- Email: [email protected]
Diagnosis and management of cholangiocarcinoma in primary sclerosing cholangitis
A1374 SSATABSTRACTS
GASTROENTEROLOGYVol. 114, No. 4
• S0003 FUNCTIONAL AND SYMPTOMATIC IMPROVEMENT IN PATIENTS WITH DIABETIC GASTROPARESIS FOLLOWING PYLOROPLASTY. Ziad E. Abouezzi. W. Scott Melvin. E. Christonher Ellison, William J. Schirmer. Department of Surgery, The Ohio State University, Columbus, Ohio. Diabetic Gastroparesis (DGP) is a cause of significant morbidity, expense and suffering in diabetic patients. No suitable therapy has been described in severe DGP refractory to medical therapy. We hypothesized that vagal nerve dysfunction may be part of the general autonomic dysfunction affecting diabetics. We present this data summarizing our observation in the initial 6 patients treated with pyloroplasty. We retrospectively reviewed the medical records of patients with severe DGP who underwent pyloroplasty for relief of symptoms. Data on the duration of symptoms, associated conditions, previous admissions and treatments, preoperative and postoperative gastric emptying studies (GES) as well as clinical follow-up (nausea-vomiting, NV) were analyzed. Six patients (4 women and 2 men) with a mean age of 39 years were treated over a period of 3 years, follow-up averaged 11.3 months (ms) (range 3 to 33). All patients had more than 13 years history of complicated type I diabetes mellitus, required hospitalizations for dehydration at least 4 times over the previous year, and all were on prokinetic drugs or combinations for at least one year with minimal improvement. The results of gastric emptying studies (GES) are summarized in the following table: Patients I 1 I 2 [ 3 I 4 GESpreop 130 > 120 285 > 120 t 1/z in min GESpostop 37 59 35 54 t ½ in rain (16 ms) (2 ms) (8 ms) (8 ms) clinical 80-90% 60-70% 60-70% 70-80% improvement
I sl 90
6 I
N/A
very delayed N/A
0%
80-90%
Pyloroplasty induced a significant shortening of gastric emptying times in 4 of 4 patients studied. Marked clinical improvement was seen in 5 of 6 patients. CONCLUSIONS: Pyloroplasty is effective in relieving symptoms of diabetic gastroparesis and should be considered in the management of this condition. • S0004 ATTENUATED FAMILIAL ADENOMATOUS POLYPOSIS: ASSOCIATION OF AGE AND POLYP CHARACTERISTICS WITH COLORECTAL CANCER,. D.R. Adams, C.A. Tement. K.M. Lin. P. Watson. A.G. Thorson. G.J. Blatchford. M.A. Christensen, H.T. Lynch, Departments of Surgery and Preventive Medicine, Creighton University School of Medicine, Omaha, NE. The purpose of this study was to analyze characteristics of colon polyps in attenuated familial adenomatous polyposis (AFAP) with respect to colorectal cancer(CRC) risk. Detailed endoscopy and cancer data of 44 proven AFAP gene carriers and 11 obligate AFAP gene carriers were analyzed. Mean ages of polyp and CRC diagnosis were compared and average annual and cumulative risk of polyp development to age 73 were determined. Endoscopy data was analyzed to compare the size and location of benign versus malignant colorectal lesions. Mean ages of colon polyp diagnosis and CRC diagnosis were 40 (range: 14-73) years and 54 (range: 31-85) years, respectively (p=0.005). Average annual risk of polyp development was 2.9%. Cumulative risk of colorectal polyp development to age 73 was 90%. Mean size of benign colon polyps was 3mm compared to 32mm for malignant lesions (p<0.001). Colorectal polyp versus cancer distributions for the right (59% vs 19%), transverse (19% vs 19%), left (20% vs 35%) and rectum (2% vs 26%) were significantly different (p<0.00001). Colorectal polyps in AFAP are diagnosed at a mean of 14 years prior to diagnosis of CRC. Cumulative lifetime risk for colorectal polyps shows a near complete penetrance by age 73. CRC in AFAP is associated with a tenfold increase in the size of colonic lesions. In spite of a right sided predominance of colorectal polyps in AFAP, colorectal cancers do not appear to follow a similar distribution. • S0005 DIAGNOSIS AND MANAGEMENT OF CHOLANGIOCARCINOMA IN PRIMARY SCLEROSING CHOLANGITIS. S.A.Ahrendt. H.A.Pitt, A.Nakeeb. A.S.Klein. K.D.Lillemoe. A.N.Kalloo. and J.L.Cameron. Depts. of Surgery and Medicine, The Johns Hopkins University, Baltimore, MD and Dept. of Surgery, Medical College of Wisconsin, Milwaukee, WI. Cholangiocarcinoma (CCA) remains difficult to diagnose and is a major cause of mortality in patients with primary sclerosing cholangitis (PSC). Recently, serum carcinoembryonic antigen (CEA) levels and endoscopic brush cytology and/or biopsy (EBC) have been reported to improve diagnostic accuracy in patients with CCA and PSC. Between 1980 and 1997, 25 patients were diagnosed with CCA among 161 patients with PSC. The diagnosis of PSC was made coincident with the diagnosis of CCA in 11 patients and preceded it by a mean of 54 months in the remaining 14 Patients. Only 4 patients had cirrhosis at the time of diagnosis of CCA. Symptoms, mean age (48 vs 47 years), Mayo risk score (3.6+_0.2 vs. 3.7_+0.1), and serum bilirubin
(8 +-2 vs. 7 . 3 - 0.8 mg/dL) were similar among patients with and without CCA, respectively. The incidence of inflammatory bowel disease was higher in patients with CCA (85 % vs. 53 %). Nine patients with CCA were managed with either extrahepatic bile duct resection (n=5), hepatic lobectomy (n=l), or liver transplantation (n=3). The remaining 16 patients were unresectable at presentation (metastases (n=13), advanced cirrhosis (n=2), or locally unresectable tumor (n=l)). The tumor site (hilar/extrahepatic biliary tree (n=19), intrahepatic (n=4), or gallbladder (n=2)) was similar among the two groups. Actuarial survival and the sensitivity of serum CEA and endoscopic brush cytology (EBC) and/or biopsy in the diagnosis of CCA were: Group Resected Unresected
1 year 45% 22%
2 year 22% 0%
Survival 4 year 22% 0%
Sensitivity CEA EBC 50% 25% 47% 55%
Four patients were managed prior to the diagnosis of CCA with endoscopic balloon dilation of dominant biliary strictures for 22 +- 3 months. Three of these patients had metastatic disease at the time of diagnosis of CCA. In summary, cholangiocarcinoma is a frequent cause of mortality in patients with primary sclerosing cholangitis and often is diagnosed early in the course of the disease. Clinical and laboratory parameters do not differentiate patients with CCA. The sensitivity of both serum CEA and endoscopic biliary cytology in diagnosing cholangiocarcinoma at a resectable stage is low. Surgical resection is associated with a modest chance for long-term survival. • S0006
I
ABDOMINAL TUBERCULOSIS. Omer Alabaz. MD. Alper Akino~lu, MD. University of (~ukurova, Department of General Surgery, Adana, Turkey. The aim of this study was to evaluate the clinical, surgery and pathologic features in patients with abdominal tuberculosis. 67 patients (aged 15 to 59 years) who underwent surgery for gastrointestinal tuberuulous(49), peritoneal tuberculous(10), and tuberculous mesenteric lymphadenitis(8) were analyzed. The diagnosis was established at operation and by the appearance of caseating granuloma on histologic examination and isolation of the causative organism of the 67 patients, 24 had tuberculous peritonitis, 21 had tuberculous enteritis, and 8 tuberculous peritonitis and enteritis, and 6 had only tuberculous mesenteric lymphadenitis. The commonest presenting symptoms were abdominal swelling(79%), abdominal pain(55%), anorexia(44%), fever and night sweats(39%), and weight loss (38%). Twenty-nine patients had complications; bowel obstruction in 18, intestinal perforation in 5, bleeding in 4, and fistulas in 2. Tuberculin skin testing was positive in 55% of patients(n:45). 42 patients no associated pulmonary tuberculosis. There were 10(14%) operative deaths in our series, 4 of which occurred after emergency surgery for bowel perforation. Operative procedures included laparotomy with biopsy(26), resection of intestine(21), division of adhesion(8), intestinal bypass(7), and evacuation of mesenteric abscesses (5). In conclusion, noninvasive procedures are helpful in the investigation of suspected cases but surgical intervention may be necessary when the diagnosis is in doubt • S0007 ARTERIAL EMBOLISATION SIGNIFICANTLY IMPROVES THE HYPERTHERMIC EFFECT OF LASER-INDUCED THERMOTHERAPY IN LIVER METASTASIS IN RATS. D. Albrecht. C. Oermer, C. Isbert. A. Roggan. HP. Ritz, D. Schuppan and HJ. Buhr. Department of Surgery, Medical Center Benjamin Franklin, Freie Universit~itBerlin, Germany. Introduction and objective: Laser-induced thermotherapy (LITT) is a method for destroying malignant tumors. The aim of this animal experimental study was to examine whether the temporary microembolization of the tumor vascular bed with starch microspheres (Spherex ®) before LI'fT leads to an increase in the effective volume. Material and methods: The colon carcinoma cell line CC-531 (106 cells/0.1 ml) was used to induce liver tumors. Animals were grouped into LIT'Ymono (n=15), EmbolizatiOnmono(n=15), LITTembolization(n=15). Intrahepatic temperatures were measured 6 mm from the applicator. A catheter was implanted into the gastroduodenal artery for starch microsphere application. Tumor vitality was determined immunohistologically by the brumodeoxyuridine-AK (BrdU) reaction and HE sections 24 h, 7 and 28 days after treatment. Results: The analysis of intraoperative temperature curves demonstrated significantly higher values for LI'I'rembolization at 68°C ( + 1) than for LITTmono at 57°C ( + 1). Vital tumor tissue was macroscopically and immunohistologically found in only 1 animal in the LI"lT?embolization group (7d) (p<0.01) (Tab.). Macroscopic and immunohistological examinations showed tumor growth in LI'gTmono and EmbolizatiOnmono 24 h, 7 and 28 days after treatment. The LITTmonogroup had a clearly reduced BrdU reaction in the tumor periphery compared to embolizatiOnmono. Correspondingly, tumor diameters in LITTmono after 21 days were a mean of 3 mm smaller than in EmbolizatiOnmono"
GASTROENTEROLOGYVol. 114, No. 4
• S0003 FUNCTIONAL AND SYMPTOMATIC IMPROVEMENT IN PATIENTS WITH DIABETIC GASTROPARESIS FOLLOWING PYLOROPLASTY. Ziad E. Abouezzi. W. Scott Melvin. E. Christonher Ellison, William J. Schirmer. Department of Surgery, The Ohio State University, Columbus, Ohio. Diabetic Gastroparesis (DGP) is a cause of significant morbidity, expense and suffering in diabetic patients. No suitable therapy has been described in severe DGP refractory to medical therapy. We hypothesized that vagal nerve dysfunction may be part of the general autonomic dysfunction affecting diabetics. We present this data summarizing our observation in the initial 6 patients treated with pyloroplasty. We retrospectively reviewed the medical records of patients with severe DGP who underwent pyloroplasty for relief of symptoms. Data on the duration of symptoms, associated conditions, previous admissions and treatments, preoperative and postoperative gastric emptying studies (GES) as well as clinical follow-up (nausea-vomiting, NV) were analyzed. Six patients (4 women and 2 men) with a mean age of 39 years were treated over a period of 3 years, follow-up averaged 11.3 months (ms) (range 3 to 33). All patients had more than 13 years history of complicated type I diabetes mellitus, required hospitalizations for dehydration at least 4 times over the previous year, and all were on prokinetic drugs or combinations for at least one year with minimal improvement. The results of gastric emptying studies (GES) are summarized in the following table: Patients I 1 I 2 [ 3 I 4 GESpreop 130 > 120 285 > 120 t 1/z in min GESpostop 37 59 35 54 t ½ in rain (16 ms) (2 ms) (8 ms) (8 ms) clinical 80-90% 60-70% 60-70% 70-80% improvement
I sl 90
6 I
N/A
very delayed N/A
0%
80-90%
Pyloroplasty induced a significant shortening of gastric emptying times in 4 of 4 patients studied. Marked clinical improvement was seen in 5 of 6 patients. CONCLUSIONS: Pyloroplasty is effective in relieving symptoms of diabetic gastroparesis and should be considered in the management of this condition. • S0004 ATTENUATED FAMILIAL ADENOMATOUS POLYPOSIS: ASSOCIATION OF AGE AND POLYP CHARACTERISTICS WITH COLORECTAL CANCER,. D.R. Adams, C.A. Tement. K.M. Lin. P. Watson. A.G. Thorson. G.J. Blatchford. M.A. Christensen, H.T. Lynch, Departments of Surgery and Preventive Medicine, Creighton University School of Medicine, Omaha, NE. The purpose of this study was to analyze characteristics of colon polyps in attenuated familial adenomatous polyposis (AFAP) with respect to colorectal cancer(CRC) risk. Detailed endoscopy and cancer data of 44 proven AFAP gene carriers and 11 obligate AFAP gene carriers were analyzed. Mean ages of polyp and CRC diagnosis were compared and average annual and cumulative risk of polyp development to age 73 were determined. Endoscopy data was analyzed to compare the size and location of benign versus malignant colorectal lesions. Mean ages of colon polyp diagnosis and CRC diagnosis were 40 (range: 14-73) years and 54 (range: 31-85) years, respectively (p=0.005). Average annual risk of polyp development was 2.9%. Cumulative risk of colorectal polyp development to age 73 was 90%. Mean size of benign colon polyps was 3mm compared to 32mm for malignant lesions (p<0.001). Colorectal polyp versus cancer distributions for the right (59% vs 19%), transverse (19% vs 19%), left (20% vs 35%) and rectum (2% vs 26%) were significantly different (p<0.00001). Colorectal polyps in AFAP are diagnosed at a mean of 14 years prior to diagnosis of CRC. Cumulative lifetime risk for colorectal polyps shows a near complete penetrance by age 73. CRC in AFAP is associated with a tenfold increase in the size of colonic lesions. In spite of a right sided predominance of colorectal polyps in AFAP, colorectal cancers do not appear to follow a similar distribution. • S0005 DIAGNOSIS AND MANAGEMENT OF CHOLANGIOCARCINOMA IN PRIMARY SCLEROSING CHOLANGITIS. S.A.Ahrendt. H.A.Pitt, A.Nakeeb. A.S.Klein. K.D.Lillemoe. A.N.Kalloo. and J.L.Cameron. Depts. of Surgery and Medicine, The Johns Hopkins University, Baltimore, MD and Dept. of Surgery, Medical College of Wisconsin, Milwaukee, WI. Cholangiocarcinoma (CCA) remains difficult to diagnose and is a major cause of mortality in patients with primary sclerosing cholangitis (PSC). Recently, serum carcinoembryonic antigen (CEA) levels and endoscopic brush cytology and/or biopsy (EBC) have been reported to improve diagnostic accuracy in patients with CCA and PSC. Between 1980 and 1997, 25 patients were diagnosed with CCA among 161 patients with PSC. The diagnosis of PSC was made coincident with the diagnosis of CCA in 11 patients and preceded it by a mean of 54 months in the remaining 14 Patients. Only 4 patients had cirrhosis at the time of diagnosis of CCA. Symptoms, mean age (48 vs 47 years), Mayo risk score (3.6+_0.2 vs. 3.7_+0.1), and serum bilirubin
(8 +-2 vs. 7 . 3 - 0.8 mg/dL) were similar among patients with and without CCA, respectively. The incidence of inflammatory bowel disease was higher in patients with CCA (85 % vs. 53 %). Nine patients with CCA were managed with either extrahepatic bile duct resection (n=5), hepatic lobectomy (n=l), or liver transplantation (n=3). The remaining 16 patients were unresectable at presentation (metastases (n=13), advanced cirrhosis (n=2), or locally unresectable tumor (n=l)). The tumor site (hilar/extrahepatic biliary tree (n=19), intrahepatic (n=4), or gallbladder (n=2)) was similar among the two groups. Actuarial survival and the sensitivity of serum CEA and endoscopic brush cytology (EBC) and/or biopsy in the diagnosis of CCA were: Group Resected Unresected
1 year 45% 22%
2 year 22% 0%
Survival 4 year 22% 0%
Sensitivity CEA EBC 50% 25% 47% 55%
Four patients were managed prior to the diagnosis of CCA with endoscopic balloon dilation of dominant biliary strictures for 22 +- 3 months. Three of these patients had metastatic disease at the time of diagnosis of CCA. In summary, cholangiocarcinoma is a frequent cause of mortality in patients with primary sclerosing cholangitis and often is diagnosed early in the course of the disease. Clinical and laboratory parameters do not differentiate patients with CCA. The sensitivity of both serum CEA and endoscopic biliary cytology in diagnosing cholangiocarcinoma at a resectable stage is low. Surgical resection is associated with a modest chance for long-term survival. • S0006
I
ABDOMINAL TUBERCULOSIS. Omer Alabaz. MD. Alper Akino~lu, MD. University of (~ukurova, Department of General Surgery, Adana, Turkey. The aim of this study was to evaluate the clinical, surgery and pathologic features in patients with abdominal tuberculosis. 67 patients (aged 15 to 59 years) who underwent surgery for gastrointestinal tuberuulous(49), peritoneal tuberculous(10), and tuberculous mesenteric lymphadenitis(8) were analyzed. The diagnosis was established at operation and by the appearance of caseating granuloma on histologic examination and isolation of the causative organism of the 67 patients, 24 had tuberculous peritonitis, 21 had tuberculous enteritis, and 8 tuberculous peritonitis and enteritis, and 6 had only tuberculous mesenteric lymphadenitis. The commonest presenting symptoms were abdominal swelling(79%), abdominal pain(55%), anorexia(44%), fever and night sweats(39%), and weight loss (38%). Twenty-nine patients had complications; bowel obstruction in 18, intestinal perforation in 5, bleeding in 4, and fistulas in 2. Tuberculin skin testing was positive in 55% of patients(n:45). 42 patients no associated pulmonary tuberculosis. There were 10(14%) operative deaths in our series, 4 of which occurred after emergency surgery for bowel perforation. Operative procedures included laparotomy with biopsy(26), resection of intestine(21), division of adhesion(8), intestinal bypass(7), and evacuation of mesenteric abscesses (5). In conclusion, noninvasive procedures are helpful in the investigation of suspected cases but surgical intervention may be necessary when the diagnosis is in doubt • S0007 ARTERIAL EMBOLISATION SIGNIFICANTLY IMPROVES THE HYPERTHERMIC EFFECT OF LASER-INDUCED THERMOTHERAPY IN LIVER METASTASIS IN RATS. D. Albrecht. C. Oermer, C. Isbert. A. Roggan. HP. Ritz, D. Schuppan and HJ. Buhr. Department of Surgery, Medical Center Benjamin Franklin, Freie Universit~itBerlin, Germany. Introduction and objective: Laser-induced thermotherapy (LITT) is a method for destroying malignant tumors. The aim of this animal experimental study was to examine whether the temporary microembolization of the tumor vascular bed with starch microspheres (Spherex ®) before LI'fT leads to an increase in the effective volume. Material and methods: The colon carcinoma cell line CC-531 (106 cells/0.1 ml) was used to induce liver tumors. Animals were grouped into LIT'Ymono (n=15), EmbolizatiOnmono(n=15), LITTembolization(n=15). Intrahepatic temperatures were measured 6 mm from the applicator. A catheter was implanted into the gastroduodenal artery for starch microsphere application. Tumor vitality was determined immunohistologically by the brumodeoxyuridine-AK (BrdU) reaction and HE sections 24 h, 7 and 28 days after treatment. Results: The analysis of intraoperative temperature curves demonstrated significantly higher values for LI'I'rembolization at 68°C ( + 1) than for LITTmono at 57°C ( + 1). Vital tumor tissue was macroscopically and immunohistologically found in only 1 animal in the LI"lT?embolization group (7d) (p<0.01) (Tab.). Macroscopic and immunohistological examinations showed tumor growth in LI'gTmono and EmbolizatiOnmono 24 h, 7 and 28 days after treatment. The LITTmonogroup had a clearly reduced BrdU reaction in the tumor periphery compared to embolizatiOnmono. Correspondingly, tumor diameters in LITTmono after 21 days were a mean of 3 mm smaller than in EmbolizatiOnmono"