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Efficacy of feeding tube placement during pancreaticoduodenectomy for chronic pancreatitis
602
Journal of Gastrointestinal Surgery
Abstracts
duct. 24 hours later, animals were sacrificed to evaluate ascites, adhesions, sentinel loop, and gross appearance of the pancreas, liver, spleen, and lung. Blood sample was collected for biochemical study. Specimens of the pancreas, liver, spleen, and lung were sent for pathological study. Ascites was found in 50% of the cases, adhesions in 66.6%, and pulmonary changes, such as edema and local eritema in 16.6%. Concerning pancreas, edema was found in 83.3%, eritema in 83.3%, and necrosis in 50% of the cases. Increase in aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin, respectively, were observed. There were no changes in gamma-glutamyltranspeptidase, amylase, and glicemia levels. Histopathological examinations showed an extense inflammatory process, edema, fat necrosis, and hemmorrhagic areas in the pancreas, as well as, pulmonary edema. No histopathological changes were found in hepatic and splenic specimens. The model showed to be easily replicable and effective to produce AP. It could be used to the development of treatment and pathophysiology of AP.
260 PANCREATICOINTESTINAL FISTULA AFTER ENDOSCOPIC NASOPANCREATIC CYST DRAINAGE (ENPCD) IN PANCREATITIS Maki Sugimoto, MD, PhD, Hideki Yasuda, MD, PhD, Tooru Tezuka, MD, PhD, Tomohiro Takenoue, MD, PhD, Masato Yamazaki, MD, PhD, Shouji Naka, MD, PhD, Hiroshi Yasuhara, MD, PhD, Kazuhiro Sato, MD, PhD, Department of Surgery Teikyo University School of Medicine Ichihara Hospital, Chiba, Japan; Department of Radiology Teikyo University School of Medicine Ichihara Hospital, Chiba, Japan Pseudocyst is a common complication of pancreatitis, may rupture into the surrounding organs. Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report here the pancreatic pseudocysts that developed spontaneous fistulas to the duodenum and jejunum, successfully treated nonoperatively with the management of endoscopic nasopancreatic cyst drainage (ENPCD). The patient was a 28-year-old male admitted with epigastric pain. After hospitalization, he was diagnosed as severe acute pancreatitis. An abdominal CT revealed that his pancreas was swollen contained pseudocycts and pancreatic fluid infiltration extended to the pelvic cavity, we treated with continuous arterial infusion therapy (CAI). After recovering from severe form, pancreatic pseudocycts developed at the maximum size of 13 × 9 cm, he complaint high fever with upper abdominal pain and distension. The patient was managed nonoperatively with ENPCD tube inserted through the papilla of Vater. The pancreatic cyst-duodenal and cyst-jejunal fistulas were radiologically evident. After 21 days from the procedure, the abdominal symptoms and signs subsided and resolution of the pseudocysts and cyst-intestinal fistulas were resolved, the tube was pulled out. For curing this disease, elimination of this potential toxic mediators was essential, our intensive IVR based therapy improved the patient’s prognosis. ENPCD is an effective method for the drainage of pancreatic fluid caused resolution of the pseudocysts and cyst-intestinal fistulas, might have an important role in the treatment of complications with pancreatitis.
261 LYMPHOPLASMACYTIC SCLEROSING PANCREATITIS: A CASE REPORT AND REVIEW OF 240 CASES Vinai Gondi, MS, John D. Allendorf, MD, William S. Twaddell, MD, Beth Schrope, MD, PhD, Heidrun Rotterdam, MD, John A. Chabot, MD, Columbia University, New York, NY We describe a case of lymphoplasmacytic sclerosing pancreatitis (LPSP), initially thought to be pancreatic carcinoma, and review the
world literature on LPSP. A 24-year-old man with a past history of paratesticular rhabdomyosarcoma presented with obstructive jaundice, weight loss, and elevated liver function tests and amylase. Abdominal CT showed a 4-cm mass in the head of the pancreas with a double duct sign. On exploratory laparotomy, the mass was found to be densely adherent to the superior mesenteric and distal portal vein. A pancreaticoduodenectomy with a portal vein resection and reverse internal jugular vein reconstruction was performed. The patient recovered uneventfully. Pathologic analysis revealed diffuse fibrosis with a patchy inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils consistent with LPSP. We reviewed the world literature on LPSP through a Medline search under the keywords “LPSP,” “autoimmune pancreatitis,” “autoimmune-related pancreatitis,” “chronic sclerosing pancreatitis,” and “duct-destructive pancreatitis.” A review of literature showed that LPSP is characterized by a diffusely enlarged pancreas without a discrete mass on CT, a diffuse irregular narrowing of the main pancreatic duct on ERCP, and an elevated serum IgG4. We identified 240 cases of LPSP, with 118 cases (49.2%) from Japan or Korea, 89 cases (37.1%) from the United States, and 33 cases (13.3%) from Europe. 146 cases were treated with surgical resection alone, 76 cases with corticosteroids alone, 2 cases with surgical resection plus postoperative corticosteroids, and 9 cases were not reportedly treated. Treatment information was unavailable on 8 cases. Recurrence was reported in 14/104 (13.5%) cases treated with surgery alone and in 11/61 (18.0%) cases treated with corticosteroids alone. Autoimmune disease was reported in 26/201 (12.9%) cases, with Sjogren’s and inflammatory bowel disease being reported in 11 and 7 cases, respectively. LPSP mimics pancreatic carcinoma clinically and radiographically. A review of literature shows subtle radiologic and serologic differences that favor the diagnosis of LPSP. Despite these differences, surgical resection is often undertaken due to diagnostic uncertainty. Reported rates of recurrence seem to be similar between surgical resection and corticosteroid therapy. A minority of LPSP cases are associated with Sjogren’s and inflammatory bowel disease.
262 CYP2E1 GENE POLYMORPHISM AND ALCOHOLIC CHRONIC PANCREATITIS Halina Lach, Maria Slomka, PhD, Krzysztof Celinski, PhD, Medical Academy in Lublin, Lublin, Poland Alcohol abuse is being regarded as the main cause of chronic pancreatitis. The aim of this study was to investigate genetic polymorphism of CYP2E1 in alcoholic chronic pancreatitis and evaluation of relationship between this polymorphism and alcoholism. Thirty-nine patients were admitted to this study: 17 with alcoholic chronic pancreatitis and 22 nondrinkers as a control group. Genotypes of CYP2E1 were identified by PCR and RELP methods using PstI and RsaI as the restriction endonucleases. Genomic DNA was extracted from peripheral leukocytes. We investigate the frequency of c1 and c2 allele occurring in these two groups. In all nondrinkers only the c1 allele was observed. All patients of control group were homozygotic c1/c1. Frequency of c2 allele in alcohol chronic pancreatitis group was 12%, and was higher than in the control group. In any patients were found homozygotic c2/ c2, two of them were heterozygotic c1/c2. These results may suggest that allele c2 may be a risk factor for the developing alcoholic chronic pancreatitis.
263 EFFICACY OF FEEDING TUBE PLACEMENT DURING PANCREATICODUODENECTOMY FOR CHRONIC PANCREATITIS Thomas Schnelldorfer, MD, David N. Lewin, MD, David B. Adams, MD, Medical University of South Carolina, Charleston, SC
Vol. 9, No. 4 2005
The frequent finding of delayed gastric emptying after pancreaticoduodenectomy for chronic pancreatitis and the associated inability to tolerate nutrition by mouth has let to a common practice of prophylactic placement of enteral feeding tubes during the procedure. This is supposed to maximize enteral nutrition and avoid or minimize the use of parenteral nutrition in postoperative care. The purpose of this study is to examine the efficacy of feeding tubes placed during pancreatic head resection. The records of 78 consecutive patients who underwent pancreaticoduodenectomy for chronic pancreatitis were retrospectively reviewed and analyzed. Forty-nine patients received feeding tubes at time of operation in form of jejunostomy tube (42 patients) and/or gastrostomy tube (40 patients). This group was compared to 29 patients without feeding tube available for postoperative care. Both groups had a similar disease progress measured by degree of pancreatic fibrosis and preoperative nutritional status measured by serum albumin level, body mass index, and Subjective Global Assessment. Preoperative symptom of anorexia was more common in the feeding tube group (no tube 3% vs. tube 18%, P ⬍ 0.05). During the time observed there was a trend towards not placing simultaneous feeding tubes (first 6 years 84% vs. last 2 years 33%). The overall complication rate after pancreaticoduodenectomy was 54% (no tube 41% vs. tube 61%, P ⬍ 0.05). Placement of a feeding tube was associated with an increase in intra-abdominal morbidity from 34% to 57% (P ⬍ 0.03). Delayed gastric emptying (7% vs. 22%), intraabdominal abscess (10% vs. 16%), and anastomotic leak (7% vs. 16%) were more frequent in the feeding tube group but not significantly different in group comparison. None of the patients had a complication directly related to placement of the feeding tube. Eighty-eight percent of the placed feeding tubes were actually used. Despite of feeding tube placement 49% of patients required postoperative use of total parenteral nutrition compared to 55% of patients without feeding tube (P ⬎ 0.05). Length of hospital stay and hospital readmission during the first postoperative year was not affected by placement of feeding tube. Simultaneous feeding tube placement along with pancreatic head resection for chronic pancreatitis can be performed safely but increases the risk for postoperative intra-abdominal complications. The majority of the placed tubes are being use in postoperative care but they do not prevent the use of total parenteral nutrition and do not shorten length of hospital stay.
264 PANCREATICOPLEURAL FISTULA: THE ROLE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY IN DIAGNOSIS AND TREATMENT Yoshitsugu Tajima IV, MD, PhD, Kenzo Fukuda III, MD, PhD, Ryuji Tsutsumi III, MD, Tamotsu Kuroki III, MD, PhD, Takashi Kanematsu V, MD, PhD, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan Pancreaticopleural fistula is an uncommon entity and it results from pancreatic duct disruption or pancreatic pseudocyt extension into the pleural cavity. We present two cases of pancreaticopleural fistula in which the diagnosis was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treatment accomplished by endoscopic transpapillary pancreatic duct stent placement and/or open surgery. A 34-year-old man with a 16-year history of alcohol intake developed a pancreatic pseudocyst and amylase-rich pleural effusion following acute pancreatitis. MRCP demonstrated a fistulous tract originating from the disrupted pancreatic duct in the mid-portion of the pancreas and extending to the mediastinum, being consistent with a diagnosis of pancreaticopleural fistula. Subsequently, endoscopic transpapillary implantation of a plastic stent into the main pancreatic duct was performed. Stent placement was effective, and the patient recovered without complications. A 48-year-old man with a long his-
Abstracts
603
tory of alcohol abuse and recurrent pleural effusion developed a mediastinal pseudocyst following acute pancreatitis. MRCP demonstrated a fistulous tract extending from the pancreas head to the mediastinal pseudocyst and a stenosis in the distal bile duct. After temporary pancreatic drainage with an endoscopic transpapillary pancreatic duct stent, longitudinal pancreaticojejunostomy, resection of the fistula, and choledochoduodenostomy were performed. The postoperative course was uneventful, and he has been well without recurrent pancreatic disease. Detection of a pancreaticopleural fistula by conventional radiologic techniques is often difficult. While diagnosis can be confirmed with ERP, it is invasive. MRCP is a reliable noninvasive tool for detecting a pancreaticopleural fistula and for planning the treatment strategy.
265 FECAL ELASTASE-1 CONCENTRATION AS A SCREENING TOOL FOR CHRONICITY IN ACUTE PANCREATITIS ADMISSIONS Richard C. Turner, MBBS, Robyn McDermott, MD, PhD, James Cook University, Cairns, Queensland, Australia Acute and chronic pancreatitis are different pathological entities, although patients presenting with acute pain and elevated serum lipase may also have underlying chronic disease. Determining the presence of chronic pancreatitis in acute clinical presentations would be useful in guiding appropriate short- and long-term management. However accepted gold standard tests for chronic pancreatitis tend to be invasive, costly or time-consuming. The relatively new fecal elastase-1 assay has been shown to have acceptable diagnostic accuracy for moderate and severe exocrine deficiency when compared to the other tests (1). The aim of this study was to evaluate fecal elastase-1 concentration [FE-1] against clinical criteria for chronicity in an acute hospital setting. [FE-1] was performed on patients admitted to a surgical unit with a provisional diagnosis of acute pancreatitis based on the acute onset of epigastric pain and a serum lipase at least twice the upper limit of normal. Suspicion of chronic disease was defined by the presence of specific clinical, pathological or radiological criteria. A 2 × 2 table comparing [FE-1] and clinical diagnosis was constructed. 117 stool specimens from 95 patients were suitable for [FE-1] determination. Values were compared to clinical case definition criteria of chronicity, after exclusion of liquid stool specimens and cases of moderate or severe acute pancreatitis (Ranson’s score ⬎2). Using a threshold for exocrine insufficiency of 200 mcg/g, [FE-1] yielded the following results as a screening tool for chronic pancreatitis in the study cohort: positive predictive value ⫽ 96.9%, negative predictive value ⫽ 86.0%, sensitivity ⫽ 79.5% specificity ⫽ 98.0%. [FE-1] is an accurate screening tool for chronicity in pancreatitis patients when taken in the course of an acute hospital admission for mild pancreatitis. Since such cases represent the majority of pancreatitis admissions, the application of the assay to determine appropriate ongoing management protocols is justified. REFERENCE: 1. Lo¨ser C, Mo¨llgaard A, Fo¨lsch UR. Faecal elastase 1: a novel, highly sensitive, and specific tubeless pancreatic function test. Gut 1996; 39:580-586.
266 CYSTIC DEGENERATION OF THE DUODENUM AND GROOVE PANCREATITIS: TWO NAMES FOR THE SAME CONDITION? Caroline S. Verbeke, S. H. Rahman, Krish V. Menon, A. G. Chalmers, K. Harris, M. J. McMahon, P. J. Guillou, St. James’s University Hospital, Leeds, United Kingdom Cystic dystrophy of the duodenal wall (CD) is a rare lesion characterized by cyst formation in ectopic pancreatic tissue localized in the
Journal of Gastrointestinal Surgery
Abstracts
duct. 24 hours later, animals were sacrificed to evaluate ascites, adhesions, sentinel loop, and gross appearance of the pancreas, liver, spleen, and lung. Blood sample was collected for biochemical study. Specimens of the pancreas, liver, spleen, and lung were sent for pathological study. Ascites was found in 50% of the cases, adhesions in 66.6%, and pulmonary changes, such as edema and local eritema in 16.6%. Concerning pancreas, edema was found in 83.3%, eritema in 83.3%, and necrosis in 50% of the cases. Increase in aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin, respectively, were observed. There were no changes in gamma-glutamyltranspeptidase, amylase, and glicemia levels. Histopathological examinations showed an extense inflammatory process, edema, fat necrosis, and hemmorrhagic areas in the pancreas, as well as, pulmonary edema. No histopathological changes were found in hepatic and splenic specimens. The model showed to be easily replicable and effective to produce AP. It could be used to the development of treatment and pathophysiology of AP.
260 PANCREATICOINTESTINAL FISTULA AFTER ENDOSCOPIC NASOPANCREATIC CYST DRAINAGE (ENPCD) IN PANCREATITIS Maki Sugimoto, MD, PhD, Hideki Yasuda, MD, PhD, Tooru Tezuka, MD, PhD, Tomohiro Takenoue, MD, PhD, Masato Yamazaki, MD, PhD, Shouji Naka, MD, PhD, Hiroshi Yasuhara, MD, PhD, Kazuhiro Sato, MD, PhD, Department of Surgery Teikyo University School of Medicine Ichihara Hospital, Chiba, Japan; Department of Radiology Teikyo University School of Medicine Ichihara Hospital, Chiba, Japan Pseudocyst is a common complication of pancreatitis, may rupture into the surrounding organs. Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report here the pancreatic pseudocysts that developed spontaneous fistulas to the duodenum and jejunum, successfully treated nonoperatively with the management of endoscopic nasopancreatic cyst drainage (ENPCD). The patient was a 28-year-old male admitted with epigastric pain. After hospitalization, he was diagnosed as severe acute pancreatitis. An abdominal CT revealed that his pancreas was swollen contained pseudocycts and pancreatic fluid infiltration extended to the pelvic cavity, we treated with continuous arterial infusion therapy (CAI). After recovering from severe form, pancreatic pseudocycts developed at the maximum size of 13 × 9 cm, he complaint high fever with upper abdominal pain and distension. The patient was managed nonoperatively with ENPCD tube inserted through the papilla of Vater. The pancreatic cyst-duodenal and cyst-jejunal fistulas were radiologically evident. After 21 days from the procedure, the abdominal symptoms and signs subsided and resolution of the pseudocysts and cyst-intestinal fistulas were resolved, the tube was pulled out. For curing this disease, elimination of this potential toxic mediators was essential, our intensive IVR based therapy improved the patient’s prognosis. ENPCD is an effective method for the drainage of pancreatic fluid caused resolution of the pseudocysts and cyst-intestinal fistulas, might have an important role in the treatment of complications with pancreatitis.
261 LYMPHOPLASMACYTIC SCLEROSING PANCREATITIS: A CASE REPORT AND REVIEW OF 240 CASES Vinai Gondi, MS, John D. Allendorf, MD, William S. Twaddell, MD, Beth Schrope, MD, PhD, Heidrun Rotterdam, MD, John A. Chabot, MD, Columbia University, New York, NY We describe a case of lymphoplasmacytic sclerosing pancreatitis (LPSP), initially thought to be pancreatic carcinoma, and review the
world literature on LPSP. A 24-year-old man with a past history of paratesticular rhabdomyosarcoma presented with obstructive jaundice, weight loss, and elevated liver function tests and amylase. Abdominal CT showed a 4-cm mass in the head of the pancreas with a double duct sign. On exploratory laparotomy, the mass was found to be densely adherent to the superior mesenteric and distal portal vein. A pancreaticoduodenectomy with a portal vein resection and reverse internal jugular vein reconstruction was performed. The patient recovered uneventfully. Pathologic analysis revealed diffuse fibrosis with a patchy inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils consistent with LPSP. We reviewed the world literature on LPSP through a Medline search under the keywords “LPSP,” “autoimmune pancreatitis,” “autoimmune-related pancreatitis,” “chronic sclerosing pancreatitis,” and “duct-destructive pancreatitis.” A review of literature showed that LPSP is characterized by a diffusely enlarged pancreas without a discrete mass on CT, a diffuse irregular narrowing of the main pancreatic duct on ERCP, and an elevated serum IgG4. We identified 240 cases of LPSP, with 118 cases (49.2%) from Japan or Korea, 89 cases (37.1%) from the United States, and 33 cases (13.3%) from Europe. 146 cases were treated with surgical resection alone, 76 cases with corticosteroids alone, 2 cases with surgical resection plus postoperative corticosteroids, and 9 cases were not reportedly treated. Treatment information was unavailable on 8 cases. Recurrence was reported in 14/104 (13.5%) cases treated with surgery alone and in 11/61 (18.0%) cases treated with corticosteroids alone. Autoimmune disease was reported in 26/201 (12.9%) cases, with Sjogren’s and inflammatory bowel disease being reported in 11 and 7 cases, respectively. LPSP mimics pancreatic carcinoma clinically and radiographically. A review of literature shows subtle radiologic and serologic differences that favor the diagnosis of LPSP. Despite these differences, surgical resection is often undertaken due to diagnostic uncertainty. Reported rates of recurrence seem to be similar between surgical resection and corticosteroid therapy. A minority of LPSP cases are associated with Sjogren’s and inflammatory bowel disease.
262 CYP2E1 GENE POLYMORPHISM AND ALCOHOLIC CHRONIC PANCREATITIS Halina Lach, Maria Slomka, PhD, Krzysztof Celinski, PhD, Medical Academy in Lublin, Lublin, Poland Alcohol abuse is being regarded as the main cause of chronic pancreatitis. The aim of this study was to investigate genetic polymorphism of CYP2E1 in alcoholic chronic pancreatitis and evaluation of relationship between this polymorphism and alcoholism. Thirty-nine patients were admitted to this study: 17 with alcoholic chronic pancreatitis and 22 nondrinkers as a control group. Genotypes of CYP2E1 were identified by PCR and RELP methods using PstI and RsaI as the restriction endonucleases. Genomic DNA was extracted from peripheral leukocytes. We investigate the frequency of c1 and c2 allele occurring in these two groups. In all nondrinkers only the c1 allele was observed. All patients of control group were homozygotic c1/c1. Frequency of c2 allele in alcohol chronic pancreatitis group was 12%, and was higher than in the control group. In any patients were found homozygotic c2/ c2, two of them were heterozygotic c1/c2. These results may suggest that allele c2 may be a risk factor for the developing alcoholic chronic pancreatitis.
263 EFFICACY OF FEEDING TUBE PLACEMENT DURING PANCREATICODUODENECTOMY FOR CHRONIC PANCREATITIS Thomas Schnelldorfer, MD, David N. Lewin, MD, David B. Adams, MD, Medical University of South Carolina, Charleston, SC
Vol. 9, No. 4 2005
The frequent finding of delayed gastric emptying after pancreaticoduodenectomy for chronic pancreatitis and the associated inability to tolerate nutrition by mouth has let to a common practice of prophylactic placement of enteral feeding tubes during the procedure. This is supposed to maximize enteral nutrition and avoid or minimize the use of parenteral nutrition in postoperative care. The purpose of this study is to examine the efficacy of feeding tubes placed during pancreatic head resection. The records of 78 consecutive patients who underwent pancreaticoduodenectomy for chronic pancreatitis were retrospectively reviewed and analyzed. Forty-nine patients received feeding tubes at time of operation in form of jejunostomy tube (42 patients) and/or gastrostomy tube (40 patients). This group was compared to 29 patients without feeding tube available for postoperative care. Both groups had a similar disease progress measured by degree of pancreatic fibrosis and preoperative nutritional status measured by serum albumin level, body mass index, and Subjective Global Assessment. Preoperative symptom of anorexia was more common in the feeding tube group (no tube 3% vs. tube 18%, P ⬍ 0.05). During the time observed there was a trend towards not placing simultaneous feeding tubes (first 6 years 84% vs. last 2 years 33%). The overall complication rate after pancreaticoduodenectomy was 54% (no tube 41% vs. tube 61%, P ⬍ 0.05). Placement of a feeding tube was associated with an increase in intra-abdominal morbidity from 34% to 57% (P ⬍ 0.03). Delayed gastric emptying (7% vs. 22%), intraabdominal abscess (10% vs. 16%), and anastomotic leak (7% vs. 16%) were more frequent in the feeding tube group but not significantly different in group comparison. None of the patients had a complication directly related to placement of the feeding tube. Eighty-eight percent of the placed feeding tubes were actually used. Despite of feeding tube placement 49% of patients required postoperative use of total parenteral nutrition compared to 55% of patients without feeding tube (P ⬎ 0.05). Length of hospital stay and hospital readmission during the first postoperative year was not affected by placement of feeding tube. Simultaneous feeding tube placement along with pancreatic head resection for chronic pancreatitis can be performed safely but increases the risk for postoperative intra-abdominal complications. The majority of the placed tubes are being use in postoperative care but they do not prevent the use of total parenteral nutrition and do not shorten length of hospital stay.
264 PANCREATICOPLEURAL FISTULA: THE ROLE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY IN DIAGNOSIS AND TREATMENT Yoshitsugu Tajima IV, MD, PhD, Kenzo Fukuda III, MD, PhD, Ryuji Tsutsumi III, MD, Tamotsu Kuroki III, MD, PhD, Takashi Kanematsu V, MD, PhD, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan Pancreaticopleural fistula is an uncommon entity and it results from pancreatic duct disruption or pancreatic pseudocyt extension into the pleural cavity. We present two cases of pancreaticopleural fistula in which the diagnosis was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treatment accomplished by endoscopic transpapillary pancreatic duct stent placement and/or open surgery. A 34-year-old man with a 16-year history of alcohol intake developed a pancreatic pseudocyst and amylase-rich pleural effusion following acute pancreatitis. MRCP demonstrated a fistulous tract originating from the disrupted pancreatic duct in the mid-portion of the pancreas and extending to the mediastinum, being consistent with a diagnosis of pancreaticopleural fistula. Subsequently, endoscopic transpapillary implantation of a plastic stent into the main pancreatic duct was performed. Stent placement was effective, and the patient recovered without complications. A 48-year-old man with a long his-
Abstracts
603
tory of alcohol abuse and recurrent pleural effusion developed a mediastinal pseudocyst following acute pancreatitis. MRCP demonstrated a fistulous tract extending from the pancreas head to the mediastinal pseudocyst and a stenosis in the distal bile duct. After temporary pancreatic drainage with an endoscopic transpapillary pancreatic duct stent, longitudinal pancreaticojejunostomy, resection of the fistula, and choledochoduodenostomy were performed. The postoperative course was uneventful, and he has been well without recurrent pancreatic disease. Detection of a pancreaticopleural fistula by conventional radiologic techniques is often difficult. While diagnosis can be confirmed with ERP, it is invasive. MRCP is a reliable noninvasive tool for detecting a pancreaticopleural fistula and for planning the treatment strategy.
265 FECAL ELASTASE-1 CONCENTRATION AS A SCREENING TOOL FOR CHRONICITY IN ACUTE PANCREATITIS ADMISSIONS Richard C. Turner, MBBS, Robyn McDermott, MD, PhD, James Cook University, Cairns, Queensland, Australia Acute and chronic pancreatitis are different pathological entities, although patients presenting with acute pain and elevated serum lipase may also have underlying chronic disease. Determining the presence of chronic pancreatitis in acute clinical presentations would be useful in guiding appropriate short- and long-term management. However accepted gold standard tests for chronic pancreatitis tend to be invasive, costly or time-consuming. The relatively new fecal elastase-1 assay has been shown to have acceptable diagnostic accuracy for moderate and severe exocrine deficiency when compared to the other tests (1). The aim of this study was to evaluate fecal elastase-1 concentration [FE-1] against clinical criteria for chronicity in an acute hospital setting. [FE-1] was performed on patients admitted to a surgical unit with a provisional diagnosis of acute pancreatitis based on the acute onset of epigastric pain and a serum lipase at least twice the upper limit of normal. Suspicion of chronic disease was defined by the presence of specific clinical, pathological or radiological criteria. A 2 × 2 table comparing [FE-1] and clinical diagnosis was constructed. 117 stool specimens from 95 patients were suitable for [FE-1] determination. Values were compared to clinical case definition criteria of chronicity, after exclusion of liquid stool specimens and cases of moderate or severe acute pancreatitis (Ranson’s score ⬎2). Using a threshold for exocrine insufficiency of 200 mcg/g, [FE-1] yielded the following results as a screening tool for chronic pancreatitis in the study cohort: positive predictive value ⫽ 96.9%, negative predictive value ⫽ 86.0%, sensitivity ⫽ 79.5% specificity ⫽ 98.0%. [FE-1] is an accurate screening tool for chronicity in pancreatitis patients when taken in the course of an acute hospital admission for mild pancreatitis. Since such cases represent the majority of pancreatitis admissions, the application of the assay to determine appropriate ongoing management protocols is justified. REFERENCE: 1. Lo¨ser C, Mo¨llgaard A, Fo¨lsch UR. Faecal elastase 1: a novel, highly sensitive, and specific tubeless pancreatic function test. Gut 1996; 39:580-586.
266 CYSTIC DEGENERATION OF THE DUODENUM AND GROOVE PANCREATITIS: TWO NAMES FOR THE SAME CONDITION? Caroline S. Verbeke, S. H. Rahman, Krish V. Menon, A. G. Chalmers, K. Harris, M. J. McMahon, P. J. Guillou, St. James’s University Hospital, Leeds, United Kingdom Cystic dystrophy of the duodenal wall (CD) is a rare lesion characterized by cyst formation in ectopic pancreatic tissue localized in the