M1454: Fatty Pancreas: A New Addition to the Metabolic Syndrome?

Abstracts EUS-BD via the translumenal approach that included bile leak, perforation and stent migration. Conclusions: In expert hands, EUS-guided biliary drainage is an effective technique for relief of biliary obstruction. The rendezvous approach appears safer but is technically successful in only 20% of cases. Although the technical success rates for the translumenal approach is high, the rates and severity of complications are significant. Dedicated accessories specifically designed to improve the safety profile of this technique are required. Until the procedural technique can be standardized, PTC should remain the first-line alternative and EUS-guided biliary drainage be attempted only as a rescue measure or under a research protocol.

M1451 EUS Guided Elastography Evaluation of Lymph Nodes in Esophago-Gastric Cancers Stuart Paterson, Fraser Duthie, Adrian Stanley Introduction: Endoscopic ultrasound (EUS) is an integral investigation in the staging of esophageal and selected gastric cancers. Determination of lymph node disease in particular is of critical prognostic importance. There have been a limited number of studies assessing the accuracy of EUS elastography for nodal assessment in upper GI malignancy. The difference in tissue stiffness between pathological and normal tissue can be detected during EUS as an elastography strain ratio. This may provide complementary information to standard EUS nodal assessment. Aim: Apply elastography at the time of EUS-FNA for upper GI cancer staging to determine if discrimination between benign and malignant nodes is possible. Methods: Patients undergoing EUS-FNA for staging of upper GI tract cancer during the period July 2007 to July 2009 had elastography of the node prior to sampling. The strain ratio was determined between the node and surrounding tissue. The mean of three strain ratio values was calculated. Lymph nodes were also characterized using standard EUS assessments of site, size, echogenicity, shape and the distinction of node boundary. FNA was performed on 3 passes using a 22 gauge needle before cytological analysis. Results: Elastography and FNA were performed on 53 lymph nodes in 50 patients. Cytological malignancy was found in 23 nodes, one was indeterminate, one was a GIST and 25 of the nodes were considered benign. On 3 occasions insufficient material was obtained at FNA for cytological analysis. The receiver operating curve (ROC) area under the curve (AUC) for elastography strain ratio was 0.87 (p⬍0.0001). A strain ratio cut off point of 7.5 was determined as a suitable cut off point for distinguishing malignant from benign nodes, with a strain ratio ⬎7.5 indicating malignant involvement. This gave elastography strain ratio a sensitivity 83%, specificity 96%, positive predictive value (PPV) 95%, and negative predictive value (NPV) 86% for distinguishing between malignant and benign lymph nodes. The overall accuracy of elastography strain ratio was 90%. Elastography was more sensitive and specific in determining malignant nodal disease than the standard EUS combined criteria of size, echogenicity, shape and distinction of boundary. Conclusions: EUS elastography is a promising modality that may complement standard EUS in the differentiation of benign and malignant lymph nodes in upper GI tract cancer.

M1452 Pancreatic Resection Guided by Preoperative Intraductal Ultrasonography for Intraductal Papillary Mucinous Neoplasms Seong Ran Jeon, Young Koog Cheon, Hyun Jong Choi, Soung Won Jeong, Young Deok Cho, Joon Seong Lee, Jong Ho Moon, Kyung Yul Hur, So Young Jin OBJECTIVES: Successful treatment requires reliable preoperative assessment of the highly variable extension of IPMN. We aimed to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN, and in selecting the method of pancreatic resection and the long-term outcome after surgery.METHODS: Forty consecutive patients who underwent IPMN resection were analyzed prospectively. Patients were randomly assigned to an IDUS group or control group in which IDUS was not performed.RESULTS: Preoperative assessment by IDUS had an 85% (17/20) diagnostic accuracy for tumor extension of IPMN compared to 50% (10/20) in cases assessed by other imaging methods without IDUS (p ⫽ 0.018). In 9 of 15 patients with invasive carcinoma, the tumor was located in the pancreatic head, and ten had a main duct-type tumor. Recurrent disease was identified in five of 13 (39%) patients with invasive IPMN at a median follow-up of 40 months; of them, one underwent preoperative IDUS and four were assessed by other imaging methods. None of the 25 patients with noninvasive IPMN had recurrent disease at follow-up. The overall cumulative 3-year survival rate was 80%.CONCLUSIONS: IDUS was useful in determining the surgical procedure and area of resection, based on a preoperative diagnosis regarding the extent of involvement of the main pancreatic duct and its branches, especially in main duct-type IPMN.

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M1453 The Utility of Endoscopic Ultrasound in the Diagnosis and Staging of Cholangiocarcinoma Mehdi Mohamadnejad, John M. Dewitt, Stuart Sherman, Julia K. Leblanc, Henry A. Pitt, Michael House, Kelly J. Jones, Evan L. Fogel, Lee Mchenry, James L. Watkins, Gregory A. Cote, Glen A. Lehman, Sidra Raoof, Yazen Beddawi, Mohammad A. Al-Haddad Background: Accurate pre-operative diagnosis and staging of cholangiocarcinoma (CCA) remains difficult. The aim of this study is to evaluate the utility of EUS in the diagnosis and staging of CCA in a series of patients referred to a tertiary care center. Methods: Records of all patients with extrahepatic CCA who underwent EUS at our institution between 2003 and 2009 were evaluated. Sensitivity of EUS guided fine needle aspiration (FNA) for diagnosing adenocarcinoma and predicting resectability was evaluated. EUS, CT and MRI criteria for unresectability included major vessel involvement, large centrally located tumor with expected low liver remnant after surgery, nonregional lymph node involvement, presence of ascites and distant metastases. All the cases were diagnosed based on either surgical pathology or unequivocal cytology (FNA or brush cytology). Using EUS criteria, CCAs involving the common bile duct within the head of the pancreas were considered distal, and all other tumors involving the biliary ducts proximal to the head of the pancreas were considered proximal tumors. Results: 68 patients (38 males; mean age 69.1⫾11.4 yrs) with CCA underwent EUS during the study period. 47 patients underwent surgery confirming CCA, and 21 had unequivocal cytological evidence of adenocarcinoma on FNA or brushings. EUS, ERCP, MRCP and CT reports and films were reviewed in the 21 non-surgical cases to confirm the biliary origin of the tumors. EUS visualized a bile duct mass in all 47 (100%) patients with distal CCAs and in 17 of 21 (80.9%) with proximal CCAs (P⬍0.01). The sensitivity of EUS alone for detection of a mass was 94.1% compared to 40.9% for MRI (p⬍0.01 vs. EUS), and 29.2% for CT scan (P⬍0.01 vs. EUS). 62 patients (91.2%) underwent EUS-FNA (median 5 passes; range 1-12) that demonstrated adenocarcinoma in 45 (72.6%), compared to 13 of 45 (28.8%) who also underwent ERCP with brushings from the same group. The sensitivity of EUS-FNA for the diagnosis of malignancy was significantly higher in distal compared to proximal CCAs (81.8% vs. 50%; p⫽ 0.01). Out the 47 patients who underwent surgery, 10 were found to be unresectable. Using surgery as the gold standard, EUS correctly identified unresectability in 5 out of 10 patients (sensitivity of 50%), and correctly identified 36 out of 37 as resectable (specificity of 97.3% for unresectability). CT and/or MRI failed to predict unresectability in 4 out of the 5 patients whom EUS staged correctly. Conclusion: EUS is sensitive for the diagnosis of cholangiocarcinoma and is very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal rather than proximal CCA.

M1454 Fatty Pancreas: A New Addition to the Metabolic Syndrome? Paul S. Sepe, Ashray Ohri, Sirish Sanaka, Tyler M. Berzin, Sandeep Sekhon, Gayle Bennett, Gaurav Mehta, Ram Chuttani, Douglas K. Pleskow, Mandeep Sawhney Background: Hepatic steatosis is associated with obesity, diabetes, hyperlipidemia, and the metabolic syndrome. While the significance of fatty pancreas is less understood than fatty liver, it may be pathologically and physiologically similar. The aim of this prospective study was to determine the prevalence of fatty pancreas and risk factors associated with its development. Methods: Demographics, tobacco/alcohol use, and comorbidities were prospectively obtained for all patients undergoing endoscopic ultrasound (EUS) at our institution. Amylase, lipase, and cholesterol were recorded. Pancreatic fat was graded I-IV at the time of EUS by one of two experienced endosonographers. Grade I: Hypoechoic/isoechoic as compared to the spleen. Grade II: Hyperechoic as compared to the spleen. Pancreatic duct (PD) delineation clear. Grade III: Significantly more hyperechoic as compared to the spleen. PD margins slightly obscured. Grade IV: Severely hyperechoic as compared to the spleen. Echogenicity obscures visualization of the PD and parenchyma. Unable to differentiate from adjacent fat. Grades I/II were considered normal; grades III/IV were considered fatty pancreas. Hepatic steatosis was also graded. Metabolic syndrome was defined as body mass index (BMI) ⱖ 30 plus two out of three associated comorbidities (diabetes, hypertension, hyperlipidemia). Results: During the study period, 141 patients were prospectively enrolled. The most common indications for EUS were pancreatic mass/cyst (39%), biliary abnormalities (16%), and esophageal mass/ Barrett’s (11%). Mean age was 63.2 ⫹/- 14.4 yrs and 55.3% were female. Mean BMI was 28.3 ⫹/- 7.2 kg/m2. Comorbidities included diabetes (24.1%), hyperlipidemia (53.2%), hypertension (51.1%), pancreatic adenocarcinoma (16.3%), history of acute pancreatitis (15.6%), and chronic pancreatitis (6.4%). The prevalence of fatty pancreas was 27.9% (24.8% grade III, 3.1% grade IV). There was no significant difference in grading between the two endosonographers (p⫽0.81). Hepatic steatosis was seen in 25.6% of patients. Factors associated with fatty pancreas on multivariate analysis were increasing

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Abstracts BMI (OR 1.06, p ⫽ 0.03), tobacco history ⱖ 40 pack-yrs (OR 3.43, p ⫽ 0.03), hepatic steatosis (OR 2.98, p ⫽ 0.01), and the metabolic syndrome (OR 3.19, p ⫽ 0.02). Age, EtOH use, diabetes, hyperlipidemia, hypertension, chronic pancreatitis, and pancreatic adenocarcinoma were not associated. When limiting analysis to grade IV fatty pancreas, only history of acute pancreatitis was associated (OR 16.7, p ⫽ 0.02). Conclusion: There appears to be a strong association between fatty pancreas and the metabolic syndrome.

M1455 Clinical Predictors of Pancreatic Malignancy in Patients >50 Years of Age With Non-Alcoholic/Non-Gallstone-Related Acute Pancreatitis Syed H. Tariq, Pavan Tummala, John T. Chibnall, Bartlomiej Posnik, Raj Shree, Banke Agarwal Background: Idiopathic acute pancreatitis may be the first presentation of pancreatic cancer. We studied the clinical and radiological factors that could predict pancreatic cancer in patients with acute pancreatitis without an obvious relation to alcohol or gallstones. Design: This is a retrospective analysis of our prospective database and compared patients with and without pancreatic malignancy in a cohort of patients older than 50 years of age acute pancreatitis (single episode or recurrent). Only patients with suggestive abdominal pain with ⬎ 3x elevation of serum lipase were considered to have acute pancreatitis. 332 patients who underwent EUS for evaluation of pancreas met these criteria. Following patients were subsequently excluded: stones in gallbladder or CBD (n⫽44), alcohol intake ⬎2 drinks/day (n⫽58), post ERCP pancreatitis (n⫽12), age ⬍50 (n⫽53) and non-availability of CT with contrast (n⫽20). 145 patients were included in the final analysis. Medical charts were reviewed following IRB approval. Patients with jaundice were included if jaundice was first noted at the time of acute pancreatitis.Results: 38 of 145 patients had pancreatic cancer. Table 1 summarizes the clinical and CT findings that were significantly different in the two groups. There were no differences between the two groups based on age, gender, diabetes mellitus, obesity, h/o cholecystectomy, family h/o pancreatic cancer, clinical severity of acute pancreatitis and CT modified severity index. Summary and conclusion: Amongst patients who present with non-alcoholic and non-gallstone related acute pancreatitis (single episode or recurrent) , ⬎10 lb. weight loss at presentation, h/o smoking, obstructive jaundice, elevated Alkaline phosphatase (in absence of jaundice), ⱕ2 episodes of acute pancreatitis, presence of dilated PD and/or a pancreatic mass lesion have significantly association with underlying pancreatic malignancy. Title: Differences in clinical and CT findings in patients with and without pancreatic cancer Variables Age Weight Loss ⬎10 lbs ⬍ 10 lbs No loss Janundice Yes No Smoking Yes No ALP* Lipase* Presence of mass on CT Yes No Gland atrophy on CT Yes No PD dilatation on CT Yes No Episodes of pancreatitis 1 2 3 or more * log transformed

Pancreatic cancer Nⴝ38

Non Pnacreatic cancer Nⴝ107

P value

67.1 ⫾ 11.0 16 4 18

64.07 ⫾ 10.1 11 11 85

0.140 0.001

12 26 21 17 2.3 ⫾ 0.41 2.7 ⫾ .41 15 23

0 107 28 79 1.9 ⫾ .18 3.0 ⫾ .59 3 104

0.001 0.001 0.001 0.02 0.001

5 33 18 20 32 6 0

3 104 39 68 63 30 14

0.02 0.001 0.009

M1456 Spectrum of Therapeutic Applications of ERCP in Patients Following Roux-en-Y Gastric Bypass (RYGB) Using a Double Balloon Enteroscope (DBE) Juan Carlos Bucobo, Laith H. Jamil, Simon K. Lo Background: RYGB is the most commonly performed bariatric surgery in the United States. Post-operative pancreaticobiliary complaints are common; yet endoscopic evaluation and therapy of these complaints are severely limited by the anatomical alterations. We have previously presented our early experience in DBE-ERCP at prior gastrointestinal society meetings. The aim of our study is to explore the therapeutic possibilities of DBE-ERCP following RYGB based on our extensive experience. Methods: A retrospective review of all DBE-ERCPs performed in patients following RYGB between November 2005 and October 2009 by a single endoscopist at our institution. Results: 50 DBE-ERCPS were scheduled on 43 patients. The most common indication was significant pancreaticobiliary-type pain (60% of procedures). The enteroscope was able to reach the native papilla and ERCP attempted in 90% (45/50) of procedures. 39

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intact papillas were encountered and cannulation was successful in 35 (90%). Biliary and/or pancreatic duct cannulation was successful in 40 procedures. Guidewire cannulation was attempted during 40 procedures and successful in 75%. Needle-knife access sphincterotomy was performed where guidewire cannulation failed and was successful in 71% of cases. A total of 35 needle-knife biliary sphincterotomies (including access sphincterotomies) were performed and 1 pancreatic duct sphincterotomy. Stone extraction was accomplished during 8 procedures. 5 stents were placed: 1 pancreatic and 4 biliary, 2 of which were nasobiliary. 35 biliary sphincterotomies were performed. Balloon dilatation of the papilla following sphincterotomy was performed in 34 cases. Unroofing of a choledochocele was performed by needle-knife incision in 1 patient. Choledochoscopy was successfully performed during 3 procedures. 8 complications (16%) were encountered, including 5 confirmed or suspected cases of pancreatitis, 1 self-limited bleed, 1 mild retroperitoneal perforation and 1 case of transient severe post-procedural pain. Conclusion: Therapeutic procedures involving the pancreaticobiliary tract are exceedingly difficult following RYGB using conventional techniques. DBE allows the endoscopist to reach the excluded duodenum for treatment of common and rare disorders of the pancreatic and biliary tract. Our experience suggests that it is possible to perform the full spectrum of therapeutic ERCP procedures, including sphincterotomy (biliary and pancreatic), nasobiliary tube placement, stone extraction, treatment of choledochele and choledochoscopy using DBE.

M1457 Clinical Presentation and Management of Afferent Limb Syndrome in Pancreatic Cancer Patients Following Pancreaticoduodenectomy and Adjuvant Therapy Rahul Pannala, John J. Brandabur, S. Ian Gan, Michael Gluck, Shayan Irani, David Patterson, Andrew S. Ross, Russell Dorer, Vincent J. Picozzi, L. William Traverso, Richard A. Kozarek Background/Aims Information on afferent limb syndrome (ALS) following pancreaticoduodenectomy (PD) for pancreatic cancer (PC) is limited. We evaluated the incidence, clinical presentation, and management of afferent limb problems in PC patients who have had PD at our institution over a 14-year period (1995-2009).Methods Using Current Procedural Terminology (CPT) codes, we identified a list of all PC patients (n⫽132) who underwent PD from January 1995 through October 2009 from our institution’s billing database. We reviewed all endoscopies performed in this group and identified 19 patients (14%) with ALS who constituted the study sample. We defined ALS as extrinsic or intrinsic obstruction or stricturing of the afferent limb at endoscopy in conjunction with pancreatobiliary obstruction. Demographic, clinical, and endoscopic information was abstracted from the electronic medical records of these patients. Follow up duration was calculated from date of surgery to date of last encounter in the medical record or death. Results Mean age of patients with ALS (19/132, 14%) was 64⫾10 years; 63% of patients were male and median follow up was 2.6 years (range: 0.9-12.5 years). Adjuvant chemoradiation was used in 18/19 patients (95%); majority (n⫽12) received the Virginia Mason protocol (externalbeam irradiation, 5-fluorouracil, cisplatin, and interferon alpha). Median time to ALS diagnosis was 1.2 years (range: 0.03-12.3 years). Patients presented clinically with obstructive jaundice or cholangitis (9/19, 47%), abdominal pain (5/19, 26%), and nausea/vomiting (5/19, 26%). Endoscopy revealed luminal stricture(s) (11/ 19, 58%), marked angulation (5/19, 26%), extrinsic compression (2/19, 10%), and edema (1/19, 5%). In addition, radiation changes were also noted in 8 patients (42%). ALS was caused by recurrent PC in seven patients (37%). Endoscopic interventions included balloon dilatation (5/19, 26%), double pigtail stent (5/19, 26%) or biliary Wallstent placement (2/19, 11%). Enteric Wallstents were placed for concomitant malignant efferent limb obstruction in three patients. Percutaneous biliary access was required in 4 patients (21%). No endoscopic intervention was performed in 7/19 patients (37%).Conclusions ALS occurs in ⬃15% of PC patients following PD and adjuvant therapy at a median of 1 year after surgery. ALS should be considered in the differential of PC patients presenting with jaundice, abdominal pain or nausea. Double pigtail stents or balloon dilation could be considered for benign obstruction and percutaneous biliary access or endoscopic biliary and/or enteric stenting are options for malignant obstruction.

M1458 Dorsal Pancreatic Duct (DPD) Stones in Pancreas Divisum (PDIV): Demographics, Associated Factors, Presentation, Management, and Recurrence Nathan Landesman, Marc F. Catalano, Tal Hazan, Nalini Guda, Joseph E. Geenen DPD stones have been described in PDIV & can cause flares of chronic pancreatitis & abd pain. Removal of ventral PD stones has been achieved in over 70% w/ improved Sx -- PDIV presents additional challenges. We present our experience. METHOD: 147 pts w/ PDIV over 16/yrs were reviewed to identify cases w/ DPD stones. ETOH & cigarette use, type 2 DM, dysphoria, & familial

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