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Extrapancreatic necrosis is not uniformly identified by european radiologists - a prospective multicenter evaluation of the revised Atlanta classification
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E-AHPBA: Free Prize Papers
dilated common bile duct. FibroScanÓ readings were graded as absent/mild fibrosis (<=7.0 kPa), significant fibrosis (7.1e9.4 kPa), severe fibrosis (9.5e12.4 kPa), cirrhosis (>=12.5 kPa). Results: The study group included 44 males and 15 females with CP. Median age was 69 yrs (37e88). The aetiological agent was alcohol in 43%. The median TE was 8.2 (2.5e34.3) kPa with 59.3% normal. Correlation for the whole group was found between pancreas atrophy (p = 0.017, median 7.7 kPa), Cambridge classification III (p = 0.010, median 10.7 kPa) and CreonÒ; >80000 units tds (p = 0.010, median 7.8 kPa). For alcohol aetiology only, this was found with CreonÒ; >80000 units tds (p = 0.018, median 11.2 kPa), abnormal bilirubin (p = 0.005, median 13.6 kPa) and intrahepatic duct dilatation (p = 0.027, median 12.0 kPa). 22% had significant fibrosis, 6.8% had severe fibrosis and 11.9% had values consistent with possible cirrhosis. The rate of fibrosis in this group was determined to be 28.8% with 47% (8/17) having normal serum LFTs. Conclusions: This study suggests that even asymptomatic CP patients with normal liver function tests may have fibrosis of their liver. Routine use of FibroScanÓ may be useful for surveillance and detection of early liver disease in this group so that timely management can be initiated.
PANCREATITIS 357 CAN INFECTED NECROTISING PANCREATITIS REALLY BE MANAGED CONSERVATIVELY? N. G. Mowbray, D. G. L. Griffith, T. Wells, T. H. Brown and B. Al-Sarireh Abertawe Bro Morgannwg University Health Board, UK Aims: Most cases of acute pancreatitis resolve with supportive management only. Unfortunately, 5% will subsequently develop Infected Pancreatic Necrosis (IPN), which carries a 30% mortality. Current guidelines advocate avoiding open necrosectomy and following a step-up approach using percutaneous drainage and minimally invasive necrosectomy. The aim of this study was to review the use of a completely conservative approach (antibiotics only) in managing patients with IPN by our regional unit. Methods: A retrospective case review was undertaken. Patients were graded using the Modified Glasgow Acute Pancreatitis Score and Ranson Score. All Computed Tomography (CT) scans were graded by a Specialist Radiologist using the CT Severity Index (CTSI). The presence of peripancreatic gas was diagnostic of infection. Results: Between October 2010 and May 2014, 12 cases of IPN were managed with intravenous antibiotics alone. 3 patients were excluded from the analysis due to incomplete data. The Median age and BMI was 73 (58e85) and 31.8 (22.8e35) respectively. The time from admission with pancreatitis to diagnosis of IPN varied from 3 to 131 days. One patient needed organ support in HDU. All patients were discharged to complete at least 6 weeks of antibiotics via a long line. 8 patients received once daily Ertapenem and one patient had Meropenem. At follow up 1 patient required both Insulin and pancreatic enzyme supplementation while a second patient had non-Insulin dependant
Diabetes Mellitus. One patient died from an unrelated cause. Conclusions: This case series does not advocate the exclusive use of conservative management in patients with IPN but does add another step to the step-up protocol. We conclude that there is a subgroup of patients who make a full recovery without the need for invasive investigation or treatment. Further work is needed to clarify both the patient, and disease, characteristics of this subgroup to allow more robust recommendations.
PANCREATITIS 382 EXTRAPANCREATIC NECROSIS IS NOT UNIFORMLY IDENTIFIED BY EUROPEAN RADIOLOGISTS - A PROSPECTIVE MULTICENTER EVALUATION OF THE REVISED ATLANTA CLASSIFICATION H. Sternby1, R. C. Verdonk2, G. Aguilar3, A. Dimova4, P. Ignatavicius5, L. Ilzarbe3, P. Koiva6, E. Lantto7, T. Loigom6, A. Pentillä7, S. Regner1, J. Rosendahl8, V. Strahinova9, S. Zackrisson1, K. Zviniene10 and T. L. Bollen2 1 Institution of Clinical Sciences, Malmo, Sweden, 2 St. Antonius Ziekenhuis, Nieuwegein, Netherlands, 3 Hospital del Mar, Barcelona, Spain, 4University Hospital for Emergency Medicine «Pirogov», Sofia, Bulgaria, 5 Lithuanian University of Health Sciences, Kaunas, Lithuania, 6East Tallinn Central Hospital, Tallinn, Estonia, 7Helsinki University Hospital, Helsinki, Finland, 8 University Clinic of Leipzig, Leipzig, Germany, 9University Hospital for Emergency Medicine “Pigorov”, Sofia, Bulgaria, 10Lithuanian University of Health Sciences, Kaunas, Lithuania Aims: In the revised Atlanta classification (RAC) new computed tomography (CT) criteria are introduced to describe local complications in acute pancreatitis (AP). These CT criteria have not yet been validated. The aim of this study was to analyse the interobserver agreement of the revised Atlanta criteria for CT findings in AP. Methods: Patients with a first episode of AP who obtained a contrast-enhanced CT (CECT) were consecutively enrolled at six European centres. A local radiologist at each centre and a central expert radiologist prospectively scored the CECTs separately using the criteria stated in the RAC. Centre dependent and independent interobserver agreement was determined using Kappa statistics. Results: The study cohort consisted of 285 patients with 388 CECTs. Aetiology of AP was gallstones in 36,6 %, alcohol in 35,9 %, and idiopathic in 27,5 % of the patients. AP was mild in 37,5 % of the patients, in 51,5 % moderately severe, and severe in 10,9 %. For most CT criteria interobserver agreement was moderate to substantial. In four categories the centre independent kappa values were fair; extrapancreatic necrosis (0.326), type of pancreatitis (0.370), characteristics of collections (0.408) and appropriate term of collections (0.356).The fair kappa values are explained by discrepancies in the identification of extrapancreatic necrosis (EXPN) and necrotic material in collections. The local radiologists identified EXPN (33% versus 59%) and non-homogeneous collections (35% versus 66%) significantly less frequently than the central expert (p < 0.0001 respectively).
HPB 2016, 18 (S2), e817ee819
E-HPBA: Free Prize Papers Conclusions: For most CT findings, interobserver agreement is good when CECTs are scored according to the RAC. However, identification of EXPN remains problematic, indicating general unfamiliarity with this entity. Given the results of this study there is a clear need for further research on the definition and recognition of EXPN.
PANCREATITIS 392 OUTCOME IN PATIENTS WITH PRESUMED GROOVE PANCREATITIS: 3-YEAR FOLLOW-UP FROM A SINGLE CENTER S. J. Lekkerkerker, C. Y. Nio, Y. Issa, P. Fockens, O. R. C. Busch, T. M. van Gulik, E. A. J. Rauws, M. A. Boermeester, J. E. van Hooft and M. G. H. Besselink Academic Medical Center, Netherlands Aims: Groove pancreatitis (GP) is a focal form of pancreatitis located in the pancreatoduodenal groove area. We aimed to describe cancer prevalence in patients with suspicion of GP, evaluate which factors can differentiate between GP and cancer, and to determine outcomes in GP patients after treatment. Methods: Patients with suspicion of GP presenting between 2001 and 2014 were retrospectively included. GP patients received questionnaires evaluating symptoms.
HPB 2016, 18 (S2), e817ee819
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Results: In total, 38 patients met the radiological criteria of GP. Ten (26%) patients were diagnosed with cancer during initial work-up (median age 58 (range 49e67), 6/10 men); 28 had GP (median age 52 (range 33e76), 17/28 men). Compared to cancer patients, GP patients more often presented with cysts in the groove area (22/28 (79%) vs 1/10 (10%), p < 0.001) and less often with jaundice (3/28 (11%) vs 6/10 (60%), p = 0.002). In 20/38 patients cysts in the groove were seen without jaundice; 19/20 of these patients had GP, 1/20 had cancer. Cytology was suspicious in 4/8 (50%) cancer patients and 2/20 (10%) GP patients (p = 0.04). Of the 28 GP patients, 14 were treated conservatively; 5/ 14 were symptom free and 6/14 improved (median followup 36 months, range 7e127). After endoscopic intervention (6/28 patients) 3/6 patients were symptom free, 2/6 improved (median follow-up 36 months, range 10-92). Surgery (8/28 patients) because of treatment failure (3/8) or inability to exclude malignancy (5/8) resulted in one postoperative death. Symptoms improved in the other 7 patients and 4/7 were symptom free (median follow-up 24 months, range 10e127). Conclusions: Suspicion of cancer is high in patients with possible GP. In patients with cysts in the groove area without jaundice, GP is the most likely diagnosis. Cytology should always be obtained, although negative outcome does not exclude malignancy. Since conservative, endoscopic treatment and surgery can all lead to symptom improvement, a ‘step-up approach’ seems advisable.
E-AHPBA: Free Prize Papers
dilated common bile duct. FibroScanÓ readings were graded as absent/mild fibrosis (<=7.0 kPa), significant fibrosis (7.1e9.4 kPa), severe fibrosis (9.5e12.4 kPa), cirrhosis (>=12.5 kPa). Results: The study group included 44 males and 15 females with CP. Median age was 69 yrs (37e88). The aetiological agent was alcohol in 43%. The median TE was 8.2 (2.5e34.3) kPa with 59.3% normal. Correlation for the whole group was found between pancreas atrophy (p = 0.017, median 7.7 kPa), Cambridge classification III (p = 0.010, median 10.7 kPa) and CreonÒ; >80000 units tds (p = 0.010, median 7.8 kPa). For alcohol aetiology only, this was found with CreonÒ; >80000 units tds (p = 0.018, median 11.2 kPa), abnormal bilirubin (p = 0.005, median 13.6 kPa) and intrahepatic duct dilatation (p = 0.027, median 12.0 kPa). 22% had significant fibrosis, 6.8% had severe fibrosis and 11.9% had values consistent with possible cirrhosis. The rate of fibrosis in this group was determined to be 28.8% with 47% (8/17) having normal serum LFTs. Conclusions: This study suggests that even asymptomatic CP patients with normal liver function tests may have fibrosis of their liver. Routine use of FibroScanÓ may be useful for surveillance and detection of early liver disease in this group so that timely management can be initiated.
PANCREATITIS 357 CAN INFECTED NECROTISING PANCREATITIS REALLY BE MANAGED CONSERVATIVELY? N. G. Mowbray, D. G. L. Griffith, T. Wells, T. H. Brown and B. Al-Sarireh Abertawe Bro Morgannwg University Health Board, UK Aims: Most cases of acute pancreatitis resolve with supportive management only. Unfortunately, 5% will subsequently develop Infected Pancreatic Necrosis (IPN), which carries a 30% mortality. Current guidelines advocate avoiding open necrosectomy and following a step-up approach using percutaneous drainage and minimally invasive necrosectomy. The aim of this study was to review the use of a completely conservative approach (antibiotics only) in managing patients with IPN by our regional unit. Methods: A retrospective case review was undertaken. Patients were graded using the Modified Glasgow Acute Pancreatitis Score and Ranson Score. All Computed Tomography (CT) scans were graded by a Specialist Radiologist using the CT Severity Index (CTSI). The presence of peripancreatic gas was diagnostic of infection. Results: Between October 2010 and May 2014, 12 cases of IPN were managed with intravenous antibiotics alone. 3 patients were excluded from the analysis due to incomplete data. The Median age and BMI was 73 (58e85) and 31.8 (22.8e35) respectively. The time from admission with pancreatitis to diagnosis of IPN varied from 3 to 131 days. One patient needed organ support in HDU. All patients were discharged to complete at least 6 weeks of antibiotics via a long line. 8 patients received once daily Ertapenem and one patient had Meropenem. At follow up 1 patient required both Insulin and pancreatic enzyme supplementation while a second patient had non-Insulin dependant
Diabetes Mellitus. One patient died from an unrelated cause. Conclusions: This case series does not advocate the exclusive use of conservative management in patients with IPN but does add another step to the step-up protocol. We conclude that there is a subgroup of patients who make a full recovery without the need for invasive investigation or treatment. Further work is needed to clarify both the patient, and disease, characteristics of this subgroup to allow more robust recommendations.
PANCREATITIS 382 EXTRAPANCREATIC NECROSIS IS NOT UNIFORMLY IDENTIFIED BY EUROPEAN RADIOLOGISTS - A PROSPECTIVE MULTICENTER EVALUATION OF THE REVISED ATLANTA CLASSIFICATION H. Sternby1, R. C. Verdonk2, G. Aguilar3, A. Dimova4, P. Ignatavicius5, L. Ilzarbe3, P. Koiva6, E. Lantto7, T. Loigom6, A. Pentillä7, S. Regner1, J. Rosendahl8, V. Strahinova9, S. Zackrisson1, K. Zviniene10 and T. L. Bollen2 1 Institution of Clinical Sciences, Malmo, Sweden, 2 St. Antonius Ziekenhuis, Nieuwegein, Netherlands, 3 Hospital del Mar, Barcelona, Spain, 4University Hospital for Emergency Medicine «Pirogov», Sofia, Bulgaria, 5 Lithuanian University of Health Sciences, Kaunas, Lithuania, 6East Tallinn Central Hospital, Tallinn, Estonia, 7Helsinki University Hospital, Helsinki, Finland, 8 University Clinic of Leipzig, Leipzig, Germany, 9University Hospital for Emergency Medicine “Pigorov”, Sofia, Bulgaria, 10Lithuanian University of Health Sciences, Kaunas, Lithuania Aims: In the revised Atlanta classification (RAC) new computed tomography (CT) criteria are introduced to describe local complications in acute pancreatitis (AP). These CT criteria have not yet been validated. The aim of this study was to analyse the interobserver agreement of the revised Atlanta criteria for CT findings in AP. Methods: Patients with a first episode of AP who obtained a contrast-enhanced CT (CECT) were consecutively enrolled at six European centres. A local radiologist at each centre and a central expert radiologist prospectively scored the CECTs separately using the criteria stated in the RAC. Centre dependent and independent interobserver agreement was determined using Kappa statistics. Results: The study cohort consisted of 285 patients with 388 CECTs. Aetiology of AP was gallstones in 36,6 %, alcohol in 35,9 %, and idiopathic in 27,5 % of the patients. AP was mild in 37,5 % of the patients, in 51,5 % moderately severe, and severe in 10,9 %. For most CT criteria interobserver agreement was moderate to substantial. In four categories the centre independent kappa values were fair; extrapancreatic necrosis (0.326), type of pancreatitis (0.370), characteristics of collections (0.408) and appropriate term of collections (0.356).The fair kappa values are explained by discrepancies in the identification of extrapancreatic necrosis (EXPN) and necrotic material in collections. The local radiologists identified EXPN (33% versus 59%) and non-homogeneous collections (35% versus 66%) significantly less frequently than the central expert (p < 0.0001 respectively).
HPB 2016, 18 (S2), e817ee819
E-HPBA: Free Prize Papers Conclusions: For most CT findings, interobserver agreement is good when CECTs are scored according to the RAC. However, identification of EXPN remains problematic, indicating general unfamiliarity with this entity. Given the results of this study there is a clear need for further research on the definition and recognition of EXPN.
PANCREATITIS 392 OUTCOME IN PATIENTS WITH PRESUMED GROOVE PANCREATITIS: 3-YEAR FOLLOW-UP FROM A SINGLE CENTER S. J. Lekkerkerker, C. Y. Nio, Y. Issa, P. Fockens, O. R. C. Busch, T. M. van Gulik, E. A. J. Rauws, M. A. Boermeester, J. E. van Hooft and M. G. H. Besselink Academic Medical Center, Netherlands Aims: Groove pancreatitis (GP) is a focal form of pancreatitis located in the pancreatoduodenal groove area. We aimed to describe cancer prevalence in patients with suspicion of GP, evaluate which factors can differentiate between GP and cancer, and to determine outcomes in GP patients after treatment. Methods: Patients with suspicion of GP presenting between 2001 and 2014 were retrospectively included. GP patients received questionnaires evaluating symptoms.
HPB 2016, 18 (S2), e817ee819
e819
Results: In total, 38 patients met the radiological criteria of GP. Ten (26%) patients were diagnosed with cancer during initial work-up (median age 58 (range 49e67), 6/10 men); 28 had GP (median age 52 (range 33e76), 17/28 men). Compared to cancer patients, GP patients more often presented with cysts in the groove area (22/28 (79%) vs 1/10 (10%), p < 0.001) and less often with jaundice (3/28 (11%) vs 6/10 (60%), p = 0.002). In 20/38 patients cysts in the groove were seen without jaundice; 19/20 of these patients had GP, 1/20 had cancer. Cytology was suspicious in 4/8 (50%) cancer patients and 2/20 (10%) GP patients (p = 0.04). Of the 28 GP patients, 14 were treated conservatively; 5/ 14 were symptom free and 6/14 improved (median followup 36 months, range 7e127). After endoscopic intervention (6/28 patients) 3/6 patients were symptom free, 2/6 improved (median follow-up 36 months, range 10-92). Surgery (8/28 patients) because of treatment failure (3/8) or inability to exclude malignancy (5/8) resulted in one postoperative death. Symptoms improved in the other 7 patients and 4/7 were symptom free (median follow-up 24 months, range 10e127). Conclusions: Suspicion of cancer is high in patients with possible GP. In patients with cysts in the groove area without jaundice, GP is the most likely diagnosis. Cytology should always be obtained, although negative outcome does not exclude malignancy. Since conservative, endoscopic treatment and surgery can all lead to symptom improvement, a ‘step-up approach’ seems advisable.