Prevalence and significance of pancreatic intraepithelial neoplasia (PanIN) in patients with periampullary adenocarcinoma

M1962

and, excepted for 1L-1RN, were RFLP analysed. Only [L-10-819 and IL-10-592 were in complete linkage. A higher frequency of IL-1b-31 T/T genotype was found in CP (57%) as compared to CS (35%) or PC (42%). In PC (43%) and CP (41%) with respect to CS (31%) a higher frequency of 1L-10-1082 A/A genotype was found (Chi-square= 11.43, p<0.05). None of the studied polymorphisms was correlated with tumor stage or grade. Considering PC and CP all together (Chi-square = 15.7, p<0.01), or PC alone (Chi-square = 21.4, p<0.001), an association was found between TNFa-863 A allele and diabetes mellitus. Considering PC patients, TNFa-1031 T/T was associated with a slightly higher frequency of metastases (79%) after surgery, in comparison with C/T genotype (55%). Survival was correlated only to tumor stage (Chi-square = 14.48, p<0.O1), but not to any cytokine studied polymorphism Conclusions: lL-lb-31 and IL10-1082 gene polymorphisms might drive the onset of pancreatic cancer or chronic pancreatitis in response to triggering events, as already described for gastric or prostate cancer; TNFa-863 gene polymorphism seems that mainly involved in favoring diabetes development in patients with PC. Cytokines gene polymorphisms do not seem involved in affecting PC patients survival: only tumor stage was confirmed to predict the outcome of these patients.

Pancreatic Head Resection for Chronic Pancreatitis in Patients with Generalized Extrahepatic Portal Hypertension Frank Makowiec, Ulrich Adam, Hartwig Riediger, Peter Uhrmeister, Jens Kroeger, Ulrich T. Hopt BACKGROUND: Chronic pancreatitis (CP) is complicated by extrahepatic generalized portal hypertension (GPH) in 5-10%. Pancreatic resection is regarded as risky or even contraindicated under these conditions but data on pancreatic head resections (PHR) in these patients are scarce. The aim of our study was to analyze the perioperative and long-term outcome in 16 patients with GPH undergoing PHR. METHODS: Of 185 patients with CP who underwent PHR during a seven-year period 16 had GPH (portal vein thrombosis 9, subtotal vein occlusion 4, occlusion of splenic and superior mesenteric vein 3). GPH was shown by angiography and confirmed intraoperatively in all patients. Indications for surgery in GPH were jaundice (10), intractable pain (9), gastric outlet obstruction (2), gastrointestinal lileedmg from an aneurysma of the pancreaticoduodenal artery (1) and a pancreato-pleural fistula (1). Six of 16 patients with GPH preoperatively had transjugular interventional recanaliaation of portal vein thrombosis. Two Whipple operations, four pylorus preserving PHR and 10 duodenum preserving PHR were carried out in patients with GPH. Perioperative data were documented prospectively. Median postoperative follow-up was 18 months (range 5-61). The perioperative and long-term outcomes were compared between the groups with (n = 16) and without (n = 169) GPH. RESULTS Preoperative recanalization of the portal vein was successful in four of six patients. Median operative time (533 vs. 420 mins; p<0.01) and number of blood transfusions (9.3 vs. 4 units; p<0,01) were significantly higher in patients with GPH compared with patients without GPH. One death occured in each group (n.s.). Overall morbidity was not different (44% in GPH vs. 36% in non-GPH; n.s.) but abdominal rebleeding occured more frequently in patients with GPH ( 13% vs. 2% in non-GPH; p<0.05). During follow-up 13 of 15 (87%) surviving patients with GPH and 79% of the patients without GPH were free of abdominal pain (n.s.). No abdominal reoperation and no variccal bleeding were documented in these patients with GPH until the end of follow-up. CONCLUSIONS Although technically demanding by the presence of generalized portal hypertension, pancreatic head resections can be performed safely with good long-term results in these patients in an experienced center. In selected cases preoperative interventional recanalization of portal vein thrombosis may render major pancreatic surgery possible by restoring portalveinous pressure and blood flow.

M1960 Prevalence and Significance of Pancreatic Intraepithelial Neoplasia (PanIN) in Patients with Periampullary Adenocarcinoma Parind Oza, Biju Thomas, Virginia Wahers, Thomas J. Vandermeer Pancreatic lntraepithelial Neopfasia (PanlN) is a proliferative epithelial,lesion of small pancreatic ducts. High-grade PanIN (PanIN 2 and 3) is postulated to be a precursor lesion in the development of invasive pancreatic ductal adenocarcinoma (PC). However, the prevalence and neoplastic potential of PanlN in patients with other types of periampullary adenocarcinoma have not been reported. We hypothesized that high-grade PanlN is common in patients with all types of periampullary adenocarcinoma (PERI). In order to test this hypothesis and to evaluate the neoplastic potential of PanIN in the setting of PER1, pathologic and clinical features were reviewed in 63 consecutive patients undergoing pancreatectomy over a 4-year period at our institution. Pathology specimens were reviewed to verify primary tumor type and to reclassify epithelial pancreatic lesions using recently defined PanlN criteria. The diagnoses included: PERI (n = 35), other types of periampullary tumors (n = 8), mucinons cystadenoma/carcinoma of the pancreatic body (n = 5), severe biliary dysplasia (n = 1), and chronic pancreatitis (n = 14). Fifty patients underwent Whipple procedures and 13 underwent distal pancreatectomies. Seven patients were found to have high-grade PanIN. The primary malignancy was cholangiocarcinoma in 3 patients, PC in 2, and duodenal adenocarcinoma in 1. One patient had severe dysplasia of the distal common bile duct. Of the patients with PER[, 17% (5/35) were found to have high-grade PanlN and 6% (2/35) had synchronous biliary and pancreatic cancers. High-grade PanIN was not found in any patients with chronic pancreatitis, mucinons tumors, or other types of periampullary tumors. Patients with highgrade PanIN were compared to the other patients with PERI and were more likely to have a personal history of other malignancies (43% vs 3%; ns). All patients with high-grade PanIN are disease-free at a median follow-up of 13 months. Smoking history, tumor size, tumor grade, lymph node status, disease-free survival and age were all similar between the two groups. We conclude that high-grade PanIN is common in patients with patients PERI but not in patients undergoing pancreatectomy for other lesions. The association between high-grade PanlN and non-pancreatic adenocarcinoma suggests that multiple mutations are affecting the periampulfary region in these patients. Molecular studies are planned to evaluate mutational changes that may cause a field effect in the periampullary region.

M1963 A Simplified Method for Computed Tomographic Estimation of Prognosis in Acute Pancreatitis Nicolas K. King, James J. Powen, Doris Redhead, Ajith Siriwardena Background: We previously reported to the American Gastroenterology Association that early computed tomography (CT) is of prognostic value in acute pancreatitis (1) and that site of necrosis predicts outcome (2). Although CT-based prognostic scoring systems are available, they are complex and impractical for routine use. This study examines the validity of a simplified CT-based scoring system in a cohort of patients with acute pancreatitis. Methods: Patients admitted during the 7-year period to December 1997 with a diagnosis of acute pancreatitis and undergoing CT were identified by review of Radiology records. This search idemified 109 patients. Of these, 32 patients were excluded because they underwent initial radiologic assessment more than 10 days after admission, whilst a further 7 were excluded as data becuse of incomplete data to yield a study population of 70 nonconsecutive patients. Admission Glasgow and APACHE II prognostic scores were calculated. CT scans were read blind to outcome and graded using Balthazar's system and the Helsinki extra-pancreatic score. Results: On univariate analysis, all components of the Helsinki scoring system were significant for predicting severity. When fitted to a multivariate logistic regression model the two significant factors that correlated best were mesenteric fat oedema and peritoneal fluid. The derived logistic regression formula was -2.567 + (3.256 x peritoneal fluid) + (2.762 x mesenteric fat oedPma). The risk of having an end-of-episode severe pancreatitis when mesenteric oedema alone was present was 61% and with peritoneal fluid alone 83%. Mesenteric oedema and peritoneal fluid on CT were used to generate a simple "MOP" score allocating one point each for either mesenteric oedema (MO) or peritoneal fluid (P) giving a maxamum score of 2. When compared with the other scoring systems the area under the ROC curves were admission Apache II 0.57, Glasgow 0.62, Balthazar 0.79, Helsinki score 0.85 and MOP score 0.87. Conclusion: The presence of mesenteric oedema or peritoneal fluid on CT appears to be a simple early predictor of disease severity in acute pancreatitis. References: 1.Powell JJ, Hill GW, Yong SM et al. Gastroenterology 1998;114: G2002.2.Powell JJ, Hill GW, Yong SM et al. Gastroenterology 1998;114: G2003.

M1961 Prediction of Clinical Course from the Data at the Time of Admission in Patients with Severe Acute Pancrearitis Takashi Ueda, Yoshifumi Takeyama, Takeo Yasuda, Makoto Shinzeki, Shinji Kishi, Naoki Matsumura, Yoshikazu Kuroda In severe acute pancreatitis, multiple organ failure in the early phase and infections complications m the Late phase are contributors to mortality. Therefore, at the time of admission, it is clinically important to predict the prognosis or the risk of progression to the life threatening complications. In the present study, predictable factors of clinical course were analyzed from the data at the time of admission in 109 patients with severe acute pancreatitis in our department. All cases (109 cases) were divided into early death group (dead within 7 days, 7 cases) and early survival group (102 cases). Early survival group (102 cases) was divided into early recovery group (64 cases) and late complication group (infection, DIC, etc., 38 cases). Late complication group (38 cases) was divided into late recovery group (14 cases) and late death group (24 cases). Factors where statistically significant difference was observed were surveyed from the data at the time of admission between two groups described above, respectively. Between early death group and early survival group, significant factors (p~Z0.01) were serum creatmine (4.5 -+ 0.6 vs. 1.6 -- 0.2 mg/dL), serum Ca (4.6-+ 0.9 vs. 7.2 _+0.2 mg/ dL), base excess (-10.2-+2.7 vs. -1.0-+0.6 mEq/L), serum lactate dehydrogenase (LD) (2,224_+828 vs. 978-+88 IU/L). In cases whose serum LD was ->2,000 IU/L on admission, the mortality within 7 days was 27.3%. Between early recovery group and late complication group, the factors (p 1,500 IU/L on admission, the incidence of late complication was 66.7%. Between late recovery group and late death group, the factors (p<0.05) were age (47.3 -+4.2 vs. 58.8_+ 2.3 years old), lymphocyte count (1,410-+444 vs. 735 -+ 120/ram3), and serum LD (838_+ 122 vs. 1,633-+ 269 IU/L). In late complication cases whose ago was ->55 years old, lymphocyte count was -<1000 mm3 and serum LD was -> 1,500 IU/L on admission, the mortality was 76.2%, 90.0%, and 90.0%, respectively. These results suggest that serum LD is the most useful factor for predicting the clinical course in patients with severe acute pancreatitis, and that age, lymphocyte count, and serum LD are important factors affecting the prognosis in patients with late infectious complications.

SSAT

Abstracts

M1964 Postoperative Jejunal Feeding and Outcome of Pancreaticoduodenectomy Hani B. Baradi, Matthew Walsh, Michael Henderson, David Vogt, Marc Popovich Complications following pancreaticoduodenectomy are common partly due to a poor preoperative nutrition. Previous studies have not shown benefit from perioperative TPN in most patients. The aim of this study is to evaluate impact of early postoperative enteral tube feeding in patients undergoing Whipple operation. A retrospective review of 180 consecutive patients who under,vent Whipple operation form 1994-2000 was performed. Patients were divided into two groups; those with early postoperative enteral tube feeding via a nasojejunal or a gastro/jejunal tube placed at surgery versus no planned enteral feeding. Use of enteral feedings was based on surgeons preference. Outcome variables were compared using t-test and included length of hospitalization, early and late complications and readmissions within 30 days of discharge. 98 patients (54%) received early postoperative jejunal feeding while 82(46%) did not. Both were comparable in age, gender, diagnosis, albumin level and operation. The mean operative time (406 vs 360 min) and incidence of blood transfusion (44% vs 18%) were higher in the jejunal feeding group while intraoperative complications were similar. Both had similar length of hospital and 1CU stay, while 1CU readmissions (6%

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