Intrahepatic portal vein aneurysm S(IHPVA) with porto-venous system shunt analysis of eleven cases

GASTROENTEROLOGY Vol. 118, No.4

A1504 SSAT ABSTRACTS

6795 OBSTRUCTION: EVALUATION WITH HELICAL COMPUTER TOMOGRAPHY. Athanasios I. Alexopoulos, Stergios Delakidis, Konstantin Dalamarinis, Garifalia Tsioga, Andreas Petroulakis, Petros Antonopoulos, SISMANOGLION Hasp, Athens, Greece. Aim: The aim of this study was to determine the level and cause of bowel obstruction with helical computer tomography. Material and Methods: Thirty five patients with suspected obstruction of the bowel, botb clinically and on plain films, underwent helical CT. Contrast material(720ml) was administrated orally or through nasogastric tube 2 hours before scanning. In 14 cases contrast material did not reach the level of obstruction. Six patients were unable to drink contrast material. Intravenous contrast material was additionally administrated in six casest 4 with recurrent malignancies, 2 with abscess). Diagnosis was established by surgery in 28 patients and clinical course in 7 patients. Results: The level and cause of bowel obstruction was accurently diagnosed in all causes. Causes of obstruction included adhesion(n= 16), hernia(n=6), recurrent malignancy (n=4), primary tumor(n=2), Crohn's disease (n=2), large bowel volvulusm =2). mesentery abscess(n=2) and colonic diverticulitis(n= I). The level of obstruction was in 27 patients in the small bowel and in 8 patients in the colon. Conclusion: Helical CT is a valuable method to determine the level and canse of bowel obstruction. We believe tbat helical CT is the procedure of choice in patients with a history of abdominal malignancy or snspected primary abdominal malignancy. Also it plays a secondary role postsurgical in patients .without cancer, most likely to have adhesive bowel obstruction.

6796 ACUTE COLONIC DIVERTICULITIS: EVALUATION WITH UN· ENHANCED THIN-SECTION HELICAL COMPUTER TOMOGRAPHY. Athanasios I. Alexopoulos, Stergios Delakidis, Garifalia Tsioga, Andreas Petroulakis, Maria Chatzopoulou, Konstantin Oalamarinis, Petros Antonopoulos. SISMANOGLION Hasp, Athens, Greece. Purpose: The aim of this study was to define the diagnostic value of thin-section helical computer tomography (CT) during the acute phase of diverticulitis. Material and Methods: Over a 12 month period 59 adult patients presented to our emergency department with suspected acute diverticulitis underwent helical computer tomography as a first imaging examination. All patients were given 500-1000ml of contrast material before scanning. After the routine helical CT exam we performed a thin-section technique (slice thickness 4-5mm, reconstruction interval 4-5mm) in the area of interest.CT results were correlated with clinical follow up in all patients, by CT exames follow up in 6 patients and by surgery in 3 patients. Results: Acute diverticulitis was diagnosed by helical CT in 50 of the cases (50/59) . Diverticula was present in all subjects (50/50), pericolonic inflammatory infiltration in 48/50(98%), focal inflammatory wall thickening in 45/50(90%), muscular wall hypertrophy in 42/50(84%),pericolonic phlegmon in 10/50(20%), abscess in 3/50(6%) and diffuse wall thickening in 1/50(2%). Nine patients (9/59) had CT results other than diverticulitis included ileitis(n=3),left tuba-ovarian abscess(n=2) and other diseases (n=4). Conclusion: Unenhanced thin-section helical CT is an accurate and effective technique to confirm or exclude clinically suspected diverticulitis and to suggest alternative conditions if they are present.

6797 INTRAHEPATIC PORTAL VEIN ANEURYSM S(IHPVA) WITH PORTO·VENOUS SYSTEM SHUNT ANALYSIS OF ELEVEN CASES. Shingo Asahara, Takaaki Ikari, Akira Kamei, Eiichi Sato, Kouichi Takano, Takuya Kudo, Naomi Sago, Kazuko Beppu, Hironori Kokudo, Cancer Institute Hosp, Tokyo, Japan. OBJECTIVE: Portal vein aneurysm has been considered to be rare. With the advent of color doppler ultrasonography, however, reports of cases have been discribed. The purpose of this study is to clarify clinical aspects and ultrasonografical findings of intrahepatic portal vein aneurysm with porto-venous system shunt. Materials and Methods: In the periods from May 1998 to March 1999, 15,871 cases of ultrasonography were performed for disease screening or disease follow-up. 1175 cases of computed tomography were also undergone during the same periods. Eight cases of IHPVA were detected with US and three with CT. All were confirmed by color doppler ultrasonography. Eleven patients consisted of two males and nine fimales with a mean age of 64.5. Clinical presentation, laboratory data and imaging findings were reviewed. Results: Liver cysts were detected in 3,900 patients(24.6%). Among them, eleven patients had IHPVA with porto-venous system shunt. Two patients presented with liver dysfunction, hyperammonemia and portal hypertension (related with HCV virus). Five patients were previously misdiagnosed as liver cyst. IHPVA were located in lateral or medial segment in four patients, anterior in two and posterior in one patient. Portal vein branch dilatation around IHPVA were recognized in ten patients and hepatic vein dilatation in eight by ultrasonography. Cystic lesions measured from 4.4 to 23.9 mm in diameter. The features of aneurysm showed simple cyst in eight patients and multilocular cyst in three. Color doppler ultrasonography revealed IHPVA with portovenous system shunt in all patients. Conclusions:IHPVA with porto-ve-

nous system shunt was visualized as cystic lesions with dilatation of hepatic or portal vein branch by ultrasonography. Color doppler ultrasonography can easly confirm blood flow and communication of aneurysm and vessels. IHPVA is not always related with portal hypertension and its clinical significance remains still unknown.

6798 "BEGER" VS. "FREY": A COMPARISON OF LIMITED PANCRE· ATIC HEAD RESECTIONS FOR BENIGN DISEASE. Gudrun Aspelund, Mark D. Topazian, Dana K. Andersen, Yale Univ Sch of Medicine, New Haven, CT. Introduction: The Duodenum-Preserving Pancreatic Head Resection (DPPHR) by Beger et al, and the Extended Lateral Pancreatico-Jejunostomy (ELPJ) by Frey, have expanded the surgical treatment of benign pancreatic disease. Improved outcomes and lower morbidity compared to the Whipple (WHIP) procedure have been reported, but direct comparisons of DPPHR and ELPJ have been limited. We reviewed our single-surgeon experience with these resections, compared to standard and pylorus-sparing WHIP resection, distal pancreatic resections (DPR) and pancreatic duct sphincteroplasties (PDS) performed contemporaneously. Methods: From 3/97 to 11/99, a total of 42 pancreatic procedures were performed, including 8 DPPHR,7 ELPJ, II WHIP, 6 DPR, and 5 PDS. We evaluated indications, including chronic pancreatitis, proximal duct stenosis, benign tumors, and malignancies; morbidity, including operative time, blood loss, length of nasogastric intubation, length of post-op stay, and major complications; and outcomes, including new diabetes mellitus, persistent analgesic use, and complete functional recovery. Results: No deaths occurred. All DPPHR, ELPJ and PDS patients had preop ERCP, and most had EUS. Operative time, including intraoperative ultrasound etc, was I hour shorter for ELPJ vs. OPPHR. Both were shorter than for WHIP. Results show low morbidity and similar outcomes with DPPHR and ELPJ. Blood loss was less and length of stay shorter for OPPHR and ELPJ than for WHIP. Major complications (including I pancreatic duct leak in OPPHR, WHIP and OPR) were absent in ELP1. Persistent analgesic use and failures to achieve full functional recovery were similar in DPPHR (14%), ELPJ (14%) and WHIP (9%) groups. New diabetes occurred after I WHIP operation but not after OPPHR or ELP1. Conclusions: Our initial experience suggests low morbidity and good outcomes witb both DPPHR and ELPJ. The early functional recovery and freedom from analgesics are similar, although OPPHR may be superior to ELPJ when ductal stenosis exists. Selection of OPPHR VS. ELPJ is therefore dictated by preop evaluation of ductal anatomy. The morbidity of DPPHR is similar to the WHIP procedure, although length of stay is comparable to lesser procedures. Long term follow up will be required to determine whether patients with benign disease benefit preferentially from DPPHR vs. ELPJ, but both appear to offer better outcomes than WHIP procedures.

6799 SURGICAL MANAGEMENT OF PANCREATIC NEUROENDOCRINE TUMORS. Mark F. Berry, Noel N. Williams, Jason H. Lee, Richard Whittington, Robert J. Canter, Ernest F. Rosato, Univ of Pennsylvania, Philadelphia, PA; Univ of Pennsylvania, Philedelphia, PA. Background: The clinical presentation of pancreatic neuroendocrine tumors is dependent on whether the tumor produces functional hormones. Objective: The aim of this study was to examine the clinical presentation, diagnosis, surgical management, pathology, and outcome in patients with pancreatic neuroendocrine tumors. Methods: A retrospective review was performed to evaluate the clinical course of 28 patients treated surgicall y at the Hospital of tbe University of Pennsylvania between 1989 and 1997 for neuroendocrine tumors of the pancreas. Results: The age of the 28 patients (14 male, 14 female) ranged from 25 to 80 with a mean of 54 ::':: 2.5 years. Ten (36%) patients had functional tumors (8 insulinomas, 2 gastrinomas), with clinical presentations consistent with syndromes of hormone excess. Eighteen (64%) patients had non-functional tumors, with the most common presenting symptoms being abdominal pain (72%) and weight loss (39%). Non-functional tumors were identified on 100% of CT scans, MRIs, and angiograms. Functional tumors were identified on only 57% of MRls, 0% of CT scans, and 0% of angiograms. Endoscopic ultrasound (80%), venous sampling (75%), and ERCP (67%) were more successful at localizing functional tumors. Tumor location within the pancreas were tail (43%), body (29%), and head (21%). Surgery included distal pancreatectomy (n= 18), Whipple procedure (n= 5), and tumor enucleation (n= 5). Pathology revealed malignancy in 17 patients and benign disease in II patients. Non-functional tumors had an average size of7.1 ::':: 1.0 ern, and functional tumors averaged 2.3 ::':: 0.4 ern (p < 0.05). Benign tumors were on average 2.8 ::':: 0.6 ern and malignant tumors 7.0 ::':: l.l cm in size (p < 0.05). The most common post-operative complications were fever (57%), atelectasis (54%), pleural effusion (29%), and infection (25%). Follow-up ranged from 2 to 115 months (mean 47 ::':: 5.6). Three of these patients have died, and 4 others have suffered distant disease failure. The overall 2, 3, and 5 year survival rates were 92.3%, 84.2%, and 72.7%. The 2, 3, and 5 year survival rates were 100% for benign disease, as compared to 87.5%, 75%, and 66.7% for malignant disease. Conclusions: Surgical resection of pancreatic neuroendocrine tumors has a low mortality and depends on location within the pancreas. Presentation and successful techniques for localization differ between functional and non-functional tumors. Malignant tumors are