PV) is not a contraindication to pancreaticoduodenectomy

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Conclusions: (1) The decrease in antisecretory efficacy of PPIs after Hp eradication is a drug class effect, particularly affecting nocturnal acid control. (2) Curing Hp infection increases intragastric acidity.

250 Antral web presenting in an adult Gregory F. Winters, MD and Steven Goldschmid, MD, FACG*. 1 Gastroenterology, University of Arizona, Tucson, AZ, United States. Purpose: Antral Webs are uncommon sources of gastric outlet obstruction in adults and are often not recognized at the time of endoscopy. Antral Webs are often mistaken for pyloric strictures. The true incidence of antral webs is unknown, with 120 reported adult cases found in the literature. Antral webs are hypothesized to have both congenital and acquired etiologies. The diagnosis of antral webs can be done endoscopically or radiographically. Methods: We present a case of a 56-year-old male who presented with nausea, vomiting, bloating, abdominal pain, early satiety and weight loss. The patient’s symptoms had been on going for 6 – 8 months. Prior to endoscopy, the patient had an upper GI study that reported a pyloric mass or stricture as the cause of his obstructive symptoms. On endoscopy, the patient was found to have an antral web. Results: Historically, the treatment of antral webs has been surgical. More recently, endoscopic approaches have been investigated. We found five cases of antral webs treated endoscopically in the literature. These include the use of snares, Nd:Yag lasers, and papillotomes. Our patient refused surgical or endoscopic intervention at the time of diagnosis. The patient was therefore treated with the promotility agent Reglan. This has provided symptomatic relief for the patient. Conclusions: The diagnosis of antral webs should be considered in adult patients with gastric outlet obstruction and the absence of a certain diagnosis on upper GI study.

251 Gastric carcinoma in patients less than 45 years old Susana Lopes, M.D., Pedro Moutinho-Ribeiro, M.D., So´ nia Barroso, M.D., Guilherme Macedo, M.D., FACG, Armando Ribeiro, M.D., Tome´ Ribeiro, PhD, Gastrenterology Unit, Hosp. S. Joo˜ , Porto, Portugal. It is a common practice in management of dyspeptic patients with less than 45 years old not to perform upper gastrointestinal endoscopy (UGE), given the low risk of cancer in this age group. However, in a country with high incidence, the biological behaviour of this neoplasia may be different justifying another algorithmic approach. Aim: To analyse the clinico-pathological features and clinical significance of gastric cancer in a young population. Material and Methods: Retrospective analysis of 25811 UGE performed by all members of the Gastroenterology Unit between 1993 and 2000, combined with histological reports from Pathology Department. Results: We have enrolled 44 patients (32 men and 12 women) with median age of 37,3 years (21– 44 years). Main indications for UGE were: gastrointestinal bleeding and anemia in 12 patients, dyspepsia in 8, abdominal pain in 8 and dysphagia in 4 patients. Endoscopic appearance was: exophytic lesion in 28, infiltrative in 10, lymphoma like in 3 and Kaposi in 3. The localization was predominantly distal (50%), with 41% located in the fundus/body and 9% with mix localization. Histological type was: intestinal adenocarcinoma in 20 patients (46%), diffuse type in 8 (18%), Kaposi tumor in 3 (7%), lymphoma in 3 (7%) and stromal tumor in 1 (2%); in 9 patients it was not possible to obtain histological identification. Conclusion: Gastric cancer in young patients is not rare among us. The lesions are predominantly located in the distal stomach and the histological type is intestinal adenocarcinoma.

AJG – Vol. 96, No. 9, Suppl., 2001

252 Primary gastric lymphoma: a rectrospective analysis of endoscopic and surgical diagnosis Pedro Moutinho-Ribeiro, M.D., Susana Lopes S, M.D., Guilherme Macedo, M.D., FACG, Clara Sambade, Ph.D., and Tome´ Ribeiro, Ph.D. Gastroenterology Unit, Hospital S.Joa˜ o, Porto, Portugal. Introduction and aim: The treatment of eradication of Helicobacter Pylori in patients with MALT Lymphoma raised the hypothesis of his role in the regression of these type of tumors and in reducing the progression to a higher degree neoplasia. However, the increased number of these more severe tumors in the last years doesn’t support this assumption and stimulate a better knowledge of our reality. Material and methods: The cases of primary gastric lymphoma diagnosed in our hospital in the last 10 years, and registered in the Pathology Department, were submitted to a retrospective study. All the histologic slides were reviewed. Results: The study included 53 cases (29 men and 24 women; mean age:61 years), 30 were diagnosed in the surgical specimen and 23 in the endoscopic biopsy. The most frequent location of the tumor was the antrum (51%) and the most prevalent macroscopic aspect was the ulcerated type (58%). The histologic types according the method of the diagnosis were: a) surgical specimen—MALT of low grade (40%), MALT in progression (17%), B cell high grade (40%) and B cell centrocitic centroblastic (6%); b) endoscopic biopsy—MALT of low grade (22%), B cells high grade (70%), mantle cell lymphoma (4%) and mediterranean lymphoma (4%). The relative percentages of those histologic types of lymphoma, in the first and second periods of 5 years in which we considered the study, was similar. Conclusions: In our study, primary gastric lymphoma comprehended neoplasias of low grade (MALT, centrocitic centroblastic B, mantle and mediterranean types) and, with a higher frequency, high grade tumors (B cells and MALT in progression types). The percentage of high grade lymphomas was higher in the group of cases diagnosed by endoscopic biopsy than in the group identified in the surgical specimen. This suggest a lower accuracy in diagnosing lymphoma of low grade by endoscopy. This fact reinforces the role of the endoscopy in the clinical cases of “dispepsya” and the necessity of doing systematic biopsies in the cases usually described as “gastritis”.

PANCREATIC/BILIARY 253 Involvement of the superior mesenteric/portal vein (SM/PV) is not a contraindication to pancreaticoduodenectomy EK Abdalla, PWT Pisters, JE Lee, JN Vauthey, KR Cleary, C Charnsangavej, DB Evans. Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas. Purpose: To compare survival duration of patients who required extended pancreaticoduodenectomy with en-bloc venous resection, to those who underwent standard pancreaticoduodenectomy for malignant tumors of the pancreatic head. Methods: 107 patients who underwent en-bloc resection of the SM/PV were identified from a database containing 314 consecutive pancreaticoduodenectomy patients from 1990 to 2000. Clinicopathologic factors, treatment and outcome variables were analyzed to determine marginnegative resection (R0), disease-free and overall survival rates. Results: Of the 107 patients who underwent en-bloc venous resection (VR), 89 had adenocarcinoma. R0 resection rates were comparable with and without vascular resection (79% vs 87%, p ⫽ NS). For the entire cohort of patients, the actuarial 5-year disease-free survival rate with VR was 33%, versus 38% without VR (p ⫽ NS). The overall survival rate with VR was 37%, versus 39% without VR (p ⫽ NS). For the subset of patients with adenocarcinoma, there was no difference in survival rate based on the need for VR:

AJG – September, Suppl., 2001

Conclusions: Survival in patients who require venous resection with pancreaticoduodenectomy is similar to that observed in patients without SM/PV involvement. SM/PV involvement by malignant pancreatic tumors is a function of tumor location rather than adverse biology; such patients should be considered for potentially curative pancreaticoduodenectomy. 254 Bouveret’s syndrome, a rare cause of upper gastrointestinal bleeding and obstruction Mouaz H Al-Mallah1 and Moustafa Ibrahim1*. 1Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States. Introduction: Erosion into the duodenum is a rare complication of gallstones (Bouveret’s Syndrome). The most common presentation is bowel obstruction. Massive gastrointestinal bleeding is a rare mode of presentation of Bouveret’s Syndrome. In most reported cases, diagnosis was made at the time of laparatomy. Only few cases were diagnosed preoperatively by CT scan and/ or endoscopy. Objective: To report a case of Bouveret’s Syndrome who presented with massive GI bleeding in which high index of suspicion at endoscopy led to the preoperative diagnosis by CT scan. Case Presentation: An 82-year-old white female with past medical history of GERD, osteoarthritis and osteoporosis presented with a massive upper GI bleeding and signs of upper gastrointestinal obstruction. Upper GI endoscopy revealed grade IV esophagitis, antral ulcer and a mass in the first part of the dueodenum. CT scan of the abdomen and an upper GI barium swallow revealed a huge mass in the post bulbar region of the duodenum and a cholecystoduodenal fistula. The patient underwent duodenotomy and cholecystectomy. Pathology revealed a 4 ⫻ 3.5 ⫻ 3.5 cm calculus. Patient had a smooth postoperative course. Conclusions: Bouveret’s Syndrome is an extremely rare cause of upper GI bleed. Since 1966, there have been around one hundred fifty reported cases of Bouveret’s syndrome with only 16 cases presenting as upper GI bleeding. In most reported cases of Bouveret’s Syndrome, the diagnosis was made at the time of laparatomy; only few cases, when the syndrome was suspected, the diagnosis was made by either CT or endoscopy. 255 Cholecystostomy in high risk surgical patients Gintaras Antanavicius, M.D.1, Michael S O’Mara, M.D.1, Devora E Hathaway, BSN1, Daniel J Gagne, M.D.1 and Philip F Caushaj, M.D., FACG1*. 1Department of Surgery, Temple University School of Medicine, Clinical Campus, The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, United States. Purpose: Cholecystostomy is a temporary procedure, indicated in high risk surgical patients with acute cholecystitis and severe comorbid status when drainage is mandatory and cholecystectomy is not feasible or unsafe. For selected patients with advanced systemic diseases it is a curative procedure. Methods: Between November 20, 1993 and January 1, 2001, 30 patients underwent cholecystostomy at The Western Pennsylvania Hospital. Retrospective chart review was performed. Comparison was made between survivors(SG) and non-survivors(NSG). Results: There were 13 male and 17 female patients. Patients ages 27-86 years. Comparing two groups, NSG n ⫽ 13 and SG n ⫽ 17, age was not significantly different (p ⫽ 0.565). Analyzing ASA class for SG and NSG we found extremely significant difference between the two groups (p ⫽

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0.0002). ASA Class II & III were much more common in the SG. At the time of procedure comorbidities included cardiovascular(CV) problems, abdominal disease, endocrine problems, pulmonary diseases, renal diseases, and multiorgan failure/sepsis. In NSG we found some statistical association with CV problems (p ⫽ 0.0924). 21 patients(70%) experienced abdominal pain with the most common symptom being RUQ tenderness (n ⫽ 18,60%). 23(77%) at the day of the procedure were found to have leukocytosis. Abnormal LFT was present in 19(63%). Folloup of the patients ranged from 1 day to 3 years and 7 months. In the SG mean follow up was 188.65d ⫾ SD 335d, in NSG mean was 19.6d SD ⫾ 16.1d. 13 of our patients died (43%) at the same admission, 5 had interval cholecystectomy (17%), and 12 patients after cholecystostomy have not had cholecystectomy either because of advanced systemic disease or because of resolved acalculus cholecystitis in debilitated patients. All deaths were the result of comorbid illness. In SG abdominal pain after procedure resolved in a higher percentage of patients compared to NSG (37% in NSG and 85% in SG (p ⫽ 0.0555)). At the time of procedure there was a higher incidence of patients with abnormal creatinine in NSG (62% of patients in NSG and 22% in SG (p ⫽ 0.610)) and resolution of creatinine abnormalities occured in 0% of NSG and 75% of SG (p ⫽ 0.0018). Conclusions: Comorbidities and severity of comorbid diseases has a major impact on mortality after cholecystostomies. Most important comorbidity is CV diseases. In our series cholecystostomy is safe and effective initial treatment of high-risk surgical patients with suspected cholecystitis. In general, if a patient with severe comorbid status shows any clinical and laboratory improvement in the first few days after cholecystostomy there is a good chance that the patient will survive.

256 Safety and efficacy of pancreatic duct gabexate mesylate infusion in preventing ERCP induced pancreatitis in dogs Tamer G Atassi, MD, Robb E Wilentz, MD and Paul J Thuluvath, MD*. 1 Gastroenterology and Pathology, Johns Hopkins Hospital, School of Medicine, Baltimore, MD. Purpose: Intravenous Gabexate Mesylate(GM), a protease inhibitor that inactivate pancreatic proteases, has been shown to prevent ERCP induced pancreatitis in controlled clinical trials. The disadvantage of GM intravenous infusion is that patients have to be admitted for at least 12-hours infusion of GM after ERCP which is not cost-effective and moreover, it has been associated with phlebitis. The aim of our study was to investigate the safety and efficacy of pancreatic duct (PD) GM infusion to prevent ERCP induced pancreatitis in dog model of acute pancreatitis. Methods: Pancreatitis was induced in dogs by forceful injection of contrast through PD till acinarization was noted radiographically followed by pancreatic sphincter cauterization. three groups of dogs were studied. pancreatitis was induced in 8 dogs; GM mixed with contrast(25mg/cc) was infused through the PD in 4 dogs(group A), and contrast without GM was infused in another 4 dogs (group B). the endoscopists were blinded about treatment in “pacreatitis” group. To determine safety, 4 dogs(group C) received GM infusion without pancreatitis.blood amylase and lipase levels were obtained at baseline, day1 and 3. all animals were sacrificed on day 3 and pathological exam was performed on the harvested pancreas. the specimens were graded (0 –3,0-no inflammation,1 minimal,2 moderate and 3 severe) based on the intensity and extent of the inflammatory response in the lobules and the interlobular septa, by a single pathologist(REW) who was masked to all groups. a scoring system was utilized. the primary endpoint was safety and the secondary endpoint was efficacy. Results: There was no ductal or vacular injury in all three groups. Similarly, there was no significant fat necrosis or hemorrhage in all three groups. Intra-lobular inflammation scores were (group A 4.15 ⫾ 2.5, group B 5.4 ⫾ 2.6, P ⫽ NS) and inter-lobular inflammation (group A 3.8 ⫾ 2.3, group B 4.7 ⫾ 2.3, P ⫽ NS) were similar in ‘pancreatitis’ group A & B. Group C had minimal or no inter or intra-lobular inflammation (0.82 ⫾ 1.8 and 1 ⫾ 1.6 respectively). the inflammatory response consisted of a mixture of acute (PMN cells) and Chronic inflammation(lymphocytes and plasma