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100 Pancreaticoduodenectomies performed for benign disease
A1212
SSAT ABSTRACTS
• RESULTSWITH THE USE OF OCTREOTIDE IN THE TREATMENTOF ENTEROCUTANEOUS FISTULA. C Alvarez, DW McFadden, HA Refer, Department of Surgery, UCLAMedical School. Los Angeles, California. Octreotide (STS-8) has been promoted as a potential aid in the closure of enterocutaneous f i s t u l a e (ECF). METHODS:We retrospectively reviewed the records of patients admittedwith ECF to our t e r t i a r y r e f e r r a l center in order to ascertain whether use of STS-8 affected f i s t u l a duration, length of hospitalization (LOH), closure rate, and morbidity (MDRB). Out of 60 patients diagnosed and treated for ECF over a 3 year period, 13 underwent a therapeutic t r i a l with STS-8. 13 other patients (CONTROL)were matched by cause, location and output of f i s t u l a , as well as age and primary diagnosis, to the group using STS-8. Comparisons were made using T-test and chi-square. RESULTS: ECF FAILED DURATION LOH CLOSURE CLOSURE MORB (d) (d) STS-8 253~I00" 100±31 54%" 46% 69%" CONTROL 314_+100 100~25 69% 31% 31% a: p=O.02 vs CONTROL ns: no significance vs CONTROL
CONCLUSIONS:While use of STS-8 was associated with a decrease in the duration of ECF, i t did not improve LOH nor the closure rate in this group of high-output, complex ECF patients. Use of STS-8 was associated with an increase merbidity, primarily in the form of sepsis and venous thrombosis. STS-8 does not appear beneficial in the long term management of ECF.
SPECIFIC RECEPTORS MEDIATE THE STIMULATORY EFFECTS OF AMYLIN ON PANCREATIC EXOCRINE SECRETION: IMPLICATIONS FOR DIABETES. A. Balasubramaniam. Y. Huana and J.E. Fischer. Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558. A m y l i n is a glucoregulatory peptide co-stored and co-secreted with insulin. The effects of amylin on exocrine secretion were investigated using the rat pancreatic acinar cell line, AR42J cells. Amylin dose-dependently stimulated the secretion of amylase and cholesterol esterase. The mechanism involved in this effec£ was investigated using fura-2 loaded AR42J cells. Amylin increased intracellular free calcium, [Ca2+]i, in a dose-dependent manner. Depolarization with high [KCI] had no effect on this response, indicating that the responses were not mediated by voltage-gated Ca z* channels. Moreover, the Ca 2÷ signal persisted even in Ca2+-free medium, suggesting mobilization from intracellular stores rather than influx. Thapsigargin consistently abolished amylin-induced responses, suggesting that Ca 2. is released from an IP3-sensitive pool. AR42J cells pre-treated with araylin did not respond to amylin, suggesting that the receptors mediating this response undergo homologous desensitization. However, pretreatment with homologous peptides, CGRP and salmon calcitonin, did not diminish [Ca2~]i mobilization by amylin. CGRP and calcitonin also failed to mobilize [Ca2+]i even at i0 ~uM. Thus, the stimulatory effects of amylin on pancreatic digestive enzymes secretion from AR42J cells a r e m e d i a t e d by specific receptors coupled to IP3dependent calcium pool. Moreover, these results provide the first direct evidence for the existence of a novel amylin receptor system that does n o t interact with CGRP or calcitonin. These findings may have clinical significance because amylin has already been implicated in obesity and type II diabetes.
GASTROENTEROLOGY,Vol. 108, No. 4
INCIDENCE OF DYSPHAGIA FOLLOWING LAPAROSCOPIC NISSEN FUNDOPLICATION. M.Anvari. C.Allen. R.Gooda~;r~, Departments of Surgery and Medicine, St. Joseph's Hospital, McMaster University. Hamilton, Canada. Dysphagia is one of the most troublesome complictions of open Nissen fundoplication. We examined the incidence and factors associated with development of dysphagic symptoms following Laparoscopic Nissen Fundoplication (LNF). From August 92 to October 94, 161 patients with proven GERD and on long-term medication underwent LNF. All patients underwent a 24 hr pH recording, esophageal manometry, gastroscopy and symptom score assessment for 6 specific GERD symptoms preoperatively. Intra-operatively the tightness of the wrap was varied by using different size (42-52 Fr) intraesophageal bougie, depending on the presence and severity of esophageal motor abnormality. 83 patients have since undergone repeat evaluations 6 months following the LNF. There was a significant improvement in 24 hr pH, LES pressure and GERD symptom score at 6 months following LNF (table). Of the 8:3 patients 34% had no dysphagia pre or postoperatively, 6% had no change in dysphagia symptom score (DSS), 14% had worsening of DSS, while 46% reported improvement in DSS following LNF. Only 3 patients (3.6%), all with moderate or severe esophageal dysmotilty, are experiencing clinically significant dysphagia with each meal. No correlation has been observed between the change in dysphagia score and the postoperative LES pressure or esophageal motor function. pre-operative GERD symptom score 58.8+ 2.1 % reflux in 24 hr 10.6 +_ 1.5 tES pressure 8.3 + 0.9 (values given as mean +_SE, * p
6 month post-op 14.6 + 1.6 * 0.7 + 0.1 * 22.1+1,4 *
These data suggest that the incidence of clinically significant dysphagia post LNF is low. Use of preoperative esophageal manometry to "tailor" the tightness of the wrap may be an important factor in prevention of dysphagia. Improvement in the dysphagia score in almost half the patients post LNF is interesting and warrants further investigation.
100 PANCREATICODUODENECTOMIES PERFORMED FOR BENIGN DISEASE. SA Barnes. HS Kaufman. KD Lillemoe. PK Santer. CJ Yeo. MA Talamini, HA Pitt and JL Cameron. Department of Surgery, The Johns Hopkins Medical Institutions Baltimore, MD. Perioperative morbidity and mortality following pancreaticoduodeneetomy (PD) has decreased markedly in a number of centers over the last decade, Yet many surgeons remain hesitant to extend the indications of this operation to non-malignant lesions. Requiring a histologic diagnosis of malignancy prior to performing PD has the potential risk of false negative pathologic sampling as well as delaying definitive therapy. Over the last 8 years, we have taken an aggressive approach in employing PD for patients presenting with a clinical picture of a periampullary neoplasm or significant chronic pancreathis confined to the pancreatic bead. METHODS: A retrospective review was completed of all patients undergoing PD between 1987 and 1994 (n=379). Final pathologic diagnosis showed a benign condition in 100 patients. RESULTS: The mean age of the patients was 56 years (range 21-81) with 51% females. Abdominal pain was the presenting complaint in 69% of patients, weight loss in 39% and jaundice in 28%. In 77 of the 10O patients, PD was performed for a suspected neoplasm, while 23 patients had a preoperative diagnosis of chronic pancreatitis. A pylorus-preserving PD was used in 82% of patients and a total pancreatectomy was necessary in 9%, The mean blood loss was 975 cc with 64 patients receiving no blood transfusions during their hospital course, There was one postoperative death. The most frequent complications were delayed gastric emptying in 29% of patients and pancreatic anastomotic leak in 20%. 51 of the patients experienced no perioperative complications. The median postoperative length of stay was 16 days (mean=19 days). The final histotzgic diagnosis was: chronic pancreatitis - n=49; benign cystic neoplasms n=20; periampullary villous adenoma - n = l l ; islet cell and other benign neoplasms - n=10; periductal fibrosis - n=6; and miscellaneous n=4, CONCLUSION: Surgeons are often called upon to perform PD for either suspicion of malignancy or symptoms due to benign disease. Concerns for morbidity and mortality should not prevent an aggressive approach for surgical resection in such patients.
SSAT ABSTRACTS
• RESULTSWITH THE USE OF OCTREOTIDE IN THE TREATMENTOF ENTEROCUTANEOUS FISTULA. C Alvarez, DW McFadden, HA Refer, Department of Surgery, UCLAMedical School. Los Angeles, California. Octreotide (STS-8) has been promoted as a potential aid in the closure of enterocutaneous f i s t u l a e (ECF). METHODS:We retrospectively reviewed the records of patients admittedwith ECF to our t e r t i a r y r e f e r r a l center in order to ascertain whether use of STS-8 affected f i s t u l a duration, length of hospitalization (LOH), closure rate, and morbidity (MDRB). Out of 60 patients diagnosed and treated for ECF over a 3 year period, 13 underwent a therapeutic t r i a l with STS-8. 13 other patients (CONTROL)were matched by cause, location and output of f i s t u l a , as well as age and primary diagnosis, to the group using STS-8. Comparisons were made using T-test and chi-square. RESULTS: ECF FAILED DURATION LOH CLOSURE CLOSURE MORB (d) (d) STS-8 253~I00" 100±31 54%" 46% 69%" CONTROL 314_+100 100~25 69% 31% 31% a: p=O.02 vs CONTROL ns: no significance vs CONTROL
CONCLUSIONS:While use of STS-8 was associated with a decrease in the duration of ECF, i t did not improve LOH nor the closure rate in this group of high-output, complex ECF patients. Use of STS-8 was associated with an increase merbidity, primarily in the form of sepsis and venous thrombosis. STS-8 does not appear beneficial in the long term management of ECF.
SPECIFIC RECEPTORS MEDIATE THE STIMULATORY EFFECTS OF AMYLIN ON PANCREATIC EXOCRINE SECRETION: IMPLICATIONS FOR DIABETES. A. Balasubramaniam. Y. Huana and J.E. Fischer. Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558. A m y l i n is a glucoregulatory peptide co-stored and co-secreted with insulin. The effects of amylin on exocrine secretion were investigated using the rat pancreatic acinar cell line, AR42J cells. Amylin dose-dependently stimulated the secretion of amylase and cholesterol esterase. The mechanism involved in this effec£ was investigated using fura-2 loaded AR42J cells. Amylin increased intracellular free calcium, [Ca2+]i, in a dose-dependent manner. Depolarization with high [KCI] had no effect on this response, indicating that the responses were not mediated by voltage-gated Ca z* channels. Moreover, the Ca 2÷ signal persisted even in Ca2+-free medium, suggesting mobilization from intracellular stores rather than influx. Thapsigargin consistently abolished amylin-induced responses, suggesting that Ca 2. is released from an IP3-sensitive pool. AR42J cells pre-treated with araylin did not respond to amylin, suggesting that the receptors mediating this response undergo homologous desensitization. However, pretreatment with homologous peptides, CGRP and salmon calcitonin, did not diminish [Ca2~]i mobilization by amylin. CGRP and calcitonin also failed to mobilize [Ca2+]i even at i0 ~uM. Thus, the stimulatory effects of amylin on pancreatic digestive enzymes secretion from AR42J cells a r e m e d i a t e d by specific receptors coupled to IP3dependent calcium pool. Moreover, these results provide the first direct evidence for the existence of a novel amylin receptor system that does n o t interact with CGRP or calcitonin. These findings may have clinical significance because amylin has already been implicated in obesity and type II diabetes.
GASTROENTEROLOGY,Vol. 108, No. 4
INCIDENCE OF DYSPHAGIA FOLLOWING LAPAROSCOPIC NISSEN FUNDOPLICATION. M.Anvari. C.Allen. R.Gooda~;r~, Departments of Surgery and Medicine, St. Joseph's Hospital, McMaster University. Hamilton, Canada. Dysphagia is one of the most troublesome complictions of open Nissen fundoplication. We examined the incidence and factors associated with development of dysphagic symptoms following Laparoscopic Nissen Fundoplication (LNF). From August 92 to October 94, 161 patients with proven GERD and on long-term medication underwent LNF. All patients underwent a 24 hr pH recording, esophageal manometry, gastroscopy and symptom score assessment for 6 specific GERD symptoms preoperatively. Intra-operatively the tightness of the wrap was varied by using different size (42-52 Fr) intraesophageal bougie, depending on the presence and severity of esophageal motor abnormality. 83 patients have since undergone repeat evaluations 6 months following the LNF. There was a significant improvement in 24 hr pH, LES pressure and GERD symptom score at 6 months following LNF (table). Of the 8:3 patients 34% had no dysphagia pre or postoperatively, 6% had no change in dysphagia symptom score (DSS), 14% had worsening of DSS, while 46% reported improvement in DSS following LNF. Only 3 patients (3.6%), all with moderate or severe esophageal dysmotilty, are experiencing clinically significant dysphagia with each meal. No correlation has been observed between the change in dysphagia score and the postoperative LES pressure or esophageal motor function. pre-operative GERD symptom score 58.8+ 2.1 % reflux in 24 hr 10.6 +_ 1.5 tES pressure 8.3 + 0.9 (values given as mean +_SE, * p
6 month post-op 14.6 + 1.6 * 0.7 + 0.1 * 22.1+1,4 *
These data suggest that the incidence of clinically significant dysphagia post LNF is low. Use of preoperative esophageal manometry to "tailor" the tightness of the wrap may be an important factor in prevention of dysphagia. Improvement in the dysphagia score in almost half the patients post LNF is interesting and warrants further investigation.
100 PANCREATICODUODENECTOMIES PERFORMED FOR BENIGN DISEASE. SA Barnes. HS Kaufman. KD Lillemoe. PK Santer. CJ Yeo. MA Talamini, HA Pitt and JL Cameron. Department of Surgery, The Johns Hopkins Medical Institutions Baltimore, MD. Perioperative morbidity and mortality following pancreaticoduodeneetomy (PD) has decreased markedly in a number of centers over the last decade, Yet many surgeons remain hesitant to extend the indications of this operation to non-malignant lesions. Requiring a histologic diagnosis of malignancy prior to performing PD has the potential risk of false negative pathologic sampling as well as delaying definitive therapy. Over the last 8 years, we have taken an aggressive approach in employing PD for patients presenting with a clinical picture of a periampullary neoplasm or significant chronic pancreathis confined to the pancreatic bead. METHODS: A retrospective review was completed of all patients undergoing PD between 1987 and 1994 (n=379). Final pathologic diagnosis showed a benign condition in 100 patients. RESULTS: The mean age of the patients was 56 years (range 21-81) with 51% females. Abdominal pain was the presenting complaint in 69% of patients, weight loss in 39% and jaundice in 28%. In 77 of the 10O patients, PD was performed for a suspected neoplasm, while 23 patients had a preoperative diagnosis of chronic pancreatitis. A pylorus-preserving PD was used in 82% of patients and a total pancreatectomy was necessary in 9%, The mean blood loss was 975 cc with 64 patients receiving no blood transfusions during their hospital course, There was one postoperative death. The most frequent complications were delayed gastric emptying in 29% of patients and pancreatic anastomotic leak in 20%. 51 of the patients experienced no perioperative complications. The median postoperative length of stay was 16 days (mean=19 days). The final histotzgic diagnosis was: chronic pancreatitis - n=49; benign cystic neoplasms n=20; periampullary villous adenoma - n = l l ; islet cell and other benign neoplasms - n=10; periductal fibrosis - n=6; and miscellaneous n=4, CONCLUSION: Surgeons are often called upon to perform PD for either suspicion of malignancy or symptoms due to benign disease. Concerns for morbidity and mortality should not prevent an aggressive approach for surgical resection in such patients.