largely only been reported in case reports. Although it is typically discovered incidentally in asymptomatic patients, it should not be ignored due to overlap with more serious hepatobiliary pathology. This especially true given the increasing use of methadone and increased risk of complications in the patients receiving this medication. Methods: Learning objectives: 1. Showcase the typical risk factors and clinical presentation of a patient with methadone-induced common bile duct dilation 2. Discuss the imaging modalities used to confirm diagnosis 3. Demonstrate the clinical importance of this finding and how it may impact future management of patients Results: 64-year-old African American male with past medical history of HIV/AIDS hepatitis C, chronic obstructive pulmonary disease, chronic kidney disease and opioid dependence was admitted for COPD exacerbation and respiratory failure. The patient’s hospital course was complicated by sepsis. Incidentally, common bile duct dilation of 1.1 cm was discovered on CT thorax. Despite no patient complaints of nausea, vomiting, or right upper quadrant pain, the degree of dilation warranted further investigation. Laboratory studies revealed a normal bilirubin level and only mildly elevated liver enzymes. MRCP revealed bile duct dilation extending from the common bile duct into the intrahepatic ducts. Despite the extent of dilation, the patient remained asymptomatic throughout the hospital course. Conclusion: As evidenced by this case, common bile duct dilation due to chronic opioid use is typically a benign finding. However, due to the increased frequency of methadone use in patients with Hepatitis C, a diagnostic work-up is still required to rule out hepatocellular carcinoma and cirrhosis. Imaging options include endoscopic ultrasound, Endoscopic retrograde cholangiopancreatography, and Magnetic resonance cholangiopancreatography. Once a diagnosis is made, clinicians should be aware of possible complications which most notably include cholangitis secondary to biliary stasis, impaired liver function due to backflow of bile, and pancreatitis. The frequency of complications is not widely studied, but may be warranted as the use of methadone increases.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 153. UPPER DIGESTIVE HEMORRAGE OF UNCERTAIN ORIGIN: HEMOSUCCUS PANCREATICUS V Cardona, A Garcia, H Alejandro, AL Pierini, AF Rabellino Presenter: Leandro Pierini MD | Hospital J. B. Iturraspe Background: A patient’s case with Upper Gastrointestinal Bleeding of unknow origin is presented, that has been studied through a six months lapse, in which the patient, during his evolution, develops a hemodynamic instability state. The article’s objective is to introduce a rare differential diagnosis that should not be excluded, the Hemossucus Pancreaticus. This entity is seen, mainly, in patient whit a history of alcoholism, chronic pancreatitis or aneurysm peripancreatic arteries. It’s shown as an acute bleeding case or, most commonly, as intermittent episodes whit the presence of melena.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 154. OBSTRUCTIVE JAUNDICE, GALLBLADDER CANCER VS MIRIZZI SYNDROME? B Conde, AS Valero, JA González, JI Miota, JL Rueda, C Camacho, O Luengo, A Sánchez, B Aguado, E García Presenter: Belén Conde MS | Complejo Hospitalario Universitario de Albacete Background: Mirizzi syndrome is a complication of long standing cholelithiasis. The reported incidence has ranged from 0.7 to 1.4% of all patients undergoing surgery for cholelithiasis. In this, obstruction of the extrahepatic bile duct by stone/s in the Hartman’s pouch or cystic duct (Mirrizi type I) may erode in to the bile duct forming cholecystobiliary fistula (Mirrizi type II). Methods: We report the case of a 84-year-old Spanish man who presented with abdominal pain and jaundice for 1 week. The results of laboratory studies TBIL 22.3 μM/L, DBIL 19.9 μM/L. Ultrasonography and CT scanning showed an atrophic gallbladder that was full of stones with thickened walls and uneven internal density, as well as dilatation of the intrahepatic bile duct and common hepatic duct. MRCP showed dilatation of the intrahepatic bile ducts and truncation of the common hepatic duct, with faint signal in both of them. Surgical findings included confirmation of the atrophic gallbladder, with a stone (2cm) impacted in the finaly of cystic duct. Therefore, cholecystectomy and commun hepaticojejunal Roux-en-Y internal drainage operation were carried out. He was discharged after an uneventful postoperative course. Results: Mirizzi syndrome, characterized by bile duct obstruction due to stone in Hartman’s pouch or cystic duct is classified in to two types. Obstruction by external compression is classified as type I and that by an eroding stone forming a cholecystobiliary fi stula as type II. Mirizzi syndrome is generally characterized by abdominal pain, jaundice, and abnormal liver function tests. However, patients with gallstones and bile duct stones often show the same clinical characteristics. Mirizzi syndrome diagnostics´ is difficult, despite the fact that there are various imaging techniques currently available, most of them have difficulties in identifying it before surgery, especially with pre-operative fistulas and the degree of adhesion and fibrosis. Cholangiography remains the mainstay of diagnosis. An eccentric filling defect in common duct at the level of gallbladder with proximally dilated and distally collapsed bile duct suggests Mirizzi syndrome. The reported incidence of gallbladder cancer in patients with Mirizzi syndrome ranges from 5 to 28%, these data can be must possible a intense and prolongation inflamation of the gallbladder. The key point for patients with Mirizzi syndrome is to consider this special type of syndrome pre-operatively and formulate surgical plans that will provide the best treatment and avoid incidental injuries and complications. Conclusion: Mirizzi syndrome diagnostics´ is difficult for its low prevalence. It is important a careful image tests interpretation. They can help surgeons to diagnose these syndrome accurately and provide optimal treatment.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 155. PROLONGED DELAYED GRAFT FUNCTION IN AN ORTHOTOPIC LIVER TRANSPLANTATION RECIPIENT: A CASE REPORT JF Barandiaran Cornejo, GS Xiao Presenter: Jose Barandiaran Cornejo MD | Drexel University College of Medicine Background: Patients undergoing orthotopic liver transplantation (OLT) can be a considerably complex population to manage post-operatively, as there are several potential complications that can arise during this period, with etiologies ranging from vascular, biliary, immune-mediated, infectious, or other causes. Any of these complications can be responsible for early graft dysfunction or delayed graft function (DGF). In each of these scenarios, the patient must be worked up in a timely manner, in order for the transplant surgeon to determine feasibility to manage the aforementioned complications conservatively, versus returning to the operating room, or even considering relisting the patient for a new organ. Methods: This is a single center, retrospective chart review of a single patient at Hahnemann University Hospital status post OLT demonstrating significantly prolonged DGF over the course of approximately four months. The data was abstracted retrospectively from the inpatient electronic medical record system, CERNER, to include sociodemographic, clinical, and management information. The primary objective of this case report is to describe the clinical and laboratory changes observed in this patient starting from post-operative day one, until normal graft function was achieved, while focusing on the non-surgical interventions performed during this time period. Results: A 56 year old male with a history of end-stage liver disease due to nonalchololic steatohepatitis with cirrhosis underwent OLT, with allograft obtained through donation after cadiac death and with biopsy proven 5 - 10% microsteatosis with no macrosteatosis, and positive hepatitis B virus and CMV serology. His post-operative course was complicated by persistent C. difficile diarrhea treated with antibiotics and eventual fecal transplantation, and multiple bile leaks originally found at the level of the donor cystic duct remnant, and later at the native cystic stump and at the anastomosis. This was reflected in laboratory results as a persistent cholestatic pattern with total bilirubin levels peaking at about 45 mg/dL with direct bilirubin fraction at about 30 mg/dL over one month after OLT. Biopsy of the allograft showed no signs of acute rejection and imaging consistent with normal vasculature and blood flow. This was managed over the course of the first four months post OLT with up to four ERCP procedures with biliary stents placement, and two visits to interventional radiology for percutaneous biliary drain placement due to hepatic collection and bacteremia. Cholestatic laboratory markers started to slowly decrease around week five after OLT, at which point the patient was deemed ready to be discharged to a local rehabilitation center, and finally they were normalized around the four-month mark. No other surgical interventions were performed during this period of time. Conclusion: Post-operative OLT patients are a complex demographic to manage clinically due to a wide array of potential complications, which can manifest either as early graft dysfunction or DGF. During these complications, there is always a question of whether the patient will need a surgical intervention or if a more conservative approach can be used to overcome said complications. This case report highlights how despite initial graft dysfunction post transplantation, demonstrated by abnormal liver function markers, a new graft can potentially achieve normal function even after prolonged periods of time via medical management and non-surgical interventions. This is clinically significant, as this approach could potentially save this fragile population an unnecessary surgical intervention, and/or prevent relisting. Further research is needed investigating this topic.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #5 P 156. LAPAROSCOPIC DISTAL PANCREATECTOMY USING 3D-MODEL NAVIGATION SYSTEM M Yasunaga, K Ryuuichi Kawahara, H Sakai, H Ishikawa, T Hisaka, Y Akagi, K Okuda Presenter: Masafumi Yasunaga MD | Kurume University School of Medicine Background: Three dimensional (3D) visualization has a critical impact on surgical decision making and 3D digital models of patient physical phantoms can be made commercially. we have experienced not a few cases to be difficult to understand and identify vascular anatomy by the lack of three dimensional perception in the 2D-image. Our institute introduced laparoscopic distal pancreatectomy (Lap DP) using 3D virtual reality(VR) image and 3D printer model for intraoperative navigation system. Methods: From November 2008 to March 2018, a total of 25 patients underwent Lap DP for benign/ low grade malignant pancreatic tumor. CT images containing pancreatic lesions were segmented into pancreas tissue, contrast-enhanced vessels, and pancreatic tumor using Synapse Vincent (Fuji Film, Japan). Results: 25 patients underwent LAP-DP. In the Lap-DP, the median blood loss was 238cc, the median operating times was 363 min. The postoperative hospital stay after Lap-DP was 15.2 days. In morbidity for Lap-DP, pancreatic fistula, rebleeding, were one case(ISGPF-Grade B), one case(reoperation). Conclusion: It became possible to create an inexpensive 3D model of the pancreas for surgical navigation system. The 3D visualization is useful for optimizing the operation scheme preoperatively and navigation surgery accurately intraoperatively in real time.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 157. PNAKTIDE ABROGATES ACCELERATED LIVER CELLS AGING/SENESCENCE INDUCED BY WESTERN DIET IN THE RODENT A Mallick, JA Sanabria, M Schade, R Aguilar, M Andryka, D Schlatzer, X Li, FE Hazlett, M Kachman, A Raskind, H Brunengraber, K Sodhi, S Pierre, US Udon, Z Xie, J Shapiro, J Sanabria Presenter: Juan Sanabria MD, MSc | Case Western, Marshall University Background: Global incidence/prevalence of chronic liver disease and its sequels ESLD/HCC are increasing, especially in people over 70 years as a consequence of prolonged human life expectancy, to an increase prevalence of HCV and a continuous spread of the metabolic disturbances related to the obesity epidemics. Although surgical procedures are expected to increase in number and complexity in the older, they may be limited by comorbidities and stage of disease at presentation. We hypothesized Western diet accelerates aging cell processes inducing liver cell portfolio to senescence/apoptotic activity with altered metabolic cycles and disturbed gut-microbiota communities mainly though a Src pathway. Methods: C57Bl6J♀ mice were exposed to normal mouse chow or high fat diet. Liver/plasma were collected at different stages of animal aging (7, 12, 16, 20, 24 and 48W). Body compartments were determined by MRI spectroscopy. The proportion of senescence cells was determined against apoptotic activity/collagen deposition. Terminal ileum/microbiota was collected and total DNA was extracted to achieve microbial community profiling by sequencing 16S rRNA v3-v4 hypervariable regions. Protein expression of cell metabolism/senescence genes (Tp53, mTOR1, Src, SIRT7, FOX01, Grb2) were determined by Western Blots. While oxidative stress was determined by glutathione sp, mitochondrial ß -lipid oxidation/insulin resistance were determined by octanoate/butyrate ratio and glucose in plasma. Metabolites were measured in treated plasma by LC/MS-MS. High output variables were interrogated by Principal component analyses (PCA).. Results: The total body weight increased with aging manly due to an increase in the fat compartment with decreased lean mass and total body water (p<0.05); changes that correlated with an increased proportion of liver cells in senescence/apoptosis (p<0.05). Morphological changes correlated with Src peak gene expression and Na/K-exchange pump activity (p<0.05). Glutathione sp. as well as both mitochondrial ß-lipid oxidation and glucose degradation cycles were disturbed with aging, changes significantly accentuated in animals exposed to HFD. Metabolic disturbances were log10 transformed to construct heat maps. Metabolic changes of animals in HFD (Figure 1A, HFD vs NMC=CTRL, p<0.01) differed significantly from animals on HFD treated with pNaKtide (Figure 1B, HFD+pNaKtide vs NMC, p<0.01). A shift in the gut-microbiota communities were observed in the mice fed HFD, shift corrected by pNaKtide (Figure 1C, p<0.01). A significant increase in Verrucomicrobia was observed in the HFD group when compared to the NMC group (p<0.05). Additionally, a significant decrease in Bacteroidetes was noted (p<0.05). pNaKtide, a 33 amino-peptide blocks the activation of Src at the α1-Na/K-ATPase subunit site abrogating metabolic, genetic and morphologic changes with normalization of mitochondrial ß-lipid oxidation through up-regulation of the PPARγ-PGC-1α complex and returning insulin sensitivity through up-regulation of the FOX01 pathway; phenotype characterized by paucity of apoptotic activity, reversal of liver fibrosis and physiological cell oxi-redox status. Conclusion: Western diet accelerates physiological liver cell aging manifested by decreased mitochondrial β-lipid oxidation, disturbed glucose degradation, decreased cell oxi-redox status and increase cell senescence/apoptotic activity with increased liver fibrosis. Changes associated with significant changes in the gut-microbiota communities and abrogated by pNaKtide through a Src/FOX01 circuit. Metabolic prints, glutathione sp. and apoptotic activity in plasma in addition to microbiota communities in stool may serve as a liver biopsy surrogate. Src pathway blockade may further be explored for its translation to the treatment of NASH and early cirrhosis. Nevertheless, its role in the treatment /prevention of advance cirrhosis/HCC remains to be determined.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 158. THE DEVELOPMENT AND IMPLEMENTATION OF LAPAROSCOPIC DISTAL PANCREATECTOMY IN THE UNITED KINGDOM: INDICATIONS, RESULTS AND LEARNING CURVE OF 570 PATIENTS S Lof, A Moekotte, S White, R Marudanayagam, B Al-Sarireh, G Kito, F Soonawalla, Z Damien, D Somaiah, A Basil, A Dhanny Gomez, G Marangoni, M Abu Hilal Presenter: Sanne Lof MD | University Hospital Southampton NHS Foundation Trust Background: Laparoscopic distal pancreatectomy (LDP) is increasingly performed due to favourable perioperative outcomes. Nevertheless, data on the development of LDP on a nationwide level is lacking. This study investigated the development and learning curve of LDP in the United Kingdom (UK). Methods: A retrospective study of patients undergoing LDP in eleven tertiary referral centres in the UK between 2006 and 2016 was performed. Development of perioperative outcomes and indications was examined by differences in trends over time periods (2006-2009, 2010-2013, 2014-2016). For learning curve analysis the first 15 LDP cases performed of each centre were combined and compared to the subsequent cases. Results: In total, 570 LDP’s were included in the analysis. Median operating time was 240 min (interquartile [IQR] 182-300) with a median blood loss 200 mL (IQR 100-350). The rate of conversion to open distal pancreatectomy was 69 (12%). Most resected tumours were neuro-endocrine tumours (n = 152 [27%]), mucinous cystic neoplasm (n = 112 [20%]) and pancreatic ductal adenocarcinoma (n = 86 [15%]). Concomitant splenectomy was performed in 68% (n = 385) of the cases. Complications occurred in 49% (n = 276) of patients. The incidence of International Study Group on Pancreatic Fistula grade (POPF) B/C was 87 (15%). 26 (5%) patients required a reoperation. A low 90-day mortality of 1.4% (n = 8) occurred. Total length of hospital stay was 6 days (IQR 5 to 8 days). Over time, LDP gained popularity and was more frequently used for PDAC (7% [n = 5] vs 19% [n = 47]; P = 0.005) in the UK. Learning curve analysis showed improvement of estimated blood loss, rate of blood transfusions, complication rate (including POPF) and length of stay after the first 30 patients. Conclusion: Laparoscopic distal pancreatectomy is increasingly considered as a useful technique for lesions of the distal pancreas, included PDAC. Clear improvements of perioperative outcomes were found with expanding experience in LPD.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 159. SHORT TERM OUTCOMES OF MINIMALLY INVASIVE VERSUS OPEN MAJOR LIVER RESECTION N DelPiccolo, E Onkendi, S Patel, H Asbun, J Burns, K Croome, J Stauffer, J Nguyen Presenter: Nico DelPiccolo MD | Mayo Clinic, Florida Background: Minimally invasive major liver surgery (MIMLS) in increasingly being performed in tertiary centers. Two main approaches utilized are hand-assisted laparoscopic surgery (HALS) and totally laparoscopic surgery (TLS). It is unclear whether or not there are short-term benefits to doing the procedures minimally invasive instead of traditional open approach. Our aim was to compare short-term (90-day) outcomes in major hepatic resections when minimally invasive approaches are attempted versus when they are not. Methods: At our institution, MIS liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who major liver resection (defined as resection of 3 or more anatomic segments) between January 2007 and December 2017 at our institution. We then analyzed the demographic and perioperative and surgical outcomes retrospectively. Results: From 1/2007 to 12/2017, 669 patients underwent liver surgery. Of these, 203 patients (30%) underwent major hepatic resection. MIMLS was attempted in 68 patients (30 TLS, 48 HALS). 16 of these patients were converted to an open procedure (these 16 patients were analyzed in the minimally invasive group). There were 135 patients who underwent open major liver surgery (OMLS). Overall, MIMLS was associated with a similar duration of operation time (314 minutes vs 290 minutes; p=0.291), similar blood loss (971 mL vs 935 mL; p=0.064), transfusion rate (24% vs 28%; p=0.544) and transfusion volume (4.6 units vs 4.2 units; p=0.230), and a shorter average postoperative hospital stay (6.2 days vs 7.9 days; p=0.0110) and shorter average ICU stay (0.66 days vs 0.90 days; p=.0299) compared with OMLS. There were no significant differences in 90 day mortality or complication rates. Conclusion: The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques and may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day post-operative complications.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 160. A COMPARISON OF LYMPH NODE RATIO WITH AJCC LYMPH NODE STATUS FOR SURVIVAL AFTER RESECTION FOR PANCREATIC ADENOCARCINOMA Y Essaji, AG Doumouras, PE Serrano, L Ruo Presenter: Yasmin Essaji MD | McMaster University Background: Metastatic lymph node involvement is a strong predictor of survival after resection for pancreatic adenocarcinoma (PDAC). Lymph node ratio (LNR) has been proposed as a novel marker of poor outcome in resected periampullary and other malignancies. We compared LNR with the current stratification of lymph node (LN) status by AJCC criteria (7th edition and 8th edition) for predicting prognosis. Methods: We identified 150 patients from a prospective surgical database who underwent pancreatic resection for PDAC from January 2011 to December 2013. The predictive value of LNR for 2-year survival using a Cox proportional hazards model was calculated. Clinicopathological risk factors for survival including patient comorbidities by Charlson Comorbidity Index were evaluated by univariate and multivariate analyses. The predictive power was determined by plotting non-parametric receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC) to compare LNR greater than 25% and nodal status as defined by the AJCC 7th and 8th editions. Results: Mean LNR was 0.183 (range 0-0.883) with mean overall survival of 568 days (range 10 – 2262). LNR in patients with survival less than 2 years was higher 0.276 (range 0 – 0.654). Patients who survived beyond 2 years had LNR 0.131 (range 0 – 0.389). Comparative analysis using receiver operating characteristic (ROC) curves established that patients with 4 or more positive LN had the highest accuracy for predicting overall survival (AUC 0.6015). LNR >25% and patients with any LN positive had similar accuracy for predicting overall survival (AUC 0.556 and 0.553 respectively). Having 1-3 positive LN was not predictive of survival in this population. Conclusion: The presence of 4 or more positive LN has the highest accuracy in predicting overall survival in patients with resected PDAC. Recent changes in nodal staging for PDAC according to the AJCC 8th edition appears to have improved prognostication.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 161. COMPARING OUTCOMES BETWEEN SURGICAL APPROACHES IN HEPATOCELLULAR CARCINOMA WITHIN THE MOUNTAIN REGION DJ Cheng, CR St. Hill, C Cross, JL Baynosa, DM Kirgan Presenter: Daniel Cheng MD, MPH | University of Nevada Las Vegas School of Medicine Background: Treatment patterns for hepatocellular carcinoma (HCC) vary across the nation, and there is currently little literature looking specifically at the Mountain Region (MR). We previously demonstrated that patients treated at Academic Centers (ACs), compared to those treated at Non-Academic Centers (NACs), had overall improved survival, were more likely to receive or be recommended surgical treatment, and were less likely to have positive margins. Our objective is to explore the effect of surgical approach on positive margin status and whether these differences in perioperative oncologic outcomes contribute to survival. Methods: Using the National Cancer Database (NCDB), we identified 6,500 HCC cases from 2004 to 2015 in the MR (AZ, CO, ID, MT, NM, NV, UT, WY). Of these cases, 3,494 (53.8%) were treated at NACs and 3,006 (46.2%) were treated at ACs. Surgical treatment was performed in 859 cases. Using logistical regression analysis, we compared surgical (including local tumor destruction) treatment patterns and positive margin status through several clinical and demographic strata. Cox proportional hazard regression and Kaplan-Meier analysis was performed to examine the effect of surgical approach on survival. A subgroup analysis was repeated within the AC and NAC subgroups. Results: There were significant differences in age, gender, race, ethnicity, Charlson/Deyo Score, NCDB Analytic Stage Group, Great Circle Distance, Primary Payer, systemic treatment, radiation treatment, and surgical approach between AC and NAC cases (p<0.01). Logistical regression and Cox proportional hazard regression were performed to control for these differences. Overall, the odds of positive margins were 3.11 times higher (p<0.01) with a laparoscopic approach compared to open or unspecified. A laparoscopic approach had a 1.94 times increased hazard (p<0.01), compared to open or unspecified. On subgroup analysis, the odds of positive margins at ACs were not significantly different between surgical approaches. The odds of positive margins at NACs were 3.493 times higher with a laparoscopic approach compared to open or unspecified (p=0.01). Conclusion: Overall, a laparoscopic approach increased the odds of positive margins. This perioperative oncologic outcome may be associated with the overall decreased survival in patients undergoing a laparoscopic approach, compared to open or unspecified. Within ACs, a laparoscopic approach was similarly associated with decreased survival, suggesting that increased survival at ACs may be associated with the higher rate of open approaches at ACs, compared to NACs. Further research is warranted to account for the differences in outcomes between open and laparoscopic approaches for HCC.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 162. COMPARISON OF SURVIVAL OF CHEMOTHERAPY AND SURGERY VS. SURGERY ALONE FOR RESECTABLE COLORECTAL LIVER METASTASIS B Teoh, B Teoh, S Prabhakaran, CC Behrenbruch, I Hayes, F Hollande, AG Heriot, M Michael, B Knowles, BN Thomson Presenter: Basilie Teoh MBBS | Peter MacCallum Cancer Centre Background: Surgery is the only potentially curative treatment for patients with colorectal liver metastases. In patients with resectable or borderline resectable liver metastasis(es) at diagnosis, the routine use of neoadjuvant chemotherapy remains controversial as no overall survival benefit has been shown and there is a proportion of patients who will progress during treatment. Methods: We conducted a retrospective cohort study comparing the survival outcomes of patients with resectable or borderline colorectal liver metastasis at diagnosis, who either had neoadjuvant chemotherapy followed by surgery, or surgery alone. Data was collected from two tertiary referral centres over a period of 13 years from a prospective database of all patients undergoing liver resection for colorectal cancer. Patients were excluded if there was evidence of extra-hepatic metastases on presentation. The primary endpoint was progression free survival. Results: A total of 61 patients were included. Of these, 24 (39%) had chemotherapy prior to liver resection and 37 (61%) had upfront liver resection. FOLFOX was given in the majority of the patients who received chemotherapy. Minor liver resections were performed in 23 (38%) patients, while 38 (62%) patients had major resections. The mean patient age at presentation with liver metastasis was 59 years and the majority of patients were male (61%). The median follow up was 38 months. The site of the primary tumour was predominantly within the rectum at 43% (26/61), with 33% (20/61) located in the left colon, 3% (2/61) in the transverse colon, and 18% (11/61) in the right colon. A total of 24 (39%) patients had disease progression following liver resection. 24 patients received neoadjuvant chemotherapy, of which 10 (42%) progressed post liver resection. 37 patients had surgery only, and 14 (38%) progressed post operatively. The median progression free survival for the group that received neoadjuvant chemotherapy was 16 months and in the surgery only group it was 12.75 months (p = 0.42). Conclusion: Our interim analysis suggests that there is no statistically significant difference in progression free survival between patients who either had neoadjuvant chemotherapy followed by surgery compared with surgery alone. Further multivariate analysis is being undertaken to determine any other contributing factors to the difference in progression free survival between the two groups.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 163. DOES PRACTICE MAKE PERFECT FOR PANCREATIC ADENOCARCINOMA? HIGHER VOLUME CENTERS DELIVERING CHEMORADIATION ARE ASSOCIATED WITH IMPROVED SURGICAL AND SURVIVAL OUTCOMES LA Bliss, AN Krepline, CA Barnes, KK Christians, B George, PS Ritch, BA Erickson, DB Evans, WA Hall, S Tsai Presenter: Lindsay Bliss MD, MPH | Medical College of Wisconsin Background: Chemoradiation delivery prior to surgical resection for pancreatic cancer theoretically may improve local control and thereby increase patient survival. Radiation techniques and concomitant chemotherapy regimens vary between centers. Facilities that have a higher patient volume receiving neoadjuvant chemoradiation may have superior radiation planning and delivery as well as supportive care. This study addresses the impact of volume of neoadjuvant chemoradiation on patient outcome. Methods: Patients with localized pancreatic adenocarcinoma who received neoadjuvant chemoradiation and surgery were identified in the National Cancer Database (NCDB) from 2006 to 2015. Facilities were stratified into low- and high-volume based on number of patients receiving neoadjuvant chemoradiation (cut point = 12). Surgical margin status, lymph node status, readmissions, mortality, and survival were compared between patients at low-volume and high-volume centers as well as patients referred elsewhere for neoadjuvant radiation. Fisher’s exact test was used to compare categorical variables between groups. Other than survival time, continuous variables were categorized. Survival was compared using Kaplan-Meier plots and the log-rank test. Cox proportional hazard regression was used to model survival time. Results: Of the 933 patients identified, 312 (33 %) received treatment at high-volume facilities and 621 (67%) received treatment at low-volume facilities. Over time, a larger portion of patients were treated at low-volume centers (74.10% in 2014-2015 vs 54.65% in 2006-2007, p=0.05). Among those treated at high-volume centers, more patients were female (54.17% vs 46.86%, p=0.037) and patients were treated at an earlier stage of disease (high-volume: stage I 25.32%, stage II 64.42%, stage III 10.26%; low-volume: stage I 21.7%, stage II 56.20%, stage III 22.06%; p<0.05). The percentage of patients age 65 years or greater, burden of co-morbidities, and local income, education and population density levels did not differ from high- and low-volume centers. Patients treated at high-volume chemoradiation facilities were more likely to have negative margins following resection (91.50% vs 84.78%, p<0.05). There was no difference in the number of lymph nodes examined, the frequency of node positivity, or the rates of complete pathologic response. Patients treated at high-volume centers had no difference in 30- or 90-day mortality rates. Post-operatively, patients at high-volume centers were more likely to undergo adjuvant therapy (33.65% vs 20.93%, p<0.05). The median survival of patients treated at high-volume centers was 31.84 months compared to 24.71 months at low-volume centers (p<0.05). Conclusion: Most patients receiving neoadjuvant chemoradiation therapy do not receive care at facilities frequently providing this service. Patients treated at high-volume centers have increased rates of negative margins at the time of resection as well as improved overall survival. The volume-outcome relationship that has been demonstrated in pancreatic surgery may translate to neoadjuvant chemoradiation, adding even further complexity to the challenge of operationalizing this observation in our current health care environment.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 164. SMALL PANCREATIC NEUROENDOCRINE TUMORS: RESECT OR ENUCLEATE? JD Beane, JD Borrebach, AH Zureikat, HA Pitt Presenter: Joal Beane MD | University of Pittsburgh Medical Center Background: Debate continues regarding the best management for small pancreatic neuroendocrine tumors (PNETs). Those who recommend observation claim that the risk of malignancy is low and that the complications of resection are high. An alternative strategy to formal resection or observation is enucleation. Small series have compared resection with enucleation, but this comparison has not been performed at the national level. The aim of this analysis is to compare the outcomes of resection and enucleation of small PNETs in North America. Methods: The 2014-16 American College of Surgeons-National Surgical Quality Improvement Program Procedure-Targeted Pancreatectomy Participant Use File was queried. Pancreatic neuroendocrine tumors classified as less than 2 cm in size and those classified as T1 or T2 were included in this analysis. Patients undergoing either distal pancreatectomy (N=563) or pancreatoduodenectomy (N=311) were included in the resection group. During the same time, 97 patients (10%) had small PNETs enucleated. The resection and enucleation patients were compared for multiple demographic, comorbidity and operative variables as well as postoperative outcomes. Standard statistical analyses were utilized. Results: The resected and enucleated cohorts were similar with respect to age (59 years), sex (53% male), BMI (30), smoking (11%), diabetes (8%), hypertension (53%), COPD (3%) and ASA class (2.67). A minimally invasive (MIS) operative approach did not differ between the resected (48%) and enucleated (46%) patients. However, distal pancreatectomy patients were more likely than those undergoing a Whipple procedure to have MIS (69 vs 10%, p<0.001). Operative time was longer (p<0.01) and perioperative transfusions were required more frequently in resected patients (p<0.01)(Table). Overall (p=0.05) and serious morbidity (p<0.04) were higher in resected patients. Clinically relevant pancreatic fistulas did not differ between resected and enucleated patients. Ten resected patients (1.1%) died postoperatively while all 97 enucleated patients survived surgery. Mean postoperative length of stay was 2 days shorter in enucleated patients (p<0.001). Conclusion: In North America only 10% of the operations performed on patients with small pancreatic neuroendocrine tumors (PNETs) are enucleations. Enucleation of PNETs takes less time and requires fewer transfusions than resection. Serious morbidity is lower and hospital stay is shorter with enucleation. Enucleation of small PNETs is an underutilized strategy.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 165. IMPACT OF SURGICAL SUBSPECIALTY TRAINING ON OUTCOMES WITH PANCREATIC RESECTION K Meredith, T Maramara, C Takahashi, J Huston, R Shridhar Presenter: Kenneth Meredith MD | Florida State University, Sarasota Memorial Hospital Background: Complex pancreatic resections are associated with high morbidity and regionalization to high volume subspecialty trained surgeons has consistently demonstrated an improvement in outcomes. We sought to examine the impact of subspecialty training on outcomes with pancreatic resections in a community setting. Methods: We queried a prospectively maintained pancreatic database to identify patients who underwent pancreatic resection prior to 2014 (PR1) and compared outcomes to patients who underwent pancreatic after 2014 (PR2) when a high volume subspecialty trained surgeon with a focus on HPB began performing pancreatic surgery in large community hospital. Statistical analyses were undertaken utilizing Mann-Whitney U-test and Pearson’s Chi Square as appropriate. All tests were 2 sided and a p-value <0.05 was considered significant. Results: We identified 201 patients a median age of 68.5 (27-92) years. There were 27 patients in PR1 and 174 in PR2. There was no difference in age (p=0.07), gender (p=0.8), BMI (p=0.24), or ASA score (p=0.35) between groups. There were 14(51.9%) open whipples and 13(48.1%) open distal pancreatic resections performed in PR1. There were 88(54.3%) open whipples, 12(7.4%) open distal, 28(17.3%) robotic whipples, and 34 (21%) robotic distal pancreatic resections performed in PR2. No minimally invasive pancreatic resections were performed in the PR1 cohort and 62(35.6%) in the PR2 group p<0.001. Mean operative time varied significantly between PR1 427±229 min and PR2 287±128, p=0.002. Mean estimated blood loss was also greater in the PR1 842±1000 vs PR2 222±247 ml, p=0.003. Complications occurred in 19(70.4%) PR1 and 63(36.2%) PR2, p<0.001. Pancreatic leaks occurred in 40.7% PR1 and 16.1% PR2, p=0.003. Oncologic outcomes as measured by R0 resections and lymph node harvested were significantly worse in PR1. The R0 resection rate was 77.8% in PR1 and 98.9% in PR1, p<0.001. The median number of lymph nodes harvested in PR1 was 7.5±6.1 and 17.4±9.8 in PR2, p<0.001. Mean length of hospitalization (LOH) also varied significantly among groups. LOH in PR1 was 12±9 and in the PR2 was 8±5, p=0.04. Conclusion: Pancreatic resections performed by a subspecialty surgeon results in decreased complications, fewer pancreatic leaks, shorter length of hospitalizations and improved oncologic outcomes. Additionally, patients have an increased likelihood of having minimally invasive approach when surgery is performed by a subspecialty trained surgeon. Pancreatic resections performed in the community setting by high volume pancreatic surgeons has equivalent outcomes to those in larger centers.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 166. HOSPITALIZATION OUTCOMES BETWEEN INTRAHEPATIC BILE DUCT CARCINOMA VERSUS EXTRAHEPATIC BILIARY CHOLANGIOCARCINOMA I Enofe, O Igenoza, O Osaghae, M Rai, E Edo-Osagie, A Aluko, H Laird-Fick Presenter: Oluwatosin Igenoza MBChB, MPH | University of Texas Southwestern Medical Center Background: Cholangiocarcinoma is an uncommon cancer with a very bad prognosis despite advances made in treatment. The location of the tumor (intrahepatic versus extrahepatic) determines surgical options. In our study, we examine variations in outcomes between patients admitted to the hospital with intrahepatic versus extrahepatic disease. Methods: Data from the NIS, a database developed for the healthcare Cost and Utilization project (HCUP) was used for our analysis. We identified patients who were 18 years and older with intrahepatic or extrahepatic biliary duct carcinoma who underwent a procedure (biliary stent, resection, bypass, pancreatic resection, liver resection and transplantation) during a hospitalization. Our primary aim was to describe outcomes in terms of inpatient mortality, length of stay and hospitalization cost based on tumor location. We used multivariable logistic regression to calculate adjusted odd ratios and mean differences for each cohort. We controlled for patient level characteristics (age, race, sex, comorbidity burden), hospital level characteristics (hospital region, size and teaching status), insurance type and procedure received during hospitalization using multivariable analysis. Results: We identified a total of 18,840 admissions in 2014 with a discharge diagnosis of cholangiocarcinoma (intrahepatic or extrahepatic). Of these, 13,930 (73.1%) were intrahepatic while 4,930 (26.1%) were extrahepatic. Inpatient mortality amongst patents with extrahepatic bile duct carcinoma was 5.5% while that for intrahepatic bile duct carcinoma was 7.69%. After controlling for confounders, including treatment received during hospitalization, patients with extrahepatic disease were 30% less likely (Adjusted Odds Ratio 0.70, 95 % CI 0.512-0.966) to die during hospitalization compared to patients admitted for intrahepatic bile duct carcinoma. Length of stay was similar between the two groups (Adjusted Mean Difference -0.10, 95 % CI -0.64 -0.44) as was average cost of hospitalization (Adjusted Mean Difference. -4126, 95% CI -1.0986.5 - 2733.16). Conclusion: The location of biliary duct carcinoma predicts inpatient mortality, even after controlling for treatment received. Intrahepatic cholangiocarcinoma has a worse prognosis than extrahepatic tumors, although length of stay and average cost of hospitalization are similar across the two cohorts. The two carcinomas have different histology, molecular characteristics, and associated genetic abnormalities. Intrahepatic cholangiocarcinoma is more likely to be associated with cirrhosis due to underlying viral hepatitis or non alcoholic fatty liver disease. It is unclear if these pathological characteristics or underlying chronic inflammation influence outcomes. We recommend prospective studies to better understand reasons for variation in hospitalization mortality seen in patients with intrahepatic cholangiocarcinoma.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 167. POSTOPERATIVE COMPLICATIONS AND EXTENDED HOSPITALIZATION IMPACT TIMELY INITIATION AND COMPLETION OF ADJUVANT THERAPY FOR PANCREAS CANCER NE Farrow, JJY Lim, K Landa, WO Lane, JK Thacker, KN Shah, DG Blazer, ME Lidsky, PJ Allen, S Zani Presenter: Norma Farrow MD | Duke University Medical Center Background: For most patients undergoing resection for pancreatic adenocarcinoma (PDAC) who have not completed neoadjuvant therapy, the standard of care is to receive adjuvant chemotherapy, however a significant proportion of patients will not receive this therapy. In this study, we investigated factors associated with receipt and completion of adjuvant therapy as well as the impact of implementation of a pancreas enhanced recovery after surgery (ERAS) program on receipt of adjuvant therapy. Methods: Patients undergoing pancreaticoduodenectomy or distal pancreatectomy for PDAC were identified using CPT codes in the National Surgical Quality Improvement Program (NSQIP) and an institutional database between 2013 and 2017. Patients undergoing resection for other diagnoses or procedures were excluded. A chart review was performed to collect demographic, clinicopathologic and outcomes data, as well as receipt and type of neoadjuvant and adjuvant therapies. Clinical outcomes were compared using Wilcoxon rank-sum test and Kaplan-Meier analysis. Outcomes were also compared for patients pre and post implementation of an ERAS pathway in 2016. Results: A total of 396 patients underwent pancreatectomy during the study period. Within this group of 396 patients, 132 (33%) underwent resection for PDAC (pancreaticoduodenectomy, n=110; distal pancreatectomy, n=22). Neoadjuvant therapy (chemotherapy and/or chemoradiation) was delivered to 99 patients (75%) and 33 patients (25%) underwent resection without any preoperative therapy. Adjuvant therapy was delivered to 98 patients (74%) and 34 patients (26%) received no adjuvant treatment. Overall, 106 patients (80%) received systemic chemotherapy (not including chemoradiation) either pre or postoperatively. Patients who did not receive adjuvant therapy were more likely to have had any NSQIP reported complication (59% vs. 39%, p=0.04) and longer hospital lengths of stay (10 vs. 8 days, p<0.01). There was no significant difference in receipt of adjuvant therapy for those who received neoadjuvant therapy versus those who did not (71% vs. 79%, p=0.36). Of those 98 patients who started adjuvant therapy, 63 completed it, with completion data missing for 10 patients. The reasons noted for incomplete courses of therapy were treatment intolerance (35%), patient preference (24%), progression of disease (21%), or unknown (20%). The median time to adjuvant therapy was 59 days (IQR 45-83). There was no significant difference in time to adjuvant therapy (58 vs. 63 days, p=0.79) or rate of completion of therapy (71% vs. 73%, p=0.84) for patients treated before and after initiation of an ERAS pathway for pancreatectomy patients. Patients undergoing pancreaticoduodenectomy who received adjuvant therapy had longer overall median survival (31 vs. 25 months, p=0.01) with a median follow up of 30 months (Figure 1). Conclusion: Despite national guidelines recommending the receipt of adjuvant therapy for patients undergoing resection for pancreatic adenocarcinoma, a significant proportion of patients do not receive it. Efforts to improve post-operative outcomes should be pursued to improve the proportion of patients who receive adjuvant therapy following resection for pancreatic adenocarcinoma. Given that a significant proportion of patients do not receive adjuvant therapy, the importance of neoadjuvant therapy should be considered.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 168. COMPARISON BETWEEN OPEN AND MINIMALLY INVASIVE RESECTION OF LIVER METASTATIC COLON A Rosales, H Asbun, J Burns, K Croome, K Mody, P Kasi, J Nguyen, JA Stauffer Presenter: Armando Rosales MD | Mayo Clinic, Florida Background: Colorectal cancer commonly metastasize to the liver, causing death in nearly two-thirds of patients with a median survival of eight-months for untreated liver metastasis. Improvement in chemotherapy has increased clinical response and survival rates. Hepatic resection of metastatic colorectal cancer (mCRC), which offers the greatest chance at long term survival, is now more being more commonly performed with a minimally invasive (MIS) approach. Our goal is to report a single institution experience and compare outcomes between a minimally invasive and open approach. Methods: After Internal Review Board (IRB) approval, we reviewed all patients with metastatic colon cancer that underwent liver resection between June 1996 and August 2018. They were grouped into a MIS (laparoscopic or laparoscopic hand-assisted approach) or open group. Results: A total of 208 patients [Female: 88 (43.31%), Male: 120 (57.96%)] with a body mass index of 27.78 ± 6.40 kg/m2 underwent hepatic resection for mCRC. Of these, 78 underwent open surgery [O-G, (Male: 47, 60.26%) and 123 underwent MIS approach (MIS-G, Male: 70, 56.91%). The majority of patients were American Society of Anesthesiologist class 3 (O-G: 57, 76%; MIS-G: 104, 85.25%). Prior to surgery, patients in the O-G significantly underwent more liver directed therapy (p=0.001), and ablation (p=0.15). Significantly more left hepatectomies and right trisegmentomies were performed in the O-G (p=0.006 and p=0.02, respectively). Patients in the MIS-G had significantly less intraoperative blood loss (p=0.003) and significantly shorter operative time (p=0.002). There was no difference on intraoperative (p=0.64) and postoperative (p=0.72) blood transfusions. Conversion rate for MIS-G was 7.11%, mainly due to non-progression 41.67% and bleeding 16.67%. There was no difference in reoperation rate (p=0.34). There was no difference in complete oncological resection (p=0.33), number of tumors (p=0.84) or total of lymph node resected (p=0.41). Patients in the O-G had significantly larger tumors (p=0.006), and significantly higher recurrence rate (p=0.03). Disease free interval (DFI) was not different between both groups (p=0.41) and median follow up was 9 months (range: 1 – 188) and 18 months (range: 1 – 104) for the O-G and MIS-G, respectively. Conclusion: MIS for mCRC resection is a safe and feasible approach. Benefits include less intraoperative bleeding and shorter operations with equivalent oncological resections. Overall cancer related outcomes including DFI and OS are similar.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 169. PANCREATIC MIXED ACINAR CELL CARCINOMA: GENOMIC ANALYSIS AND CHARACTERIZATION OF A PATIENT-DERIVED ORGANOID CULTURE BA Rheinheimer, TS Riall, RL Heimark, T Jie Presenter: Tun Jie MD, MS | University of Arizona Background: Mixed acinar cell carcinomas occur in <2% of all pancreatic cancers and express markers for both neuroendocrine and acinar cell differentiation. The clinical prognosis and molecular characterization of mixed acinar cell carcinomas are not well understood; therefore, we initiated a study to link genomic and transcriptomic analysis of mixed acinar cell carcinomas with pathogenesis. This case study represents a mixed acinar cell carcinoma in the pancreatic head that was surgically resected by a pancreaticoduedenectomy. The tumor was clinically staged pT3N1MX with a KI-67 labeling index of 5%. Methods: The macrodissected tumor specimen was subdivided for genomic analysis and explantation in organoid culture. After digestion with collagenase, the tissue was washed and plated in 50% Matrigel in Human Complete Organoid media. The cultures were subsequently established and characterized by immunolabeling for neuroendocrine and acinar lineage markers and by quantitative RT-PCR. After 3 passages of the organoid cultures, the cultures were then placed in 2D culture on 2% Matrigel coated dishes. DNA was isolated and whole exome sequencing was performed using the Nextera Rapid Capture Exome Kit by Illumina on an Illumina HiSeq 2000/2500. The following criteria were used to define genetic variants: bidirectional, non-synonymous, clean mapping in IGV, ≥ 15X coverage, and an alternate allele frequency of 0.3 ≤ x ≤ 0.7. Results: The primary tumor showed a mixed population of cell types on H&E. Tumor cells were positive for intracytoplasmic trypsin staining indicative of acinar differentiation. Tumor cells were also positive for the neuroendocrine markers synaptophysin and chromogranin A suggesting a population of cells that show both acinar and endocrine histology. The tumor was negative for gastrin, insulin, somatostatin, and glucagon. Cell growth in the initial organoid culture resulted in a mixed culture with 3D acinar structures and a second population of cells with multiple protrusions that invaded into the Matrigel. Whole exome sequencing of the dissected primary tumor showed mutations in several genes including MEN1, histone modification genes, and DNA repair pathway genes. Conclusion: Our approach is to combine patient-derived PanNET organoid cultures with cancer biology and molecular genetic analyses to understand their clinical significance.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 170. LAPAROSCOPIC HEPATECTOMY FOR PREOPERATIVE SUSPECTED HEPATOCELLULAR CARCINOMA: PERIOPERATIVE RESULTS AT A SINGLE CENTER CU Marino, DA Daroch, AN Ramírez, JF Guerra, J Martínez, NP Jarufe, E Briceño Presenter: Carlo Marino MD | Pontificia Universidad Católica de Chile Background: Liver resection in cirrhotic patients is associated with higher rates of morbidity and mortality. On the other hand, the laparoscopic approach for hepatocellular carcinoma (HCC) resections has been associated with better perioperative outcomes, including less blood loss, shorter length of hospital stay and reduced postoperative complications. The aim of this study is to describe the perioperative results of laparoscopic hepatectomy for preoperative suspected HCC in our center. Methods: We performed a case series study. Between August 2006 and August 2018, all patients undergoing laparoscopic hepatectomy for preoperative suspected HCC were included. All clinical records were reviewed, registering information regarding to age, gender, comorbidities and chronic liver failure status. We also registered the size of the tumor on preoperative imaging, alpha-fetoprotein (AFP) levels, type of liver resection, intraoperative red blood cells transfusions, operative time, conversion rates, postoperative complications (according to Clavien-Dindo classification) and mortality, reintervention rates, postoperative length of stay, readmissions and pathology. Descriptive statistics were used to analyze the results. Results: A total of 20 laparoscopic liver resections (LLR) for suspected HCC were performed in the study period. The median age of the group was 68 years (19-82) and 70% (N=14) of the patients were men. 60% (N=12) and 30% (N=6) had hypertension and type 2 diabetes, respectively. 80% (N=16) had chronic liver failure and, among them, 87,5% (N=14) were Child-Pugh A classification. The median size of the tumor, measured in preoperative imaging, was 3,3 cm (1-11) and the median of AFP was 4,55 ng/mL (0,7-26,9). 50% (N=10) of the patients underwent non-anatomic liver resections, 15% (N=3) right hepatectomies, 10% (N=2) left lateral segmentectomies and 25% (N=5) other types of resections. 20% (N=4) needed intraoperative red blood cells transfusions. The median operative time was 120 min (45-420). 20% (N=4) of cases were converted to open surgery, mostly because of technical difficulties during dissection. 30% (N=6) of patients had postoperative complications, one of them had Clavien-Dindo ≥ 3 classification. None of the patients presented postoperative liver failure, need for reintervention nor mortality. The median length of hospital stay was 7 days (3-31) and the readmission rate was 15% (N=3). Pathology confirmed hepatocellular carcinoma in 65% (N=13) of cases, fibrolamellar hepatocellular carcinoma in 5% (N=1), dysplastic nodules in 10% (N=2), focal nodular hyperplasia in 5% (N=1), liver abscess with intrahepatic lithiasis in 5% (N=1) and liver cirrhosis in 5% (N=1). There was one missed pathology data (5%). Of the confirmed hepatocellular carcinoma cases, 71,4% (N=10), 14,3% (N=2) and 14,3% (N=2) were T1, T2 and T3, respectively, according to the classification of the American Joint Committee on Cancer (TNM) seventh edition. Among them, 85,7% (N=12) had negative margins. Conclusion: In our experience, laparoscopic liver resection for preoperative suspected hepatocellular carcinoma is a feasible technique with relatively low conversion and intraoperative transfusion rates. Median operative time is similar to reports made by other groups. Despite the high rate of complications (30%), only one patient presented major postoperative morbidity (Clavien-Dindo 3a). No mortality was seen in the group. Pathology analysis confirmed the suspected diagnosis in 70% of the cases, with a high rate of negative margins.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 171. MINIMALLY-INVASIVE DISTAL PANCREATECTOMY WITH SPLENECTOMY: DOES (TUMOR) SIZE MATTER? R Borscheid, EE Cho, T Petree, J Kurtz, H Osman, DR Jeyarajah Presenter: Rene Borscheid MD | Methodist Richardson Medical Center Background: Minimally invasive distal pancreatectomy with splenectomy for both malignant and benign indications compare favorably and is performed with increasing frequency. The aim was to compare the perioperative outcomes between laparoscopic and robotic procedures and to compare oncologic efficacy in those cases where distal pancreatectomy was performed for malignant disease. Methods: We performed a retrospective chart review on patients undergoing robotic (RDPS) or laparoscopic distal pancreatectomy with splenectomy (LDPS) between 8/2012 and 4/2018 at the Methodist Dallas and Richardson hospitals. We obtained data relating to patient demographics, diagnosis, details of the operation, postoperative hospital course and histological data from the electronic medical record. Consent of the patients and IRB approval had been granted prior to chart review. Results are given as percentages of the total case numbers. Results: A total of 61 patients underwent minimally-invasive distal pancreatectomy with splenectomy, of which 31 had LDPS and 30 had RDPS. The age range was 17 to 81, 60.7% were female. Conversion rate in LDPS was 22.6% and 33.3% in RDPS. Blood loss was comparable between the laparoscopically and robotically completed patients (180.2 ml vs 136.8ml), conversion equaled higher blood loss (380 ml for laparoscopic cases and 527 ml for robotic surgery). Length of stay was similar for laparoscopic, robotic and robotic-converted (5.2d, 5.4d and 5.7d); converted laparoscopy increased the stay by three days. Malignancy was the indication 59% of all cases combined, 92% of these were either pancreatic adenocarcinomas or neuroendocrine tumors. In the converted groups tumor size was at least twice as large (7.95 cm vs 3.86 cm, in the laparoscopic patients and 6.13 cm vs 2.22 cm in the robotic patients) and the rate of positive margins was higher (50% vs 7.1% in LDPS and 14.3% vs 0% in RDPS). Mortality was zero for all groups. Overall morbidity was higher in both converted groups. Conclusion: Minimally-invasive distal pancreatectomy with splenectomy for malignant and benign indications can be performed with low mortality and comparable morbidity. There is little difference between the laparoscopically- and the robotically-completed technique in terms of blood loss, complications and length of stay. The choice of either should be driven by surgeon preference and institutional infrastructure. In those cases completed laparoscopically or robotically for malignant diseases, the case can be completed with margin negative resection. However, in those cases where cases were converted to an open, the margin positivity was significantly higher. There seems to be an association between tumor size and margin positivity. This brings to a question on whether tumor size should be a major factor in selecting cases to be completed via the open technique.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 172. MODIFIED BALAD SCORE PREDICTS INCOMPLETE LOCOREGIONAL THERAPY TREATMENT IN HEPATOCELLULAR CARCINOMA PATIENTS KG Nunez, T Sandow, S Robertson, PT Thevenot, AJ Cohen Presenter: Ari Cohen MD | Ochsner Health System Background: BALAD score has been shown useful in predicting recurrence in resected hepatocellular carcinoma (HCC) patients. Whether BALAD score is prognostic for treatment response in HCC patients undergoing downstaging or bridge to transplant remains unknown. Methods: HCC patients receiving doxorubicin-eluting bead transarterial chemoembolization (DEB-TACE) were prospectively enrolled. Blood was collected immediately prior to embolization and utilized to measure a-fetoprotein (AFP), des-g-carboxy prothrombin (DCP), and Lens culinaris agglutinin-reactive a-fetoprotein (AFP-L3) with the uTASWako i30 autoanalyzer. Median followup imaging was 111 days. Tumor response to DEB-TACE was determined by mRECIST. Results: HCC patients had a median age of 60, 69% male, 78% were hepatitis C, 88% within Milan criteria with an average MELD-Na score of 10. Median BALAD components were as follows: bilirubin 1.5 mg/dL, albumin 3.2 g/dL, AFP 7 ng/mL, AFP L3% 8, and DCP 2.8 ng/mL. Fifty percent of the cohort had a complete response to DEB-TACE. Univariate analysis revealed BALAD score was significantly associated with treatment response (p=0.04). Seventy-two percent of patients with BALAD score ≥ 2 had incomplete treatment response. Analysis of individual BALAD components revealed no independent association with treatment or complete response. Bilirubin levels were significantly increased with decreasing BALAD albumin thresholds. The BALAD score was modified by altering the biomarker thresholds. Modified BALAD was significantly associated with treatment (p=0.02) and complete response (p=0.04). Twenty-two pecent of patients had disease progression defined as rising AFP (>400 ng/mL), multifocal disease, or metastatsis. Only 5% of patients with modified BALAD score ≤ 1 had disease progression. Conclusion: Modification of biomarker components from the BALAD score provides insight into treatment response in HCC patients awaiting transplantation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 174. EVALUATION OF QUALITY OF LIFE BEFORE AND AFTER REPAIR OF BILIARY SURGICAL INJURY, RESOLVED BY SPECIALISTS IN A HIGH-VOLUME CENTER M Poupard, E Quiñonez, RM Vergara Sandoval, ML Del Bueno, M Chahdi Beltrame, M Lenz, FJ Mattera Presenter: Emilio Gaston Quiñonez MD | Hospital el Cruce Background: The introduction of the laparoscopic approach in cholecystectomies has revolutionized the field of general surgery. The decrease in recovery time, the shorter time of hospital stay and the aesthetic benefits offered by this surgical technique have made it the gold standard for the treatment of benign gallbladder pathology. But also has led to an increase in surgical bile duct injuries (BDI), and the number of studies that aim to find the right technique to solve this event. However, only a few studies have investigated the psychosocial and quality-of-life effects related to health (HRQoL) in BDI and its repair. Methods: Between December 2015 and December 2017, 36 patients with a diagnosis of BDI were treated in our center. The analyzed variables were sex, age, definitive treatments. The surgery in which the lesion was caused was evaluated, being in 91.7% a cholecystectomy, laparoscopic as a primary approach in 66.7%. The SF-36 health questionnaire was used as an instrument to evaluate HRQOL. In order to complete this formulary, we choose the interview or telephone survay modality. The patients inicially completed a first form retrospectively considering how they felt 2 weeks before the resolution of their desease, then they competed a second form according to how they felt currently. Patients who did not receive definitive tratment until December 2017 filled out only one questionnaire prospectively. Results: 77.8% (n = 28) of the patients were female, the average age was 38.4 years (r 14-68). Only 5 surgeries that resulted in BDI were emergencies. 71.4% of the patients required a major surgical intervention, in 5,7% a percutaneous treatment was sufficient and 8,5% was resolved successfully by endoscopic treatment. One patient received combination treatment (RendezVous). Of the total of 36 registered patients, 3 were excluded due to descess and 14 due to lack of follow-up. Of the 19 patients evaluated, 4 were awaiting definitive treatment. In the assessment of the results of the SF 36 survey, it was observed that 68.4% considered their HRQOL with the lowest possible score prior to their treatment at El Cruce Hospital, 15.8% considered a quality of life ¨Regular ¨ and 15.8 referred to it as ¨Well¨, no patient opted for the option ¨Very Well¨ or ¨Excelent¨. It is noteworthy that after the final repair 73.3% of the patients reported their HRQOL between the two maximum satisfaction scores. Mortality prior to definitive treatment was 2.8% (n = 1) in a patient who presented a hepatic hematoma with bleeding in two periods after the exchange of percutaneous drains in the context of acute cholangitis. Mortality after definitive treatment was 2.8% (n = 1) in a patient who required a liver transplant and evolved with hepatic artery and portal vein thrombosis in the immediate postoperative period. 1 Patient received 3 years after the definitive repair, without any complications, due to an AMI. Conclusion: In our series, 73.3% of the patients referred to their quality of life as excellent or very good, presenting in 100% of them a clear improvement in their HRQoL after being referred to a high volume center and receiving treatment by specialists.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 175. INCREASED CANCER RECURRENCE AND DECREASED SURVIVAL IN PATIENTS WITH COMBINED HEPATOCELLULAR CARCINOMA AND CHOLANGIOCARCINOMA AFTER LIVER TRANSPLANTATION RM Platoff, MM Crutcher, EM Gleeson, S Shang, D Reich, S Guy, G Xiao Presenter: Rebecca Platoff MD, MSc | Drexel University College of Medicine Background: Combined hepatocellular and cholangiocarcinoma (cHCC-CC) is a rare and deadly disease which has been shown to have a poorer prognosis than hepatocellular carcinoma (HCC) alone. This study aims to contribute to the gap in knowledge regarding the management options for this condition. In this study, we compare patients with cHCC-CC to patients with HCC alone who underwent liver transplantation for presumed HCC at a single institution over a ten year period. Methods: We reviewed records of each patient who received a liver transplantation for a presumed diagnosis of HCC between 2008 and 2018 at our institution. Variables collected include underlying liver disease, HCC work up and treatment, pathology, immunosuppressive medications, chemotherapeutic agents, and death. Follow-up was calculated from time of liver transplantation to last clinic visit, recurrence, or death, and post transplant overall survival and disease-free survival were assessed. Data analyses were performed with chi-square, Mann-Whitney U, and log rank test. Results: Of the 89 patients who underwent liver transplantation for diagnosis of HCC between 2008 and 2018, 6 (6.7%) had cHCC-CC histology and the remaining 83 (93.3%) had HCC alone. Patients with cHCC-CC were found to have statistically greater incidence of cancer recurrence with 4 of the 6 cHCC-CC patients experiencing cancer recurrence (66.7%) as opposed to only 6 of the 83 patients with HCC alone (7.2%) (p=0.03). Of the 6 patients with cHCC-CC, one cHCC-CC patient had local recurrence with tumor in the abdominal wall before dying of metastatic disease 60 months after transplant. Three patients developed metastases diffusely and died within one year of transplantation. Two patients with cHCC-CC pathology have had no cancer recurrence at 9 months and 49 months from transplant. Of the 89 patients transplanted for HCC from 2008 to 2018, 10 patients (11.2%) experienced tumor recurrence, of which 4 of 10 patients had cHCC-CC and 6 of 10 had HCC alone. The patients with cHCC-CC experienced an average time from transplant to recurrence of 10.8 months (compared with 18.7) and average time from transplant to death of 21.2 months (compared 28.9 months) for patients with HCC (p=.00). The data demonstrate earlier recurrence and death in patients with cHCC-CC pathology. Though only 6 out of 89 patients transplanted had cHCC-CC disease, half of the patients who experienced tumor recurrence were from the cHCC-CC group. Conclusion: cHCC-CC is a tumor variant that is often more aggressive than HCC alone, resulting in accelerated recurrence and death after liver transplantation. Data from our institution show a statistically increased rate of tumor recurrence for cHCC-CC compared with HCC alone (66.7% vs 7.2%), disproportionate high recurrence and low survival rates in this population reduced recurrence-free survival. Atypical radiologic findings for HCC should prompt a pre-transplant biopsy to evaluate for cHCC-CC. If pathology shows cHCC-CC instead of HCC, consideration should be given to treatment other than transplantation as outcomes are likely to be poor. Treatment options at the time of pathological diagnosis such as prophylactic reduced immunosuppression, closer surveillance, or initiation of early chemotherapy should be further explored to improve outcomes in this population.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 176. A 10 YEAR EXPERIENCE WITH RARE GALLBLADDER CANCER: A SINGLE INSTITUTION REVIEW BJ Sullivan, NL DeNicola, EY Bekhor, D Solomon, U Sarpel, DR Magge, DM Labow, BJ Golas Presenter: Brianne Sullivan MD | Icahn School of Medicine at Mount Sinai Background: Malignant neoplasms of the gallbladder are often lethal with the vast majority represented by adenocarcinomas. While the number of patients is low, previous reports support that approximately 10% of patients are noted to have non-adenocarcinoma histology on pathologic analysis. Little is known about how these rare histological variants affect presentation and survival. Methods: 145 patients with pathologically confirmed neoplasms of the gallbladder underwent surgery at our institution from 2007-2017 and were included from a prospectively maintained database. Pathological analysis revealed 8 histologic types distinct from adenocarcinoma. Presenting symptoms, pathologic stage, overall survival (OS), and progression free survival (PFS) were evaluated for each histology. Results: Out of 145 patients, 79 patients had adenocarcinoma (AC, 54%) and 66 had non-adenocarcinoma (non-AC, 46%) histologies. Of the 8 non-AC variants, the histologies included papillary (n=20), adenosquamous (AS) (n=12), mucinous (n=8), squamous (n=3), signet ring (n=3), lymphoma (n=3), neuroendocrine (NE) (n=3), and sarcomatoid (n=1). The majority of histologic types presented in the 6th decade (median 65 years), although neuroendocrine and sarcomatoid presented earlier and later (57 years, 93 years), respectively. The majority of patients were symptomatic at presentation regardless of histology (75-100%). While 29% of AC patients presented with jaundice, it was not seen in any patients with AS (0/11), squamous (0/3), or NE (0/3) variants and all patients with signet ring (3/3) and sarcomatoid variants (n=1). Lymph node involvement was 54% in AC patients and 46% in non-AC patients (p=0.896). The majority of AS (75%) and signet ring (100%) tumors were poorly differentiated versus 47% of AC tumors. Mean overall survival was 23 months in AC patients versus 26 months in non-AC patients (p=0.159) while progression-free survival was 20 months and 22 months, respectively (p=0.951). Conclusion: While non-adenocarcinoma variants of gallbladder cancer are rare, our data suggest they are more common than previously reported in the literature, representing 46% of our cohort. Retrospective reviews and meta-analysis could provide enough data to determine if differences exist between various subtypes, and thus guide future studies in an effort to optimize management of a very challenging disease.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 177. THE INCIDENCE OF CANDIDATE GENETIC VARIANTS OF NON ALCOHOLIC FATTY LIVER DISEASE IN SAUDI ARABIAN POPULATION FA AlSaif, HS AlMadany, MA AlOtaiby, MA AlMayouf, M Ahmed Presenter: Hadeel AlMadany MD | King Saud University Background: Worldwide, the prevalence of obesity, type 2 diabetes mellitus (T2DM) and the numbers of Non Alcoholic fatty liver disease (NAFLD) are increasing in a parallel manner. NAFLD became a great health concern in Saudi Arabia because of the abundance of obesity and T2DM within the population. Variations in ethnic prevalence of NAFLD suggests a hereditary impact on the disease. Candidate-gene association studies identified potential hereditary factor that can relate to the disease. In many ethnic groups certain genetic variants were identified as potential risk factors for NAFLD. Selected variants in HFE, PNPLA3, TM6SF2, MTHFR are of concern in this study. Methods: In this study, 175 adult patients of both genders aged 18 years and above who were booked for cholecystectomy due to gallstones were chosen to participate in the study. Patients with viral hepatitis, alcoholic hepatitis, drug-induced hepatitis, α1-antitrypsin deficiency, and Wilson’s disease were excluded from the study. Subjects were categorized as normal, obese grade 1, obese grade 2-3 and overweight based on their BMI. A histopathological NAFLD Assessment Score (NAS) was given based on the liver biopsy. Purified amplified products were sequence amplified using BigDye terminator, and all the samples were individually checked for the variant at the site of polymorphism. The Sequenced samples were analyzed using Sequencing Analysis software and comparative analysis for positive and negative samples were done using the SeqScape software. Results: A total of 121 samples categorized as normal, obese grade 1 and obese grade 2-3 were used and screened for H63D (c. 187 C>G) and C282Y (c. 845 G>A) mutation in Haemochromatosis (HFE) gene. The allele frequencies were 29.7 % for the heterozygous and 3.3 % for the homozygous H63D mutation and 6.75 % for the heterozygous C282Y mutation. Conclusion: The H63D mutation allele frequency considering the screened samples is higher compared to other known ethnic group studies worldwide. The C282Y mutation allele frequency is moderate in comparison to worldwide statistics. The allele frequency may proportionately increase when all the samples are screened. Also, a large scale study with similar study criteria is approved and would be an interesting research keeping in view the high allele frequency encountered. The preliminary data of variants in other genes PNPLA3 (I148M, V162M, S453I), TM6SF2 (E167K), MTHFR (A222V, E429A) will be statistically analyzed after complete analysis of all the samples. The results of other gene variants may express a similar pattern as the already screened variants of HFE gene.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 178. DISPARITIES IN SURVIVAL AMONG PATIENTS WITH PANCREATIC NEUROENDOCRINE TUMOR USING THE NATIONAL CANCER DATABASE: EFFECTS OF INSURANCE STATUS AND TREATMENT FACILITY ZN Rifat, CE Bailey, X Shu, M Tan, K Idrees Presenter: Zeeshan Rifat MD | Vanderbilt University Medical Center Background: Little is known regarding the impact of treating facility type on socioeconomic-driven survival disparities in patients with pancreatic neuroendocrine tumors (PNET). The primary aim of this study is to quantify disparities in overall survival (OS) associated with age, gender, race, insurance status and treatment facility type for patients with PNET. Methods: A retrospective cohort study was performed using the National Cancer Database. All patients with histologically confirmed PNET from 2004 to 2014 were included. Treatment facility were classified as community cancer center (CCC; 100-500 cases/year), comprehensive community cancer center (CPCC; >500 cases/year), academic hospital (AH; teaching hospital with >500 cases/year), or integrated network cancer center (INC; multi-center organization). Demographic and clinical factors were compared according to treatment facility type. Kaplan-Meier and log-rank analysis were used for survival analysis. Cox proportional hazard analyses were used to assess the impact of age, gender, race, insurance status, and treatment facility type on OS. Results: A total of 11,275 patients met inclusion criteria. The median age at diagnosis was 61. The majority of patients were white (83.2%), male (53.5%), and had private insurance (51.5%). 3.8% of patients received treatment at CCC, 27.1% at CPCC, 58.6% at AH, and 10.5% at INC. Increasing age was associated with worse OS. Females had improved OS compared to males (100.4 months vs 79.2 months, P<0.001). Patients with private insurance had improved OS compared to patients with other insurance (112 months vs 65.6 months, P<0.001). Median OS was 30.6 months for patients treated at CCC, 56.7 months for CPCC, 109.8 months for AH, and 90.7 months for INC (P<0.001) [Figure 1]. There was no difference in OS according to race. On multivariable analysis, increasing age was associated with worse OS (Hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.06-1.09, P<0.001). Females had improved OS compared to males (HR 0.90, 95% CI 0.87-0.95, P<0.001). In comparison to private insurance, patients with Medicaid (HR 1.25, 95% CI 1.13-1.39, P<0.001) and other insurance (HR 1.12, 95% CI 1.06-1.18, P<0.001) had worse OS. Patients treated at an AH also had improved OS compared to treatment at CCC (HR 1.23, 95% CI 1.11-1.37, P<0.001), CCCP (HR 1.22, 95% CI 1.16-1.29, P<0.001) and INC (HR 1.26, 95% CI 1.16-1.36, P<0.001). Gender (Pinteraction = 0.6313) and insurance disparities (Pinteraction = 0.5661) were not mitigated according to type of treating facility whereas age-related disparities (Pinteraction = 0.015) were slightly diminished by treatment at non-AH. Conclusion: Younger age, female sex, private insurance and treatment at AH were independently associated with improved OS in patients with PNET. Gender-based and insurance-based survival disparities were not mitigated by treatment at an AH. Conversely, age-based disparities were diminished for patients treated at non-AH.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 179. SURGICAL DECISION MAKING IN PATIENTS WITH CIRRHOSIS: A SYSTEMATIC REVIEW OF THE LITERATURE DB Major, FR Sutherland, E Dixon, OF Bathe, A Bressan, WP Francis, Z Ahmed, CG Ball Presenter: Don Major MD | University of Calgary Background: The incidence of cirrhosis is increasing and many patients affected by this disease process will require some form of operation (elective vs emergent). In these individuals, the decision making process can be quite demanding. These individuals require adequate assessment for the degree of hepatic dysfunction, extent of both portal hypertension and their comorbidities for perioperative optimization. Some of the common operations performed in patients with cirrhosis involve biliary, colorectal disease and ventral hernias. The primary aim of this study is a systematic review of the literature to determine the decision making process involved with three common emergent surgical cases. Methods: A systematic review of the literature using Pubmed, Medline and Embase was performed. Non case reports and retrospective reviews of patients with cirrhosis undergoing emergency surgery were identified. In addition to the systematic review, 3 specific cases were utilized to highlight the issues involving patients with cirrhosis and common gastrointestinal emergencies. These cases involved patients with cirrhosis who developed: ischemic bowel, acute cholecystitis and an incarcerated umbilical hernia. The decision making aspect in each case involved deciding whether to perform a primary anastomosis post bowel resection versus creation of a stoma, laparoscopic cholecystectomy versus percutaneous drainage and finally the ideal management of an incarcerated umbilical hernia with ascites. Results: High grade evidence for decision making is lacking. In patients with cirrhosis complicated by ischemic bowel, individuals with Child Pugh A or a MELD score <10 display the best outcomes. Whether to create a stoma versus resection and primary anastomosis in end stage liver disease, there is no level 1 evidence to support either. There were no studies identified for this patient population and most studies involved individuals with colorectal disease. However, in the French Association of Surgery series, patients with cirrhosis that had a protective stoma are at risk for stoma complications such as ascites leakage, ascites infection, peristomal varices. There was a 7% fistula rate in individuals with resection and primary anastomosis. Acute cholecystitis in patients with Child Pugh A / B can be treated with laparoscopic cholecystectomy and or subtotal cholecystectomy. For Child Pugh C medical management should be attempted followed by percutaneous transhepatic cholecystostomy tube as necessary. Finally, individuals with an incarcerated umbilical hernia should have emergent surgery and repair of their hernia. Intraoperatively placed closed suction drains can be used to control post-operative ascites and allow for adequate wound healing. Ascites should also be managed aggressively with medical therapy and possible emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) as necessary. Conclusion: Advanced liver disease complicates many common gastrointestinal surgeries. The decision making process surrounding these operations is far from standardized as high grade evidence recommending optimal management is lacking. Management of cirrhosis in these not un- common emergency settings rely mostly on retrospective data and small cohort studies thus the treatment can vary from surgeon to surgeon.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 180. PRESERVATION OF RIGHT GASTROEPIPLOIC VEIN TO LESSEN LEFT-SIDED PORTAL HYPERTENSION AFTER PANCREATICODUODENECTOMY WITH COMBINED PORTAL VEIN RESECTION H Ishikawa, M Yasunaga, T Hisaka, R Kawahara, H Sakai, Y Goto, G Nakayama, K Okuda, H Tanaka, Y Akagi Presenter: Hiroto Ishikawa MD,PhD | Kurume University School of Medicine Background: In pancreaticoduodenectomy (PD) resection of portal vein (PV) and superior mesenteric vein (SMV) confluence, splenic vein (SV) and inferior mesenteric vein (IMV) division may cause left sided portal hypertension (LPH). Preservation of right gastroepiploic vein (RGEPV) may reduce congestion of the stomach and spleen after PD with concomitant vascular resection. Methods: The 42 of 133 pancreatic ductal adenocarcinoma patients who underwent PD with concomitant vascular resection between January 2008 and September 2018 were included in this retrospective study. These patients were classifed into 4 groups: SV and IMV were preserved Group A (n=22), SV and IMV were divided in GroupB ( n=5) , SV was divided in Group C (n=10), SV and IMV were divided and RGEPV was preserved in GroupD ( n=5) The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery. Results: The spleen volume ratio at 6months after operation comparing to preoperative value was 1.00, 1.4, 1.00, 1.03 in Group A, B, C and D, respectively (Group B vs. A, C and D: p<0.01, p<0.01 and p<0.03). The incidence of postoperative varices and congestion in Group A, B, C and D was 0, 75, 0 and 0%, respectively (p<0.001). Gastric remnant venous congestion and bleeding ocured only in Group B (n=4), and esophageal varices without hemorrhagic potential occured only in Group B (n=4). LPH associated findings were less frequently observed when left gastric vein -portal vein and IMV-SV confluences were preserved, even if SV was divided. Preservasion of EGEPV may be effective against the LPH when SV , LGV and IMV were divided. Conclusion: In PD with resection of PV-SMV confluence, SV and IMV division causes LPH, but concomitant preservation of RGEPV may attenuate LPH.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 182. INDOCYANINE GREEN FLUORESCENT IMAGING IN REVISIONAL LAPAROSCOPIC PORTAL NODE DISSECTION AND LIVER RESECTION FOLLOWING INCIDENTAL FINDING OF GALLBLADDER ADENOCARCINOMA AFTER CHOLECYSTECTOMY MR Driedger, MJ Truty, RL Smoot, DM Nagorney, TE Grotz, ML Kendrick, SP Cleary Presenter: Michael Driedger MD | Mayo Clinic, Rochester Background: Indocyanine green (ICG) is an anionic molecule that upon delivery to the vascular system becomes rapidly bound to plasma protein. It has a half-life of 2.5 to 3 minutes and is exclusively extracted by the liver and excreted into the biliary system. ICG becomes fluorescent when excited by laser or near infrared light (700–900 nm). The maximal concentration of ICG in the biliary system occurs between 30 min and 2 h after injection, thus enabling imaging of the biliary tree. Methods: A 66-year-old female underwent a laparoscopic cholecystectomy for a gallbladder polyp. Pathology revealed an invasive adenocarcinoma of the gallbladder, T2Nx. The lesion was located in the fundus adjacent the liver surface, the cystic duct margin was negative. Staging was negative for distant disease. She was therefore planned for a revisional laparoscopic portal node dissection and liver resection. 2.5mg of ICG was delivered intravenously to the patient 60 min prior to the beginning of the operation. Near infrared laparoscopic fluorescence imaging was utilized. Results: The patient underwent a successful laparoscopic portal node dissection and liver resection. She was discharged home on post-operative day 3. Final pathology, including 6 lymph nodes, revealed no residual malignancy. Conclusion: Utilization of ICG fluorescence imaging improves the ability to landmark and visualize the biliary system during surgery. This may improve operative outcomes in certain settings and help facilitate adequate portal lymphadenectomy which has been an issue in gallbladder malignancy.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 183. ROBOTIC ASSISTED PUNCTURE ASPIRATION INJECTION & RE-ASPIRATION OF HEPATIC ECHINOCCAL CYSTS I Mukherjee, A Demin, A Ogrodnik, A Mironenko, KE Gibbs Presenter: Indraneil Mukherjee MD | Staten Island University Hospital Background: Echinococcal or Hydatid cysts are an uncommon entity in the United States. It is endemic in certain regions with a temperate climate, especially in Europe and Asia. The liver and the lung are the most common areas of Echinococcal cysts. We present the management of a case of multiple cysts in the liver, maximum measuring 20 cm who had migrated from a central Asia. Methods: Our patient was started on Albendazole. She underwent Robotic Assisted Puncture Aspiration Injection Re-Aspiration of Hepatic Echinococcal cysts. This Cyst had cause atrophy of most of the right lobe of the liver and had a communication into the Right Hepatic Duct. The communication was ligated and a portion of the Fibrotic Ectocyst was left. She was continued of postoperative Albendazole for 2 months. Results: She tolerated the procedure well. On Postoperative Day 4, her drained turned bilious. She Underwent an ERCP and stent placement into the right hepatic duct. Two weeks later her drain was removed. She was continued on 2 more months of Albendazole. She is doing well 6 months after the surgery. Conclusion: We do suggest that Minimally Invasive Surgical option is the optimal approach for such echinococcal cyst, even when they are multiple, large, disfiguring the liver anatomy and having cyst to duct communication.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 184. LAPAROSCOPIC PARTIAL-ALPPS, STAGE 1. INITIAL EXPERIENCE J Lipman, JA Graham, S Bellemare, M Kinkhabwala, JP Rocca Presenter: Jeffrey Lipman MD | Montefiore Medical Center Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), continues to evolve into different variations and provoking debate about indications, associated morbidity and oncologic outcomes. Throughout this progression, the benefits of a laparoscopic approach and a partial parenchymal transection on the initial stage are becoming more evident (as opposed to a complete transection) in achieving the desired hypertrophy of the future liver remnant (FLR), while decreasing the overall severity of associated complications and simplifying their management between stages . We present our initial experience with Laparoscopic Partial-ALPPS, focused on the stage 1. Methods: 4 cases reviewed at multidisciplinary HPB tumor board, decided to proceed with extended right hepatectomy via ALPPS. Laparoscopic Partial ALPPS was performed during stage 1. Technical steps: 1-Cholecystectomy; 2-Traction cystic-duct stump exposing Right Hepatic Artery (RHA) and Main Portal Vein (MPV) extending into Right Portal Vein (RPV); 3-Circumferential dissection RHA and RPV; 4-Ligation RPV (tie and/or clips); 5- Partial parenchymal transection 50% preserving Middle Hepatic Vein (MHV) outflow. Postoperative imaging confirmed desired hypertrophy of the remnant liver volume within 9-11 days and the stage 2 ALPPS was carried out 14-16 days after stage 1. Three out of the four stage 2 cases were initiated with laparoscopy and intentionally converted to open extended right hepatectomy following a planned learning curve. Results: Case 1: 74F HCV s/p Harvoni, 6 cm HCC in segment 8, abutting the right hepatic and middle hepatic veins. Advanced liver fibrosis. Total liver volume 950 ml, volume of FLR 253 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeat imaging POD#11, hypertrophied FLR 501ml. Stage 2-POD#16 Lap converted-to-open right extended hepatectomy. Discharged POD#6. Case 2: 58F PMHx of colon cancer, synchronous metastasis to the liver. FOLFOX+ Avastin. Total liver volume 910 ml. Right lobe 622 ml, 2 lesions occupy 58 ml. Left lobe 288 ml, 1 lesion occupies 23ml. Stage 1-Lap wedge LLS lesion+Lap Partial ALPPS. POD#2 Re-laparoscopy, bleeding-control hemostasis. Stage 2: preop imaging hypertrophied FLR 369 ml. POD#15- Open right hepatectomy + extended right colectomy. Discharged on POD#6. Case 3: 66M HCV s/p Harvoni, 3.5 cm HCC segment 8, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 557 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#11, hypertrophied FLR 720 ml. Stage 2- POD#15, Lap converted-to-open right extended hepatectomy. Discharged POD#5. Case 4: 67M HCV s/p Harvoni) with 5 cm HCC segment 7, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 583 ml. TACE followed 3 weeks later by Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#9. Hypertrophied FLR 976 ml. Stage 2-POD#14 Lap converted-to-open right extended hepatectomy. Complicated postop course, bleeding and infection. Reoperation/washout. Discharged POD#23. Conclusion: Each case is presented with a short video clip highlighting the technical steps of the Laparoscopic Partial-ALPPS during Stage 1, which were overall carried out without intraoperative difficulties and with satisfactory recovery and prompt discharge in all cases, while achieving the FLR hypertrophy within the expected timeframe. An additional video clip presents the laparoscopic findings during stage 2 prior to converting to open procedure, illustrating the amount of inflammation that challenged the laparoscopic completion of Stage 2 during this initial experience.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 185. ROBOTIC SEGMENT V LIVER RESECTION, PORTAL LYMPHADENECTOMY, CHOLECYSTECTOMY, AND VENTRAL HERNIA REPAIR LG Melstrom, JP De Andrade, CL Stewart Presenter: James De Andrade MD | City of Hope Cancer Center Background: In this video, we present a patient who developed a metachronous colorectal liver metastasis in segment V as well as suspicious portal lymphadenopathy. We demonstrate our technique in performing this liver resection and portal lymphadenectomy, as well as cholecystectomy and ventral hernia repair with mesh. We highlight the use of indocyanine green (ICG) to help delineate a margin around the metastasis as well as identification of biliary anatomy.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 186. ROBOTIC EXTRAHEPATIC BILIARY RESECTION WITH ROUX-Y HEPATICOJEJUNOSTOMY SB Ross, I Sucandy, A Giovannetti, TJ Bourdeau, AS Rosemurgy Presenter: Sharona Ross MD | Florida Hospital Background: The incidence of cholangiocarcinoma is increasing but the treatment outcomes remain poor. Chemotherapy offers limited survival benefits without surgical resection. Complete surgical resection is the only hope for a cure. Minimally invasive techniques, specifically robotic surgery has proven to be safe and feasible in the field of hepatobiliary surgery. We report our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy for type 1 Klatskin tumor. Methods: A 69 year old woman presented with fatigue and obstructive jaundice. After preoperative workup, including right upper quadrant ultrasound, CT scan, MRCP/MRI and ERCP, a diagnosis of type I Klatskin tumor was made. She was taken to the operating room and general anesthesia was administered. Diagnostic celioscopy was undertaken with no evidence of metastatic disease. The remaining 3 robotic trocars were placed under direct visualization and the robot was docked. The operation began with the placement of a liver retractor to expose the porta hepatic structures. The common hepatic artery was identified and followed distally towards its bifurcation. Results: The common bile duct was identified and isolated. Further dissection was undertaken cephalad towards the hepatic duct bifurcation. The gallbladder was dissected off the liver bed but left attached to the bile duct. The distal common bile duct was transected at the level of the pancreatic head. Proximal bile duct transection was undertaken removing part of the bile duct bifurcation with attention not to injure the crossing right hepatic artery. Frozen section confirmed the absence of malignant cells in the area of thickened bile duct wall. Intraoperative liver ultrasound examination did not show evidence of intrahepatic mass. Exploration of intrahepatic biliary ducts was undertaken with 3 Fr Fogarty catheter. Roux-en-Y hepaticojejunostomy was constructed with a 60 cm jejunal Roux limb. A side to side jejunojejunostomy was constructed with 60mm robotic stapler. Both, the right and left hepatic ducts were sutured side by side together to create a single bilioenteric anastomosis. Robotic hepaticojejunostomy was constructed with 2 running 3-0 V-Lock barbed sutures. A 10 Fr flat JP drain was placed dorsal to the hepaticojejunostomy. The patient tolerated the procedure well without intraoperative complications. Her postoperative recovery was uneventful. She was discharged home on postoperative day 4. Conclusion: The use of robotic technology in hepatobiliary operations is increasing but is still limited to a few specialized high-volume centers and in the hands of experts. Superior three-dimensional visualization and increased maneuverability with ease of suturing are only few of many advantages of the robotic technology.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 187. ROBOTIC COMPLETION RADICAL CHOLECYSTECTOMY FOR INCIDENTAL T2 GALLBLADDER CANCER DE Kleiner, AW McGregor Presenter: Andrew McGregor MD | Danbury Hospital Background: Gallbladder cancer carries a low 5 year survival rate especially in metastatic disease. However, early gallbladder cancer if detected early can provide adequate survival benefit. T2 gallbladder cancer is managed usually with portal lymphadenectomy, resection of IVb/V segments of the liver , and cholecystectomy. Incidental specimens of T2 gallbladder cancer are indicated for further resection. We demonstrate a 74 year old female who underwent completion robotic radical cholecystectomy for incidental T2 gallbladder cancer. She remains disease free at 2 years and 8 months. Methods: This is a video demonstrating the use of the DaVinci Robot in radical completion cholecystectomy Results: 74 year old female referred to our hepato-biliary center for incidentally found T2 gallbladder cancer found after elective cholecystectomy for biliary colic. She was offered robotic completion radical cholecystectomy given her affinity to have minimally invasive surgery and her BMI. Portal lymphadenectomy was performed and segments IVB/V were resected. The patient was discharged on post operative day 2 and final pathology demonstrated negative margins and 21 benign lymph nodes. She remains disease free at 2 years and 8 months Conclusion: Robotic Hepato-biliary surgery is feasible in selected patients. The use of the DaVinci Robot and the minimally invasive approach was successful and had led to a good long term disease control.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 188. DEVELOPMENT OF AN INTERACTIVE VIRTUAL REALITY HEPATOBILIARY SYSTEM FOR PRECLINICAL MEDICAL EDUCATION JD Chait, DJ Carmichael, I Bandovic, A Vasilyev, GP Saggio Presenter: Dylan Carmichael | NYIT College of Osteopathic Medicine Background: Virtual reality (VR) has been shown to improve retention and student satisfaction in the realm of medical education. Mastery of gastrointestinal pathophysiology often poses a challenge to preclinical medical students due to the complex anatomy of the hepatobiliary system. This difficulty may lead to decreased interest in the field of hepatobiliary surgery during clerkships and residency selection. In order to change this paradigm, we decided to utilize VR to “gamify” the hepatobiliary portion of the preclinical gastroenterology curriculum. This study aimed to determine the feasibility of development of an interactive, 3-dimensional (3D), VR environment involving hepatobiliary anatomy, physiology, and pathophysiology. Methods: 3D anatomical models were edited using Blender, an open source graphics software, and Oculus Medium, a VR sculpting platform. Pathophysiologic processes were created utilizing the Unity gaming engine, which employed the C# coding language. Physiologic processes include bile synthesis and flow, gallbladder wall contraction, and Sphincter of Oddi constriction. Pathophysiologic processes include obstruction by gallstones and tumors at various portions of the biliary tree. As seen in the video, students are not only able to view the normal and pathologic disease states, but are also able to create obstructions in the anatomy, allowing them to observe the results of their changes in real time. Additionally, virtual office visits allow students to apply their diagnostic and decision making capacities in an interactive clinical setting. Results: Development and beta testing of our interactive VR hepatobiliary curriculum has proven the feasibility of this project. Various surgeons, clinicians, and medical education professionals have advised and oversaw the specifics of the curriculum and its goals. This model is currently being implemented into our preclinical curriculum for use by medical students and will be evaluated for construct validity against traditional teaching methods, such as didactic lectures, textbooks, and videos. Conclusion: We propose that this novel, interactive learning environment will significantly improve student engagement and retention in hepatobiliary anatomy, physiology, and pathophysiology. The combination of enthusiasm and competence in this area of preclinical medical education may lead students to consider hepatobiliary surgery as a future career choice.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 189. PASSIVE VENO-VENOUS BYPASS INSTEAD OF CENTRIFUGAL PUMP IS FEASIBLE AND LOW COST FOR EXPERIMENTAL PIG LIVER TRANSPLANTATION JA Kalil, MA Sanchez-Galvez, M Hertl, E Schadde Presenter: Jennifer Kalil MD | Rush University Medical Center Background: Pig models are increasingly common in transplantation research. Pigs tend to become hemodynamically unstable during the hepatectomy phase of orthotopic liver transplantation (OLT). Historically, veno-venous bypass centrifugal pumps are often used to complete OLT. Here, we describe a simplified method of passive veno-venous bypass in landrace pigs in the context of a pilot study to establish pig liver transplantation in our large animal lab. Methods: Donor and recipient operations were performed sequentially. Heparin-bonded 3/8-inch diameter polyvinyl chloride, Y-shaped bypass tubes were created with venous cannulas on each end. Heparinized saline filled the tubing and 30 U/kg of systemic heparin administered. The left internal jugular (IJ) vein was cannulated with the single arm of the Y. The portal vein (PV) was cannulated with one of the double arms, then divided. Clamps were removed to establish PV-IJ flow. Infra-hepatic inferior vena cava (IVC) was then cannulated, divided and flow established. Cannulas were secured with Rumel tourniquets and additionally secured to the tubing. Suprahepatic IVC was clamped and liver was removed. The suprahepatic IVC anastomosis was completed, then the PV and infrahepatic IVC anastomoses. Bypass time, flow, and one-hour post-reperfusion pH were recorded. Results: Eleven liver transplants were performed from eleven donor pigs. Mean weight of the donor and recipient animals was 23.5 kg +/- 4.1 and 29.2 kg +/- 6.4, respectively. There were two peri-operative mortalities: one pig died due to portal bypass cannula dislocation and the other due to inadequate ventilation. Of the 9 animals successfully transplanted with the use of passive veno-venous bypass, all survived until sacrifice. The mean time on bypass was 52 minutes +/- 15.5. The mean flow (L/min) at 10, 20, and 30 minutes on bypass was 0.55 +/- 0.06, 0.54 +/- 0.06, and 0.33 +/- 0.25. The mean pH at 1-hour post-reperfusion was 7.4 +/- 0.17. The cost per set up was approximately 112 USD. Conclusion: This series of experimental orthotopic liver transplantation in pigs shows that the use of passive veno-venous bypass with heparin-bonded polyvinyl chloride tubing to maintain hemodynamic stability during the recipient hepatectomy, is a less expensive alternative compared to bypass with a centrifugal pump.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 190. A MODEL FOR LIVER SURGERY TRAINING: LEFT OPEN HEPATECTOMY IN SWINE VB Jeismann, JAP Kruger, GM Fonseca, DM Cesconetto, FF Coelho, P Sakai, P Herman Presenter: Vagner Jeismann MD | Hospital das Clinicas of University of Sao Paulo Background: Major advances have occurred in the last decades in liver surgery. Perioperative mortality of less than 5% was reported in specialized centers. Nevertheless, hepatic resections through laparotomy or laparoscopy remain complex procedures with long learning curve. Liver surgeons training must include the development of skills that are difficult to acquire other than in practical activities, and this has ethical implications. Important contributions may come from simulators, artificial models, cadavers and animal models. The porcine model is an interesting option for this purpose, as there are similarities between the morphology of the liver of the pig with that of humans. Methods: We will present a video in which the standardized technique of open left hepatectomy in porcine model for resident training is demonstrated. An "inverted T" incision is used. Complete mobilization of the liver is performed through the section of the falciform, triangular, coronary and hepatogastric ligaments. The total vascular control performed routinely. Extrahepatic access to glissonian pedicles is the technique of choice for approaching hepatic influx. The transection of the parenchyma can be performed in several ways: conventional bipolar, advanced bipolar, harmonic scalpel, ultrasonic aspirator, hydrodissection, "kellyclasia", "silklasia", among others. Results: The porcine model presents a satisfactory correlation with the human liver anatomy and has been shown to be a great complementary tool for liver surgery training in our center. Conclusion: Liver resections in swine does not replace the experience of surgeries in real patients. However, it is an effective and safe complementary teaching method in liver surgery training.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 191. LAPAROSCOPIC-ASSISTED ERCP M Elkahly, A Lee Presenter: Mohamed Elkahly MD | Riverside Community Hospital Background: Conventional ERCP has become the gold standard for visualization and extraction of common bile duct stones. Gastric bypass patients pose a unique challenge, especially in a community setting in which double-balloon ERCP is not readily available. Several modalities are available for this patient population, including: PTC, double balloon ERCP, and open/laparoscopic surgery. Our patient―a 71 year old female with history of cholecystectomy and multiple bariatric surgeries, including gastric bypass―was admitted and treated for cholangitis. IV antibiotics per sepsis protocol were initiated and definitive treatment was done by laparoscopic-assisted ERCP. Methods: The procedure was done under general endotracheal anesthesia. Five trocar technique was performed using 12 mm supraumbilical Hasson trocar for camera, 5 mm RUQ, RLQ and LLQ trocars for instruments, and 15 mm RUQ trocar for endoscope. Extensive lysis of adhesions were taken down with combined blunt and sharp dissection using harmonic scalpel and endoshears. The gastric remnant was identified and entered between two stay sutures using harmonic scalpel. Esophagogastroduodenoscope was inserted through 15mm RUQ port and gastrotomy. ERCP was then successfully performed by the gastroenterologist with extraction of two large stones and subsequent visualization of clear biliary tract on fluoroscopy. Gastrostomy was subsequently closed by endo-GIA 65 mm blue load and over-sewn with 3-0 silk sutures. Results: Operative time was approximately 180 minutes including intraoperative ERCP. Blood loss was estimated at 10cc. Successful entry into the gastric remnant and subsequent cannulation of Ampulla of Vater with extraction of 2 large common bile duct stones was achieved71-year-old and subsequent visualization of clear biliary tract on fluoroscopy was seen. The patient tolerated surgery well with normalization of abnormal labs by postoperative day 2 with subsequent discharge home in stable and improved condition. Conclusion: Laparoscopic-assisted ERCP may be a viable treatment modality for patients with history of multiple bariatric surgeries presenting with cholangitis, especially in a community setting where double-balloon ERCP is limited.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 192. ROBOTIC PANCREATICODUODENECTOMY AND CHOLECYSTECTOMY SB Ross, I Sucandy, A Giovannetti, TJ Bourdeau, AS Rosemurgy Presenter: Sharona Ross MD | Florida Hospital Background: A 49 year old woman diagnosed with a distal CBD/ampullary neuroendocrine tumor. The intra and extrahepatic biliary tree were dilated on preoperative MRCP/MRI. ERCP was undertaken which showed an enlarged and bulging papilla with a submucosal lesion causing stenosis of the biliopancreatic orifice. An endoscopic biopsy confirmed the diagnosis. The patient was taken to the operating room for a robotic pancreaticoduodenectomy and cholecystectomy. Methods: Diagnostic celioscopy was undertaken through an 8 mm trocar, which was placed at the umbilicus. No evidence of metastatic disease was found. The remaining 3 robotic trocars were placed. A Gelport® was placed between the midclavicular line and the umbilicus on the patient’s right. An AirSeal® insufflation port was placed at the right anterior axillary line. The operation began with the opening of the gastrohepatic ligament to identify the common hepatic artery. The gastroduodenal artery was doubly clipped and transected. Dissection continued with lysis of adhesions between the gallbladder and the duodenum. Kocher maneuver was undertaken and the ligament of Treitz was identified and divided. Results: The gastrocolic ligament was opened and the dissection was carried distally toward the first portion of the duodenum, distal to the pylorus. The robotic stapler was utilized to transect the first portion of the duodenum. Dissection along the inferior margin of the pancreas was undertaken to identify the SMV and develop a tunnel posterior to the pancreatic neck. Division of the gland was achieved using robotic electrocautery hook. The uncinate process of the pancreas was dissected off the SMV, SMA and portal vein using the robotic vessel sealer. The dissection was then carried along the ventral surface of the aorta towards the distal CBD. The CBD was transected and the pancreaticoduodenectomy and cholecystectomy specimen was extracted through the Gelport®. On frozen section all margins were negative. The jejunum was then brought under the root of the mesentery. The hepaticojejunostomy anastomosis was constructed using barbed sutures in a single layer running fashion. A 2 layers end to side pancreaticojejunostomy duct to mucosa anastomosis was constructed using barbed and 4-0 polypropylene sutures. Next a loop of jejunum was brought in an antecolic fashion to construct the end to side duodenojejunostomy using a single layer running technique. A 10Fr drain was placed behind the hepaticojejunostomy and pancreaticojejunostomy. The patient tolerated the operation well and was discharged from the hospital on POD 4 without postoperative complications. Conclusion: The robotic approach has been shown to be feasible and safe for complex operations such as pancreaticoduodenectomy and cholecystectomy. The 3D visualization and the increased dexterity offered by this technology allows surgeons to expand the boundaries of minimally invasive surgical techniques.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 193. LAPAROSCOPIC PANCREATICOJEJUNOSTOMY POST PANCREATICODUODENECTOMY WITH A SMALL PANCREATIC DUCT AS Khithani, K El-Hayek, TB Cengiz, GJ Morris-Stiff, T Augustin, RA Simon, RM Walsh Presenter: Amit Khithani MD | Cleveland Clinic Foundation Background: Pancreatico jejunostomy post pancreaticoduodenectomy in patients with small pancreatic duct can be a challenge, especially with a minimally invasive approach. We present a technique of Laparoscopic pancreaticojejunostomy post pancreaticoduodenectomy in patients with a small pancreatic duct. Methods: A 70-year-old male presented with obstructive jaundice and cholangitis. CT scan showed 2.8 cm mass in the head of Pancreas. Pancreatic duct Size was 3mm. Results: Technique: The Pancreaticoduodenectomy was performed Laparoscopically. Due to a small pancreatic duct, a separate duct to mucosa pancreaticojejunostomy was not performed. A two-layered anastomosis was done between the pancreas and the small bowel. A posterior layer of 3-0 v-lock suture was placed starting at the corners between the pancreatic capsule and small bowel serosa. This was continued downward ensuring to grab the duct and the mucosa to reapproximate them. This was followed by an anterior layer using the same technique. The patient had an uneventful postoperative course and was discharged on postoperative day 4. Conclusion: Laparoscopic pancreaticojejunostomy can be done in 2 layers without an interrupted true duct to mucosa anastomosis in patients with a small pancreatic duct.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 194. TOTAL PANCREATECTOMY WITH SPLENECTOMY: FEASIBLE AND SAFE KJ Lafaro, O Eng, B Lee, G Singh Presenter: Kelly Lafaro MD | City of Hope Cancer Center Background: The use of robotics in pancreatic surgery has increased dramatically over the past decade. Studies have shown reduction in blood loss, major complications and hospital stay [1,2] when comparing robotic to traditional pancreaticoduodenectomy, however, it is still not a wildly utilized technique. Robotic total pancreatectomy with splenectomy offers a minimally invasive approach for a surgery which was previously only offered as a major open operation resulting in a long inpatient recovery period. Methods: This video demonstrates a systematic and reproducible technique for a robotic total pancreatectomy with splenectomy using the da Vinci Xi robotic system and a 5 port, supine approach. The patient is a 62 year old woman diagnosed with renal cell carcinoma in the setting of Von Hippel Lindau syndrome with multiple solid and cystic lesions throughout the pancreas consistent with metastatic renal cell carcinoma. Conclusion: A total pancreatectomy with splenectomy was performed after 2 non diagnostic FNAs. While a majority of robotic total pancreatectomies are performed in the setting of pancreatic adenocarcinoma, we demonstrate its utility in other settings such as multifocal solid and cystic lesions, premalignant lesions and metastases from renal cell tumors. Breaking the operation down into individual steps creates a feasible and reproducible approach for surgeons to replicate.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 195. FROM DIAGNOSIS TO REPAIR OF AN E3 + C BILE DUCT INJURY JF Rekman, MM Bonds, GB Baison, FG Rocha Presenter: Janelle Rekman MD | Virginia Mason Medical Center Background: Common bile duct injury (CBDI) is a rare, but serious, complication of laparoscopic cholecystectomy. Management of these injuries is complex and requires management and surgical treatment tailored to the individual patient. This case describes the presentation, work-up, definition of anatomy, and surgical repair of a Strasberg classification E3 + C biliary injury at the time of laparoscopic cholecystectomy in a patient with aberrant biliary anatomy. Methods: A 61 year old male had a difficult emergency laparoscopic cholecystectomy for acute on chronic cholecystitis. The gallbladder was scarred, shrunken, and there were multiple small stones. One week post-operatively he returned to a peripheral hospital with right upper quadrant abdominal pain. An abdominal computed tomography (CT) scan demonstrated a collection in the gallbladder fossa which was found to be bile, on percutaneous drainage. After source control, the anatomy of the bile duct injury was further defined using magnetic resonance cholangiopancreatography (MRCP), CT angiogram, tube cholangiogram, and endoscopic retrograde cholangiopancreatography (ERCP). To achieve more controlled drainage of the intra-hepatic biliary system, a percutaneous transhepatic biliary-drain (PTBD) was placed into a dilated duct through the right liver into the presumed hilum of the liver. Results: These tests revealed a Bismuth-Strasberg E3 + C-type injury with the IR drain sitting in a biloma at the base of the hilum without concomitant vascular injury. A PTBD was placed in the right anterior duct and tube cholangiogram through the first IR drain demonstrated an additional, low aberrant right posterior duct disconnected from the hilum. An additional PTBD was placed in this right posterior duct for pre-operative drainage and to use for localization intra-operatively. Two months following his original injury, the patient was brought to the operating room for a laparotomy and roux-en-Y hepaticojejunostomy. The drain was used to localize the stump of the hilum. Careful non-circumferential dissection and debridement of the bile duct stump, as well as the aberrant right posterior duct, were performed. A single enterotomy was used to anastomose the right posterior duct (with PTBD across the anastomosis) and the remainder of the hilum with good effect on post-operative cholangiogram. Conclusion: CBDI is a rare complication of laparoscopic cholecystectomy that should be treated in specialized centers with the diagnostic and therapeutic capabilities to control sepsis, define the vascular and biliary anatomy, and plan appropriate surgical repair.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 196. LEFT HEPATECTOMY WITH MIDDLE HEPATIC VEIN INJURY AND VIDEOLAPAROSCOPIC REPAIR MB de Oliveira, L Coutinho, A Godoy Presenter: Marcos Belotto de Oliveira MS | Sírio Libanês Hospital Background: Laparoscopic liver resection has been performed worldwhile with safe results for both benign and malignant diseases. In addition to the already known benefits of the technique such as reduction of postoperative pain, shorter hospital stay and early return to usual activities, recent studies show that, for liver lesions, the technique still reduces the blood loss and mortality without causing losses to recurrence of malignant diseases or survival. We present the video of a left hepatectomy by videolaparoscopy performed in a 31-year-old male patient presenting with a symptomatic and progressive nodule on this topography. Methods: A 31-year-old man with a history of hepatic nodules underwent elective laparoscopic left hepatectomy. Details of the procedure are shown in the video Results: A 31-year-old man with a history of hepatic nodules diagnosed by routine exams performed follow-up since 2016. During this period, the nodule progressed from 2 to 11 cm and began to present symptoms: the patient reported constant abdominal pain in the left hypochondrium. Due to the evolution of the case, elective laparoscopic left hepatectomy was chosen. A lesion of the hepatic vein was successfully repaired during the procedure, with no other intraoperative occurrences. The postoperative courses were uneventful and no blood transfusion was required. The patient was discharged after 4 days. Subsequently, the result of the pathological analysis demonstrated clear cell carcinoma of the liver. Conclusion: We conclude that videolaparoscopy is a safe surgical approach for the treatment of focal liver lesions and its achievement should be considered.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #6 P 197. LAPAROSCOPIC EXCISION OF CHOLEDOCHAL CYST WITH END-BLOC CHOLECYSTECTOMY AND HEPATICODUODENOSTOMY RECONSTRUCTION A Rosales, DL Cardoso, JA Stauffer Presenter: Armando Rosales MD | Mayo Clinic, Florida Background: In 80% of choledochal cyst they are diagnosed in infants and young children within the first decade of life. The incidence ranges from 1 in 100,000 to 1 in 150,000 individuals in Western countries, and are four-times more common in females. Etiology is unknown etiology, but anomalous pancreaticobiliary duct union is seen in 30 – 70% of all cysts. Biliary malignancies are seen in 10% to 30% of choledochal cyst. Methods: Our patient is a 34-yo M with incidental finding of a type 1 choledochal cyst during computer tomography for nephrolithiasis. This was followed by a MRCP that showed a 5.3 x 3.4 cm saccular type 1 choledochal cyst involving the lower common hepatic duct and upper to mid common bile duct, and gallbladder polyp measuring 6 mm. He underwent a laparoscopic choledochal cyst excision with en-bloc cholecystectomy and hepaticoduodenostomy reconstruction Results: The operation was uneventful. Patient was discharged home on postoperative day three tolerating a soft diet and having bowel function. Final pathology was consistent with a bile duct with a 4 cm choledochal cyst with insertion of cystic duct into type 1 cyst without evidence of dysplasia or malignancy. Conclusion: Laparoscopic choledochal cyst excision is a feasible and safe approach, decreasing the chance of malignant transformation and with the benefits of minimally invasive surgery, faster recovery and less pain.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 198. AMPULLARY STENOSIS AND BILIARY COMPLICATIONS POST ROUX-EN-Y GASTRIC BYPASS: CHALLENGES OF BILIARY ACCESS AND INTERVENTION AD Wisneski, JT Carter, EK Nakakura, AM Posselt, M Arain, KS Kirkwood, K Hirose, L Stewart, CU Corvera Presenter: Andrew Wisneski MD | University of California, San Francisco Background: Roux-en-Y gastric bypass (RYGB) is commonly performed as surgical treatment for morbid obesity. This results in anatomy rendering traditional endoscopic access to the biliary system difficult or impossible. Our institution has encountered several cases of ampullary stenosis and choledocholithiasis post-RYGB, with joint advanced endoscopic and surgical expertise required for successful evaluation and intervention. Methods: 13 patients (5 male, 8 female) with mean age 53.7±9.8 years underwent RYGB for morbid obesity 10.8±5.2 years prior to diagnosis of biliary pathology confirmed by combination of abnormal liver function tests (LFTs) and dilated common bile duct on imaging (MRCP or cholangiogram). Presenting complaints/signs/diagnoses included: abdominal pain (6 patients), back pain (1 patient), incidentally noted elevated LFTs (1 patient), primary sclerosing cholangitis (1 patient), radiographic evidence of choledocholithiasis (4 patients), ascending cholangitis (6 patients). 8 patients had cholecystectomies prior to presentation. 2 patients (1 male, 1 female) had comorbidities of systemic lupus erythematosus (SLE), 1 patient had congenital adrenal hyperplasia, 5 patients had hypothyroidism. 4 patients had documented chronic opioid use. 3 patients had positive anti-nuclear antibody, which included both patients with SLE. Results: A combination of endoscopic/surgical interventions were performed on these cases. 4 patients underwent laparoscopic trans-gastric ERCP for sphincterotomy and stone extraction, 2 patients underwent common bile duct exploration (1 open, 1 laparoscopic) with stone extraction (1 with choledochoduodenostomy reconstruction), 2 patients underwent open transduodenal ampullectomy (1 with choledochoduodenostomy reconstruction). 1 patient underwent open cholecystectomy with choledochoduodenostomy. 1 patient was treated with percutaneous transhepatic biliary drainage alone. 1 patient was diagnosed with primary sclerosing cholangitis and received liver transplantation. 1 patient had suspected ampullary malignancy and underwent a pylorus sparing Whipple procedure. 1 patient underwent laparoscopic cholecystectomy alone as diagnostic maneuver for abdominal pain. In total, three ampulla specimens were negative for malignancy, and all remaining hepatobiliary and cytopathology specimens were negative for malignancy. The mechanism of ampullary stenosis after RYGB is postulated to be multifactorial with potential contributions from metabolic/hormonal derangements, chronic opioid use, or autoimmune conditions. Conclusion: We present 13 cases of ampullary stenosis and choledocholithiasis in post-RYGB patients, which were treated with a variety of interventions. Joint endoscopic/surgical intervention with transgastric ERCP has proven an effective technique for biliary access. Ampullary stenosis post-RYGB appears to be a benign process and additional studies are needed to elucidate the pathophysiology. As weight loss procedures resulting in discontinuity of alimentary and biliary limbs continue to be commonly performed, we report our small series to make surgeons aware of this rare entity.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 200. PANCREATIC RESECTIONS: OUTCOMES IN OCTOGENARIANS ST Levi, C Darcy, BL Gough, NJ Petrelli, JJ Bennett Presenter: Shoshana Levi MD | Christiana Care Health Care Background: Pancreatic tumors are frequently found in a geriatric population. Given that the median age of patients with pancreatic cancer is 70 years at diagnosis and the ubiquity of CT imaging has increased the detection of pancreas masses, pancreatic surgeons often find themselves operating on patients of advanced age. This study sought to evaluate the outcomes of pancreatic resection in an octogenarian population at a single institution with a dedicated surgical oncology team. Methods: A retrospective chart review was performed for all patients undergoing pancreatic resection over a 12-year period at an academic community cancer center. Patient characteristics and operative outcomes were compared between patients aged 80 and older, and those younger than 80. Student t-tests and chi-squared tests were used for univariate analyses. Results: Over the 12-year period, a total of 48 patients of 403 undergoing pancreatic resections were aged 80 or older. Of these 48 patients, 35 underwent pancreaticoduodenectomy and 13 underwent distal pancreatectomy. Patient characteristics including ASA classification were similar among the two age groups. The procedures themselves were equally complicated with similar operative times, transfusion requirements, estimated blood losses, and portal vein resections. The number and severity of complications such as delayed gastric emptying and pancreatic leak were not statistically different between the two groups. Additionally, the 30-day reoperation, readmission, and mortality rates were not statistically different. The total number of deaths in the octogenarian group was 2 (4.2%) vs. 6 (1.7%) in the non-octogenarian group (p = 0.25). The length of stay was 1.6 days shorter in the octogenarians undergoing distal pancreatic resection (p = 0.02). The length of stay after a pancreaticoduodenectomy was similar among the two age groups. All of the octogenarians undergoing distal pancreatectomy and 57% of those undergoing pancreaticoduodenectomy were discharged to home. Discharge to a facility was not predicted by a calculated modified frailty index. Conclusion: At a large-volume academic community cancer center with a dedicated surgical oncology team, octogenarians can undergo complex abdominal surgeries safely with similar outcomes to their younger counterparts.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 201. TUMOR MAXIMAL DIMENSION FOR GALLBLADDER CANCER AS AN IMPORTANT PROGNOSTIC FACTOR EY Bekhor, B Sullivan, D Solomon, N DeNicola, M Hofstedt, BJ Golas, U Sarpel, DR Magge, DM Labow, N Bolton Presenter: Eliahu Bekhor MD | Icahn School of Medicine at Mount Sinai Background: Gallbladder cancer (GBC) is a rare malignancy, which carries a poor prognosis. Currently, TNM staging is the major prognostic tool used to dictate treatment. The role of tumor size in GBC has not been broadly published. Methods: All patients in a single large health care system, with gallbladder carcinoma, were retrospectively analyzed between 2007 and 2017. We compared oncological outcomes for two groups of patients separated by their tumor maximal dimension, using 5 cm as the cutoff between the two groups. Results: We analyzed the data of 112 patients who underwent cholecystectomy for gallbladder cancer between 2007 and 2017. In comparing the group with smaller tumors to those with larger tumors, age (mean, years, 65 vs. 66), gender (female, 64% vs. 58%), and ASA class (%) (I – 24 vs. 29, II- 42 vs. 29, III- 24 vs. 42, IV, 10 vs. 0) were all similar (p=NS). Patients with smaller tumors had significantly more laparoscopic surgeries (%, 52 vs. 15, p<0.00), and the majority of them were found to have GBC incidentally (%, 91 vs. 19, p=0.00). Tumor characteristics were compared; T-stage III-IV (%, 33 vs. 69, p<0.00), TNM stage III-IV (%, 68 vs. 81, p<0.00), and positive lymph nodes (%, 34 vs. 58, p=0.03) were all significantly better for the smaller tumors group. At median follow-up of 26 months, 52 patients recurred. There was significant difference between disease-free survival (mean months, 25 vs. 9, p<0.00) and overall survival (mean months, 28 vs. 13, p= 0.02). Conclusion: As expected, patients with larger tumors have poorer prognoses than those with smaller tumors. For some other tumors, tumor size is part of TNM staging and thus one of the tools used by clinicians to determine patient prognosis and treatment. This preliminary data analysis suggests that tumor size has a role in gallbladder cancer staging.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 202. HEPATITIS C DEPRESSION SEVERITY DECREASES AFTER AN 8-WEEK EDUCATIONAL PROGRAM FE Ramirez, N Nedley, JW Chon Presenter: Francisco Ramirez MD | Weimar Institute Background: Research has shown that those with hepatitis C are more susceptible towards depression and morbid thoughts that could lead to suicide. This study documents the response of an 8-week program on depression levels and morbid thoughts of individuals with hepatitis C. Methods: Participants from 5 continents who finished the educational program were studied. Those who chose to participate met once a week for 8 weeks for a 2 hour program. It consisted of a 45 minute DVD presentation followed by a small group discussion. No doctor patient relationship was established. The program was offered by previously trained facilitators that were certified. This program focused on educating participants on healthy behaviors such as exercise, plant-based diets, sleep hygiene and others. Each participant answered at the beginning of the program and at the end of the program the Depression and Anxiety Assessment Test. It assessed depression level based on DSM-5 [The Diagnostic and Statistical Manual of Mental Disorders Volume 5] criteria, demographics and hepatitis C positivity. Results: From 5997 participants that finished the 8 week program, n=99 participants had hepatitis C. That group mean age was 49, SD 14.8, and n= 32 (62.7%) were female. At baseline n=15 had no depression. By the end of the 8 weeks. Those with baseline severe depression (n=28), 27 no longer had severe depression, n=1 continue with severe depression. Those with baseline moderate depression(n=31), 24 had less than moderate depression. Those with baseline mild depression (n=24), n=15 end up with no depression. Baseline depression was 13.3 (moderate) SD 6.4 end depression mean values were 8 (mild depression) SD 6. Conclusion: The educational intervention effectively improves depression and decreases severity in most of the participants. This model should be studied further and a long term follow up should be done to investigate how the changes continue on the long term.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 203. ENHANCED RECOVERY AFTER SURGERY PROTOCOL IN PANCREATIC SURGERY, CRITICAL FACTORS FOR RAPID PATIENT RECOVERY K Pineda-Solis K, LI Ruffolo, DC Linehan, LO Schoeniger, E Galka Presenter: Karen Pineda MD | University of Rochester Background: Enhanced Recovery After Surgery (ERAS) is an evidence-based pathway with the purpose of optimizing recovery from surgery and potentially decreasing postoperative pain, reducing complications, and shortening hospital stay. With ERAS implementation multiple variables are changed simultaneously and identification of the factor(s) that drive improvement can be difficult. The aim of this study is to determine which ERAS factors are most impact on length of stay (LOS). Methods: All patients undergoing a pancreaticoduodenectomy (PD) at a quaternary referral center from Jan 2014 to Jun 2018 were identified. Patients were divided in two groups, pre-ERAS and ERAS. For the purposes of this analysis all patients who had minimally invasive surgery (MIS) and vascular reconstructions (VR) were excluded. Perioperative data was collected for clinicopathological features and ERAS adherence. Postoperative data was collected including, length of stay at the hospital (LOS), readmission rate 30 days after surgery, morbidity, and mortality. We used the ERAS guideline’s evidence levels and recommendation grades (Lassen et al) to assign a score for each factor from our institutional ERAS protocol. Factors with the highest scores were identified to form a core group with the most impact. (Table 1) Results: 191 patients underwent PD during this study period. We excluded 87 patients who had 22 MIS, 53 VR, and 12 having both, thus 104 patients were included in this study. Among these patients 56 (54%) were pre–ERAS and 48 (46%) were in the ERAS group. Patients’ median LOS was 10.5 days in pre-ERAS vs 7 days in the ERAS group (p < 0.001). The factors whose adherence was associated with favorable impact on LOS include: IV fluid balance during OR; starting a clear liquid diet POD#1; full liquid diet POD#2 and 3; early removal of urinary catheter (UC) POD#2; starting regular diet POD#4; and continuing regular diet on POD#5. In the ERAS group, the patients who adhered to these factors had a median LOS of 5 days compared to 7 days with statistical trend towards significance. (p = 0.1). Statistical analysis was performed utilizing Student’s T, Mann Whitney U, and Chi Square. Conclusion: The implementation of ERAS principles reduced LOS without harm to the postoperative recovery of patients. Strict fluid balance in the OR, early urinary catheter removal; early liquid intake; and a rapid progression to a regular diet were associated with a decreased LOS. This study showed that

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 204. TOTAL PANCREATECTOMY FOR PANCREATIC HEAD CANCER – TRADING PANCREATIC FISTULAS FOR DIABETES R Schmitz, K Freischlag, M Adam, DG Blazer Presenter: Robin Schmitz MD | Duke University Medical Center Background: Standard of care for resectable pancreatic head cancer is the Whipple procedure (PD). One major morbidity of this procedure is a postoperative pancreatic fistula (POPF), which can have significant impact on short and long-term mortality. Total pancreatectomy (TP) spares the patient this complication with the downside of postoperative diabetes mellitus. This national study compares short- and long-term outcomes from patients with pancreatic head cancer who underwent PD vs. TP Methods: Patients treated for pancreatic head adenocarcinoma were identified from the National Cancer Database (2006-2015). The cohort was divided in two groups; patients who underwent pancreaticoduodenectomy and total pancreatectomy. The two groups were matched 2:1 for local cancer stage. Hospital length of stay, resection margin positivity, 30-day readmission rate, 30-day mortality, 90-day mortality, and overall survival were compared between the two groups. Results: A total of 17,167 patients with pancreatic head adenocarcinoma were identified. The PD group included 16,539 patients and 628 patients underwent TP. There were no significant differences in patient age, gender, race or comorbidities between the two groups. Patients undergoing TP had a significantly lower rate of positive resection margins (18.4% vs. 24.2%, p=0.001). Thirty-day readmission rate was significantly higher in the PD group (6.8% vs. 3.9%, p=0.004) likely representing the morbidity of POPFs. There was no significant difference in long-term survival identified. Conclusion: Total pancreatectomy has a lower short-term morbidity and similar long-term survival compared to pancreaticoduodenectomy for patients with pancreatic head adenocarcinoma. Therefore, total pancreatectomy is a reasonable alternative to pancreaticoduodenectomy that should be utilized more liberally if clinically indicated.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 205. A COMPARISON OF THE SENDAI AND FUKUOKA GUIDELINES FOR SIDE BRANCH INTRADUCTAL PANCREATIC MUCINOUS NEOPLASMS AT A SINGLE INSTITUTION BL Gough, CH Kriza, ST Levi, NJ Petrelli, JJ Bennett Presenter: Benjamin Gough DO | Helen F Graham Cancer Center & Research Institute Background: Cystic lesions of the pancreas are present in up to 2.4% of asymptomatic patients, with increasing incidence secondary to widespread use of imaging for unrelated evaluations. Due to their ability to harbor malignancy, image based risk stratification and appropriate surgical intervention are of utmost importance. The 2006 Sendai consensus guidelines were developed for management of intraductal papillary mucinous and mucinous neoplasms, with the more specific 2012 Fukuoka guidelines proposed to prevent overtreatment. The objective of this work is to compare the diagnostic accuracy of the Sendai and Fukuoka criteria in identifying aggressive pathology. Methods: A retrospective chart review was performed for patients who underwent surgical resection of pancreatic cystic neoplasms from 2006-2018 at an academic community cancer center. A total of 105 cases were identified, with 30 mucinous cystic neoplasms, 8 main duct intraductal pancreatic mucinous neoplasms (MD-IPMNs), and 28 side branch intraductal pancreatic mucinous neoplasms (SB-IPMNs) noted on final pathology. SB-IPMNs were then evaluated, having both the Sendai and Fukuoka guidelines applied to each case. Results: 28 patients who underwent resection were found to have SB-IPMN on final pathology. 89% (25/28) of SB-IPMN patients met the Sendai criteria and 86% (24/28) met the Fukuoka criteria for resection. All patients who underwent resection after 2012 met both guidelines, but did not demonstrate a statistically significant increase in aggressiveness on final pathology relative to prior resections (P=1.000, Fisher’s exact test). The single patient that differed between the two criteria demonstrated a final pathology with moderate dysplasia. Conclusion: Despite the 2012 changes in guidelines for resection of SB-IPMN, this study suggests that the more stringent Fukuoka criteria does not result in a greater percentage of aggressive SB-IPMNs being resected compared to the Sendai criteria. Furthermore, our findings raise concern that a minority of SB-IPMNs that should be resected based on final pathology may be missed when only applying the Fukuoka guidelines.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 206. SIMPLE CHOLECYSTECTOMY FOR T1B AND GREATER NODE NEGATIVE NON METASTATIC GALLBLADDER CARCINOMA EY Bekhor, B Sullivan, D Solomon, N DeNicola, M Hofstedt, BJ Golas, U Sarpel, DR Magge, DM Labow, N Bolton Presenter: Eliahu Bekhor MD | Icahn School of Medicine at Mount Sinai Background: Gallbladder carcinoma is a rare malignancy, which carries a poor prognosis. Radical cholecystectomy is considered the treatment of choice for most resectable gallbladder carcinoma. Methods: We retrospectively analyzed all patients who underwent surgical resection with curative intent for gallbladder carcinoma in our institution from 2007 to 2017. Patients with non-metastatic nor node involving disease greater than T1a were included. We compared clinical and oncological outcomes of patients who underwent Radical cholecystectomy compared to simple cholecystectomy. Results: Overall 30 patients with GBC T stage Ib,II,IIIa (N0M0) underwent simple cholecystectomy. We matched a group of 33 patients underwent Radical cholecystectomy who had comparable variables. Age (mean, years, 70 vs. 66), gender (female, %, 60 vs. 76), ASA score (%) (I – 11 vs. 30, II – 39 vs. 40, III 32 vs. 24, IV – 18 vs. 6), TNM stage (%, T1b – 30 vs. 18, T2 – 53 vs. 67, T3 – 17 vs. 15), surgical approach (laparoscopic, %, 70 vs. 54) and adjuvant therapy (%, 21 vs. 27) were all comparable (p=NS). As would be expected, incidental finding was significantly lower for those who underwent RC (%, 83 vs. 61, p=0.05), although the gallbladder carcinoma was incidentally found in the majority of patients in both groups. Tumor maximal dimension was significantly different between groups (mean, mm, 18 vs. 32, p=0.01). At median follow-up of 29 months, 26 patients recurred. Mean disease-free survival was 19 vs. 29 months (p=0.85), and overall survival was 22 vs. 32 months (p=0.38). Conclusion: In this small analysis of stage matched patients with gallbladder carcinoma with node negative disease there was no statistically significant difference in overall survival or disease free survival. Simple cholecystectomy may be considered definitive therapy in patients with advanced age or poor performance status.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 207. TRAINEE AND TEACHER LEARNING TOGETHER: DUAL CONSOLE AND THE THREE ARMS T Jackson, EE Cho, HG Osman, DR Jeyarajah Presenter: Terence Jackson MD | Case Western Reserve University School of Medicine Background: Transitioning from open to laparoscopic surgery was a slow process, often taking several years. The transition to robotics has been more systematic but growth from a robotic surgeon to a teacher without impeding trainee education has been challenging. As faculty surgeons get trained in robotics, there is generally a year-long hiatus in trainee participation. We describe a method of robotic education involving the use of the fourth arm (Xi) or third arm (Si), allowing for faculty and trainee growth together. Methods: A tertiary care hospital system with hepatopancreaticobiliary and advanced GI surgery fellowships was the back drop for this trial program. The surgeons were recently trained and the aim was to gain personal robotic surgery experience without compromising trainee experience. The fourth arm (Xi) or third arm (Si) was used on every robotic case that was performed by the surgeons at the institution. These cases performed consisted of advanced hepatobiliary and foregut procedures and included basic procedures like a cholecystectomy. The trainee was then transitioned from the fourth arm (X) or third arm (Si) to arm one and two. Results: All trainees completed online training modules and performed simulations prior to any console work. The fourth arm was used in every case. The trainees were placed in the dual console positon rather than at bedside which was felt not provide robotic-specific experience. As the trainees showed competence in the assistant role; could finger-clutch and show arm control, the surgeon handed over two operating arms and took the fourth arm. Using this technique of graduated responsibility and robotic-specific training, trainees were able to graduate to dual arm work quickly. For example, a routine hiatal hernia repair could be handed over to the trainee using two robotic arms within three cases. More importantly, both the faculty and trainee obtained robot-specific experience together. Conclusion: Use of the fourth arm allows for a graduated progression in robotic training. We believe that dual console position allows for more superior and relevant robot-specific training than bedside laparoscopic assistant position. This method allows for a quicker transition to a dual-arm robotic surgeon role for the trainees, and a concomitant learning curve for faculty and trainee. We would propose a multi-center trial to look at this method of robotic training.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 208. INSURANCE STATUS EFFECTS ON LOCALIZED PANCREATIC CANCER: A STUDY AT THE LARGEST PROVIDER OF UNCOMPENSATED CARE IN NEW JERSEY JK Kim, J Patel, S Ahlawat, O Mahmoud, R Chokshi Presenter: Jin Kim MD | Rutgers University Background: Cancer outcomes have been associated with racial and socioeconomic disparities. With pancreatic cancer affecting 55,440 patients with an estimated 44,330 deaths in 2018, understanding issues that may affect outcomes is an important public health issue. We reviewed pancreatic cancer resections at an academic urban tertiary medical center that provides the largest uncompensated care in New Jersey, to investigate whether demographics and insurance status were linked to outcomes. Methods: We reviewed an IRB approved pancreatic database at a single institution. We included patients who underwent resections for aggressive or benign localized pancreatic malignancy between 2010-2017. Patients were divided by insurance status: privately insured versus underinsured. We defined underinsured patients as those who were covered by Medicaid, Medicare, or Charity Care. All demographic and outcome data was analyzed using SPSS version 17. Results: Between 2010-2017, a total of sixty patients underwent resection for localized pancreatic malignancy. Thirty-nine (65%) were underinsured and twenty-one (35%) were privately insured. The mean age was significantly higher in the underinsured group (62 years old) versus the privately insured group (54 years old); (p=0.04). The mean BMI was significantly lower in the underinsured group (23) compared to 28 in the privately insured group; p=0.014. There were no significant differences in gender, race, distance traveled, delay in time to surgery, tumor location, or tumor type. The pancreatic head was the most common location of a mass in both groups. Overall survival at 2-years was worse in the underinsured group (58.3%) compared to the privately insured group (83.3%), but not statistically significant (p=0.13). Conclusion: Insurance status has been shown to be a prognostic factor in cancer patients. Aside from age and BMI, the demographic data of patients at our institute was not statistically different between the insured and underinsured groups. We did see a trend toward worse outcomes in the underinsured group, however this was not statistically significant. This may be explained by the small sample size, varying tumor pathology, and heterogenous population in this analysis. More research is needed to truly tease out the effects of insurance status on outcomes for locally advanced pancreatic malignancies.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 209. THE PANCREAS AS A TARGET OF METASTASES. FIRST MULTI-CENTRIC STUDY IN ARGENTINA JS Rubio, F Pattin, J Glinka, M Balmer, P Capitanich, P Barros Schelotto, G Kohan, O Mazza, GE Gondolesi Presenter: Juan Santiago Rubio MD | Hospital Universitario Fundación Favaloro Background: The pancreas is an uncommon site for metastases, accounting for 0.25% to 5% of pancreatic tumors, so that solitary pancreatic metastases (PM) are rare. The most frequent primary tumors capable to metastasize into the pancreas are Renal Cell Carcinoma. Surgical resection remains as the best therapeutic alternative to achieve long term survival. Our aim is to present the long-term results of the first multi-centric review of pancreatic resection due PM in Argentina. Methods: multi-centric, retrospective review of adult patients operated for pancreatic metastases during July/2010 to October/2017 in 4 high volume Argentinian HPB surgery centers. Results: 672 pancreatic surgeries were performed, 27 (4%) due PM. Median age was 5911 years old, 14 (51%) were male. The most frequent primary tumor was Renal Cell Carcinoma (19) followed by Colorectal Cancer (3). Mean number of pancreatic lesions was 1.7 (range: 1 – 7), 16 distal pancreatectomies, 9 duodenopancreatectomies and 2 total pancreatectomies were performed. Twelve (44%) patients had complications and 4 (15%) patients required reoperations. The overall patient survival was 72%, while the mean disease free survival was 44% at 5 years. Conclusion: Despite PM are rare, surgical resection offer the best oncological alternative, and must be though as possible diagnose in patients with history of renal cell or colon cancer.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 210. METASTASIS TO THE PANCREAS FROM PRIMARY SOLID TUMORS H De la Fuente, J Gonzalez, E Waugh, J Chapochnick, C Derosas Presenter: Hernán De la Fuente MD | Clinica Santa Maria Background: Metastases to the pancreas from solid primary tumors are rare, representing around a 2-5% of all pancreatic tumors. The primary tumors that most frequently metastasize to the pancreas are renal cell cancer, melanoma, colorectal cancer, lung cancer, breast lobular cancer and sarcomas. The affinity of the metastasis from renal cell carcinoma to the pancreas is a well known peculiarity but not studied in depth. The objective of the following report is to analyze the experience in the management and surgical results of a cohort of patients with pancreatic metastases. Methods: Retrospective study of patients operated by the authors from 2002 to date. Descriptive and analytical statistics. Results: We have identified 14 patients treated for metastatic lesions to the pancreas from solid primary tumors as a single site of metastasis. Twelve cases corresponded to isolated metastasis of renal cell carcinoma , one to Leiomyosarcoma and the other one to Sarcoma Phyllodes . Two patients (14.3%) presented with synchronous lesions and 12 with metachronous tumor (85,7%) . Seven patients were resected initially by pancreatoduodenectomy and 7 by distal pancreatectomy. In the follow up two patients with renal cell carcinoma metastasis develop new lesions at the remainder gland , both receive a total pancreatectomy as a definitive management. There was not perioperative mortality. Thirteen of the fourteen patients are still alive, three of them develop extrapancreatic distant metastasis at the follow-up with an average recurrence-free interval of 18 months and a median follow-up of 5 years. Conclusion: Metastasis of renal carcinoma to the pancreas are rare, but should be treated by resective surgery when they presented as a single site of metastasis. The most common presentation is as metachronous metastasis, with long disease-free intervals. In these patients , surgery offers a benefit in disease-free survival and local control.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 211. ESTABLISHMENT OF A MULTI-DISCIPLINARY PREHABILITATION PROGRAM FOR PATIENTS WITH HEPATOPANCREATICOBILIARY AND FOREGUT CANCER IN A COMMUNITY HOSPITAL I Siddiqui, C Cuteri, P Winter Presenter: Imran Siddiqui MD | St. Vincents Medical Center Background: Prehabilitation optimizes health by taking a proactive approach to promoting exercise, nutrition, and lifestyle modifications.This study is a pilot of an ongoing comprehensive multi-disciplinary prehabilitation program which is established to optimize perioperative outcomes of patients undergoing surgery for hepatopancreaticobiliary/foregut malignancies. The intent of the study is to identify if such a program would help improve perioperative outcomes, impact survival and improve quality of life. Our hypothesis is that prehabilitation will help in improving functional outcomes, quality of life and indirectly improve survival rates and allow a larger percentage of otherwise poor surgical candidates to be transitioned to the surgical cohort. Methods: All patients undergoing surgery for foregut and hepatopancreaticobiliary cancers are seen in the prehabilitation clinic. They undergo individual evaluation and assessment by an oncology nutritionist, physical/occupational therapist, psychologist/social worker in addition to palliative care medicine and pain management and allied services like yoga, massage therapy and outpatient support groups. Data including age, BMI, weight loss percent, fat percent, fluid percent, muscle percent, hand grip strength, TUG (time up and go) score, muscle group strengths, sensation, co-ordination, fatigue severity scores, ECOG class, modified SF-36 quality of life and distress screening scores are evaluated upon the first visit. Interventions are made and patients are followed up either via follow-up visits or telephonic interviews. Patients continue to be followed in the hospital and then for 6 weeks postoperative Results: Primary outcomes will include hospital and the stay, 30 day morbidity and 90 day mortality and Clavien 3 and 4 complications as well as 30 day readmission rates. Secondary outcomes to include oncological outcomes of the procedure, time to return to adjuvant therapy, time to return to preoperative functional status, quality of life delta between postoperative and preoperative periods. Other long-term data will include impact on 1 year and 3 year overall survival and disease-free survival. Initial results from the preoperative assessment are listed in the table. Completion of data entry will be done during the designated post-operative visit at 6 weeks and then patients will be followed longitudinally in coordination with medical oncology and survivorship clinic to assess disease free and overall survival and quality of life for survivors. This data is to be available for evaluation and discussion by February 2019. Conclusion: This pilot study demonstrates the successful setup of a multi-modal prehabilitation program that evaluates and addresses the preoperative patient not only from a physical and nutritional standpoint but from a behavioral and psycho-social setup. We believe that data from this study will demonstrate that it is well received and has effect on outcomes and quality of life of patients undergoing surgery for hepatopancreaticobiliary and foregut malignancies.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 212. PANCREATIC CARCINOSARCOMA: A RARE CASE REPORT AND SYSTEMATIC REVIEW OF THE LITERATURE NK Dave, JK Kim, RJ Chokshi Presenter: Nikita Dave MS | Rutgers University Background: Carcinosarcoma of the pancreas is a rare malignant neoplasm with a dismal prognosis. These tumors harbor a varying mix of carcinomatous and sarcomatous components. Due to its low incidence, there is a paucity of literature describing the pathogenesis and management of this cancer. Methods: A review of the literature using PubMed search words “carcinosarcoma pancreas” was conducted. We identified 25 cases of pancreatic carcinosarcoma worldwide. The majority of reported tumors were located in the pancreatic head (n=17, 68%) and the remainder were identified in the body/tail (n=8, 32%). Ductal adenocarcinoma was the most common carcinomatous component (n=18, 72%), with rare cases reporting mucinous cystadenocarcinoma or adenosquamous carcinoma. For the sarcomatous component, most reported malignant, poorly-differentiated spindle-cell proliferations (n=15, 60%), with some cases identifying fibrous histiocystoma, leiomyosarcoma, osteosarcoma, or embryonal rhabdhomyosarcoma components. All patients underwent surgical resection of their tumors and twelve patients (48%) received adjuvant chemotherapy (gemcitabine: n=5, gemcitabine/adriamycin/cisplatin: n=1, gemcitabine/paclitaxel: n=1, unspecified: n=5). The majority of patients (n=13, 52%) died within 15 months of surgery due to recurrence. Results: We describe a rare case of pancreatic carcinosarcoma in a 42-year-old woman from the Republic of Congo who presented with vague complaints of epigastric pain radiating to the back with associated nausea, vomiting, bloating, and watery non-bloody diarrhea for four days. Abdominal CT with contrast revealed a heterogenous, complex solid and cystic mass (11.3 x 7.3 x 10.6 cm) in the distal body and tail of the pancreas and a cystic lesion in the porta hepatis (7.0 x 4.0 x 7.8 cm). There was no dilatation of the pancreatic or bile ducts. Serum lipase, CA 19-9 and CEA were elevated (10,947, 9,966, 65.5, respectively) while liver function tests were normal. The patient subsequently underwent endoscopic ultrasound with fine-needle aspiration of the pancreatic mass with cytology highly suspicious for malignancy. Enbloc resection involving subtotal pancreatectomy, splenectomy, left colectomy and left partial adrenalectomy was performed to remove the mass. Pathologic studies revealed invasive carcinosarcoma composed of mixed mucinous cystadenocarcinoma and a heterologous anaplastic sarcomatous component with foci of angiosarcoma (CD31+), smooth muscle differentiation (SMA+) and osteoid production as well as osteoclast-like giant cells. There was focal extension of tumor into the mesocolon and colon with lymphovascular invasion. All 17 lymph nodes were negative for malignancy. Final staging was pT3N1M0. Conclusion: Our review of the literature demonstrated pancreatic carcinosarcoma to be extremely aggressive, with many patients presenting with locally advanced stage of disease. Carcinosarcoma of the pancreas is predominantly seen in women in their seventies, although the reported age at presentation ranges from 38 to 82 years. Long-term survival based on scant data has demonstrated dismal outcomes despite surgery and adjuvant therapy, with most patients succumbing to recurrence within a year of initial surgery. Due to the paucity of data and literature on this tumor subtype, there are no evidence-based treatment recommendations available; however, the current standard of care entails surgical resection and adjuvant therapy with gemcitabine. Our patient tolerated surgery well and has been evaluated by Radiation and Medical Oncology for consideration of adjuvant therapy.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 214. EFFECTIVENESS OF A VASCULARIZED PEDICLE WRAP AT THE PANCREATIC ANASTOMOSIS IN PREVENTING POSTOPERATIVE PANCREATIC FISTULA IN PANCREATICODUODENECTOMY PATIENTS: A CASE SERIES AND SYSTEMATIC REVIEW SB Peer, PHY Leung, NCF Lau, S Quigley, C Smith, D Pace, M Hogan Presenter: Syed Peer MD | Memorial University of Newfoundland Background: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) can result in significant morbidity or mortality. Moriura et al. (1994) described an omental flap technique that could protect a pancreatic anastomosis. Iannitti et al. (2006) proposed a technique using the round ligament (falciform ligament) as a vascular pedicle to cover the pancreatic anastomosis. This study combines a retrospective case series with a systematic review to assess whether wrapping of the pancreatic anastomosis in PD affects POPF rates. Our small case series followed PD patients who received a vascularized pedicle wrap at their pancreatic anastomosis to determine the rate of POPF. Methods: All patients (n=6) who had undergone wrapping of the PJ during PD between January 2016 and May 2018 were identified from a retrospective database. PD was performed by a single hepatobiliary surgeon at a tertiary care hospital. Demographic data, pathology results, and post-operative findings were assessed from the retrospective chart review. POPF was defined using the updated 2016 International Study Group criteria (ISGPS) for POPF. A systematic literature search of the buttressing technique was also performed using the following databases: Pubmed, Embase, and Medline. Results: Six patients received a vascularized pedicle wrap at the PJ anastomosis: Two patients received omental wraps and four patients received falciform wraps. Indications for procedure were: pancreatic ductal adenocarcinoma (33.3%), pancreatic pseudocyst, no malignancy (16.7%), ampullary adenoma, high grade dysplasia (16.7%), peri-ampullary adenocarcinoma (16.7%), cholangiocarcinoma (16.7%). No patients had clinically significant pancreatic fistula. One patient had a biochemical leak, requiring no intervention. There were no major complications, readmissions, or mortality. A systematic review (following PRISMA guidelines) identified 8 observational studies, 586 cases and an incidence of clinically relevant POPF(CR-POPF) of 16.4%. A sensitivity analysis, excluding retrospective survey data, resulted in an adjusted CR-POPF rate of 3.6% . Conclusion: The results of our systematic review indicate that wrapping of the pancreatic anastomosis may reduce the rate of POPF. The small case series at our institution has shown promising results. Large-scale controlled studies are necessary to confirm the effectiveness of this technique.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 215. SOLID PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS: A SINGLE INSTITUTION EXPERIENCE JK Kim, N Dave, S Ahlawat, R Chokshi Presenter: Jin Kim MD | Rutgers University Background: Pancreatic solid pseudopapillary neoplasm (SPN) is a rare cystic tumor. It is thought to have low malignant potential, however due to its scarcity, little is known about its long term sequelae and pathogenesis. Curative surgical resection is recommended as the best treatment for long term survival. Methods: Using our IRB approved pancreatic database, we performed an analysis of pancreatic resections from 2011 to 2017. We identified a total of five patients diagnosed with pancreatic solid pseudopapillary neoplasm. Of these patients, four underwent resection at our institute. All demographic and outcome data statistics were analyzed using SPSS v 17.0 software. Results: All five patients were female with a mean age at diagnosis of thirty-two. All patients presented with a complaint of vague abdominal pain as the most common presenting symptom. The average BMI for all patients was 29.4. Racial make-up of this population included African American (2, 40%), Hispanic (2, 40%), and White (1, 20%). There was no history of alcohol or tobacco use in any of the patients. Three patients (60%) were uninsured while two patients (40%) had private insurance. CT was the most common initial imaging used to identify the pancreatic mass. None of the five patients presented with metastatic disease. Tumor size varied greatly; mean size of 7.7cm (with a range 1cm-17cm). SPN was most commonly located at the head of the pancreas (60%). Four (80%) patients underwent definitive resection at our institute with R0 resection. The fifth patient was lost to follow-up. The estimated blood loss for each operation was less than 200ml. The mean length of hospitalization was eight days. There were no major perioperative complications and no evidence of recurrence during follow-up. Conclusion: SPN is a rare pancreatic mass that predominately occurs in young women. We describe five cases at our institute during a six year period. Regardless of the size of tumor, best practice includes R0 resection with clinical follow up to monitor recurrence for excellent prognosis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 216. PORTAL VEIN ANEURYSM REPAIR: A RARE ENTITY VS Pandit, T Son, H Ho, H Aziz, R Harland, T Jie Presenter: Viraj Pandit MD | University of Arizona Background: Portal vein aneurysm is a rate entity with only a few cases reported in the literature. The management of portal vein aneurysms remains controversial. The aim of the case report is to describe the management of a patient with symptomatic portal vein aneurysm. Methods: Our patient a pleasant 67 year old woman with h/o HTN, right shoulder rotator cuff surgery, pancreatitis four years ago was having vague abdomen pain for which she underwent a CT scan that demonstrated a portal vein aneurysm. She subsequently underwent an MRI which demonstrated a 5.2 cm saccular aneurysm arising from the superior aspect of the main portal vein, with neck measuring 2.4 cm. (figure 1). Physical exam was unremarkable. As she was symptomatic she was scheduled for surgical repair of the aneurysm Results: After endotracheal intubation, we made an upper midline with a right subcostal incision was made. Then we mobilized the liver completely followed by a kocher maneuver and dissection at the head of the pancreas. The portal vein aneurysm was observed from the right side, which was not involving the vena cava. We identified and isolated the common hepatic, proper hepatic and bile duct. The aneurysm was intimately attached to the common hepatic artery. Then we performed meticulous dissection in the posterior aspect of the portal vein to isolate the aneurysm and portal vein. The aneurysm appeared to have started at the mid portion of the portal vein with a an identifiable neck. (figure 2) A Satinsky vascular clamp was applied from the right side to partially occlude the portal vein. The aneurysm sac was resected and the neck of the aneurysm was repaired with a 5-0 and 6-0 Prolene suture, respectively. After confirming hemostatisis, a drain was placed and abdomen was closed. Post Op: The patient post op course was unremarkable and liver function test were normal. She was started on Po 81mg aspirin and discharged on post-op day 4. She followed up in clinic post-op day 14 and staples removed and was doing well. She has a scheduled MRI abdomen scheduled to evaluate the portal vein post reconstruction. Conclusion: This is one of the first case reports to describe the pre-op, intra-op and post-op management approach for a patient with symptomatic portal vein aneurysm. Further consensus guidelines need to be established for management of these patients.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 217. LAPARSOPCIC REMOVAL OF AN INTRADUCTAL ERCP STONE RETRIEVAL BASKET FOLLOWING GUIDE WIRE FRACTURE RT Fleck, P Higgins, N McInerney, P Waters, G McEntee, JB Conneely Presenter: Robert Fleck MRCS, MBBCh, BAO | Mater Misericordiae University Hospital Background: Gallstones within the common bile duct are a common cause of biliary obstruction. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and stone retrieval using either balloon catheters or wire basket devices is the gold standard treatment. Methods: We present the case of an 85 year old lady who presented with obstructive jaundice and deranged LFTs. Ultrasound confirmed choledocholithiasis and common bile duct (CBD) dilation. She proceeded to ERCP and sphincterotomy where multiple CBD stones were noted, the largest measuring 12mm. Prior to removal using a wire basket device an attempt was made to crush the largest stone. In doing so the guidewire fractured with the basket and stone still within the common bile duct. A rescue mechanical lithotriptor was used in an attempt to clear the duct unsuccessfully. Further attempts to remove the stone and basket through the sphincterotomy were also unsuccessful and the patient proceeded to laparoscopy. Results: A four port laparoscopic approach was used with x1 12mm umbilical port and x3 5mm epigastric and right subcostal ports. A longitudinal choledochotomy revealed several stones and the wire basket. The wires were cut using scissors and the basket was retrieved along with the large impacted stone. Proximal and distal ducts were cleared using a fogarty balloon catheter. The CBD was closed using interrupted intracorporeal vicryl sutures and a T-Tube was inserted. A cholecystectomy was then performed and the specimen along with the wire basket and stones were removed using an endobag through the umbilical port. The T-Tube was brought out though one of the right subcostal ports. The patient returned to the ward and had an uncomplicated post op recovery. The T-Tube was removed several weeks later following a satisfactory tube cholangiogram. Discussion ERCP is the gold standard of treatment for the removal of common bile duct stones, with a success rate of over 95%.(1) Wire basket retention as a result of stone impaction within the basket and less commonly as a result of guide wire fracture occurs in 0.6% of cases. (2). Management of these complications can involve the use of balloon catheters, further mechanical lithotripsy techniques and in the setting of an impacted stone, extracorporeal shockwave lithotripsy (ESWL). However if these endoscopic methods fail then surgical intervention is indicated. Conclusion: Intraductal ERCP wire basket retention following wire fracture can be safely and effectively managed laparoscopically when traditional endoscopic methods have failed. This is associated with a significantly reduced level of morbidity when compared to traditional laparotomy and in specialist centres it should be considered as a first line treatment in such cases. (we have excellent video for this case that was not available at the time of this submission but will be accessible in the coming days)

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 218. GENETIC PROFILE OF COLORECTAL METASTASES IN THE CHILEAN POPULATION X Aretxabala, G Rencoret, R Humeres, G Cardenas, J Francisco Tabilo, M Vivanco Presenter: Oliver Maida MD | Clínica Alemana de Santiago Background: In Chile we also consider surgery as a treatment in the hepatic metastases of colorectal cancer. We present the first series that measures the Chilean genetic profile Methods: We reviewed the clinical records of all colorectal cancers operated in our center from 2005 to the present. Conclusion: We found a RAS mutation is very common in our population. Which is a bad genetic factor in our population

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 219. CEPHALIC DUODENOPANCREATECTOMY RESECTION: TECHNIQUE, MORBIDITY AND MORTALITY PE Lada, C JaniKow, M Sánchez, M Massa, F Caballero, N Menso, J Martínez Peluaga, D Mariot, F Flórez Nicollini, L Gramática Presenter: Paul Lada MD | Hospital J. B. Iturraspe Background: Advances in recent decades in the massive form of diagnostic techniques for images, a better understanding of pancreatic diseases and management pre, intra, and postoperative patients has affected in some centres of reference, a significant reduction of mortality and an increase in the survival of the cephalic pancreaticoduodenectomy for the treatment of malignant and benign tumours of the confluent bile-duodenum-pancreatic today this surgery is performed with acceptable morbidity and mortality. The objective of this study is to evaluate the incidence of the disease, pancreatic resection technique, morbidity and mortality of the Pancreaticoduodenectomy. . Methods: Between December 2000 and December 2014, 96 PDC have been operated. Of them, 54 male and 42 female, whose ages ranged from 27 to 79 years old (average of 59 years) In relation of symptoms, in 89 patients had weight loss which varied between 4 to 15 kg, 83 opportunities presented jaundice, in 82 cases looked for pain, 51 vomiting and fever in 14 cases. All the patients out an ultrasound of the abdomen, to detect 80 times allowed observing tumours, noting in addition in 82 cases the main bile duct dilatation. Likewise, was performed in all patients a CT scan of the abdomen, which showed in 86 opportunities dilatation of Wirsung duct and 89 cases bile duct dilatation hepatic intra and extra hepatic. Results: All patients underwent a PD and as it is our custom, trying to expand the pancreatic resection as much as possible to the left of the mesenteric-portal axis in patients with tumours of the head of pancreas and lymphadenectomy in the hepatic pedicle prolonged by the artery to the celiac trunk. In addition, we have extended lymphadenectomy to the superior mesenteric artery and tissue retro-portal. We rebuild by pancreatic-jejunostomy term-terminal invagination anastomosis with a tutor in the Wirsung duct in cases of pancreas mild. 10-15 cm from it makes the hepatico-jejunostomy anastomosis end-side. About 40 cm of pancreatic-jejunostomy anastomosis jejunum is sectioned to make a Y -shaped Roux, whose distal sector, previous close terminal, allow the gastro-jejunostomy With respect to mortality within 30 days, 5 patients (4, 80%) died. Subsequently, 5 more patients died within 90 days (9.3%). With respect to morbidity, we divide them into in two, clinics that were 17 patients (16.32%), which were 3 lung disease, 6 febrile syndromes, 4 diabetes, 1 arrhythmia, 1 IAM, respiratory failure and an atrial fibrillation last two died. 50 patients were surgical (48%). Within pancreatic fistula was in 32 patients (30, 72%), divided into type A: in 25 cases (24%) where there was no clinical impact, type B: 4 opportunities (3.84%) and finally type C: 3 (2.88%), which one of them after being intervened. C patient died. With respect to the gastric emptying was present in 19 (18.24%) who had more than 10 days the SNG. Finally 5 (4.80%) had intra peritoneal bleeding, which were re intervened and one of them died. In addition, 8 patients had a biliary fistula (7.62%). Conclusion: Finally, we would like to talk about strong evidence that high-volume centres have lower mortality than low-volume centres. There is evidence that patients treated at high-volume centres have reduced surgical mortality and morbidity, higher survival in the long term, greater number of lymph nodes in the surgical specimen, increased frequency of R0, less hospital stay, and generate lower costs. The results of our work support the concept that surgeons with low volume of PDC annually, but with strict training in institutions with adequate infrastructure and a multidisciplinary team, can also get good results in the malignant and benign lesions of biliary-duodenum-pancreatic confluent.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 220. SURGICAL RESECTION OF LOCALLY ADVANCED PARAVISCERAL NEUROGANGLIOMA L Yohanathan, GC de Oliveira, AL Folpe, TC Bower, MJ Truty Presenter: Guilherme C de Oliveira MD | Mayo Clinic, Rochester Background: Neurogangliomas are rare, benign tumors of neural crest origin most commonly seen in the mediastinum/retroperitoneum and can involve critical vasculature. They are indolent and slow-growing tumors that present with symptoms based on mass effect and location. A 29-year old male presented with 2 months of worsening abdominal pain, early satiety, and diarrhea. Initial outside imaging revealed an indeterminate abdominal mass with EUS biopsy consistent with neuroganglioma. Triple phase CT revealed a large (10 x 7 x 9cm) abdominal mass that appeared to arise from the right diaphragmatic crus and involving the paravisceral arteries of the abdominal aorta.. . Methods: The mass spared the left gastric artery but circumferentially encased the common hepatic artery with extension to the proper hepatic/gastroduodenal artery bifurcation, and circumferential encasement of the proximal splenic artery and superior mesenteric artery origin from the aorta extending down to the middle colic artery take-off with sparing of distal superior mesenteric root branches. The mass abutted the body/tail of the pancreas and anteriorly displaced the main portal, splenic vein and distal superior mesenteric vein with narrowing and there was encasement of the coronary vein. The left renal vein was involved and two right renal arteries were abutted but left renal artery uninvolved. After multidisciplinary discussion with no other viable treatment options in a highly symptomatic patient with a paravisceral ganglioneuroma, surgical resection was recommended Results: The patient was taken to the operating room for attempted vascular-sparing resection with plan for en bloc multi-arterial resection and reconstruction. A midline laparotomy was performed, the left lateral bisector was mobilized from its diaphragmatic attachments and reflected medially. The omentum was taken off transverse mesocolon, lesser sac entered and gastro-hepatic ligament divided. The right and left colon were mobilized and full Kocher maneuver performed. The medial wall of IVC and left renal vein and right renal arteries were dissected from the mass arising from the right diaphragmatic crus. The distal CHA at the proper hepatic/gastroduodenal bifurcation was dissected free and GDA was ligated. The omentum was divided close to the spleen and short gastric vessels ligated. The spleen and distal pancreas were dissected,mobilized in a retrograde fashion along left kidney/adrenal gland andIMV was ligated. The left diaphragmatic crus was divided and left renal artery preserved. Dissection was carried onto the aorta and the origins of the variant visceral vessels were isolated The splenic artery required ligation at its origin but the CHA and SMA origins preserved. Splenectomy was performed preserving the distal pancreas.The distal uninvolved SMA from the mesenteric root was dissected identifying the middle colic artery. The tumor was divided over the course of the SMA distally to its origin from the aorta circumferentially dissecting it from the encased SMA ligating several lateral pancreaticoduodenal branches going to the uncinate of the pancreas preserving distal jejunal mesenteric branches. Similarly the mass was dissected where it was encasing the common hepatic from the proper hepatic to the CHA origin with circumferential dissection of the vessel. Tumor was adherent to the portal vein and pancreas. Conclusion: Ligation of various venous tributaries including coronary vein was performed and tumor was carefully dissected off the uncinate and the specimen removed en bloc. Despite ligation of short gastric arteries and GDA there was still adequate arterial gastric inflow via the preserved right and left gastric arcade and this was confirmed with intraoperative Doppler signals and ICG injection under SPY device revealing good perfusion. Ganglioneuromas are rare, benign tumors that can arise in challenging anatomic locations with no other effective options other than resection. In our case pathology revealed benign paravisceral ganglioneuroma. Tumors involving visceral aortic branches require careful preoperative planning, experience with advanced resection and anatomical dissection, and attention to anatomical variants that can assist with R0 resection with minimal morbidity.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 221. ROBOTIC PANCREATICODUODENECTOMY WITH RIGHT HEPATIC ARTERY RESECTION HKM Wei, J Kim, S Zani Jr. Presenter: Hung-Kuang Wei MD | Duke University Medical Center Background: Pancreaticoduodenectomy(PD) with en bloc hepatic arterial resection and reconstruction remains a controversial topic. Although use of robotic surgery has been increasing worldwide in patients requiring PD, hepatic arterial resection and reconstruction has not been previously described. This video depicts a first in utilizing the Davinci Si robotic system to perform a hepatic arterial vascular resection and anastomosis during PD. Methods: A 69 year-old female, presenting with obstructive jaundice, was diagnosed with a distal common bile duct cancer by ERCP and brushing cytology. CT scan imaging revealed the suspected tumor mass involving the proximal right hepatic artery. We performed a total robotic PD. Right hepatic artery (RHA) was involved by the tumor and segmental resection was performed to achieve en bloc resection. End-to-end anastomosis of RHA stump to distal part was carried out by using 5-0 proline suture robotically. The reconstruction, including the modified Blumgart fashion pancreatojejunostomy, choledochojejunostomy and gastrojejunostomy, were all accomplished intracorporeally using the robotic platform. Results: The total operative time was 499 minutes and estimated blood loss was 500ml. The patient was discharged on post-OP day 4 without complications. The final pathology was moderately differentiated pancreatic adenocarcinoma with extensive perineural invasion. Metastatic carcinoma was found in one of the ten lymph nodes. Conclusion: PD with hepatic artery resection and reconstruction can be performed safely using robotic surgery. Restoration of the resected hepatic artery may ensure the bilio-enteric anastomosis in the immediate and late post-operative course.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 222. ROBOTIC ASSISTED ROUX-EN-Y LONGITUDINAL PANCREATO-JEJUNOSTOMY (PUESTOW'S PROCEDURE) E Fernandes, R Bustos, V Valle, G Aguiluz, PC Giulianotti Presenter: Eduardo Fernandes MD, PhD | University of Illinois at Chicago Background: Chronic pancreatitis is a severely invalidating condition of complex etiology associated with severe pain symptoms. The chronic inflammation often results in multi-level obstruction of the pancreatic duct causing dilatation and chronic pain. Several surgical procedures are available for the treatment of chronic pancreatitis. With the increasing availability of the robotic platform, complex pancreatic procedures requiring fine suturing are re-gaining popularity as an alternative to less durable endoscopic stenting. We present a case of a robotic assisted Roux-en- longitudinal pancreato-jejunostomy (Puestow's procedure). Methods: A 44 year-old male with a history of chronic pancreatitis secondary to several episodes of biliary pancreatitis presented at our institution for outpatient consultation. He had previously undergone pancreatic duct stenting, which had failed to resolve his symptoms following stent removal. He was offered surgical drainage of the pancreatic duct via robotic assisted Roux-en-Y longitudinal pancreato-jejunostomy (Puestow's procedure). Results: Patient underwent an elective robotic assisted Roux-en-Y longitudinal pancreato-jejunostomy (Puesto's procedure). The operative time was 150 minutes. Blood loss was 120 cc. The patient post-operative course was uneventful and he was discharged on post-operative day 6. At 6 week follow-up his pain symptoms had markedly improved (subjective pain scored 1 on visual analogue scale from 7 pro-operatively) and he no longer required narcotics medications for symptoms control. Conclusion: Robotic assisted Roux-en-Y longitudinal pancreato-jejunostomy (Puestow's procedures) can be performed safely and is effective in reducing symptoms of patients with chronic pancreatitis and pancreatic duct dilatation of inflammatory/fibrotic etiology. Even though the Puestow's procedure had decreased in popularity at the expenses of endoscopic stenting, the robotic minimally invasive approach has sparked new interest towards this procedure. According to our institutional experience the Puestow's represents a very valid mean of symptoms control in patients with chronic pancreatitis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 223. TECHNICAL ASPECTS OF SURGICAL REPAIR OF COMPLEX IATROGENIC BILIARY STRICTURES ERR Figueira, T Bacchella, AA Miranda-Neto, TN Costa, R Jureidini, GN Namur, TC Ribeiro, I Cecconello Presenter: Estela Regina Ramos Figueira MD, PhD | Hospital das Clinicas of University of Sao Paulo Background: Currently, iatrogenic bile duct injury during cholecystectomy remains a major concern in biliary surgery due to associated morbimortality, and optimal management is still a medical challenge. Definitive treatment depends on type of injury and time of diagnosis. Minor injuries can be successfully treated using endoscopic techniques with placement of stents. Nevertheless high-level injuries Bismuth 3 and 4 can accomplish good outcome with surgical reconstruction. At our Unit patients are referred to late repair, either for primary late repair or for retreatment after fail of bilioenteric reconstruction. Our aim is demonstrated the surgical technique to reconstruction of high-level biliary injury. Methods: In this video, it is demonstrated a technique to surgical reconstruction of a biliary stricture, Bismuth type 3-4, that involves the technique described by Machado et al. in 1986 associated to the dissection of right biliary duct as described by Straberg et al. in 2001. Results: A 29-year-old female was diagnosed with bilioenteric anastomosis (BEA) stricture (Bismuth 3). The BEA has been performed initially to repair biliary injury during laparoscopic cholecystectomy by the same team. Later patient was referred to our Center and submitted to a new side-to-side BEA. Patient was submitted to general anesthesia and received prophylactic ceftriaxone and metronidazole. Bilateral subcostal incision was performed. After identification of previous biliary anastomosis, an incision was performed in segment 4B just above hilar plate. Round ligament was dissected, umbilical fissure was opened and the liver bridge between segment 4 and 2/3 was divided until reaching left bile duct underside of segment 4. Left bile duct was opened anteriorly, exposing the entrance of left and right bile ducts. Dissection of hilar plate was performed continuing toward the right, passing into the liver at base of segment 5, circling the right duct in direction of right portal vein. Right duct was opened 0.5-to-1cm anteriorly. MR cholangiography and the final aspect of biliary dissection are showed in the Video. The liver is opened trough round ligament, crossing above hilar plate at the base of segment 4B, and circling right hepatic duct at segment 5. Note the large open of right and left hepatic ducts, exposing a health mucosa, and showing the ostia of posterior and anterior right hepatic ducts and left ducts. A Roux-en-y side-to-side hepaticojejunostomy is performed using a continuous running suture of 5.0 PDS. At the end, bilateral TRU-CUT liver biopsies were performed. A flat silicone drain was placed posteriorly to the anastomosis. Postoperative period was uneventful, without any complications. The pathologic examination revealed periportal non-ductopenic fibrosis, without bridging. Conclusion: Surgical repair of complex biliary strictures highly located can achieve excellent results even when previous surgery has failed when performed in specialized Centers. Roux-en-Y hepaticojejunostomy should be performed with adequate mucosa apposition without the need of transanatomosis biliary stent.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 224. LAPAROSCOPIC RADIATION SPACER FOR UNRESECTABLE LIVER TUMORS L Yohanathan, CL Hallemeier, RL Smoot Presenter: Lavanya Yohanathan MD | Mayo Clinic, Rochester Background: Radiation therapy is an option for localized, unresectable, hepatic malignancies (both primary and metastatic). The ability to deliver optimized doses of radiation can be hindered by adjacent structures, most typically bowel. For patients in this situation, we have adopted an approach consisting of placement of a customized biologic mesh-based spacer to move adjacent viscera away from the radiation field. This video demonstrates our approach. Methods: Following IRB approval, patients undergoing surgical placement of spacers to facilitate radiation therapy were identified. A single case was video-taped and we describe the clinical case corresponding to this video. Case: The patient is a 59 year old male with Child-Pugh A compensated alcoholic cirrhosis who was being monitored and found to have a 7-mm enhancing lesion in the liver in May of 2014, which was enlarging on surveillance imaging in October 2014, up to 2.7 cm. Radiographic features were consistent with hepatocellular carcinoma. Results: Liver transplant evaluation was performed and the overall consensus was for locoregional therapy at that time. Initial attempt for RFA was made, however, on CT scan the lesion was in close proximity to the duodenum. RFA was not performed and instead alcohol ablation followed by transarterial chemoembolization was undertaken. Recurrent disease in August and November 2015 was treated with TACE. He continued to have progressive disease in the form of enlarging lesion. After multidisciplinary discussion, repeat locoregional radiation therapy was agreed upon. Given the proximity of the duodenum, he was referred to HPB surgery for spacer placement to facilitate safe administration of radiation. The video shows the technique of laparoscopic spacer placement. Shown in the video is the site of HCC in segment 4 of the liver as well as its proximity to the duodenum and colon. An open Hasson technique was used to gain entry into the abdomen and three 5mm ports were placed based on the location of the target lesion. After sizing the area needed for spacer placement, Surgimend mesh was folded and a pocket created with a running #1 prolene suture. The spacer was introduced by extending the supraumbilical port and was positioned underneath the liver followed by a single tacking suture between the stomach and the liver and a single tacking suture between the spacer and mesentery of the right colon to secure the mesh in appropriate position. Fiducials were placed using a clip applier surrounding the visualizable lesions within the liver. Postoperative scan shows full expansion of the spacer. The patient had no complications following surgery and started radiation therapy 11 days after surgery (50Gy in 5 fractions, photon). Conclusion: For patients with unresectable tumors, that are amenable to radiation therapy, placement of a spacer to allow for safe administration of full doses of radiation is a feasible strategy to address proximity of adjacent organs and critical structures. There is minimal morbidity associated with these procedures in our limited experience, including in patients with cirrhosis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 226. ONBOARDING FOR ADVANCED PRACTICE PROVIDERS AM Yee, MA Becks Presenter: Alisa Yee MSN | University of California, San Francisco Background: Between 2010 and 2025, the supply of non-primary care advanced practice nurses full time equivalents is expected to grow by 141 percent and the supply of non-primary care physician assistants is projected to more than double by 2025. Academic medical centers who provide specialized services for complex diseases, illnesses and injuries are challenged with onboarding of their growing advanced practice provider (APP) staff. A strategic, standardized, consistent onboarding process was developed for the APP staff at a major academic hospital in California. Methods: We constructed a year long onboarding program for all APPs newly hired or new to their role (internal transfer). The program consisted of 5 mandatory in person sessions facilitated by an APP who have been employed at the Medical Center for at least 3 and as many as 15 years. Each session was strategically designed to standardize their knowledge base regarding professional responsibility, risk management, thriving as a provider, professional development and committee opportunities at the University of California, San Francisco. This onboarding program is standardized and is meant to enhance the individual’s departmental precepting. Results: Since the implementation of onboarding program there have been 66 new hires that represent 37 different specialties. All but one new hire have remained in their specialty for more than 6 months. The hepatobiliary pancreas surgery oncology department hired a PA who successfully completed the onboarding program and is a contributing member of the team. Conclusion: The supply of APP in non-primary care specialties is projected to grow substantially in the near future. Organizations need to be prepared to invest in these employees with a formal onboarding process since their decision to stay with the organization long term is made within the first six months of employment/

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 227. ABDOMINAL CATASTROPHE AS A RESULT OF AN INCOMPLETE RESECTION OF A CHOLEDOCAL CYST, RESOLVED WITH ROBOTIC SURGERY E Jimenez-Chavarria, SA Pimentel-Melendez, H Noyola-Villalobos Presenter: Samuel Pimentel MD | Hospital Central Militar Background: The cysts of the biliary tree are congenital entities, which can occur not only in common bile duct, but throughout the biliary tree, often accompanied by an anomalous pancreatobiliary junction. With an incidence of 1 case per 100,000 inhabitants, and a ratio of 4:1 female-malr. They may be asymptomatic or may present with symptoms, such as abdominal pain or jaundice. Type 1 of the Todani classification is more frequent, and this type is the one that carries the greatest long-term oncological risk, making its resection mandatory prophylactically or acutely, in a high level and high volume center. Methods: 19-year-old female, who in January of this year presented with painless jaundice, diagnosed as a choledocholithiasis by ultrasound, treated by ERCP, which failed with suspicion of choledochal cyst, a 2nd ERCP was performed and then went into the OR to be subject of an unspecified biliodigestive bypass, right afer with acute abdominal pain, abdominal distension, re-entering the operating room and going to the ICU area where she would stay for 1 month, with multiple admissions to the operating room for undisclosed surgerys. The patient is then discharged but continue with abdominal pain and biliary leakage, and presented to our center, with biliary leakage trough the abdominal drainage, presenting with malnutrition and dehydration. Results: During surgery, a terminal-terminal cholecystojejunal anastomosis is identified, with partial dehiscence of it and a bile leak from the anastomosis, dismantling it, and proceeding to complete the surgery, resecting the gallbladder and the cystic lesion until the confluence of the hepatic ducts, performing a hepatojejunal anastomosis with barbed suture. Conclusion: The use of cholecystojejunal anastomosis has been described mainly in unresectable lesions of the bile duct with a viable cystic duct, but not in resectable cystic lesions, since they precede the principle of this pathology to seek the widest resection possible in order to avoid the dreaded 8% of cholangiocarcinoma and gallbladder carcinoma risk that can be present in the long term. In addition, this type of procedures must be performed in a high volume center because of the complexity that represents, since the morbidity that this procedure involves decreases with the experience of the surgeon, reaching a success of up to 90% in experienced hands.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #7 P 228. ROBOTIC RESECTION OF CHOLEDOCHAL CYST, PORTAL LYMPH NODE DISSECTION, AND ROUX-EN-Y HEPATICOJEJUNOSTOMY EJ Merle, LM Kranker, M Hellan, JR Ouellette Presenter: Evan Merle MD | Wright State University Boonshoft School of Medicine Background: A 33-year-old female presented with acutely-worsening right upper quadrant pain of several months duration. Ultrasound demonstrated a focal common bile duct dilation with choledocholithiasis. Blood chemistries and tumor markers were normal. MRCP showed a fusiform dilation, believed to be a Type I choledochal cyst, measuring 2.6 x 1.5 cm. Over 80% of choledochal cysts are diagnosed within the first decade of life, and surgical removal is the standard of care. In the adult, the risk of malignant transformation is 10 to 30%, with Type I and IV cysts having the highest rates. Methods: Using the Da Vinci Xi Surgical System, the patient underwent resection of choledochal cyst, portal lymph node dissection, and roux-en-y hepaticojejunostomy. There were no intraoperative complications. Results: The total operative time was 3 hours and 54 minutes; total robotic time was 3 hours and 27 minutes. The specimen was completely excised with adequate margins on frozen and final pathology. Recovery was without incident or complication. Conclusion: In our experience, a robotic assisted approach provides better anatomic visualization and increased dexterity for suturing the hepaticojejunostomy anastomosis, when compared to laparoscopy. Minimally-invasive excision is a safe alternative to open excision; this approach offers decreased post-operative pain and ileus, shorter hospital stay, and improved cosmesis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 229. CASE REPORT: TOTAL PANCREATECTOMY IN A WOMEN WITH VON HIPPEL LINDAU SYNDROME GP Carranza, JC Sabogal, A Isaza Presenter: Juan Carlos Sabogal Olarte | Hospital Universitario Mayor Mederi/Universidad del Rosario Background: The association between pancreatic disease and Von Hippel Lindau (VHL) syndrome has rarely been exposed, the main lesions in pancreatic parenchyma are serios cyst, they are usually asymptomatic lesions but when they increase in size and generate obstruction in neighboring organs is necessary to perform a surgical approach Methods: Descriptive study, type case control, clinical case report of a patient with Von Hippel Lindau syndrome and the association with serous cysts and the requirement of total pancreatectomy Results: Fe male patient in puerperium with obstructive biliary syndrome, in imaging studies is evident polycyst serous that makes messes art to perform total pancreatectomy that requires correction of glucometry levels and diarrhea Conclusion: The von hipple lindau syndrome (VHL) is an autosomal dominant disease, in which the VHL protein is compromised, generating an increase in the production of vascular endothelial growth factors that predispose to the development of hemangioblastomas of the retina and the system central nervous system, renal cell carcinoma, pheochromocytoma, endolymphatic sac tumors, pancreatic lesions such as simple cysts, serous cystadenomas, neuroendocrine tumors and adenocarcinoma of the pancreas. Serous cystadenomas of the pancreas represent 10-15% of the cystic lesions of the pancreas, are characterized by a benign behavior and heterogeneous macroscopic findings, The association found in patients with VHL syndrome represents an average incidence of 50%, The risk of presenting diabetes mellitus is low despite the complete replacement of pancreatic parenchyma by cysts.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 230. IS PANCREATIC LEAK AFTER PANCREATECTOMY ASSOCIATED WITH INCREASED RISK OF VTE T Soleimani, J Raccuia, S Kavuturu Presenter: Tahereh Soleimani MD | Michigan State University College of Human Medicine Background: Venous thromboembolism (VTE) events are a known complication of pancreatectomies, including pancreatoduodenectomy and distal pancreatectomy, reported at a rate of 3.1% within 30 days after surgery. Previous studies have shown association between bile leak and VTE amongst patients undergoing hepatectomy. The aim of this study is to evaluate the association between pancreatic leak with VTE in patient undergoing pancreatoduodenectomy and distal pancreatectomy. We hypothesize that the post pancreatectomy patients that have a pancreatic leak will have a higher rate of VTE than those without a leak. Methods: All patients with pancreatectomies identified in the 2005 to 2015 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database will be selected and will be grouped into those with and without pancreatic leak (organ space infection). Using bivariate and multivariate analysis, the rate of VTE will be compared between the two groups, while adjusting for potential confounding variables including demographics and other complications. Conclusion: VTE is a known complication of major surgeries including pancreatectomy, that could cause significant morbidity and mortality. While no current data is available on current practice regarding post-pancreatectomy VTE pharmacologic prophylaxis, on a survey of Hepato-pancreato-biliary surgeons, only 14% indicated that they discharge patients with VTE pharmacologic prophylaxis after hepatectomy. The purpose of current study is to compare the rate VTE amongst pancreatectomy patients with and without pancreatic leak. If the results of the current study confirm the hypothesis that the risk of VTE is higher for the patients with pancreatic leak, important recommendations could be made regarding whether or not to continue post-operative pharmacologic prophylaxis in these high-risk patients upon discharge.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 231. REPORTING A PHASE II, OPEN-LABEL STUDY ASSESSING THE SAFETY AND EFFICACY OF MS1819-SD, A RECOMBINANT LIPASE, FOR THE TREATMENT OF EXOCRINE PANCREATIC INSUFFICIENCY L Lebreton, G Smith, P Jais, M Schue, T Spoor Presenter: Luc Lebreton PhD | AzurRx Background: Chronic pancreatitis is the most common cause of exocrine pancreatic insufficiency (EPI) in adults. EPI is a deficiency in exocrine pancreatic enzymes resulting in an inability to maintain normal digestion. This inadequate digestion, especially fat malabsorption, occurs when intraduodenal levels of lipase fall below 5–10% of normal enzyme output. Furthermore, in EPI due to chronic pancreatitis, decreased bicarbonate output leads to impairment of micelle formation of fats. Fat maldigestion is compounded by decreased pancreatic secretion of lipase and colipase, further dampening hydrolysis of intraluminal fat. Methods: A multicenter, Phase II, open-label, non-randomized study was conducted to investigate the safety of escalating doses (280mg/day, 560mg/day, 1120mg/day and 2240mg/day) of MS1819 Spray Dried (MS1819-SD, a lipase produced by the LIP2 gene of Yarrowia lipolytica using recombinant DNA technology) in patients with chronic pancreatitis (NCT03481803) and decreased fecal pancreatic elastase-1 (FE-1). Patients ‘washed-out’ their standard of care treatment for EPI establishing a baseline. Each patient subsequently received escalating doses of MS1819-SD in 2-week increments. The total treatment phase ranged from 48 to 60 days. Safety was assessed by adverse event (AE) incidence, including clinical or laboratory abnormalities, and efficacy was determined using Coefficient of Fat Absorption (CFA) change from baseline. Systemic exposure and immunogenicity potential of MS1819 were investigated in patients’ serum. Results: A total of 11 patients (9 males, 2 females) were enrolled in France, Australia and New Zealand. The study mean age was 59.2 years (11.19 standard deviation [SD]) and mean weight was 70.6 kg (12.84 SD). Disease etiology was alcoholism in 4 patients, idiopathic in 3 patients, genetic in 2 patients, auto-immune in 1 patient and gallstone induced pancreatitis for 1 patient. In the highest dose group (2240 mg/day) 4/10 patients reported an AE. One serious AE occurred at this dose but it was not considered to be treatment related (pre-planned removal of stent). A drug-related AE was reported at the 1120 mg dose (slight hepatic cytolysis, mild in nature). No circulating MS1819 was detected hence the mechanism of this adverse event cannot be explained or related to systemic exposure. MS1819 immunogenicity was observed in some patients with post-treatment anti-drug antibodies (ADAs) detected. However, some pre-existing ADAs were also detected and the incidence of ADAs was mild (3/10 patients) with moderate ADA titers. Increases in CFA were reported with all doses of MS1819-SD, these increases were particularly high in patients with baseline CFA <40%. Comparing CFA with FE-1 (24 patients with both recorded at screening) a positive spearman rank correlation of 0.64 (p<0.001) was obtained. Although the study was not powered to detect a difference in efficacy parameters, the least square mean increase in CFA was 21.8% with MS1819-SD 2240 mg (p=0.002; per protocol analysis). Conclusion: In general, a favorable safety profile was reported at all doses of MS1819-SD included in the study. Statistically significant and clinically meaningful increases in CFA compared to baseline were recorded. Although the efficacy analysis was pre-planned, the study was not powered to demonstrate differences in the groups and only a small number of patients were included. Favorable trends were also observed on other evaluated endpoints, including the Bristol stool scale, number of daily evacuations and stool weight. Additional studies are warranted to further evaluate the use of MS1819-SD to treat EPI in patients with chronic pancreatitis or cystic fibrosis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 233. THE ROLE OF LIVER SURGERY IN PATIENTS WITH ISOLATED BREAST CANCER LIVER METASTASES: A META-ANALYSIS RA Fayne, FI Macedo, K Kelly, D Yakoub, D Franceschi, AS Livingstone, V Dudeja, NB Merchant Presenter: Francisco Igor Macedo MD | University of Miami Miller School of Medicine Background: Management breast cancer liver metastases (BCLM) is currently limited to palliative systemic chemotherapy. For selected patients, however, surgical resection may be associated with superior outcomes. Methods: An online database search of MEDLINE was performed. Key bibliographies were reviewed. Studies comparing outcomes for patients with BCLM after liver resection versus medical management were included. Odds ratios with corresponding 95% confidence intervals (CI) by random fixed effect models of pooled data were calculated. Primary endpoints were 1-year, 3-year and 5-year overall survival (OS). Results: The initial literature review yielded 232 articles. Seven articles met inclusion criteria and 4 were included in the final analysis. A total of 890 patients with BCLM were included in the analysis: 234 (26.3%) underwent liver resection and 656 (73.7%) underwent non-surgical management. Mean age was 48.7 years vs. 53.3 years (resection vs. no resection, respectively, p=0.354). No statistical difference in hormone receptor status, staging, adjuvant therapy was found between 2 groups. Mean time from breast cancer to BCLM was 38.6 and 37.4 months, respectively (p = 0.941). The median survival time was 54.3 months vs. 21.4 months (resection vs. no resection, respectively, p=0.023). Resection yielded superior 1-year (OR 0.09, 95% CI 0.02-0.49, p < 0.001, Fig. 1), 3-year (OR 0.06, 95% CI 0.04-0.10, p < 0.001, Fig. 2), and 5-year (OR 0.20, 95% CI 0.14-0.28, p = 0.005, Fig. 3) OS when compared to medical management. Conclusion: This is the first meta-analysis assessing the outcomes for patients with BCLM who underwent surgical liver resection. Resection is associated with superior outcomes and should be considered in selected patients with isolated BCLM.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 234. ALPPS FOR THE TREATMENT OF GIANT HEPATOCELLULAR CARCINOMA J Ramirez, F Vergara, L Barrera, M Duque Presenter: Fabio Vergara Suarez MD | IPS Universidad de Antioquia, Clinica Leon XIII Background: Liver resections are the treatment of choice for most liver tumors. Thanks to hepatic regeneration, various procedures have been emerging to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associative Liver Partition and Portal Vein Ligation for Staged Hepatectomy). Which consists of performing a hepatectomy in two stages, achieving faster hypertrophies and in less time. This surgical technique can have high rates of morbidity and mortality, which is why it is very important to select patients appropriately Methods: We present our first case of a two-stage hepatectomy using the ALPPS. Male patient of 65 years, with abdominal ultrasound finding of a mass in right hepatic lobe. Magnetic resonance imaging of the abdomen shows a hepatic giant tumor in the right lobe and part of the IV segment compatible with probable hepatocellular carcinoma in a non-cirrhotic liver. Hepatic volumetry and previous preanesthetic assessment were performed with liver, cardiac and pulmonary function tests. Given the insufficient hepatic remnant, and the large tumor burden that it represented, it was decided to perform an ALPPS in order to obtain a more rapid liver hypertrophy. Results: The first stage was performed by laparoscopic technique, achieving right portal ligation (the anterior and posterior branches separately) and the hepatic transection without the need for Pringle's maneuver. The postoperative evolution was without complications. After 10 days, a new abdominal tomography was performed to assess the hypertrophy. A hepatic remnant of almost 40% is achieved. We proceed then to the second stage of the ALPPS, this time with an open approach. The hepatic transection is completed with ligature of the right hepatic artery, control of the right bile duct and section of the hepatic veinhe procedure was without complications, did not require blood transfusion or vasopressor support, extubation was achieved and transfer to ICU for surveillance where it was 2 days. He had no signs of liver failure, and was discharged at 8 days. The pathology reveals hepatocelluar carcinoma on a non-cirrhotic liver. Conclusion: ALPPS is an alternative in the treatment of liver tumors where the liver remnant is insufficient, and because of its tumor biology a hypertrophy is required in less time or when the other forms of hypertrophy have failed. However, it is a procedure that can have high morbidty and mortality, which is why it is important to select patients in a multidisciplinary team.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 235. EMPIRIC NASOGASTRIC DECOMPRESSION AFTER PANCREATICODUODENECTOMY IS NOT NECESSARY D Moris, J Lim, KN Shah, D Blazer 3rd, M Lidsky, P Allen, S Zani Presenter: Dimitrios Moris MD, PhD | Duke University Medical Center Background: The necessity of nasogastric tube (NGT) decompression after abdominal surgical procedures has been increasingly questioned for several years. Since the widespread application of enhanced recovery programs (ERAS), early withdrawal or even placement of the NGT is questioned after pancreaticoduodenectomy (PD). The aim of the present study was to evaluate the effect of routine NGT decompression after PD on postoperative outcomes. Methods: Patients undergoing PD between January 2015 and October 2017 at a single center were identified using the National Surgical Quality Improvement Program’s (NSQIP) database and retrospective chart review performed. Continuous variables were compared using paired t-test analysis and categorical variables assessed with chi square analysis. NSQIP definitions were used to identify rates of postoperative complications. Specifically, we compared rates of DGE, the length of stay (LOS), the operative time, the 30-day readmission as well the time to first oral intake. Results: During the study period, 150 patients underwent PD, with 62 having routine NGT placement after surgery. One patient in the NG group died within 30 days in hospital who was not omitted from analysis. There were no differences in patient characteristics between the two groups in terms of diabetes, smoking, ASA class. Nasogastric tube was in place for average of 1.8 days (SD 1.23) after surgery. The two groups were in hospital for median of 9 days (IQR: 7-17 vs 7-13; NG vs no NG) (p=0.36). Average operative time for the routine NGT placement group was significantly longer (504 vs 430 mins, p=0.0015) with no difference in % of vascular reconstruction (19.3% vs 15.9%, p=0.58). Twenty-four percent of the patients (15/62) in routine NGT placement group ended up getting NGT replaced, while 15.9% (14/88) in no prior NGT group ended up getting an NGT. This difference was not statistically significant (p=0.23). The time to first oral intake was 2 days for the NGT group (IQR:1, 2) vs 2 days (IQR:2,4) in the no NGT group [p= 0.55]. When we compared the NSQIP reported complications, no differences were seen. Specifically, the proportion of patients who developed DGE in NGT group was 19.35% (12/62) whereas in no NGT group was 13.64% (12/88). The difference did not reach statistical significance (p=0.26). Thirty day readmission rates were also similar: 16.1% in NGT group vs 13.6% in no NGT group (p=0.67). Conclusion: Our retrospective analysis showed that empiric placement of NGT after PD does not reduce the time to first oral intake, DGE, 30-day readmission rates, LOS and NGT reinsertion rates. In the era of ERAS protocols, the findings of our study along with a growing body of literature question the utility of routine NGT placement in patients after PD.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 236. DOTA PET COMPARED TO STANDARD IMAGING IN METASTATIC NET: A MORE SENSITIVE TEST? EE Cho, R Borscheid, J Kurtz, J Gnasigamany, H Osman, DR Jeyarajah Presenter: Edward Cho MD, ScM | Methodist Richardson Medical Center Background: DOTA- Pet is becoming a popular imaging technique for detecting neuroendocrine (NET) tumors. The sensitivity of DOTA-PET compared to standard cross sectional imaging with triple phase CT or MRI with Eovist has not been looked at. Methods: DOTA PET scans ordered at our institution between 11/2017 and 7/2018 were reviewed. All patients showing positive liver metastases were sorted and cross sectional imaging results were reviewed. Specifically, numbers of lesions were recorded by cross sectional imaging and compared to whether these were less, equal, or greater in number than those noted on the DOTA-PET. Results: 21 patients with 24 tests were identified that had DOTA- Pet scans during this period. Primary tumors were pancreatic (42%), small bowel (29%), gastroduodenal (10%) and not localized (19%). Of these cases, 18/24 (63%) had CT scans and 14/24 (58%) had MRI scans. 17/24 (71%) of patients had increased numbers of liver metastases noted by DOTA-Pet compared to either CT or MRI. 5/24 (21%) had the same number of lesions on all studies. 2/24 (8%) of patients had fewer lesions noted on DOTA-PET compared to standard cross sectional imaging. Conclusion: DOTA-Pet should be considered the test of choice when evaluating patients with metastatic NET to the liver. While standard cross sectional imaging will be needed for surgical planning, DOTA will identify lesions that may not be seen on other imaging modalities and this could result in inadequate tumor clearance. It is important that HPB surgeons have a good understanding of DOTA- PET scans.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 237. EPIDURAL ANALGESIA VERSUS FASCIAL PLANE BLOCKS: A CRITICAL APPRAISAL IN THE CONTEXT OF HEPATOPANCREATICOBILIARY ENHANCED RECOVERY PATHWAYS A Greenbaum, H Wilcox, C Teng, V Phuoc, M Billstrand, T Yen, T Petersen, A Sandoval, R Campbell, I Nir, N Bordegaray Presenter: Alissa Greenbaum MD | University of New Mexico Health Sciences Center Background: Epidural analgesia (EA) is an effective method to both control post-operative pain and reduce perioperative complications after major abdominal surgery. However, with the introduction of Enhanced Recovery (ER) pathways, potential side effects associated with EA such as hypotension and oliguria are in conflict with core ER endpoints. Novel methods, collectively named facial plane blocks (FPB), offer a promising alternative, providing effective pain control while negating unwanted side effects associated with EA. This study compares EA to FPB in hepatopancreatobiliary surgery in an established ER practice. Methods: Data for 34 patients who underwent open liver, pancreas, or extrahepatic biliary surgery were prospectively acquired and retrospectively analyzed. Patients were randomly assigned into two arms, EA and FPB. The FPB group included three methods: transversus abdominis, quadratus lumborum, and erector spinae blocks. The route was based on the anesthesia provider’s preference. EA and FBP groups were compared on continuous variables (e.g. age, BMI) with Wilcoxon-Mann-Whitney test, binary variables (e.g. sex) with Fisher’s exact test, and categorical variables with >2 categories (e.g. ethnicity) were compared with chi-squared test. Results: 19 patients received EA and 15 FPB. There were no differences regarding age, sex, ethnicity, indication for surgery (benign vs. malignant), ECOG performance status and BMI between EA and FPB groups. The pre-incision anesthesia preparation time (73 vs 50 min, for the EA and FPB respectively; p<0.001) and procedure time for the analgesia intervention (21 vs 13 min; p=0.02) were both shorter in the FPB arm. Mean intraoperative intravenous colloid infusion was 296ml in the EA group vs 95ml in the FPB group (p=0.03). Post-operatively, arterial hypotension (systolic blood pressure < 90mmHg) was observed in 54% of EA vs 8% of the FPB patients (p=0.03). FPB was also favorable in regards to Foley catheter removal and time to first ambulation, both being achieved 24 hours earlier. There was no statistically significant differences in pain scores between the two arms. Post-operative complications were not noted to differ between the two groups. Conclusion: In major open abdominal operations, there were no significant differences in pain scores or complications between FPB and EA. Our data suggest superiority of the former in several key ERAS endpoint domains. These outcomes will be further validated in a prospective randomized fashion. Of additional interest are the economic implications of FPB, potentially positively affecting operating room time and utilization.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 238. THE HYDROCHOLERETIC BILE ACID DEHYDROCHOLIC ACID IS A SAFE AND MODERATELY EFFECTIVE TREATMENT FOR RECURRENT ACUTE CHOLANGITIS DUE TO BILIARY STASIS SM Strasberg, JG Grossman, RB Sullivan, T Stoentcheva, LA Worley Presenter: Julie Grossman MD | Washington University, St. Louis Background: Biliary stasis leading to recurrent bouts of cholangitis in the absence of strictures is a rare but extremely vexing problem. Such patients often have dilated ducts in which sludge and stones form repeatedly despite endoscopic clearance and antibiotic treatment. We hypothesized that stasis could be reduced and cholangitis lessened by continuous hydrocholeresis. Dehydrocholic acid (DHC) is a synthetic non-micellar tri-keto bile acid shown to be a potent hydrocholeretic in animals and man. It is much more potent than micellar bile acids such as ursodeoxycholic acid (Actigall) by virtue of its non-micellar structure. Methods: An IRB approved registry was established to study the effect of DHC in patients with recurrent cholangitis who did not have biliary obstruction due to strictures. Eleven patients treated for at least one year were included in this analysis. DHC was initiated at 250mg three times per day and the subsequent daily dose was titrated to avoid watery diarrhea, a known side-effect of this cathartic drug. Patients were regularly examined. Laboratory testing of hepatic, renal, and hematologic function was performed approximately every three months. Results: Eight men and three women, ranging in age from 36 to 75 have been treated for one to nine years. Six patients had a prior hepaticojejunostomy, and five patients had had cholecystectomy and biliary sphincterotomy. Two patients had been previously, unsuccessfully, treated with ursodeoxycholic acid. Comparing the year prior to and after initiation of DHC, there was a statistically significant decrease seen in inpatient hospital admissions (p<.05) and total number of episodes of cholangitis (p<.005) (Figure 1). One patient experienced nausea, diarrhea, 8-pound weight loss, and pain in hands and feet on DHC. The symptoms abated after DHC was stopped and did not return when it was restarted. Other patients have not experienced similar or other symptoms, other than occasional diarrhea, controlled by dose adjustment. There have been no other clinically significant side effects. Conclusion: DHC was effective in reducing bouts of cholangitis in eight of the 11 patients who have been treated for over one year. It has an excellent safety profile when used long- term in patients with recurrent bouts of cholangitis due to biliary stasis. Patients with recurrent cholangitis due to biliary stasis and without flow limiting strictures should be considered for a trial of DHC.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 239. HPB TRAINING IN ASTS TRANSPLANT FELLOWSHIPS: MORE PANCREAS PLEASE! R Borscheid, E Cho E, F Lewis, H Osman, J Kurtz, A Saharia, AO Gaber, DR Jeyarajah Presenter: Rene Borscheid MD | Methodist Richardson Medical Center Background: The American Hepatopancreatobiliary Association (AHPBA) is a leader in HPB fellowship training. Interestingly only about 15% of the active HPB surgeons have undergone training in a dedicated HPB program - the majority has been educated in other fellowships, including transplant. Apart from self-reported deficiencies in ultrasound and laparoscopic techniques, little is known about attitude towards the specialty and perception of HPB training among the trainees in transplant fellowships. Methods: With the permission of the American Society of Transplant Surgeons (ASTS), we evaluated HPB training in ASTS-accredited transplant programs with the help of an IRB-approved, anonymous survey, administered online via Survey Monkey. The questionnaire included 37 items concerning demographics, pre-fellowship and fellowship education, exposure to core HPB procedures and competency, didactic environment, evaluation of program strength/weaknesses and suggestions for improvement, as well as future practice goals/current practice setup. The target population were current and previous fellows in ASTS clinical training programs. Of 294 trainees and graduates contacted, a total of 110 (37%) participated in the survey. The responses are given as percentages of total answers. Results: The age of responders ranged from 31 to 60, 30% were female. A sizeable number attended an international medical school (44%) and/or trained abroad (34%). Although the overwhelming majority (94%) trained in a program with an ASTS-accredited liver transplant track, 44% of these fellowships did not have an official HPB or HB accreditation. 62% of participants cite a ‘strong interest in HPB surgery’ and 91% of current trainees want their future practice to include HPB. Among graduates, 72% perform HPB cases in their current practice. Most training programs have less than 25% of total volume dedicated to HPB. Only 20% of ASTS-trained surgeons had performed 25 or more pancreas cases during fellowship. Almost 60% of trainees had done between 0 and 5 Whipple operations and only 51% felt competent to perform the procedure independently. For 4 other pancreas index procedures, more than half of surgeons did not feel comfortable operating alone. Conclusion: Many transplant trainees have a strong interest in hepatopancreatobiliary surgery, and the majority of ASTS fellowship trained surgeons are active in HPB practices. On the other hand, current trainees have only little exposure to pancreaticoduodenectomy and other index pancreas procedures and do not feel comfortable taking care of these patients. Improving exposure to pancreatic surgery cases and possibly aligning training criteria with non-transplant HPB fellowship programs may better equip transplant fellows for their future HPB practice.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 240. SURGICAL OUTCOMES IN OCTOGENARIANS WITH LEFT-SIDED PANCREATIC DUCTAL ADENOCARCINOMA: A MULTI-INSTITUTIONAL ANALYSIS F Alemi, Z Jutric, GR Marshall, EJ Scott, J Grendar, AM Roch, LL Pereira, PD Hansen, EP Ceppa, HJ Asbun, S Warner, AA Alseidi Presenter: Farzad Alemi MD | St. Vincents Medical Center Background: Surgical resection for pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) accounts for 11.5% of all pancreatectomies. Of those, only 20% are performed on patients older than 80 years. This study characterizes this extremely small population of octogenarian patients with left-sided PDAC to establish their unique clinicopathologic, surgical, and treatment outcomes. Methods: Patients at five high-volume pancreatic centers with PDAC-NBT who underwent surgical resection with curative intent were retrospectively analyzed. Clinical, radiographic, pathologic, and treatment outcomes for the octogenarian cohort were compared to those of younger patients. Results: 370 patients were surgically treated between 2001 and 2016. Of those, 44 patients were greater than or equal to 81 years of age at diagnosis. Compared to patients aged less than 61 (n=87), octogenarians exhibited no differences in presentation symptoms but exhibited significantly lower BMI (24.4 vs 29.2, p<0.0001). Clinical characteristics were similar except that octogenarians presented with smaller tumors (3.4 cm vs 5.1 cm, p=0.016) and were more likely to have elevated CA 19-9 (88% vs 52.9%, p=0.020). The use of neoadjuvant therapy was similar between all age groups, but adjuvant chemotherapy was significantly under-utilized in octogenarians (36.6% vs 80.5%, p<0.00001). Surgically, octogenarians had significantly shorter operative time (247 vs 300 minutes, p=0.04), had fewer lymph nodes recovered (14.3 vs 22.2, p=0.03) and were more likely to undergo a non-R0 resections (38.5% vs 18.5%, p=0.02). Postoperatively, there were no differences in blood transfusions, complications, pancreatic fistulas, or hospital length of stay. Pathologically, no differences were found between tumor stage, lymph node ratio, perineural or lymphovascular invasion. Likewise, there were no significant survival differences attributable to age. Conclusion: Octogenarians with PDAC-NBT have significant differences in surgical and medical treatment metrics, including lower rates of R0 resection and adjuvant therapy. Despite this, there were no overall differences in perioperative morbidity, mortality, or survival. These data suggest that resection should be pursued in the appropriately selected octogenarian as outcomes are not associated with age-related clinicopathologic factors.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 241. FEMALE GENDER ASSOCIATED WITH POOR OUTCOMES FOLLOWING TEMPORARY INACTIVATION ON THE LIVER TRANSPLANT WAIT-LIST LA Dageforde, N Vachharajani, J Campbell, AS Khan, JR Wellen, WC Chapman, MBM Doyle Presenter: Leigh Anne Dageforde MD, MPH | Massachusetts General Hospital Background: Temporary inactivation on the liver transplant waitlist or “Status7” is a transplant center dependent practice. Patients can be inactivated or made Status7 for a variety of reasons including: temporarily too sick, temporarily too well, insurance issues, incomplete work-up, non-compliance and substance abuse, candidate choice, high BMI, and because they cannot be contacted. The criteria to inactivate patients is dependent on individual centers. While Status7, patients are not eligible for liver transplantation. Outcomes of patients following Status7 have not been reported. Methods: All patients removed from a single center’s waitlist from 2005-2016 were retrospectively reviewed. Patients were removed from the waitlist and transplanted or removed prior to transplant. Data collected included: demographic factors, reason for temporary inactivation and waitlist removal, number of times and length of time of inactivation on the waitlist, MELD score, and organ and patient survival after transplant. Univariate and survival analyses were performed. Results: Of 1567 patients removed (1075 transplanted; 492 not-transplanted), 31.0% were Status7 at least once. Of the Status7 patients, only 25.1% (n=122) were transplanted, whereas 88.2% (n=953) patients never made Status7 were transplanted (p 0.09). Overall, a higher proportion of women than men were not transplanted (36.5% vs 28.5%) (p=0.002). However, a similar proportion of women and men were Status7 at least once (32.4% vs 29.9%) for similar reasons (52.6% vs 51.3% “too sick”). A significantly lower proportion of women were transplanted after Status7 (17.7% vs. 29.6%) (p=0.004) (Table). Conclusion: Overall, a history of being Status7 was associated with a higher likelihood of being removed from the waitlist without transplantation. However, patients who were transplanted after a history of temporary inactivation for being “too sick”, there was similar patient and organ survival. Women were statistically less likely to ultimately reach transplant despite a similar proportion women and men being made Status7 while on the waitlist. Women were significantly less likely to be transplanted after an episode of temporary inactivation on the waitlist. Investigation is needed to identify why less women recover from temporary inactivation than men.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 242. DO CO-MORBIDITIES, CLINICAL VARIABLES, OR SURGICAL APPROACH PREDICT READMISSION POST LIVER RESECTION? PJ McLaren, DJ Monlezun, JK Sulzer, C Li, MR Mvula, AS Volk, KY Van Anh, M Darden, G Parker, JF Buell Presenter: Patrick McLaren MD | Louisiana State University Health Science Center Background: The ability to predict 30-day readmission for patients following liver resection can improve health outcomes and equity. Methods: A case-control retrospective study was conducted for readmission in a large single center including 1,147 liver resection patients from 2000-2016. Multivariate propensity score (PS)-adjusted regression was conducted for causal inference to determine the most predictive comorbidities and clinical variables. Regression analysis included age, sex, race, ASA (American Society of Anesthesiologist) score >2, body mass index (BMI), major resection, cirrhosis, hypertension (HTN), diabetes (DM), obesity, tumor size and margin, prior abdominal surgery, and the likelihood of undergoing laparoscopic versus open surgery. Results: The mean age in the study was 57.22 (standard deviation [SD] 13.61), 452 (43.88%) were female, and 100 (13.46%) were readmitted. Patients who were readmitted were significantly more likely to be African American and have American Society of Anesthesiologist scores >2, Medicare or Medicaid instead of commercial insurance, hypertension, and diabetes (all p<0.01). In multivariate regression, laparoscopic versus open surgery had no association with readmission. The top readmission predictors were hypertension (OR 8.56, p<0.001) followed by African American race (OR 2.77, p<0.001). Conclusion: Our analysis identified significant racial and insurance disparities in readmission following liver resection, in addition to specific comorbidities and clinical variables. This analysis suggests efforts to reduce health disparities and target patients with particular risks factors may produce more effective, equitable care.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 243. PREOPERATIVE RADIOGRAPHIC MEASUREMENTS CAN PREDICT POSTOPERATIVE PANCREATIC FISTULA FORMATION FOLLOWING PANCREATODUODENECTOMY EW Box, DE Morgan, L Deng, R Xie, JK Kirlin, S Reddy, TN Wang, MJ Heslin, JB Rose Presenter: Edmond Box BS | University of Alabama - Birmingham Background: Postoperative pancreatic fistulas (POPF) are a major contributing factor to pancreatoduodenectomy associated morbidity. Established risk calculators exist to help predict POPF formation, but most rely on subjective or intraoperative assessments. We hypothesized that various objective preoperatively determined computed tomography (CT) measurements could predict POPF as well as validated models and allow for more informed operative consent in high risk patients. Methods: Patients with POPF following elective pancreatoduodenectomy between January 2013 and April 2018 were identified in a prospective database. A propensity matched control cohort was selected for comparison. Clinicopathologic parameters were utilized to generate predictive models for POPF development using receiver operating characteristics (ROC) curves. Pancreatic neck radiodensities (Hounsfield units) were measured by pancreatic protocol CT (venous phase, coronal plane) at 0, 5, and 10mm from the anterior surface of the portal vein. A pancreatic density index (PDI) was created to adjust for differences in contrast timing by dividing the mean of these measurements by the portal vein radiodensity. Total areas of subcutaneous fat and skeletal muscle were calculated at the L3 vertebral level on axial CT. Pancreatic duct (PD) size was determined by CT. Results: Thirty-two patients were identified with POPF and propensity matched to an equal number of patients that did not develop POPF. Age, sex, race, and operative indication were not different between cohorts. Within our dataset a validated predictive model based on BMI, PD size (truncated at 5mm maximum), and gland texture (soft vs. non-soft) performed poorly by ROC curve analysis (AUC 0.590). Additional ROC curves were created using combinations of gland texture, body mass index, skeletal muscle index, sarcopenia, PDI, PD size, and subcutaneous fat area indexed for height (SFI). The model most predictive of POPF included SFI, PDI, and PD size (AUC 0.684). Conclusion: A combination of preoperative objective CT measurements can adequately predict POPF in this small dataset. Validation in a larger dataset would allow for better preoperative stratification of high risk patients and improve informed consent.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 244. PRACTICE PATTERNS AND LONG-TERM OUTCOMES AMONG PATIENTS WITH PANCREATIC GIANT CELL TUMORS FI Macedo, SH Cass, B Azab, N Song, D Yakoub, AS Livingstone, NB Merchant Presenter: Francisco Igor Macedo MD | University of Miami Miller School of Medicine Background: Pancreatic giant cell tumors (PGCT) are extremely rare and highly malignant tumors. They have been divided into two subtypes, osteoclast-like (O-PGCT) and pleomorphic (P-PGCT). Due to its rarity, current management of PGCT are limited to case report series. We sought to examine the long-term outcomes and practice patterns of patients with PGCT in a large national cohort. Methods: National Cancer Data Base (NCDB) was queried for patients with PGCT to the liver diagnosed from 2010 to 2014. Actuarial estimates for overall survival (OS) were calculated using Kaplan-Meier methods. Log-rank and Cox multivariable regression analysis were performed to compare the outcomes of patients with PGCT undergoing chemotherapy and pancreatectomy. Results: A total of 131 patients with PGCT were included in the analysis. Median age was 66 years (range, 41-88 years). Of these, 115 (87.8%) patients were Caucasians and 79 (60.3%) were male. Fifteen patients (19%) presented with liver metastasis at diagnosis. The majority of tumors were O-PGCT (93.1%), and 6.9% were P-PGCT. Adjuvant chemotherapy was used in 21.4% and only 41 (31.3%) underwent pancreatectomy: 51.2%, Whipple procedure and 31.7%, distal pancreatectomy. Of those undergoing resection, median OS was 21.1 (range, 0.4-112.9) months: O-PGCT, 29.7 vs. 4.5 months (Fig 1A, p=0.526). Adjuvant chemotherapy was associated with improved OS (68.8 vs. 16.6 months, p<0.001, Fig 1B). After controlling for patient and disease-related factors, age (HR 0.862, 95% CI 10.011-1.061) and liver metastasis (HR 2.297, 95% CI 1.214-4.344) negatively impacted OS, while chemotherapy was independently associated with superior outcomes (HR 0.345, 95% CI, 0.186-0.640). Conclusion: This is the first series assessing the long-term outcomes among patients with PGCT. Only a minority of patients undergo conventional multimodal therapy, including chemotherapy and pancreatectomy. Survival rates are dismal for those presenting with PGCT liver metastasis. However, surgical resection and chemotherapy show improved OS.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 245. ADJUVANT CHEMOTHERAPY FOR PANCREATIC NEUROENDOCRINE TUMOR: IS THERE A REAL BENEFIT? A Masi, R Misawa, M Zhobin, JF Renz, A Gruessner, R Gruessner, FM Serafini Presenter: Antonio Masi MD | SUNY Downstate Medical Center Brooklyn Background: Extensive surgical resection for pancreatic neuroendocrine tumor (PNET) offers a survival benefit. However, the use of adjuvant chemotherapy remains poorly defined. The aim of this study is to elucidate in which subset of patients chemotherapy offers a real benefit. Methods: We retrospectively investigated the US National Cancer Data Base and evaluated patients who underwent pancreatic resection (pancreaticoduodenectomy, partial and distal pancreatic resection) for PNET from 2004 to 2014. Differences between two groups, Chemotherapy Group (CH), and Surgery Alone Group (S) were analyzed, and comparison was performed to identify the beneficial effect of chemotherapy. Study end point was overall survival. Results: Population study included 13822 patients , 8259 were in Group CH and 5563 were in Group S The two groups were well matched in demographic profile including age, race distribution, co-morbidities (Charlson/Deyo Score), pathological stage, grading and status of resection margins. Multivariable Cox proportional hazard regression model demonstrated pathological grade (HR1.680), positive surgical margin (HR 1.403), local invasion (HR 1.645) associated with overall survival, instead lymphovascular invasion (HR 1.030, NS) and positive node (HR 1.175) have a marginal effect on it. Kaplan-Meier analysis demonstrated no superior survival for Chemotherapy group when compared to Surgery alone group despite positive node (mean OS 27.3 months vs 27.8 months, NS),positive surgical margin (mean OS 27.3 months vs 28.5 months, NS), positive lymphovascular invasion (mean OS 28.4 months vs 36.1 months, NS) and local invasion (mean OS 29.0 months vs 29.9 months, NS). Chemotherapy has a limited effect only with poorly/undifferentiated lesion (mean OS 25.5 months vs 17.6 months, p < .005), Conclusion: Current chemotherapy regimen has a beneficial effect limited to high grade lesion. Extensive surgical resection is the only treatment that offers a survival benefit even for cancer that presents with aggressive features including positive margins, local invasion, positive lymphnode and presence of lymphovascular invasion.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 246. IMAGE PROCESSING WORKFLOW FOR VIRTUAL AND AUGMENTED REALITY PLATFORMS IN LIVER SURGERY JB Seal, C Stewart, J McGee, T Nguyen, D Sonnier, R Milani, G Loss, K Sarkar Presenter: John Seal MD | Ochsner Health System Background: Immersive technology platforms including virtual reality (VR) and augmented reality (AR) are a rapidly growing component of the technology sector. As translational applications for direct use in surgery are being developed, immersive technology for case planning and education is currently accessible using commercially available products. We present a workflow for image acquisition, post-processing and use in VR and AR platforms developed at our institution as a guide for early-adopters. Methods: Translating patient-specific imaging into VR and AR platforms includes 4 phases: Image acquisition, segmentation, file export formatting and use on an immersive platform. When possible, images should be obtained prospectively to optimize CT or MRI protocol including 3-5mm slices and DICOM file export prior to compression for storage. DICOM files from axial imaging are uploaded to segmentation software (IQQA®, EDDA Technology, Inc) where a multi-component 3D digital object is created through a semi-automated process to define critical anatomic structures. After segmentation, the 3D model can be exported in an STL file format for use on other applications including 3D printing and commercially available VR (Samsung Gear VR Headset) and AR devices (Microsoft HoloLens). Results: Using this workflow, we have generated multiple case-use applications for operative planning, resident education and patient engagement using VR and AR platforms. QR codes will link to online access to models of living donor nephrectomy, hepatic artery aneurysm repair, pediatric hepatoblastoma, vena cava thrombectomy, a liver resection cases. Conclusion: Application of immersive technology in liver transplant and hepatobiliary surgery is possible with currently available commercial products for early adopters and translational applications.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 247. IMPACT OF ADJUVANT CHEMOTHERAPY COMPLETION RATES ON OUTCOMES FOLLOWING PANCREATICODUODENECTOMY FOR PANCREATIC DUCTAL ADENOCARCINOMA K Leslie, RQ Liu, S Patel, C Garcia-Ochoa, D Breadner, S Welch, A Skaro Presenter: Rachel Liu MD, MSc | London Health Sciences Centre Background: Prognosis of resectable pancreatic adenocarcinoma improves with the use of adjuvant chemotherapy with 5-year survival rate approaching 21% following a complete course. Despite these promising results, many patients who undergo resection do not complete the planned adjuvant regimen. The benefit from partial treatment is largely unknown. Understanding what factors lead to reduced chemotherapy completion rates and its impact on patient outcomes will help to guide management decisions in this patient population. Methods: A cohort analysis was performed using a clinical database from a tertiary referral hospital and included patients undergoing pancreatic resection for ductal adenocarcinoma from 2007 to 2016. Patients who completed planned adjuvant chemotherapy were compared to those who did not. Overall survival and disease free survival using a Cox proportional hazards model adjusting for confounding variables was used. A logistic regression analysis was performed to evaluate what factors may influence adjuvant chemotherapy completion rates following resection. Results: The study cohort included a total of 98 patients with 54 completing chemotherapy and 44 who did not. Disease free survival at 1-year was significantly improved with completing chemotherapy (HR 0.225, p < 0.01). However, this effect was no longer seen when overall disease free survival was evaluated (HR 0.901, p = 0.76). There were no measurable differences in 1-year (HR 0.997, p = 0.99) or overall survival (HR 0.993, p = 0.98) between these groups. Chemotherapy completion rates were reduced with increasing age (p < 0.01) and improved with the addition of adjuvant radiation (p < 0.01). Peri-operative complications, pancreatic fistula, length of stay, and time from resection to first chemotherapy treatment did not have a significant impact on chemotherapy completion rates. Sub-group analysis showed in patients who received adjuvant radiation, completion of chemotherapy was associated with a significantly reduced 1-year disease free survival (HR 0.100, p < 0.01). This relationship was not seen in patients who did not receive radiation (HR 0.35, p = 0.11). Conclusion: Completion of adjuvant chemotherapy in patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma appears to have a disease-free survival benefit within the first year, but its effect is lost beyond this point. Despite incomplete treatment, overall and 1-year survival did not appear to be adversely affected. These results suggest that complete and partial adjuvant chemotherapy have similar long-term benefits. Patients who received radiation therapy had a higher rate of completion of their planned chemotherapy regimen, possibly secondary to the break from the chemotherapy agents while receiving radiation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 248. HOSPITAL READMISSIONS FOLLOWING PERCUTANEOUS LIVER TUMOR ABLATION USING THE NATIONWIDE READMISSIONS DATABASE M Qadan, G Molina, NM Sell, CR Ferrone, KK Tanabe, N Elias, LA Dageford, RN Uppot, JY Wo, L Goyal Presenter: George Molina MD, MPH | Massachusetts General Hospital Background: Percutaneous liver tumor ablation (PLTA) is a safe and potentially curative option for appropriately selected patients with primary or metastatic disease to the liver. The aim of this study was to evaluate readmission rates following PLTA. Methods: We used the Nationwide Readmissions Database (2012-2014) to identify adult patients who underwent an elective and uncomplicated PLTA (based on length of inpatient stay of 2 days) for primary or secondary liver malignancy. We evaluated national all-cause 7-day and 30-day readmission rates, including at non-index hospitals. Results: There were 579 patients (median age 65, IQR 58-75; 33.6% female) who underwent PLTA between 2012 and 2014 nationally. All patients had a Charlson Comorbidity Index (CCI) score of 2 or greater (10.0% CCI 2, 19.8% CCI 3, and 70.2% CCI 4). Median household income based on zip code was evenly distributed among quartiles (22.6%, 21.9%, 24.8%, and 30.7% were in the 1-25th, 26th-50th, 51st-75th, and 76th-99th percentile, respectively). Most patients had Medicare insurance (55.2%), compared to private insurance (29.6%), Medicaid (12.2%), or other insurance (3.0%). Estimated 7-day and the 30-day all-cause readmission rates were 1.5% (95% CI, 0.5%-4.4%) and 6.5% (95% CI, 4.4%-9.5%), respectively. Conclusion: PLTA is viewed as a safe procedure with low morbidity. However, all-cause 7-day and 30-day readmission rates following PLTA are not trivial. These data should be carefully considered in the context of multidisciplinary management of these patients, and further studies to identify reasons for and to reduce readmission rates are warranted.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 249. DECREASING SIZE DURING SURVEILLANCE OF NON-PSEUDOCYST PANCREATIC CYSTIC LESIONS: WHAT IS THE LIKELIHOOD? VR Rendell, ER Winslow, AM Awe, MG Lubner Presenter: Emily Winslow MD, MS | University of Wisconsin School of Medicine and Public Health Background: Determining malignancy risk for pancreatic cysts is challenging due to a limited understanding of their natural history. Cyst size as a predictor of malignancy has had variable results. Recently, increased rate of cyst growth has been associated with increased risk of malignancy. However, decreasing cyst size is a rare phenomenon that is not well studied. We aimed to characterize decreasing cysts at our institution and determine whether these decreases in maximum axial diameter (MAD) correspond to actual volumetric changes. Methods: A single-institution retrospective analysis was performed for a cohort of patients with a contrast-enhanced CT or MR scan confirming a pancreatic cyst 1cm in 2012-2013. Definite pseudocysts were excluded. Imaging records from the cohort were used to identify the first and most recent studies ≥ 6 months apart demonstrating the cyst. Cyst MAD and volume were collected on both studies using HealthMyne, a novel analytics software. Differences in MAD and volume over time were calculated, and cysts that decreased by >5mm were identified. Clinical information, including presumed cyst diagnosis, radiologic features, patient history and radiologic findings of pancreatitis, and endoscopic ultrasound-fine needle aspiration (EUS-FNA) or biopsy results, was collected to characterize these cysts. Results: Of 193 patients, 171 had pancreatic cysts demonstrated on at least two imaging studies ≥6 months apart. Of these, 62 (36%) grew by >5mm, 18 (11%) grew between 3-5mm, 75 (44%) had size change between 0-3mm, 5 (3%) decreased between 3-5mm, and 10 (6%) decreased by more than 5mm. Five patients were excluded due to a history or imaging findings of pancreatitis. The overall rate of decreasing non-pseudocyst pancreatic cystic lesions in this cohort was therefore 2.9%. The majority of patients with decreasing cyst size were women (80%) with median age 61 years and standard deviation (SD) of 9.9 years. The presumed clinical diagnosis of the cyst was IPMN for all 5 patients. Two cysts were in the pancreatic head and three in the pancreatic body. Two cysts had septations, and one also had a calcification. None had mural nodules, wall thickening, pancreatic duct dilation or lymphadenopathy. None of the cysts were resected. The first and most recent imaging modality differed for one patient; after the initial MR scan, a contrast-enhanced CT was the only available recent follow up scan. While two patients had an EUS-FNA performed between studies, both had an interval imaging study demonstrating stable cyst size at least four months after the FNA was performed. The median time between scans was 47 months (SD 39 months). The cysts decreased by an average of 9.0 mm (SD 3.2 mm) with the range of size change from -5.1 mm to -12.7 mm. All cysts demonstrated a corresponding decrease in volume with an average volume decrease of 3002 mm3 (SD 2910 mm3) with range of volume change from -323 mm3 to -7336 mm3. Conclusion: Decreasing size of non-pseudocyst pancreatic cysts is a rare phenomenon. Our cohort demonstrated a higher rate of decreasing pancreatic cyst size than the only other study where this has previously been described (2.9% vs 0.38%). We confirmed that decreasing maximum unidimensional diameter in these cysts corresponds to an actual decrease in cyst volume. The clinical significance of these decreasing cysts remains unknown.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 250. PANCREATICODUODENECTOMY FOR PERIAMPULLARY ADENOCARCINOMA IN A PATIENT WITH A PREPANCREATIC PORTAL VEIN MM Bonds, JF Rekman, GB Baison, FG Rocha Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Prepancreatic portal vein (PPPV) is a rare congenital anomaly that results in the portal vein coursing anterior to the neck of the pancreas due to aberrant regression of the vitelline veins. The presence of this anomaly can present challenges when planning pancreatectomies, even for experienced surgeons. Previously, distal pancreatectomy and total pancreatectomy of an annular pancreas have been described in patients with PPPV. This case demonstrates that pancreaticoduodenectomy for malignancy can be successfully performed in a patient with a PPPV. Methods: An 80 year old woman presented with abdominal pain and obstructive jaundice. Endoscopy demonstrated a 2.7 centimeter periampullary mass that invaded the distal common bile duct requiring stent placement. Biopsy of the mass confirmed the diagnosis of adenocarcinoma. On pre-operative pancreatic protocol computed tomography, she was found to a have a PPPV without evidence of metastases. Given her good functional status and desire for curative therapy, she was consented for a pancreaticoduodenectomy. Results: After confirming the tumor was resectable, we created a tunnel around the pancreas to the left of the PPPV. Pancreatic dissection was continued in the standard fashion. The splenic vein was identified coursing behind the common hepatic artery and superior to the pancreatic body; it was followed to identify the take-off of the gastroduodenal artery which was adjacent to the splenic vein-portal vein confluence. After the bile duct and proximal duodenum were transected, the pancreatic neck was divided. The pancreas was freed from the retroperitoneum with Ligasure device, taking extreme care to preserve the superior mesenteric artery at the mesenteric root. The pancreas was adhered to the posterior superior mesenteric vein (SMV); it was able to be removed with ligation of the middle colic vein and controlled creation of a small venotomy in the SMV with less than five minutes of clamp time. Reconstruction was performed in the standard fashion. Conclusion: PPPV is a rare congenital vascular anomaly. Identification of unusual vascular anatomy is essential prior to undertaking any procedure in the right upper quadrant. Most descriptions of PPPV in the literature are in the pediatric population; there are two pancreatectomies reported in adults for malignancy but neither required a pancreatic anastomosis. We have shown that PPPV does not preclude successful pancreaticoduodenctomy for a malignant process. Pre-operative imaging and planning are essential when approaching any pancreatic procedure in a patient with PPPV.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 251. UPDATED BARBED SUTURE FOR PANCREATIC ANASTOMOSIS DURING PANCREATICODUODENECTOMY DECREASES INCIDENCE OF CLINICALLY SIGNIFICANT PANCREATIC FISTULA; OUR FIRST 50 PATIENTS AA Guzowski, J Gabra, NS Ali Presenter: Andrew Guzowski MD | Cleveland Clinic, Akron General Background: Pancreatic leak continues to be a high cause of morbidity during pancreaticoduodenectomy, regardless of the technique. It seems that a consensus acceptable pancreatic leak rate at high volume centers is 25%. Barbed suture is being utilized in many clinical applications due to ease of use and potential higher burst strength during gastrointestinal anastomosis. To date, no studies have looked at the impact of utilizing barbed suture in pancreatic reconstruction during pancreaticoduodenecotmy. Methods: A retrospective analysis of a prospective database was reviewed off all pancreaticoduenectomy cases performed by a single surgeon from 2015-2018 at a tertiary care regional medical center. Pancreatic anastomosis was performed as a pancreaticojejunostomy in an end to side fashion; an outer layer of mattress vicryl suture was utilized first followed by inner running layer of barbed suture. No stent was utilized during anastomosis. Drain amylase was checked on POD 1 and 3. Fistula rates were recorded in accordance with the International Society of Grading of Pancreatic Fistula descriptions. This data was compared to published leak rates found in a literature review. Results: A total of 50 consecutive pancreaticoduodenectomies performed by a single surgeon were examined. One patient was not included in the study because drain amylase levels were not in the medical record. No intervention was required on the patient not included in the study. There was no difference in age, operative indication, pancreatic texture, and duct diameter between patients. 22 patients had elevated amylase levels (44.9%) Of these, 20/49 Grade A (40.9%), 2/49 Grade B (4.1%), 0/49 Grade C (0%). Two patients required percutaneous drainage on POD 9 and POD14 that resolved the leak. No patients required operative intervention for pancreatic fistula. The mean time to drain removal was 7 days. There were no deaths related to pancreatic fistula during the study period. This study shows an overall pancreatic fistula rate of 44.9%, on the upper end of the published rates. However, the clinically relevant pancreatic fistula rate (Grade B or C) in the study were 4.1%, which is lower than the rate found on literature review of 16%. Conclusion: Barbed suture utilization is a reliable and safe method of pancreaticojejunostomy creation during pancreaticoduodenectomy. This study shows that the rate of clinically relevant fistula (Grade B or C) was 4.1%, this is lower than the published rate of 16%. This is an improvement on the reported literature leak rate and is an easily reproducible procedure.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 252. “RENDEZ-VOUS” TECHNIQUE IN CHOLEDOCHOLITHIASIS N Tarigo, P Vanerio, J Folonier, A Taullard, G Andreoli, R Valiñas Presenter: Nicolas Tarigo MD | Hospital de Clínicas Background: Gallstone disease is a common clinical condition and it can be associated with choledocholithiasis. Strategies to approach choledocholithiasis are multiple but there is no evidence in which one is superior in terms of safety, efficacy, morbidity or mortality. Rendez-vous technique is one of the options available, this technique combines laparoscopic cholecystectomy (LC) with intra operative endoscopic retrograde cholangiopancreatography (ERCP). Benefits include a single procedure decreasing cost and morbidity, management of difficult cases and a minimal rate of complications such as duodenal/bile duct perforation or pancreatitis. The goal of this study was to describe our experience in this technique. Methods: Patients were selected in a period of 2 years between March 2016 – April 2018. 12 patients diagnosed with choledochal lithiasis confirmed by magnetic colangioresonance (MRC) were included. MRC was performed in patients with elements of suspicion of choledocholitiasis,s uch as cholangitis, pancreatitis,or altered liver function test.I n these patients,the intraoperative cholangiography confirmed the choldocolithiasis in all cases. The technique consists in a laparoscopic cystic duct catheterization introducing a guide wire which is passed all the way through the common bile duct (CBD) to the duodenum. The guide is captured via endoscopy and papillotomy is performed. After litiasis extraction, a control cholangiography is perfomed. Last step is cholecystectomy. Success rate, morbidity (Dindo-Calvien Classification) and mortality were registered. Results: In the period, 12 patients with choledocolithiasis were treated with “rendez-vous” technique. 10 female and 2 male patients, mean age was 47.5 years (range 19-76 years). 7 patients were diagnosed with acute cholangitis, 2 patients with acute pancreatitis, and 3 patients with altered liver function tests. All patients were successfully treated, having all of them normal cholangiographies after intra operative ERCP. Mean procedure time was 100 minutes. Mean hospital stay after the procedure was 1.75 days (1-5 days). 2 patients had Dindo-Clavien type I complications (emesis and congestive heart failure). No mortality was registered. Conclusion: “Rendez-vous” technique is safe and an excellent option for the treatment of choledocholithiasis. Assisted cannulation of the CBD reduces failure rates and complications such as pancreatitis and perforation. It is feasible procedure if you have an experienced endoscopist,reducing costs and improving de results In our experience we believe it is a safe and effective option in patients with choledocholithiasis.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 253. IMPLEMENTATION OF A HIGH RISK PANCREATIC CYST SURVEILLANCE PROGRAM UTILIZING 2015 AGA GUIDELINES SB Bhagwandin Presenter: Shanel Bhagwandin DO, MPH | Jupiter Medical Center Background: There has been a steady increase in the incidental detection of pancreatic cystic neoplasms directly related to the use of cross-sectional imaging in the hospital setting. Although only 1-2 % of mucinous cysts of the pancreas progress to pancreatic adenocarcinoma, we aimed to develop a hospital-based algorithm for the surveillance of asymptomatic pancreatic cysts. A preliminary retrospective review was proposed to justify the prospective nature of a cyst surveillance program based on the 2015 American Gastroenterological Association (AGA) Guidelines. Methods: A query was made from the radiology imaging database, PACS, to identify all dictated reports that had included the term “IPMN” (intraductal papillary mucinous neoplasm) from November 2017- June 2018. 57 cases were identified for preliminary review. Cyst characterization was defined by size, nodule, associated main pancreatic duct dilatation, symptoms, type of cross-sectional imaging, and specialty of ordering physician. Results: Of the 57 cases, 26 were female and 31 were male. Cyst size ranged from 0.2 cm to 4.1 cm, evenly distributed throughout the pancreas and multiple in 27%. 22 of 57 (38.5%) were detected incidentally with computed tomography (CT) scan, (72%). The majority of the scans were ordered by primary care physicians, emergency department, and other specialists unrelated to surgery or gastroenterology. When AGA guidelines were applied, 6/57 (11%) patients had worrisome features such as a dilated pancreatic duct, jaundice, size > 3cm, or associated mass necessitating further intervention such as endoscopic ultrasound and fine needle aspiration (FNA). Conclusion: The majority of pancreatic cystic neoplasms can be safely observed over time. Current AGA guidelines suggest the need for surveillance to reduce the risk of pancreatic adenocarcinoma related mortality. The role for a cyst surveillance program was demonstrated by our preliminary review of incidentally discovered cysts

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 254. LAPAROSCOPIC CHOLEDOCHODUODENOSTOMY AND COMMON BILE DUCT EXPLORATION WITH CHOLEDOCHOSCOPY FOR PRIMARY BILE DUCT STONES E Alonso, AM Schneider, PD Hansen Presenter: Emilio Alonso MD | Providence Portland Medical Center Background: Patients with recurrent primary bile duct stones present a challenge, specifically when these are not amenable to endoscopic retrieval. In selected patients with favorable anatomy, a laparoscopic common bile duct exploration with choledochoscopy, and creation of a choledochoduodenstomy may be accomplished laparoscopically. This may allow for a safer minimally invasive procedure, with faster recovery. Methods: We present a case of a 79 year-old female with history of recurrent primary bile duct stones after having undergone a cholecystectomy 20 year ago. Patient has undergone multiple attempts at endoscopic retrieval but non have been successful at clearing the biliary tract. Each time a plastic biliary stent has been left behind in an effort to facilitate the egress of bile and breakdown the stones Results: Patient successfully underwent a laparoscopic exploration with intraoperative ultrasound, followed by a common bile duct exploration with choledochoscopy, and retrieval of all the biliary stones. Finally a laparoscopic choledochoduodenostomy was performed. The patient tolerated the procedure well and was discharged on her second post-operative day. Currently she has recovered well and has returned to her normal activities and work in her farm. Conclusion: In selected patients a laparoscopic choledochoduodenostomy after a common bile duct exploration with choledochoscopy is a feasible and safe option, with the known benefits of a minimally invasive operation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 255. MODIFIED DISTAL PANCREATECTOMY WITH CELIAC ARTERY RESECTION (DP-CAR) FOR LOCALLY ADVANCED PANCREATIC CANCER H Ito, Y Ono, T Sato, Y Mise, Y Inoue, Y Takahashi, A Saiura Presenter: Hiromichi Ito MD | Cancer Institute Hospital, Japanese Foundation for Cancer Research Background: The involvement of celiac artery (CA) has been one of common reasons for unresectablity for pancreatic body cancer. In the era of effective modern chemotherapy, however, radical resection with enbloc arterial resection has been performed with reasonable oncologic outcomes than before. Herein, we illustrate the case of the patients with locally advanced pancreatic body cancer with CA, who underwent radical distal pancreatectomy with CA resection following neoadjuvant systemic chemotherapy. Results: Case: The patient was a 75-year-old woman who presented with back pain and elevated CA19.9. The work-up revealed locally advanced pancreatic body cancer with contact to CA. The tumor was deemed borderline resectable and she received 9 cycles of systemic chemotherapy with gemcitabine and gemcitabine nab-paclitaxel with excellent response. Given no progression of disease, radical resection with arterial resection was recommended. The radical resections included radical distal pancreaticosplenectomy (RAMPS) with CA resection. The left gastric artery was preserved and her post-operative course was uneventful.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 256. POSTERIOR HEPATECTOMY IN INTRAHEPATIC LITHIASIS ME Lenz, ML Del Bueno, JPS Duran, M Poupard, RM Vergara, M Chahdi, FJ Mattera Presenter: Marcelo Enrique Lenz Virreyra MD | Hospital el Cruce Background: Intrahepatic bile duct strictures associated with segmental dilatation and intrahepatic lithiasis are rare and may respond to malignant as well as benign etiologies. Among the benign causes, the most frequent is the surgical lesion of the bile duct but others are: pyogenic recurrent cholangitis, primary sclerosing cholangitis, sclerosis due to IgG4, Caroli's disease and HIV cholangitis. In order to establish a correct differential diagnosis, a complete anamnesis, imaging studies and laboratories are esential, although in many cases the diagnosis is only achieved by pathology requiring liver resections as a definitive treatment. Results: We introduce the case of a 43-year-old woman presented with hyperbilirubinemia in routine studies. A history of open cholecystectomy 23 years ago, cholestasis of pregnancy, intestinal perforation, colostomy and reconstruction as a complication of a caesarean section. Imaging studies show segmental dilatation of the bile duct associated with the presence of lithiasis and atrophy of the hepatic parenchyma (posterior right segment). In the laboratory at the time of the evaluation, a slight cholestatic pattern was observed. She had attempted previous endoscopic treatment at another center without success. We decided to perform hepatectomy of the right posterior segment with intraoperative biopsy. Pathology reports segmental subacute cholangitis with sclerosis area without atypia. The outcome was favorable without complications. Conclusion: Hepatic resection in cases like these one allows a correct treatment of the disease with low rates of complications and mortality.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 257. ROBOTIC DISTAL PANCREATICOSPLENECTOMY FOR LARGE COMPLEX ONCOCYTIC PANCREATIC NEUROENDOCRINE TUMORS: A RARE PANCREATIC NEOPLASTIC VARIANT TB Tran, AV Maker Presenter: Thuy Tran MD | University of Illinois at Chicago Background: Minimally invasive techniques are being used increasingly in patients with pancreatic neuroendocrine tumors. Oncocytic pancreatic neuroendocrine tumors are rare morphologic variants often diagnosed after surgery due to the lack of specific clinical features in preoperative fine-needle aspiration. Unlike other subtypes, oncocytic pancreatic neuroendocrine tumors may exhibit more malignant behavior. We report a rare case of a patient with a large, complex oncocytic pancreatic neuroendocrine tumor who underwent curative-intent robotic left pancreaticosplenectomy. We demonstrate the benefit of the robotic platform in facilitating dissection of large pancreatic tumors. Methods: This is a 57-year-old female with hypertension, diabetes, hyperlipidemia, and morbid obesity presenting with a large symptomatic mass in the tail of the pancreas. Contrast-enhanced computed tomography (CT) identified a 5.6 x 5.5 x 4cm complex solid-cystic tumor in the tail of the pancreas. She underwent robot-assisted laparoscopic left pancreatectomy. The splenic artery was dissected first with an EndoGIA stapler. Intraoperative ultrasound confirmed the location of the pancreatic tumor. Once mobilized away from surrounding structures, the pancreas was divided with an EndoGIA stapler over two minutes, with progressive pressure to compress the gland. The splenic vein was divided, with great care taken to identify and protect the inferior mesenteric vein. The tumor was dissected off the retroperitoneum and the specimen was sent to pathology. Results: Blood loss was negligible. There were no perioperative complications. Final surgical pathology revealed a grade 1 oncocytic pancreatic neuroendocrine tumor with no nodal involvement and negative surgical margins. Ki67 was 2.8% and mitotic count was 2 per 50 high power fields. The tumor exhibits cystic areas, fibrous bands, and partial encapsulation with invasion into the fibrous capsule and focal extension into peripancreatic fat. She recovered well after surgery without any complications. Conclusion: Contrary to other morphologic variants, oncocytic pancreatic neuroendocrine tumors have been found to have more aggressive malignant behavior. Minimally invasive pancreatectomy may lead to minimal blood loss and allows for adequate margin clearance of large, complex pancreatic tumors in the body and tail of the pancreas. The robotic approach adds precision to the movement while adhering to oncologic principles, which can be helpful when treating morbidly obese patients with large pancreatic tumors.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 258. BIKINI LAPAROSCOPIC CHOLECYSTECTOMY: A REPLICA OF NOTES CHOLECYSTECTOMY GR Verma Presenter: GR Verma MS | PGIMER Chandigarh Background: Conventional four port laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis. Single incision lap. chole, Needloscopic cholecystectomy, NOTES Lap. chole. and Robotic cholecystectomy has been described primarily to further minimize the trauma and to improve cosmetic outcome. However, the cosmetic benefit is offset by expenses, non ergonomic approach and a steep learning curve. A new economic and an aesthetic approach of laparoscopic removal of gall bladder through bikini incisions is described. The purpose of this study is to find out the feasibility and safety of this technique Methods: Non obese Patients (BMI <25) with normal gall bladder wall thickness were included. Informed consent for conversion was obtained. Intra operative bladder decompression was done by urinary catheterization. Surgery was performed by standard operative steps in split leg position. Both legs were placed at 200 below the level of torso. The surgeon stood in middle of legs. Long bariatric instruments were used. The first assistant on left side and the scrub nurse was positioned on the right side of patient. A 10 mm camera port was inserted in mid line 2 cms above pubic symphysis and two 5 mm working ports in both mid clavicular lines in lower iliac fosse. Fourth 3 mm port to retract fundus was made in right hypochondrium if required. Results: Eighteen patients were operated with this technique as day care surgery from Nov. 2017-Sept. 2018. Patients of acute cholecystitis, abdomino pelvic surgery, Pancreatitis and endoscopic retrieval of CBD stones were excluded. Sixteen were female and two were male patients. Majority of them, 88.9% were young (24-40 years). Operative steps were similar to conventional laparoscopic cholecystectomy. Surgery was completed by three ports in ten patients. Eight patients (44.44%) required fourth 3 mm port in right hypochondrium to retract gall bladder fundus. Mean duration of surgery 50.6 minutes (35- 75). Specimen was retrieved through supra pubic port under vision by putting a camera from one of the 5 mm port. No conversion or complications was observed. Patients were discharged on the same day. Mean Post op followed up was 6.8 months. All patients are doing well and none developed port site infection or hernia. Conclusion: Bikini laparoscopic cholecystectomy is feasible, safe, and can be successfully performed with conventional long laparoscopic instruments. Learning curve is minimal. Like NOTES hybrid cholecystectomy, this technique leaves an invisible scar hidden under garments and there is no escalation of the cost from conventional four ports Laparoscopic Cholecystectomy.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 259. ROBOTIC HEPATECTOMY FOR HEPATIC ADENOMA MB de Oliveira, L Coutinho, A Godoy Presenter: Marcos Belotto de Oliveira MS | Sírio Libanês Hospital Background: Robotic surgery is increasingly used in minimally invasive liver surgeries, bringing results comparable to open surgery, but with the benefits of laparoscopic surgery. Current data show that when performed by experienced surgeons and selected patients, robotic hepatectomy is safe and effective, resulting in a low conversion rate, reasonable blood loss, and low postoperative morbidity. Despite all the published results, the technique remains practiced by a select group of surgeons in specialized and large-volume centers. We present the video of a hepatectomy performed by robotic technique in a patient of 42, presenting lesion in the left hepatic lobe. Methods: A 42-year-old woman underwent left segmentectomy by robotic technique for hepatic adenoma treatment. Details of the procedure are shown in the video. Results: A 42-year-old woman with two months history of epigastralgia, difficulty in digestion, and a full stomach sensation . During the investigation, he underwent a high digestive endoscopy that showed a bulging extrinsic to the stomach, compressing the organ. Image exams showed a 13 cm lesion located in the left hepatic lobe. Due to the case, left segmentectomy was performed by robotic technique. Surgery occurred without the need for blood transfusion and there were no intra- or postoperative complications. The patient was discharged on the third postoperative day. Subsequently, the anatomopathological result demonstrated hepatic adenoma Conclusion: The video shows the performance of uncomplicated robotic hepatectomy, reinforcing evidence on the feasibility and safety of the technique

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 260. ROBOTIC GASTRODUODENOPANCREATECTOMY FOR PANCREATIC ADENOCARCINOMA MB de Oliveira, L Coutinho, A Godoy Presenter: Marcos Belotto de Oliveira MS | Sírio Libanês Hospital Background: Although the use of the robotic platform for pancreatic surgeries is still restricted to specialized centers and experienced surgeons, current studies characterize it as feasible and safe. Pancreatic surgery presents numerous challenges to the surgeon and, in this context, robotics has presented advantages in terms of intraoperative hemorrhage, hospitalization time, systemic inflammation and surgical site infection, as well as applicability in a wide variety of cases. Regarding fistulas and mortality, it was shown to be equivalent to other methods. We present the video of a robotic gastroduodenopancreatectomy performed in a 73 year old man for the treatment of pancreatic adenocarcinoma. Methods: A 73-year-old male underwent elective robotic Gastroduodenopancreatectomy for pancreatic adenocarcinoma treatment. The video presents details of the surgical procedure. Results: We report the case of a 73 year old man who sought care presenting with jaundice. No other complaints were reported. He was diabetic and hypertensive, also had previous abdominal surgery 40 years ago due to gastric ulcer perforated with peritonitis. The investigation of the clinical picture found a tumor in the head of the pancreas and the patient underwent gastroduodenopancreatectomy by the robotic technique for its treatment. Subsequently, the anatomopathological result was the adenocarcinoma of the pancreas with staging T3 N0, in addition to a neuroendocrine tumor and 2 lymph nodes in the surgical specimen. Conclusion: We conclude that, despite the challenges posed by the technique, the robotic approach is actually feasible, safe and adequate for performing Gastroduodenopancreatectomy and its achievement should be considered.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 261. ROBOTIC ASSISTED WHIPPLE PROCEDURE EE Cho, J Kurtz, R Borscheidt, H Osman, RD Jeyarajah Presenter: Edward Cho MD, ScM | Methodist Richardson Medical Center Background: Patient is a 65 year old female with obstructive jaundice. Preoperative workup suggested a periampullary mass. EGD and biopsy showed an adenoma with evidence of high grade dysplasia. After appropriate preoperative optimization, patient was taken to the operating room for a robot-assisted Whipple procedure. Methods: The patient's procedure was video taped. Appropriate consent was obtained prior to taping. The video contents were edited to fit the allotted time for submission.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 262. ISOLATED BOWEL TRANSPLANT WITH AORTIC AND CAVAL VASCULAR CONDUITS BA Sayed, A Fung, P Kelly, J Qu, G Tait, L Hotoyan, G Sapisochin, PD Greig, ID McGilvray Presenter: Blayne Amir Sayed MD PhD | University of Toronto Background: Although bowel transplantation has been an accepted surgical procedure for several decades, there is no standard approach to establishing the arterial inflow and venous outflow. Use of the pancreas and bowel grafts from an individual donor can be challenging given that both rely on revascularization through the superior mesenteric artery (SMA) and superior mesenteric vein (SMV). In this video we present a case of an isolated bowel transplant in which the arterial inflow and venous outflow were established using donor arterial and venous interposition grafts. Results: A 22-year-old woman had a traumatic avulsion of the SMA and SMV. She was left with 30cm of jejunum, transverse colon, descending colon, and rectum. The donor intestine is separated from the pancreas so that both can be used in separate recipients. This is achieved by carefully preserving the inferior pancreaticoduodenal artery on the pancreas side and middle colic artery on the intestinal side. In the recipient operation, vascular grafts are attached to the inferior vena cava and infrarenal aorta. With vascular grafts in place, the bowel graft is easy to orient and vascular anatomosis of SMA and SMV are straightforward and fast. Conclusion: The use of jump grafts in intestinal transplantation preserves vessel length for use of both the pancreas and bowel grafts in separate recipients. Given the limited number of suitable deceased donors, this approach allows for greater utilization of a limited resource without compromising the recipient operation.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 263. LAPAROSCOPIC RESECTION OF A GANGRENOUS FALCIFORM LIGAMENT S Kawak, AM DeMare, MR Villalba Presenter: Samer Kawak MD | William Beaumont Hospital Background: Necrosis of the falciform and round ligament of the liver is a very rare condition. There are only 15 case reports describing this phenomenon in the literature. Patients typically present with acute abdominal pain and imaging demonstrating inflammation or gangrenous changes associated with the falciform ligament. No consensus has been reached on the pathogenesis or optimal management of this disease process. Herein we report a case of gangrenous falciform ligament managed by laparoscopic excision and debridement. Results: The patient is a 70-year-old Caucasian male with multiple comorbidities who presented with four days of epigastric and periumbilical abdominal pain. He described the pain as a dull, aching sensation associated with nausea, anorexia, and fevers. Patient’s medical history included severe coronary artery disease and ischemic cardiomyopathy with a depressed left ventricular ejection fraction. He was a 40-pack-year smoker and heavy drinker. On physical examination, he has mild tenderness from his epigastrium to his periumbilical region with mild bruising around the umbilicus. A computed tomography of the abdomen and pelvis revealed an inflammatory process in the subcutaneous tissue of the periumbilical region, which followed the course of the falciform ligamentum as it entered the liver. His laboratory values demonstrated leukocytosis and thrombocytopenia. He was started on broad-spectrum antibiotics and admitted to the hospital for observation. With persistent symptoms throughout the following day, he was recommended for a diagnostic laparoscopy. In the operating room, he was found to have a frankly necrotic falciform ligament that was excised off the anterior abdominal wall, fully mobilized to the liver, and ligated. Tissue culture of the specimen demonstrated Enterococcus faecium and Escherichia coli. The abdominal pain eventually improved after surgery, and patient was discharged to a rehabilitation center with a long-term course of intravenous antibiotics. Patient was readmitted 6 weeks postoperatively with an intra-abdominal abscess and a non-occlusive portal venous thrombus. He required underwent image-guided drainage, further antibiotics, and systemic anticoagulation. Conclusion: Due to the rarity of the disease, the pathogenesis is not well understood. The round ligament represents the obliterated left umbilical vein remnant and forms the free border of the falciform ligament. A complex network of lymphatics and vascular pathways are associated with the round ligament that may serve as a nidus for this pathology. Recanalization of the umbilical vein with subsequent thrombosis and infection, similar to a suppurative thrombophlebitis, is one plausible theory. Conclusion A diagnosis of a necrotic falciform ligament is a rare condition that may detected on cross-sectional imaging during the evaluation of acute abdominal pain. In cases that permit, we recommend laparoscopic excision and debridement of the falciform ligament to achieve source control.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 265. PURE LAPAROSCOPIC VERSUS OPEN LIVING DONOR RIGHT HEPATECTOMY USING A PROPENSITY SCORE MATCHED ANALYSIS: CHALLENGE TO 0% OF COMPLICATION HD Cho, KH Kim, YI Yoon, SK Lee, DH Jung, GC Park, S Hwang, CS Ahn, DBog Moon, TY Ha, GW Song, JH Kwon, SG Lee Presenter: Ki-Hun Kim | University and Asan Medical Center Background: Because donor hepatectomy is not a surgical procedure under pathological conditions, it is important to consider the quality of life such as postoperative pain or cosmetic effect. Therefore, laparoscopic donor hepatectomies with less postoperative pain and shorter hospital stay has been attracting attention recently and is being performed gradually in various centers. The aim of this study was to compare the result of pure laparoscopic living donor right hepatectomy (LLDRH) and conventional open living donor right hepatectomy (OLDRH) to evaluate the safety and efficacy of LLDRH. Methods: From November 2014 to October 2017, total of 38 cases of LLDRH and 907 cases of OLDRH were performed. To minimize selection bias, 1:1propensity score (PS) matching was performed between the LLDRH and OLDRH cohorts. After PS matching, finally 36 patients were included in each group.From November 2014 to October 2017, total of 38 cases of LLDRH and 907 cases of OLDRH were performed. To minimize selection bias, 1:1propensity score (PS) matching was performed between the LLDRH and OLDRH cohorts. After PS matching, finally 36 patients were included in each group. Results: There was no open conversion and no reported complication during study period in LLDRH group. The operative time was significantly longer in LLDRH (372.47 ± 53.06vs. 313.39 ± 47.79 min, p=0.000); however, the estimated blood loss was significantly much less in LLDRH (175.56 ± 47.24 mL vs. 283.89 ± 53.47 mL, p=0.000). The time to diet was faster in the LLDRH group (2.22 ± 0.54 vs. 3.00 ± 1.35 days, p=0.005). And the postoperative hospital stay was also shorter in the LLDRH group (8.58 ± 1.95 vs. 10.17 ± 1.40 days, p=0.000). Conclusion: Our study showed that LLDRH can be safely performed by a well-experienced surgeon in donors selected using strict indications.

AHPBA 2019 Annual Meeting | ePoster Abstracts Friday, March 22, 2019 & Saturday, March 23, 2019 | ePoster Display Only, Kiosk #8 P 266. INITIAL EXPERIENCE OF LAPAROSCOPIC RIGHT LOBECTOMY AFTER PORTAL VEIN EMBOLIZATION HD Cho, KH Kim Presenter: Ki-Hun Kim | University and Asan Medical Center Background: Portal vein embolization is a technique used before hepatic resection to increase the size of remnant liver after surgery. This therapy redirects portal blood to segments of the future liver remnant, resulting in hypertrophy. The purpose of this study was to find out the safety and feasibility of laparoscopic right lobectomy after portal vein embolization. Methods: All consecutive cases of laparoscopic right lobectomy after portal vein embolization between July 2014 and April 2018 in a tertiary referral hospital were enrolled in this retrospective cohort study. All surgical procedures were performed by one surgeon. There were 14 cases of laparoscopic right lobectomy after portal vein embolization. The group was analysed in terms of donor demographics, preoperative data, postoperative outcomes. Results: The mean age of the donors was 51.3 ± 9.2 years, the mean operative time was 266.4 ± 67.9 minutes and mean postoperative hospital stay was 9.8 days. The number of complications was 2 cases (14.3%) and among them, the Clavien-Dindo classification III or higher complication was 1 (7.1%). There were no mortality cases. Conclusion: Laparoscopic right lobectomy after portal vein embolization was a safe and feasible procedure for selected patients. It showed an acceptable incidence of complications. The authors suggest that laparoscopic right lobectomy after portal vein embolization could be a reasonable operative option for selected patients.