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Left lateral sectionectomy (LLS) is one of the most commonly performed minimally invasive liver resections. While laparoscopic (L)-LLS is a well-established technique, over traditional open resection, it remains controversial if robotic (R)-LLS provides any advantages of L-LLS.A post hoc analysis of 997 patients from 21 international centres undergoing L-LLS or R-LLS from 2006 to 2020 was conducted. A total of 886 cases (214 R-LLS, 672 L-LLS) met study criteria. 1:1 and 1:2 propensity score matched (PSM) comparison was performed between R-LLSL-LLS. Further subset analysis by Iwate difficulty was also performed. Outcomes measured include operating time, blood loss, open conversion, readmission rates, morbidity and mortality.Comparison between R-LLS and L-LLS after PSM 1:2 demonstrated statistically significantly lower open conversion rate in R-LLS than L-LLS (0.6% versus 5%, p = 0.009) and median blood loss was also statistically significantly lower in R-LLS at 50 (80) versus 100 (170) in L-LLS (p = 0.011) after PSM 1:1 although there was no difference in the blood transfusion rate. Pringle manoeuvre was also found to be used more frequently in R-LLS, with 53(24.8%) cases versus to 84(12.5%) L-LLS cases (p 0.001). There was no significant difference in the other key perioperative outcomes such as operating time, length of stay, postoperative morbidity, major morbidity and 90-day mortality between both groups.R-LLS was associated with similar key perioperative outcomes compared to L-LLS. It was also associated with significantly lower blood loss and open conversion rates compared to L-LLS.

Controversies exist among liver surgeons regarding clinical outcomes of the laparoscopic versus the robotic approach for major complex hepatectomies. The authors therefore designed a study to examine and compare the perioperative outcomes of laparoscopic left hepatectomy or extended left hepatectomy (L-LH/L-ELH) versus robotic left hepatectomy or extended left hepatectomy (R-LH/R-ELH) using a large international multicenter collaborative database.An international multicenter retrospective analysis of 580 patients undergoing L-LH/L-ELH or R-LH/R-ELH at 25 specialized hepatobiliary centers worldwide was undertaken. Propensity score-matching (PSM) was used at a 1:1 nearest-neighbor ratio according to 15 perioperative variables, including demographics, tumor characteristics, Child-Pugh score, presence of portal hypertension, multiple resections, histologic diagnosis, and Iwate difficulty grade.Before the PSM, 190 (32 %) patients underwent R-LH/R-ELH, and 390 (68 %) patients underwent L-LH/L-ELH. After the matching, 164 patients were identified in each arm without significant differences in demographics, preoperative variables, medical history, tumor pathology, tumor characteristics, or Iwate score. Regarding intra- and postoperative outcomes, the rebotic approach had significantly less estimated blood loss (EBL) (100 ml [IQR 200 ml] vs 200 ml [IQR 235 ml]; p = 0.029), fewer conversions to open operations (n = 4 [2.4 %] vs n = 13, [7.9 %]; p = 0.043), and a shorter hospital stay (6 days [IQR 3 days] vs 7 days [IQR 3.3 days]; p = 0.009).Both techniques are safe and feasible in major hepatic resections. Compared with L-LH/L-ELH, R-LH/R-ELH is associated with less EBL, fewer conversions to open operations, and a shorter hospital stay.

Background: Despite the rapid advances that minimally invasive liver resection has gained in recent decades, open conversion is still inevitable in some circumstances. In this study, we aimed to determine the risk factors for open conversion after minimally invasive left lateral sectionectomy, and its impact on perioperative outcomes. Methods: This is a post hoc analysis of 2,445 of 2,678 patients who underwent minimally invasive left lateral sectionectomy at 45 international centers between 2004 and 2020. Factors related to open conversion were analyzed via univariate and multivariate analyses. One-to-one propensity score matching was used to analyze outcomes after open conversion versus non-converted cases. Results: The open conversion rate was 69/2,445 (2.8%). On multivariate analyses, male gender (3.6% vs 1.8%, P = .011), presence of clinically significant portal hypertension (6.1% vs 2.6%, P = .009), and larger tumor size (50 mm vs 32 mm, P < .001) were identified as independent factors associated with open conversion. The most common reason for conversion was bleeding in 27/69 (39.1%) of cases. After propensity score matching (65 open conversion vs 65 completed via minimally invasive liver resection), the open conversion group was associated with increased operation time, blood transfusion rate, blood loss, and postoperative stay compared with cases completed via the minimally invasive approach. Conclusion: Male sex, portal hypertension, and larger tumor size were predictive factors of open conversion after minimally invasive left lateral sectionectomy. Open conversion was associated with inferior perioperative outcomes compared with non-converted cases.

Background Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS). Methods An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts. Results Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100–400) versus 450 (200–900) ml, respectively; P 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients). Conclusion R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

Background: Application of curative therapy for hepatocellular carcinoma is crucially dependent on underlying liver function. Using the recently described ALBI grade we examined the long-term impact of liver dysfunction on survival of early-stage hepatocellular carcinoma (HCC) patients. Methods: This cohort study comprised 2559 HCC patients from different geographic regions, all treated with curative intent. We also examined the relation between indocyanine green (ICG) clearance and ALBI score. Survival was measured from the date of treatment to the date of death or last follow-up. Results: The ALBI score correlated well with ICG clearance. Among those undergoing surgical resection, patients with ALBI grade-1 (good liver function) survived approximately twice as long as those with ALBI grade-2 (less good liver function), although more than 90% of these patients were classified as Child–Pugh (C-P) grade A. In the cohort receiving ablative therapies, there was a similar difference in survival between ALBI grade-1 and grade-2. Cox regression analysis confirmed that the ALBI score along with age, gender, aetiology and tumour factors (AFP, tumour size/number and vascular invasion) independently influenced survival in HCC patients receiving curative treatments. Conclusions: The ALBI score represents a simple approach to the assessment of liver function in patients with HCC. After potentially curative therapy, those with ALBI grade-1 survived approximately twice as long as those with ALBI grade-2. These data suggest that ALBI grade-1 patients are appropriately treated with surgical resection whereas ALBI grade-2 patients may, where the option exists, be more suitable for liver transplantation or the less invasive curative ablative therapies.

Area under the ROC curve was 0.68 (95% CI 0.540.82), p-value 0.05 Mo1457 Endoscopic Ultrasound Correlates With Histology in Patients With Chronic Pancreatitis Undergoing Total Pancreatectomy Elham Afghani*, Amitasha Sinha, Michael Cruise, Mahya Faghih, Martin a. Makary, Kenzo Hirose, Marcia I. Canto, Mouen Khashab, Anne Marie Lennon, Vikesh K. Singh GI, Johns Hopkins, Baltimore, MD; Pathology, Johns Hopkins Hospital, Baltimore, MD; Surgery, Johns Hopkins Hospital, Baltimore, MD Background: Endoscopic ultrasound (EUS) is commonly used to diagnose chronic pancreatitis (CP). However, there have been few studies which have evaluated EUS with histology. Aims: To evaluate the association between EUS scoring with the degree of fibrosis in patients with CP who have undergone total pancreatectomy (TP). Methods: All consecutive adult patients with CP (ageR18 years) who underwent preoperative EUS followed by TP from 8/2011 to 10/2013 were included. EUS criteria were defined by the 9 ductal and parenchymal features. Surgical wedge biopsies were obtained from the head and body/tail during TP and histology was evaluated by a pathologist blinded to the results of EUS. Perilobular and intralobular fibrosis scores were determined from the wedge biopsy specimen for each patient and averaged. Mild fibrosis was defined as a fibrosis score (FS) of 0-6 and severe fibrosis was defined as FS of 7-12. The association between FS and EUS criteria was evaluated using Pearson’s correlation coefficient. The diagnostic accuracy of EUS for predicting severe fibrosis was assessed using the area under receiver operating characteristic curve (AUROC). Results: There were 29 patients (68.9% females, mean age of 44 12 years). All patients underwent EUS at mean time of 27.6 15.3 weeks prior to TP. There were 8 (27.5%) patients with calcifications. There were 13 (44.8%) patients with mild and 16 (55.2%) with severe fibrosis. There was a significant correlation between FS and EUS criteria (rZ0.57, 95% CI 0.28, 0.78, p!0.001) as seen in Figure 1. The diagnostic accuracy of EUS for predicting severe fibrosis by AUROC was 0.65 (95% CI 0.45, 0.85). An EUS cut-off of R6 criteria had a sensitivity of 37.5% but specificity and positive predictive value of 100% for severe fibrosis. Conclusion: EUS correlates with fibrosis but no criteria threshold is accurate enough to predict severe fibrosis. AB444 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Mo1458 Endosonography-Guided Gallbladder Drainage With a Lumen Apposing Stent Reduced Recurrent Biliary Events After Acute Cholecystitis As Compared to Percutaneous Cholecystostomy Anthony Y. Teoh*, Takao Itoi, Philip W. Chiu, Raymond S. Tang, Charing C. Chong, Enders K. NG, Francis K.L. Chan, James Y. Lau Surgery, Chinese University of Hong Kong, Hong Kong, Hong Kong; Tokyo Medical University Hospital, Tokyo, Japan; Institute of Digestive Disease, Hong Kong, Hong Kong Background: Endosonography-guided gallbladder drainage (EGBD) has been shown to be feasible in previous studies. However, how the approach compares to percutaneous cholecystostomy (PTC) in patients who were unsuitable for surgery is uncertain. Methods: This was a retrospective case-controlled study of all patients who suffered from acute cholecystitis and were deemed high-risk for surgery, that were admitted to the Prince of Wales Hospital between January 2010 and November 2013. The patients that received EGBD were matched with those that received PTC based on sex, age and American society of anesthesiology grading. EGBD was performed using a linear echoendoscope (GF-UCT180 Olympus, Japan) and a lumen apposing stent (AXIOS, Xlumena, CA, USA) was used to drain the gallbladder in to the stomach or duodenum. Outcome measurements included technical and clinical success, morbidities, mortalities, the number of device-related events and unplanned admissions. Results EGBD was performed in 18 patients and they were case-matched with 18 patients who received PTC. There were no significant differences in background demographics between the EGBD and PTC groups(Table 1). All procedures were technically successful and clinical success was obtained in 88.9% and 94.4% of the patients respectively. 11 patients in the EGBD group underwent cholecystoscopy and all stones were removed in 81.8% of the patients. There were no differences in morbidities (33% vs 33.3%, P Z 1) and mortalities (11.1% vs 5.6%, P Z 1). Patients who underwent PTC suffered from significantly more device related events (61.1% vs 16.7%, P Z 0.015) and required more unplanned admissions (2.11 +/2.32 vs 0.11 +/0.47, P Z 0.002). The causes of device-related events in the PTC group included dislodgement, slipping of anchoring sutures and peri-tubal leak. Conclusion: EGBD and PTC were both effective means of obtaining gallbladder drainage. In the absence of a percutaneous tubing, EGBD was associated with reduced number of device-related events and unplanned admissions. Furthermore, EGBD allowed for removal of gallstones after the procedure. Comparison of outcomes between EGBD and PTC. EGBD N [ 18 PTC N [ 18