Vol. 9, No. 42005 Abstracts 583

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HISTOLOGIC CLASSIFICATION OF REMNANTS OFHEPATIC METASTASES FROM COLORECTALCANCER FOLLOWING CHEMOTHERAPYTammy L. Znajda, MD, Shinichi Hayashi, MD, Peter J. Horton,MD, John B. Martinie, MD, Prosanto Chaudhury, MD, Jeremy R.Jass, MD, MBBS, Victoria A. Marcus, MD, FRCP, Peter Metrakos,MD, McGill University, Montreal, PQ, Canada

Accepted management for colorectal cancer (CRC) involves resectionof the primary tumor followed by adjuvant therapy. Debate continuesover the ideal order of chemotherapy and hepatic metastatectomy.While chemotherapy is intended to minimize tumor bulk, informationabout local histologic change is lacking. We sought to determine ifpreoperative chemotherapy aimed at CRC liver metastases can resultin complete pathologic response and replacement with scar tissue.The Hepatobiliary Database at the Royal Victoria Hospital, McGillUniversity, was searched for patients with CRC liver metastasestreated between December 2003 and September 2004. Forty-onepatients were identified and their charts reviewed. Those who receivedchemotherapy prior to liver resection (oxaliplatin or irinotecan) werefurther evaluated. Resected liver specimens were re-examined bypathologists (SH, JJ, VM) and categorized according to histologicchanges seen. Of 41 patients (mean age 59 � 13 years), 13 did notreceive the preoperative chemotherapy protocol, 5 were unresectable,and 2 had no available specimen. The remaining twenty specimenswere classified based on the proportion of viable tumor, dirty necro-sis, mucin and fibrosis. Calcification and granuloma formation weregraded (0 to 3). Forty-three tumor nodules were identified, giving anaverage number of 2.15 tumor foci per patient. Seventy percent weremoderately differentiated and the average size was 1.8 � 1.7 cm.The mean composition of these nodules was dirty necrosis 27.8 �

37.4%, mucin 17.0 � 34.0% and fibrosis 31.9 � 34.4%, with viable

tumor only 23.3 � 28.2%. The average grades of calcification andgranulomawere 0.4� 0.8 and 0.3� 0.7, respectively. In some patients,lesions seen on imaging were not identified on pathologic review.One patient with four lesions on the preoperative CT-scan had noneidentified on pathology. In another, one focus of adenocarcinoma wasfound from 11 lesions seen on pretreatment imaging, along withmultiple areas of mucin pooling. Oxaliplatin and irinotecan demon-strate benefit for CRC hepatic metastases and should be offered toall patients prior to liver resection. In some patients metastases areobliterated completely, but in others remnants of uncertain malignantpotential (RUMP) remain. Further investigation is required to deter-mine the natural history of these RUMP lesions, and the ability topredict the subtype of a given RUMP lesion from the histology ofthe primary tumor.

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MANAGEMENT OF TYPE III AND IV MIRIZZISYNDROMEArmen Aboulian, MS, David K Imagawa, MD, PhD, University ofCalifornia, Irvine Medical Center, Orange, CA

Mirizzi syndrome, first described in 1948, is an uncommon complica-tion of longstanding cholelithiasis. Many cases have been reportedpresenting earlier in the course of the disease as Mirizzi Type I*(external compression of common bile duct without cholecystobiliaryfistula) or Type II (with cholecystobiliary fistula involving less thanone-third of the circumference of the common bile duct). However,little data exists regarding later presentation of the disease, describedas Mirizzi Type III (erosion involving up to two-thirds of the circum-ference of the common bile duct) or IV (complete destruction of theentire wall of the common bile duct). We reviewed 1104 total cases

Journal ofGastrointestinal Surgery584 Abstracts

Fig. 1.

Bouveret’s syndrome is an unusual presentation of duodenal obstruc-

of open and laparoscopic cholecystectomies performed at a singleuniversity institute in the last six years. We report 3 cases of Type IIIMirizzi syndrome and one case of Type IV, all occurring in the lasttwoyears.Allpatientswere femalewithanaverageageof70.3at the timeof surgery. All had a previous diagnosis of uncomplicated cholelithiasis,the earliest diagnosis made 27 months prior to the operation. Allpatients presented with obstructive jaundice and underwent an endo-scopic retrograde cholangiopancreatogram (ERCP), which demon-strated impacted stones in the biliary system. Laparoscopiccholecystectomy was initially attempted, then converted to open withthe realization of the extent of the disease and confirmation of TypeIII or IVMirizzi syndrome. Treatment consisted of either hepaticojej-unostomy or choledochojejunostomy. All Type III patients were dis-charged from the hospital in approximately one week with no majorcomplications. The single Type IV patient remained in the hospitalfor two weeks with a small anastomotic leak and also required a secondERCP to release an impacted stone in the ampulla of Vater, whichwas causing ongoing pancreatitis. There have been no late complica-tions. In cases such as these with later presentation and extensiveinvolvement of the common bile duct, we adhere to the practice thatMirizzi syndrome Types III and IV should be treated with openexploration of the effected area with a bilioenteric anastomosis. *Stag-ing based on the “unifying classification” for Mirizzi syndrome pub-lished by A. Csendes et al. in Br J Surg, 1989.

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LAPAROSCOPIC COMMON BILE DUCT EXPLORATION(LCBDE) FOR DIFFICULT STONESMohan Narasimhan, P. Kumar, Rajesh Nambiar, Abhiram Paranjape,Ramesh Ardhanari, MS, Meenakshi Mission Hospital and ResearchCentre, Madurai, India; Meenakshi Mission Hospital and ResearchCentre, Madurai, India

A retrospective analysis of LCBDE patients was done from 1998 to2004. A total of 52 patients who underwent LCBDE were analyzed.The patients were divided into two groups: Group A, from 1998 toDecember 2001, and Group B, from January 2002 to present. Ingroup A 18 patients underwent LCBDE. There were 3 conversionsto the open procedure. One patient had a post-LCBDE retained stoneand had ‘T’ tube track extraction. All patients had latex T’ tubesplaced in this period. Six patients had post ‘T’ tube removal bileleakage, which settled on its own. Since January 2002 (group B) anew policy of taking out large stones (�1.5 cm) electively by LCBDE,placement of nasobiliary drain (NBD), and primary closure of ductwas adapted. In this period 34 patients underwentLCBDE.All patientshad their bile ducts clearedof stones. All but twopatients hadpreopera-tive NBD placed. The CBD was primarily closed in these patients.Three patients underwent laparoscopic choledochoduodenostomy.The group B. had no conversions but one patient had hand-assistedcholdochoduodenostomy (CD). One patient after CD had postopera-tive bile leak which settled down. One patient died of acute myocardialinfarction on third postoperative day. The NBD helped by achieving awater-type closure ofCBD. It was removed after 24-48 hours followingNBDgram. The patients did not need a second ERCP for stent re-moval. It is our belief that elective LCBDE for difficult stones withpreoperative NBD placement is a safe and effective management.

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BOUVERET’S SYNDROME: A RARE COMPLICATIONOF GALLSTONESKongkrit Chaiyasate, MD, Michael Jacobs, MD, Sumet Silapaswan,MD, Vijay Mittal, MD, Providence Hospital, Southfield, MI

tion caused by the passage of a large gallstone through a cholecystodu-odenal fistula. The symptomatology of patients with Bouveret’ssyndrome can be nonspecific. Physical signs are consistent with thosefound in patients with gastric outlet obstruction. Plain radiography,abdominal ultrasound, and CT scan can be helpful, but endoscopy re-mains the mainstay of diagnosis and moreover, has added advantage ofbeing therapeutic in some instances, especially in patients with highsurgical risk. Surgical intervention, however, is generally the mostaccepted form of treatment. Controversy still exists between simpleenterolithotomy and enterolithotomy in association with cholecystec-tomy and correction of the internal fistula as a one- or two-stageprocedure. We reported the case of 72-year-old women with Bouver-et’s syndrome who underwent a one-stage surgical managementafter unsuccessful endoscopic retrieval (Fig. 1).

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NONALCOHOLIC FATTY GALLBLADDER DISEASE:THE INFLUENCE OF DIETMatthew I. Goldblatt, MD, Deborah A. Swartz-Basile, MD, HayderH. Al-Azzawi, MD, Khoi G. Tran, MD, Attila Nakeeb, MD, HenryA. Pitt, MD, Ohio State University Medical Center, Columbus, OH;Medical College of Wisconsin, Milwaukee, WI; Indiana UniversitySchool of Medicine, Indianapolis, IN

The obesity epidemic has contributed to an increased prevalence ofgallstones and a higher percentage of chronic acalculous cholecystitis.In addition, obesity is associated with Type II diabetes and hyperlipid-emia. We have previously reported an inverse relationship betweengallbladder contractility and serum glucose, insulin, cholesterol, andtriglycerides in murine models of obesity. However, the relative roleof insulin resistance and gallbladder fat infiltration in this phenomenonremains unclear. Therefore, we tested the hypothesis that gallbladderwall lipids are related to obesity and diet and are inversely correlatedwith gallbladder contractility. One hundred lean control and 36 obeseleptin-deficient 8-week-old femalemice were fed either a trace choles-terol, low fat chow diet or a 1.0% cholesterol (XOL), 15% butterfatdiet for four weeks. After an overnight fast, a cholecystectomy wasperformed. Gallbladders were frozen, pooled into groups of 3-10, andsubsequently analyzed for free fatty acids (FFA), phospholipids (PL),