QS268. Pancreatic Nesidioblastosis Following Gastric Bypass

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS 373 Yoshihiko Sadakari, Toshinaga Nabae, Shunichi Takahata, Masao Tanaka; Kyushu University, Fukuoka, Japan Background: Delayed gastric emptying or gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy (PPPD). Recently, some studies revealed that reconstruction with antecolic duodenojejunostomy improved early gastric stasis after PPPD. However; there are few reports about detailed gastric motility especially in the fasting state. We investigated fasting gastric motility with the two different types of reconstruction after PPPD; antecolic or retrocolic duodenojejunostomy. Patients and Methods: Between September 2001 and September 2005, 50 Japanese patients underwent PPPD with the modified Child reconstruction and were enrolled in this study. Patients who had major postoperative complications were excluded. From 2001 to 2003, retrocolic duodenojejunostomy was performed after PPPD in 18 consecutive patients (retrocolic group). Subsequently, antecolic duodenojejunostomy was employed in 32 consecutive patients (antecolic group). A manometric tube assembly with four recording holes (two in the stomach, two others in the jejunum) was inserted into the stomach via a small incision on the anterior wall and down into the gastric antrum and jejunum. Gastrointestinal motility was recorded for 3 hours a day, starting on 6 to 14 days after surgery, and repeated at a weekly interval until the first appearance of gastric phase 3 motility. Phase 3 was identified as contractions lasting for at least 2 minutes. Clinical parameters possibly affecting the recovery course of gastric motility were also assessed. Values were expressed as a mean ⫾ standard deviation. The difference between two groups was analyzed using the unpaired t test. A univariate analysis regarding the recovery course of gastric phase 3 was performed using simple regression analysis. A P value less than 0.05 was considered statistically significant. Results: Thirty-four of the 50 patients gave a written consent to accept the manometric tube. Recovery of gastric phase 3 was identified in 19 patients; those with no recovery were excluded from comparison this time. There was no significant difference in their backgrounds regarding age, gender, preoperative levels of albumin, total bilirubin, and hemoglobin, operating time and blood loss between the two groups. The rate of early gastric stasis was significantly greater in the retrocolic group (8/8 vs 1/11, p⬍0.0001). The interval for recovery of phase 3 in antecolic group was shorter than in retrocolic group (13.9⫾6.2 days vs 35.9⫾9.2 days, p⬍0.0001). The amount of gastric juice output during fourteen postoperative days was larger in retrocolic group than in antecolic group (4911⫾1516ml vs 837⫾719ml), and the length until the first water intake(28.3⫾6.9 days vs 13.5⫾9.7 days), food intake (33.3⫾6.9 days vs 18.5⫾9.5 days), intravenous hyperaliminentation (38.9⫾8.8 days vs 22.7⫾9.0 days), hospital stay (51.4⫾12.5 days vs 42.5⫾8.8 days), was longer in retrocolic group than in antecolic group (p⬍0.05). Conclusions: Antecolic reconstruction contributes to early recovery of gastric phase 3 in patients after PPPD. This phenomenon may partly contribute to prevention of early gastric stasis. QS267. GROOVE PANCREATITIS: A CASE SERIES. Laura M. Rosenberg, Negar Golesorkhi, Kandace McGuire, Eugene P. Kennedy, Charles Yeo, Ernest Rosato; Thomas Jefferson University, Philadelphia, PA Context: Groove pancreatitis (GP) is a rare segmental chronic pancreatitis characterized by an expansion of inflammatory disease into the anatomic “groove” formed by the union of the head of the pancreas, the duodenum, and the common bile duct (CBD). Clinical presentation & histopathology of GP is variable, thus posing a challenge in diagnosis and proper treatment. Herein, we report 3 cases of GP, each with unusual presentation and histology. Case 1: A 59year-old male with a 10-year history of chronic alcoholic pancreatitis, suffered from abdominal/back pain, and early satiety; presented with new-onset of obstructive jaundice. Elevated liver function values were noted. An ERCP revealed CBD stenosis, requiring an endoprosthesis. CT scan revealed a large pancreatic head mass with CBD

dilatation. A pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. Features of GP were present histologicaly in a background of chronic pancreatitis. Case 2: A 57-year-old female presented with a 4-month history of worsening epigastric abdominal pain, anorexia, weight loss and obstructive jaundice. MRI demonstrated complex mass like collection centered in the pancreaticoduodenal groove, suspicious of ruptured pancreatic adenocarcinoma. ERCP for CBD decompression and endoprosthesis placement was performed. Biopsy revealed adenocarcinoma. She underwent a classic pancreaticoduodenectomy. Gross examination revealed focal inflammatory obliteration of pancreatic ducts with intralumnial concretions. Low-grade spindle cell proliferation, without mitoses or atypia was present on histology. Immunohistochemistry was positive for markers associated with reactive inflammatory myofibroblastic tumor (IMT), in setting of GP. Case 3: A 48-year-old female with a 2-yr history of dyspepsia and early satiety complained of 1 month worsening epigastric pain, nausea, vomiting, and 10 kg weight loss. MRI revealed multicystic mass centered at the medial wall of descending portion of duodenum, without ductal dilatation. A PPPD was performed. Gross examination demonstrated multiple cystic spaces filled with clear fluid surrounded by dense fibrotic tissue in the duodenal wall. Histology demonstrated spindle cell proliferation, consistent with GP. Discussion: GP is a rare entity with variable presentation. Establishing a diagnosis of GP can be difficult. Twothirds of our cases presented with gastric outlet obstruction, 2/3 with biliary obstruction. 1/3 suffered from both biliary and gastric outlet obstruction. Only 1/3 possessed the “classic” presentation of alcoholic pancreatitis associated with GP. Biliary obstruction is rarely observed in the GP. Preoperative imaging in 2/3 of our cases revealed cystic mass with variable involvement of pancreatic and CBD. GP has variable radiologic findings. GP histologic morphology ranged from the typical duodenal wall cyst in background of pancreatitis, to the unusual IMT, and spindle cell proliferation. The presence of a reactive IMT secondary to GP is extremely rare. While IMT has been documented to occur secondary to autoimmune pancreatitis, it is not widely documented in the setting of GP. GP is often misdiagnosed as pancreatic adenocarcinoma on preoperative biopsy. The management of GP may be more conservative than pancreatic adenocarcinoma; the proper diagnosis of GP remains challenging. GP is a pathologic diagnosis, other more sensitive markers for diagnosis of GP remain to be investigated. QS268. PANCREATIC NESIDIOBLASTOSIS FOLLOWING GASTRIC BYPASS. Stacey A. Milan, Ernest L. Rosato, Francis E. Rosato, Jr., Karen A. Chojnacki, Bernadette Profeta, Serge A. Jabbour; Thomas Jefferson University, Philadelphia, PA Introduction: Pancreatic nesidioblastosis is an uncommon cause of symptomatic hyperinsulinemic hypoglycemia that has been described in several case reports.Nesidioblastosis has been reported with increased frequency in patients who have undergone gastric bypass surgery.Several theories have been postulated regarding the etiology of post gastric bypass nesidioblastosis, however a specific causal relationship has not been established.Patients present with neuroglycopenic symptoms including dizziness, weakness, diaphoresis, and altered mental status. The glycopenia seen in post-gastric bypass nesidioblastosis is postprandial as opposed to the fasting hypoglycemia that characterizes insulinoma. Neuroglycopenia separates nesidioblastosis from dumping syndrome. Laboratory studies reveal hypoglycemia and inappropriately elevated insulin levels.Extensive imaging fails to demonstrate a discrete pancreatic mass. Selective arterial calcium stimulation may allow gradient-guided pancreatic resection. The extent of pancreatic resection in nesidioblastosis remains controversial. Conservative pancreatic resection may predispose to recurrent neuroglycopenia necessitating reoperation. Overly aggressive resections may result in diabetes mellitus.Histopathology following pancreatic resection demonstrates diffuse

374 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS non-neoplastic hyperplasia and hypertrophy of islet cells. Methods: We report a case of a 28 year old female who underwent Roux-en-Y gastric bypass in 2004 and subsequently developed episodes of postprandial hypoglycemia.These symptoms could not be controlled with diet modification.Random serum glucose was obtained with concurrent insulin, proinsulin, and C-peptide levels.Urine sulfonylurea screen was negative.CT scan demonstrated an enlarged, bulky pancreatic tail, with increased enhancement, but without focal mass. MRI of the abdomen revealed normal signal intensity without focal mass. Selective arterial calcium stimulation showed the splenic artery to have the greatest increase in insulin release. Following this workup the patient underwent distal pancreatectomy for presumed nesidioblastosis. Results: The patient underwent an uncomplicated distal pancreatectomy. Intraoperatively, no insulinoma was detected by palpation.Based on selective arterial calcium stimulation, the pancreas was resected at the origin of the splenic artery. Pathologic examination confirmed the diagnosis of nesidioblastosis. Sections of resected pancreatic tissue showed diffuse islet cell hyperplasia and hypertrophy. Immunopathology demonstrated insulin stain highlighting hypertrophied islet cells. Glucagon positive and rare somatostatin positive cells were also present. The patient resumed euglycemia in the postoperative period, and has experienced no further instances of hypoglycemia. Conclusion: Obesity is a growing crisis that threatens the health of millions of Americans in all demographic groups. An estimated 40 million Americans are obese. Bariatric procedures are an effective method of durably reducing weight and alleviating comorbid medical conditions.This case report is an addition to the growing number of patients with pancreatic nesidioblastosis following gastric bypass for morbid obesity, a clinical entity that general surgeons may encounter with increased frequency. QS269. OUTCOME OF LAPAROSCOPIC HEPATIC CYST RESECTION IN 48 PATIENTS. Shane E. Holloway, T. Clark Gamblin, Jason Heckman, Tsafrir Vanounou, David Geller; University of Pittsburgh Liver Cancer Center, Pittsburgh, PA Background: Hepatic cysts occur in 4-7% of the population. Laparoscopy has emerged as an effective management tool. We sought to evaluate the safety and usefulness of laparoscopic resection of symptomatic cysts in a large series of patients. Methods: Between August 2001 and August 2007, 48 patients underwent laparoscopic resections for symptomatic hepatic cysts. In each case, attempts were made to remove as much cyst wall as possible, typically 70-80%, leaving the remnant back wall overlaying the intra-hepatic portal and hepatic veins. Resection of cyst wall and attenuated liver parenchyma was accomplished with combination of Ligasure and endoGIA vascular staplers. Data was collected in a prospective data base. Results: The mean age of the patients was 60 years (range 33 to 81years). 10 were male and 38 were female. The median diameter of the lesions was 13cm (range 4 - 21cm). The indication for surgical treatment was pain in 92% of the patients. Laparoscopic resection was successfully performed in 100% of the patients on whom it was attempted. 58% of patients were resected with a pure laparoscopic approach (4 trocars), and 42% of patients utilized a hand port due to size/location of the cyst. The median operating time was 178 minutes (range 54 to 380minutes). The pre-operative diagnosis was polycystic liver in 88% and congenital biliary cyst or simple hepatic cyst in 12%. Histological examination of the cyst wall showed that 90% were simple cysts and 10% were cystadenomas. There were 9 intraoperative or postoperative complications which included 2 port site hernias, 2 pleural effusions, a port site hematoma, a subcapsular hematoma, and 2 post-op arrhythmias. The mean and median hospital stay was 2 days (range 1 to 11 days). Complete relief of symptoms after surgery was achieved in all of the patients operated on for pain, with a median follow-up of 13 months. Only 2 patients required re-operation for recurrence of the same cyst (4%), and these were due to large central cysts that extended from the R lobe dome to the

caudate lobe. There were no operative transfusions, and there were no postoperative bile leaks. A JP drain was placed in all cases, and was removed on POD#2 in the majority of cases prior to discharge. Conclusion: Laparoscopic resection of symptomatic liver cysts is a simple and effective method to relieve symptoms with minimal surgical trauma. Traditional surgical Methods should be reserved for cases in which laparoscopic resection is not feasible. QS270. LEPTIN BLOCKS GALLBLADDER ABSORPTION BUT NOT SECRETION. Kyle W. Yancey, Deborah Swartz-Basile, Abhishek Mathur, Debao Lu, Attila Nakeeb, Henry A. Pitt; Indiana University School of Medicine, Indianapolis, IN Introduction: The gallbladder has both absorptive and secretory functions, and alterations in these functions are significant contributing factors in gallstone pathogenesis. We have recently demonstrated that obese, leptin deficient (Lep ob) mice have enlarged gallbladder volumes and decreased gallbladder contractility and that leptin regulates gallbladder genes related to absorption and secretion. In addition, we have shown that hyperleptinemic (Lep db) mice have resting gallbladder secretion rather than gallbladder absorption found in leptin-deficient (Lep ob) and lean control mice. However, the effect of leptin on gallbladder fluid transport remains unclear. Therefore, we sought to determine whether exogenous leptin administration would alter fluid flux across the gallbladder epithelium. Methods: Eight week old lean, (C57BL/6J, n⫽18), obese leptin-deficient (Lep Ob, n⫽14) and obese leptin-resistant (Lep Db, n⫽13) female mice were fed a 25% fat diet for four weeks. At 12 weeks of age, the mice were fasted overnight, anesthetized and underwent laparotomy. The gallbladders were cannulated in vivo with a PE10 (0.61 mm) polyethylene tube and inflated with Krebs buffer to a pressure of 15mmHg. The gallbladder was then excised and suspended in a bath containing oxygenated Krebs buffer (37°C) for 1 hour and weighed at 10 minute intervals. Recombinant murine leptin was added to the bath (6ng/mL) of 5 lean, 4 Lep Ob and 5 Lep Db gallbladders. The gallbladders were then opened longitudinally and placed on a grid to determine and control for surface area. Data were analyzed by Anova and Tukey testing. Results: Results for weight change are presented in the table.

C57BI/6J Lep Ob Lep Db

% Baseline Weight

% Baseline Weight

% Baseline Weight

% Baseline Weight

0–30 min Vehicle 94.8 ⫾ 0.5 96.6 ⫾ 0.5† 102.2 ⫾ 0.5†

0–30 min Leptin 100.0 ⫾ 0.7* 99.3 ⫾ 0.8* 101.9 ⫾ 0.7

30–60 min Vehicle 88.2 ⫾ 0.7 92.7 ⫾ 0.8† 98.5 ⫾ 0.9†

30–60 min Leptin 98.7 ⫾ 1.1* 96.9 ⫾ 1.2* 98.9 ⫾ 1.1

* p⬍0.05 vs vehicle. † p⬍0.05 vs other strains. Conclusions: These data suggest that 1) leptin blocks absorption in the lean C57Bl/6J and obese Lep ob mice, and 2) leptin has no effect on absorption or secretion in Lep Db mice. Therefore, we conclude that leptin influences gallbladder absorption but not secretion. QS271. MEN EXHIBIT MARKEDLY INCREASED TISSUE LEVEL CYTOKINES IN ACUTE CHOLECYSTITIS. Jill Fehrenbacher, Ken Hargreaves, Lisa J. Rodriguez, Wayne H. Schwesinger, Kenneth Sirinek, Kent Van Sickle, Sara Olivarri, Peter Lopez, Juliane Bingener; University of Texas Health Science Center, San Antonio, TX Background: Male sex is a predictor for poor outcomes in patients undergoing cholecystectomy. Although socioeconomic and behavioral