Basel · Freiburg · Paris · London · New York · Bangalore · Bangkok · Singapore · Tokyo · Sydney Pancreatology 2005;5:97–107 Published online: March 31, 2005 DOI: 10.1159/000084401 The abstracts are only available online, free of charge, under www.karger.com/doi/10.1159/000084401 30th Annual Meeting of the Pancreatic Society of Great Britain and Ireland November 11–12, 2004, Plymouth, UK Abstracts Guest Editor Richard M. Charnley, Newcastle upon Tyne, UK Contents Oral Presentations 98 Abstracts 1–12 Posters Presentations 102 Abstracts 13–26 Author Index 107
Transcript
Basel · Freiburg · Paris · London · New York ·Bangalore · Bangkok · Singapore · Tokyo · Sydney
Pancreatology 2005;5:97–107 Published online: March 31, 2005DOI: 10.1159/000084401
The abstracts are only available online, free of charge, underwww.karger.com/doi/10.1159/000084401
30th Annual Meeting of thePancreatic Society of Great Britain and IrelandNovember 11–12, 2004, Plymouth, UK
Expression of Thymidylate Synthase (TS) and Thymidine Phosphorylase (TP) in DuctalAdenocarcinoma of the PancreasR. Albazaz1, A. Hall1, A. Anthoney2, H. Koeppen3, C. Verbeke1
1Department of Histopathology, 2Department of MedicalOncology, 3Leeds Teaching Hospitals NHS TrustDepartment of Pathology, Genentech Inc., San Francisco,Calif., USA
Aims: Thymidylate synthase (TS) plays an essential role inthymine nucleotide synthesis and is the target enzyme for 5-FU. Intra-tumour expression of thymidine phosphorylase (TP) correlateswith increased angiogenesis, tumour growth and invasive potential.TP affects the sensitivity to cytotoxic agents that target thymidinemetabolism, (5-FU, capecitabine, novel fluoropyrimidine derivatives).The expression of TS and TP and its prognostic significance inpancreatic cancer were examined.
Methods: TS, TP and p53 expression was investigated byimmunohistochemistry on tissue microarrays comprising 116 chemo-naïve pancreatic ductal adenocarcinomas resected between 1982and 2002. Results were correlated with clinicopathological data andsurvival.
Results: High TP and TS protein levels were observed in 44(40%) and 46 (41%) tumours, respectively. High TP expressioncorrelated with poor tumour differentiation (p � 0.06). Survival of16 months or more was less likely in patients with high TP expression(16%) than in those with low levels (46%, p � 0.03). No correlationwas found between TS expression level and clinicopathologicalvariables. However, in cancers with high TS expression and positive(�aberrant) p53 immunostaining, post-operative survival �16months was signficantly lower (p � 0.006).
Conclusion: TP and TS combined with aberrant p53 aretreatment-independent negative prognostic markers in resected pan-creatic cancer.
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Laparoscopic PancreaticoduodenectomyC. Ponzano, M. Di Paola, C. Huscher
Department of Surgery, San Giovanni-Addolorata Hospital,Rome, Italy
Aim: The results of Pancreaticoduodenectomy (PD) have gradu-ally improved with a mortality rate decreased to well below 5%.Surgery still produces minimal survival benefits for cancer patientsalthough it remains the only curative chance. Laparoscopy has beenproven to reduce immune suppression and postoperative pain anddiscomfort, while providing enhanced vision and magnification ofanatomic structures. The laparoscopic approach could add to the effec-tiveness of standard surgical treatments the less invasive endoscopicapproach.
Methods: We retrospectively analyzed 42 consecutive PD per-formed in a single center between December 1999 and April 2004.
Results: 23 Whipple procedure and 19 pylorus preserving PDwere performed for 32 malignant and 10 benign tumors. Conversionrate was 28.5%: for tumor extension (4 cases), for vascular infiltra-tion of a major vessel (3), for intraoperative bleeding (5).
Mean operative time was 410� (300�–550�), mean length ofhospital stay was 14 days (9–51). The morbidity rate was 54%:15cases of pancreatic fistula, 4 cases of biliary leak, 3 hemorrhage, and1 cases of lymphorrea. One patient died on the 14th p.o. day, for anhemorrhage from portal vein (2.3% mortality rate).
Conclusions: Laparoscopic PD is technically feasible. Shortterm results favourably compare to open surgery. The theoreticalbenefits of a better quality of life and improved immune response arenot yet proven.
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The Incidence of Pancreatic Cancer inFamilies with a Cancer PredispositionSyndrome and in Non-Syndromic FamiliesL.C. O’Dair1, F.S. Douglas1, R.M. Charnley2
1Northern Genetics Service, 2Hepato-Pancreato-BiliaryUnit, Freeman Hospital, Newcastle upon Tyne, UK
Pancreatic cancer is associated with several genetic predispositionsyndromes but in some cancer families known mutations cannot beidentified nor are there phenotypic features suggestive of predisposi-tion syndromes. This implies other genes might predispose to pancre-atic cancer.
Aims: To identify the incidence of pancreatic cancer in familiesattending the cancer genetic clinic.
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Methods: A search of the cancer database was done and datacollected on the incidence of mutations and pancreatic cancer.
Results: 32 families were suitable for study. The numbers offamilies (individuals) with pancreatic cancer with known cancerpredisposition syndromes were: FAP 4 (4); HNPCC 3 (3); VHL 1 (1);BRCA2 1 (1); total 9 (9); accounting for 14% of the cancer diagnoses.34 individuals with pancreatic cancer were identified in 24 otherfamilies (31% of all cancers in these families). 16 families had onecase of pancreatic cancer, 6 had 2 cases and 2 had 3 cases.
Conclusions: More detailed family history taking is warrantedfrom patients affected with pancreatic cancer. As in hereditary pan-creatitis, there may be a rationale for offering pancreatic screeningin families with a known cancer predisposition syndrome and also inselected families with clinical predisposition that is not due to knowngene mutations.
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A Significant Anti-Proliferative Role for the PPAR-Gamma Agonist Rosiglitazone in the Human Neuroendocrine PancreaticTumour Cell Lines BON and QGP1M. Hanson, M. Korbonits, A.B. Grossman, R. Hutchins, S. Battacharya
Department of Hepatobiliary Surgery, Department ofEndocrinology Barts and the London NHS Trust
Aim: To assess whether the PPAR-� agonist rosiglitazone has asignificant anti-proliferative effect on the human neuroendocrinepancreatic tumour cell lines QGP1 (a somatostatinoma) and BON (a carcinoid).
Methods: Cells from both QGP1 and BON cell lines were har-vested and mRNA extracted and subjected to reverse transcriptionand PCR for PPAR-�. Protein was extracted and subjected to Westernblotting using a specific monoclonal PPAR-� antibody. Cellularproliferation was measured using tritiated-thymidine incorporation.The cells were treated with rosiglitazone in the concentration range100 �mol/L–1 nmol/L, and incubated for 48 hours.
Results: PPAR-� mRNA and protein was shown to be present byboth RT-PCR and Western blotting respectively. Rosiglitazone produceda significant reduction in proliferation of QGP1 cells at concentrationsof 1 �mol/L and above (P � 0.0001). A significant reduction in theproliferation of BON cells occurred at concentrations of 10 �mol orabove (P � 0.0001).
Conclusions: PPAR-� is expressed in the human pancreaticneuroendocrine tumour cell lines BON and QGP1, both at the RNAand protein level. Proliferation of these cell lines can be significantlyreduced by the PPAR-� agonist rosiglitazone. These results addfurther evidence to the potential anti-proliferative role of this class ofdrugs, and suggest possible therapeutic interventions.
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A Study of the Efficacy of a NovelTechnique of Endoscopic Placement ofNasojejunal Feeding Tubes in ProvidingNutritional Support for Pancreatic DiseaseL. Murray2, J.E.M. Crozier1, C.W. Imrie1, C.J. McKay1, C.R. Carter1
1West of Scotland Pancreatic Unit, Glasgow RoyalInfirmary, Glasgow, 2Dept of Dietetics, Glasgow RoyalInfirmary, Glasgow
Aims: Enteral support has superseded TPN wherever possible,however gastric stasis may limit intake. NJ feeding requires insertionunder radiological or endoscopic control, but can be technically chal-lenging. We describe a novel technique (7FG NBC (Cook PLC))allowing accurate jejunal placement, and present an audit of enteralsupport using this technique specifically for pancreatic disease in2002/3.
Results: Sixty-nine patients received enteral feed either via aNG tube (28), a NJ tube (15) or both (NG � NJ) (26), usually due tointolerance of NG feeding (21). Of 41 patients who had a NJ tube,only 4 required a second tube inserted for blockage or dislodgement,the tubes remained in-situ for a mean of 24 days (range 1–183).Twenty-nine of the 41 NJ patients returned to oral diet, 3 requiringongoing support (1 PEG, 1 home NJ feeding and 1 TPN) and 9 diedfrom disease progression. Of 28 fed through a NG only, 23 returnedto oral diet, 2 subsequently died, 2 died with continued feeding, and3 required ongoing support (1 PEG, 2 discharged with continuedfeeds).
Conclusion: We have shown the use of the 7FG NBC for NJfeeding to be well tolerated and effective in providing prolongednutritional support, and our technique of insertion obviates many ofthe difficulties in achieving accurate placement.
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Mortality in Pancreatic SurgeryR.C.G. Russell, B.A. Theis
Middlesex Hospital, Mortimer Street, London, UK
Introduction: Mortality related to surgery in pancreatic diseaseremains high. This study was undertaken to determine factors inmortality.
Methods: Between November 1975 and May 2004, 1167 pro-cedures were undertaken in 1084 patients by a single surgeon. Themedical records were reviewed and standard data entered onto a SPSSdatabase.
Results: Mortality, defined as death in-hospital or 60-day, variedfrom 0–8% per year. There were a total of 43 (3.7%) deaths: 4.4%after surgery for malignancy, 5.4% benign neoplasms and 2.9%benign inflammatory. Mortality following subtotal proximal pancrea-tectomy (n � 593) was 4.6%, distal pancreatectomy (n � 286) 2.5%,total pancreatectomy (n � 22) 4.5%, completion pancreatectomy(n � 57) 1.8%, cyst drainage (n � 54) 7.4%, duct drainage (n � 71)2.8%, and sphincteroplasty (n � 45) 2.2%. Mortality after subtotal
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proximal pancreatectomy fell from 7% for the first 100 operations to1% for the fifth, but rose again to 5% for the last hundred. Urgentsurgery (n � 57) had a higher mortality (21.1%) than elective surgery(2.6%; n � 1091). The commonest causes of morbidity and mortalitywere infection in 32.2% (severe in 116 patients) and bleeding in 86patients.
Conclusion: Serious infection is the major complication. Therecent increase in mortality is related to hospital acquired infections.
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Correlation of Secretin MRCP Quantificationof Exocrine Function with Faecal Elastase 1and Urinary Pancreolauryl TestsA. Gillams, S.P. Pereira, W. Lees
Department of Medical Imaging, Gastroenterology, The Middlesex Hospital, London, UK
Aim: Secretin MRCP (sMRCP) provides a non-invasive, directtechnique for quantifying exocrine function. We correlated pancreatic-duodenal flow rates from sMRCP with faecal elastase 1 (FE1) and/orurinary pancreolauryl (PL) tests in 33 patients with suspected/ knownchronic pancreatitis.
Methods: Standard, multi-slice, single shot fast spin echosequences were obtained before and at 2 minute intervals following0.1 ml/kg IV Secretin (Sanochemia, Germany). Change in fluidvolume � mean signal intensity/voxel volume of the region ofinterest/Signal intensity in a 100% water voxel.
Volume was plotted against time and the flow rate derived fromthe gradient, with a rate �4.5 ml/min being defined as abnormal.FE1 PL tests were performed in all patients.
Results: There were 33 patients (21M, 12F), median age 52(range 34–79) years. In 27 patients, there was complete concordancebetween MR flow rate and FE1/PL, with 16 patients having normalvalues (mean flow rate 7.7 2.5 ml/min) and 11 abnormal(3.5 0.8; p � 0.001 by Students t test). Two patients had normalFE1 and abnormal flow rates, 4 had abnormal FE1 but normal flowrates (p � 0.001 by Fisher’s exact test).
Conclusion: sMRCP provides ductal, parenchymal and func-tional information in a single test.
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Early Severity Stratification and Referral tothe High Dependency Unit for Patients withSevere Acute PancreatitisB. Vijaynagar, A. Amin, R. Nadarajah, C.H. Knowles, J. Refson
Department of General Surgery, Princess AlexandraHospital, Harlow, UK
Aims: Early referral to the high dependency unit (HDU) is sug-gested for patients with acute severe pancreatitis. Patient outcomes
were assessed with respect to their initial severity stratification,referral time to HDU, length of stay and mortality rate.
Methods: Retrospective case-note review of 114 patients withacute pancreatitis. Based on the documentation of the modifiedGlasgow Score within 48 hours of admission, two groups weredefined. Group 1 (n � 21): patients who were predicted to have doc-umented severe acute pancreatitis and Group 2 (n � 45): patientswhose clinical workup failed to document evidence of a ModifiedGlasgow Score. 48 patients with documented mild pancreatitis wereexcluded.
Results: 13 patients in Group 1 were transferred to the HDU,with a mean referral time of 3 days. There were 3 deaths and the meanduration of stay was 17 days. 7 patients in Group 2 were transferredto the HDU with a mean referral time of 6 days. There were 5 deathsand the mean duration of stay was 32 days.
Conclusions: Accurate clinical documentation of a severityscore in patients with acute severe pancreatitis leads to earlier admis-sion to HDU and may decrease length of stay and mortality.
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Trans-Papillary Pancreatic Duct Stenting in the Management of Pancreatic DuctDisruptionC.R. Carter, M. Talbot, W.R. Murray, C.W. Imrie, C.J. McKay
West of Scotland Pancreatic Unit, Glasgow RoyalInfirmary, Glasgow
Aims: Pancreatic duct (PD) disruption usually presents with acommunicating pseudocyst, ascites, or as a consequence of necrosis.Traditional therapy involves surgical or endoscopic pseudocystdrainage. We describe our experience with PD stenting as part of amulti-modality management algorithm for pancreatic pseudocyst andascites.
Methods: A prospectively collated database of endoscopic find-ings was supplemented by retrospective record review. Between 1996and 2004, 6576 ERCP’s were performed, 523 for the investigation of‘cysts’. PD disruption was confirmed in 142 (95 male/47 female,median age 51 (range 10–82), median follow-up 143 weeks (range3–396).
Results: Trans-papillary stenting was technically successful in126 patients (89%). PD stricture preventing passage of a guide wirewas the commonest cause of failure (14/15). Mortality was 2%(3/142). Of 126 successful stents, primary resolution occured in 93(74%). The disruption was in the pancreatic head in 28 (20%), neck51 (36%), body 26 (18%) and tail 37 (26%). Resolution was unaf-fected by the site of the disruption, etiology (AP(42%)/CP(56%)),stent diameter (5FG/7FG) or whether the disruption was crossed bythe stent (81% vs. 68% p � 0.77). The absence of a proximal ductstricture significantly improved the likelyhood of resolution of thedisruption. (79% vs. 51% p � 0.042).
Conclusion: Trans-papillary PD stenting is effective in control-ling duct disruption. Proximal duct stricture adversely affects outcome.
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Minimal Access Techniques in theManagement of Infected PancreaticNecrosisR. Lochan1, D.M. Manas1, K. Gould2, A.J. Kilner3, J. Scott4, K.E. Oppong1, C. O’Suilleabhain1, B.C. Jaques1, R.M. Charnley1
1Hepato-Pancreato-Biliary Unit, 2Departments ofMicrobiology, 3Perioperative and Critical Care, 4Radiology,Freeman Hospital, Newcastle upon Tyne, UK
Aims: To determine the impact of introducing percutaneousretroperitoneal necrosectomy (in July 1999) and endoscopic transgas-tric necrosectomy (in May 2002) on the management of patients withinfected pancreatic necrosis.
Methods: Data was collected to compare APACHE 2 score onadmission, length of ITU stay, total hospital stay and mortality inpatients with bacteriologically confirmed infected pancreatic necro-sis. Comparison was made between 3 different time periods related tothe availability of the different techniques: 1995–1999 open necro-sectomy only; 1999–2002 open and percutaneous; 2002–2003 open,percutaneous and endoscopic.
Results: See table below.Conclusions: Although overall mortality is unchanged follow-
ing the introduction of minimal access techniques, hospital stay issignificantly reduced. Percutaneous and endoscopic necrosectomyshould be considered in patients with infected pancreatic necrosis.
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One-Step Drainage of PancreaticPseudocysts with Multiple Stents Using aLarge Channel Therapeutic EchoendoscopeS.M. Denley, C. Shearer, J. Barnard, C.J. McKay, C.R. Carter
West of Scotland Pancreatic Unit, Glasgow RoyalInfirmary, Glasgow
Aims: Until recently, EUS-guided approaches to endoscopiccyst-gastrostomy have utilised single, 7Fr or 8.5Fr stents, limitinguse to carefully selected patients. We report our experience with the
placement of multiple stents using a one-step EUS guided approachin 15 patients with pancreatic pseudocysts.
Patients and Methods: All patients had persistent, symptom-atic cysts. Aetiology was acute pancreatitis (7 cases) or chronicpancreatitis (8 cases). 3 cysts were infected. ERCP was either unsuc-cessful (5 cases) or demonstrated no communication (6 cases). In2 cases ERCP was not attempted. In the remaining 2 cases, cysts per-sisted despite pancreatic duct stenting. Cyst drainage was carried outunder EUS control using a therepeutic echoendoscope with a 3.8 mmworking channel and bridge. 2 or more pigtail stents were insertedafter dilatation of the cystgastrostomy to 10 mm.
Results: There were no procedure-related complications. Cystsresolved in 13 cases. One patient died following surgery for a per-sistent, infected cyst. A second death occurred due to liver failurefollowing successful cyst drainage.
Conclusion: One step, EUS guided endoscopic cyst-gastrostomywith multiple stents is feasible using the new generation of therapeuticechoendoscopes. The use of EUS facilitates selection of a safe puncturesite and allows drainage without a visible endoscopic ‘bulge’.
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The Relationship Between Cystic Fibrosisand PancreatitisJ. Krysa, P. Luce, A. Steger
Department of Surgery, University Hospital Lewisham,Lewisham, London, UK
Aims: The mutations of the CFTR gene are associated with highincidence of pancreatitis (up to 37% of patients with idiopathicpancreatitis vs. 5.3% in random population). The aim of this study isto investigate the incidence of pancreatitis in patients with cysticfibrosis (CF) in the UK.
Method and Results: None of 71 patients (children and adults)at a CF centre had pancreatitis over 5-years. To increase the samplesize, data was obtained from the UK CF database. Data was gatheredby CF database questionnaires. It was available from 1948 to 2002and included 6932 patients who are still alive. 37 had a history ofpancreatitis. Median age at the time of diagnosis was 11 (0–46).
Conclusion: Patients with CF have a higher risk of developingpancreatitis (0.05%) than the general population (0.01–0.02%) butlower than people with CFTR gene mutation (12%). CF patients onceidentified can be followed appropriately. The identification of thosewith CFTR mutation raises greater ethical problems. The total number
Table for the abstract 10 [median (range)]
Open necrosectomy Open and percutaneous Open, percutaneous and p value1995–1999 1999–2002 endoscopic 2002–2003
No of patients 33 37 27Procedures per patient 1 (1–9) 3 (1–24) 2 (1–10) N.S.APACHE 2 on 11 (4–16) 12 (3–34) 12 (4–24) N.S.
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of CF patients with pancreatitis may increase as they survive longer.Since chronic pancreatitis is a risk factor for pancreatic cancer,patients with CF and CFTR mutations should be reviewed regularly,as early diagnosis has a potential for curative resection.
Poster Presentations
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Is Positive Intraoperative Bile CultureA Determinant Factor for PostoperativeMorbidity and Mortality After BiliaryPancreatic Surgery?P. Limongelli, M. Pai, A. Alvand, G. Pambu, R.C.N. Williamson, L.R. Jiao
Department of Surgery, Hammersmith Hospital, Imperial College, London, UK
Aims: Controversy exist regarding the impact of preoperativefactors in predicting accurately intraoperative bactibilia and on theimpact of positive intraoperative bile culture (IBC) on morbidity andmortality rates after biliarypancreatic surgery. The objective was toanalyze risk factors for bile colonization and to determine the rela-tionship between IBC and the biliarypancreatic surgery-related mor-bidity and mortality.
Methods: Morbidity and mortality rates were evaluated in 220patients who underwent biliarypancreatic operations excludingpatients who underwent pre-referral biliary bypass. Statistical analy-ses were performed on several preoperative variables to define riskfactors for bactibilia and the relationship between both bactibilia andpreoperative biliary drainage (PBD) with postoperative morbidity andmortality.
Results: Independent risk factors for bactibilia were age over70, coronary artery disease, neoplasia, ALP � 100, and PBD. Theinfectious complications and wound infection risks were higher inpatients with positive IBC. PBD did not appear to increase the rate ofpostoperative complications.
Conclusions: Independent risk factors increase the risk for pos-itive IBC. Patients with positive IBC have an increased risk forsubsequent infectious complications and wound infection but not fordeath. Besides, PBD increases the risk of bactibilia but alone does notincrease the risk for postoperative complications and death.
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Endoscopic Ultrasound-Guided TissueSampling By Fine Needle Aspiration (FNA)or Trucut Needle Biopsy (TNB): A Prospective, Single-Centre StudyJ. Wittmann, W. Tam, S.P. Pereira
Department of Gastroenterology, University CollegeLondon Hospitals NHS Trust, London, UK
Background/Aims: There are few prospective data comparingthe safety and accuracy of endoscopic ultrasound (EUS) guidedFNA TNB of the pancreas with other sites in the upper gastro-intestinal tract.
Methods: Over a 2 year period, 129 patients (70M: 59F, medianage 62 yrs) underwent EUS-FNA TNB of the pancreas (n � 72) orother sites (n � 57: mediastinum 41; oesophagus 9; stomach 5; other 2)using 22 g FNA 19 g trucut biopsy needles.
Results: EUS-FNA Adequate samples were obtained by EUS-FNA in 93% of patients and by EUS-TNB in 89%. In a group with aprevalence of malignancy of 54%, the overall sensitivity of EUS-FNA TNB was 79%, with a specificity of 100%. The first 50 andsubsequent 79 procedures had a sensitivity of 86% vs. 75% (n.s.).EUS-FNA TNB of the pancreas was less sensitive than for othersites (64% vs. 97%; p � 0.001) with a specificity of 100% in bothgroups. In 28% of patients, EUS-TNB allowed further characteriza-tion of the tumour. There were no complications.
Conclusions: EUS-FNA TNB is very safe. TransduodenalEUS-FNA TNB of pancreatic lesions is technically more difficultand associated with a higher false negative rate than other biopsysites.
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The Outcome of LaparoscopicGastrojejunostomy in Malignant Gastric Outlet ObstructionS.M. Denley, S.J. Moug, C.J. McKay, C.R. Carter
West of Scotland Pancreatic Unit, Glasgow RoyalInfirmary, Glasgow
Aims: The development of gastric outlet obstruction (GOO) inadvanced pancreatic cancer patients is regarded by some as a terminalevent. There are several interventional options available includinglaparoscopic gastrojejunostomy (LGJ). There is little data on the effec-tiveness of this intervention.
Methods: A retrospective analysis of all patients with pancreaticor peri-ampullary cancer that underwent LGJ for GOO. All LGJ wereperformed by two consultant surgeons. Patient notes were assessedfor: survival time after LGJ; post-operative complications; resump-tion of oral intake; time to discharge and recurrence of GOO aftersurgery.
Results: 18 patients underwent LGJ for GOO between 2000 and2004. Median age was 66.5 years (range 40 to 79). There were twoconvertions to an open procedure for technical reasons, both died in
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the post-operative period. Of the remaining 16, 15 had successfulrelief of GOO. The remaining patient underwent revisional opensurgery 15 days post-operatively due to persistent GOO. Two patientsdied in hospital but 14 were discharged with symptom relief. Mediansurvival for these patients was 59 days (range 12 to 248).
Conclusion: The development of GOO in pancreatic and peri-ampullary cancer should not be regarded as a terminal event. LGJshould be considered as a treatment option in these patients.
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Prospective Regional Audit of AcutePancreatitis Management – Compliance with United Kingdom GuidelinesR. Ravindran, V. Shanmugam, Z.H. Krukowski
Aberdeen Royal Infirmary, University of Aberdeen
Objective: Prospective study of management of acute pancre-atitis to compare local practice with published United Kingdomguidelines.
Patients and Methods: The management of all patients withacute pancreatitis admitted to Grampian University Hospitalsbetween 1/04/02 and 31/03/04 were recorded.
Results: There were 186 episodes of acute pancreatitis in 160patients (90 male). Mean age 55 years (range 9 to 91). 3 were diag-nosed during laparotomy; one each with CT scan, urinary and pleuralamylase. Gallstone was the commonest precipitating factor (42%)followed by alcohol (24%). Only 55% of patients were stratified forseverity. Correct diagnosis was made within 48 hours in 93%. CTscan was performed on the basis of clinical necessity in 69 (37%)patients. ERCP was performed only in 42% of patients requiringbiliary decompression. Index admission cholecystectomy was per-formed in 32% of patients with gallstone.
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Antibiotic Prophylaxis for PancreaticNecrosis: Does the Choice of AntibioticRegimen Matter?E. Villatoro, R. Hall, M. Larvin
Division of GI Surgery, Wolfson Digestive DiseasesCentre, University of Nottingham at Derby, UK
Controversy continues over the role of prophylactic antibiotics inpancreatic necrosis. Randomised controlled trials (RCT) have beeninconclusive, and meta-analysis is hindered by variable entry criteriaand antibiotic regimens.
The aim of the study was to examine whether choice of antibioticinfluenced outcome from pancreatic necrosis. Appropriate RCTs weresought using contrast-enhanced CT as an entry criterion, or were CTdetails were extractable.
Five relevant RCTs were identified, three evaluating a betalactamtype regimen (175 patients), and two a quinolone/imidazole combi-nation (102 patients). No study was adequately powered, and only one(a quinolone/imidazole regimen), was adequately double-blinded.Meta-analysis was performed using RevMan v4.2 (Update, Oxon).
Overall meta-analysis showed significantly reduced mortalityfrom antibiotic therapy (p � 0.01, odds ratio [OR] 0.37). Mortalitywas lower, but not significantly in betalactam (p � 0.13, OR 0.45)and quinolone/imidazole (p � 0.25, OR 0.45) subgroups. Infectednecrosis was not significantly reduced overall (p � 0.1, OR 0.62), butwas in the betalactam subgroup (p � 0.02, OR 0.41) and not in thequinolone/imidazole subgroups (p � 0.61, OR 1.29).
These results and those observed for other end points conflict withtissue penetration studies, and suggest that antibacterial spectrum ismore important than pharmacokinetics. Further adequately powered,double-blinded studies are required to confirm the findings.
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The Role of the Clinical Nurse Specialist in the Management of Patients Within A Tertiary Referral Pancreatic UnitE. Cowan, A. Reid, H. McDonald, C.J. McKay, C.W. Imrie, C.R. Carter
West of Scotland Pancreatic Unit, Glasgow RoyalInfirmary, Glasgow
Clinical nurse specialists (CNS) are taking an expanding rolewithin the management of pancreatic cancer patients, particularlythose requiring palliative management. Their role is both ill-definedand in evolution and we present an audit of pancreatic cancer refer-rals in 2002–3 to explore the extended role of the CNS and how thishas impacted on patient management.
103 patients were identified from database and CNS documenta-tion (51 male/52 female) with pancreatic cancer (n � 72), bile ductcancer (n � 19) and ampullary cancer (n � 11). Twenty-five under-went potentially curative resection (Whipple 23, distal 2, resectionrate (24%)) and were therefore excluded from subsequent analysis.Treatment options were discussed within an MDT format.
Conclusion: Mortality was low (5.6%) compared with nationalguidelines. However, rate of severity stratification, ERCP, CT scanutilisation and index cholecystectomy are sub-optimal.
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Of 78 patients, 66 patients had biliary stents placed endoscopicallyor percutaneously, 10 patients had subsequent palliative chemotherapy.Late gastric outlet obstruction was treated by gastroenterostomy in 8,and 1 patient received argon plasma coagulation to an ampullary lesion.8 patients with cancers of the body and tail of the pancreas were treatedsymptomatically. 11 individuals were alive at 31st July 2003 (meansurvival 185 days range (5–530)).
An audit of CNS interaction in the streamlining of the investiga-tive and admission pathway, patient and relative counselling, infor-mation documentation, outpatient clinic management, GP liaison, andcommunity patient contact is presented.
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Identifying Patients with Acute Pancreatitis(AP), in whom Serum Amylase was Normal(�300U/Dl), by Using Urinary Trypsinogen-2TestingL. Husain, Mr. Oommen, Dr. Lord, J.C. Cooper
Department of Surgery, Rotherham District GeneralHospital, Moorgate Road, Rotherham, UK
Aims: Acute pancreatitis (AP) is a serious illness with significantmorbidity and mortality. Diagnosis is based on clinical symptoms,signs and raised serum amylase. Some patients have normal serumamylase at presentation, posing a diagnostic and therapeutic dilemma.Urinary trypsinogen-2 is a simple test carrying high sensitivity andspecificity in diagnosing AP.
Methods: We report our experience, over a 12 month period(September 02–August 03), of the use of this test on patients in whomAP was a possible differential diagnosis, but their serum amylaseremained normal. Diagnosis of AP was based on radiological imagingor laparotomy.
Results: 35 patients with acute abdominal symptoms and signsmimicking AP with normal serum amylase were urinary trypsinogen-2tested. Of the 35 tested, 26 had a negative result and 9 had a positiveresult. On subsequent imaging or laparotomy, all 26 negative resultsproved not to have AP while 3 of the 9 positives proved to have AP.
Conclusions: In our study, urinary trypsinogen-2 testing provedto have high sensitivity (100%). This meant no patients with AP weremissed. Intensive treatment and monitoring could be focused on thosetesting positive, until a definitive diagnosis was obtained.
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Novel Therapies for Pancreas CancerJ. Abbott, A. Sultana, D. Vimalachandran, S. Shore, S. Vinjamuri, D.B. Smith, J.P. Neoptolemos, P. Ghaneh1Division of Surgery and Oncology, University ofLiverpool, Liverpool, UK, 2Department of NuclearMedicine, Royal Liverpool University Hospital, Liverpool,UK, 3Clatterbridge Centre for Oncology, Wirral, UK;Acknowledgements: 131IKAbI KS Biomedics/Xenova,Slough, UK; MetXia is a registerd trademark of OxfordBiomedica, Oxford, UK
It is estimated that 90% of patients diagnosed with pancreascancer have unresectable disease at diagnosis. Although Gemcitabineis the recommended palliative treatment for this patient group; itsbenefits are limited and it is recognised that novel treatment modali-ties should be developed. We are currently recruiting to two phase I/IIstudies which use novel approaches for unresectable disease.
131IKAb201 is an open, randomised, phase I/II trial of a novel, super-high affinity, partially humanised monoclonal antibody for patients withhistologically proven pancreatic ductal adenocarcinoma; participantsare randomised to receive the drug via either the intra-arterial or intra-venous route.
MetXia is a phase I/II study designed to evaluate the safety andefficacy of the gene (Cytochrome P450) and cyclophosphamide forpatients with histologically proven pancreatic adenocarcinoma.Metxia, a retroviral vector, is delivered intra-arterially to the pancreas.Once transfected the tumour cells facilitate the metabolism of aregionally delivered prodrug (cyclophosphamide). The first part of thestudy primarily seeks to determine the extent to which gene transferoccurs.
The purpose of this poster is to highlight the practicalities ofconducting such studies in the general surgical setting. A brief outlineof the science underpinning the studies and the studies’ design willalso be provided.
21
Gallstone Pancreatitis. Is CholecystectomyNecessary?A. Talwar, J. Pain, T. Dudding
Department of Pancreatico-biliary surgery, Poole Hospital,Poole, UK
Introduction: Gallstone pancreatitis (GSP) patients can bemanaged by endoscopic sphincterotomy (ES) or cholecystectomy toprevent recurrence. We reviewed patients after ES for GSP to assessthe incidence of recurrent biliary symptoms (RBS) with gallbladderin situ.
Methods: All patients had an ERCP between 1992 and 1998, nohistory of gallbladder symptoms, a thin walled gallbladder on USS,sphincterotomy and ERC demonstrating cleared ducts upon dis-charge. Retrospective review was by case note analysis, operatingtheatre record and GP questionnaire. Patients under 70 were com-pared to patients over 70.
105Pancreatology 2005;5:97–107Abstracts
Results: 47 patients were identified who had endoscopic sphinc-terotomy as treatment for gallstone pancreatitis. The frequency ofrecurrent biliary problems was similar in the two groups (45.5% vs.40%, p � 0.5).
Conclusion: We suggest that cholecystectomy is appropriate forall patients who present with gallstone pancreatitis (and are fit forGA) to prevent RBS.
22
Management of Cystic Tumours of thePancreasD. McKay, C. Marron, S. Mathew, L. McKie, T. Diamond
The Department of Surgery, The Mater InfirmorumHospital, Crumlin Road, Belfast, Northern Ireland
Aims: Cystic tumours of the pancreas account for 5% of pancreaticneoplasms and are frequently misdiagnosed as pancreatic pseudocysts.We present our experience of managing these tumours highlighting theclinical presentation, diagnostic difficulties and operative treatment.
Methods: This is a retrospective study of all patients diagnosedto have cystic tumours of the pancreas treated at our institution, dur-ing a 5-year period from 1997 to 2002. Literature was reviewed andguidelines for the management of these tumours have been outlined.
Results: Seven patients with cystic pancreatic tumours weretreated over this time period. All patients were women with a medianage of 40. Two of these patients were initially diagnosed as pseudo-cysts and were treated elsewhere by cystgastrostomy. The tumour wasresected in all patients. All but one was benign. At follow up, rangingfrom 13–66 months, all patients were alive and well.
Conclusions: Cystic tumours of the pancreas are uncommonand generally slow growing. It is important not to assume that a cysticlesion in the pancreas, especially in middle-aged women, is a pseudo-cyst. Satisfactory surgical resection may be possible even after previ-ous operative procedures on the pancreas. Prognosis after resectionremains good.
23
Early ERCP in Acute PancreatitisP. Srivastava1, S.D. Roy1, M. Ballal1, A. Jibawi1, D.J. Corless1, M. Deakin2, J.P. Slavin1
1Surgical Research Unit, Department of Surgery, Leighton Hospital, South Cheshire, 2Department ofSurgery, University Hospital of North Staffordshire,Stoke on Trent, UK
Aims: The incidence of acute pancreatitis (AP) in UK is approx-imately 40 per 100,000 population per year. Gall stones are thecommonest cause and twenty percent of patients will suffer a severeattack. It has been suggested that all patients with predicted severegallstone AP should undergo early (i.e. within 48 hours of admission)endoscopic retrograde cholangiopancreatography (ERCP) �/� endo-scopic sphincterotomy (ES). We aimed to study the use of early ERCPin AP in England.
Methods: Hospital Episode Statistics (HES) data for the years1998–2002 were obtained from the Department of Health. The datawas imported into an access database for analysis. Patients admittedas an emergency with AP were identified using the ICD 10 code andthe relevant HES code. OPCS 4 coding was then used to identifypatients undergoing ERCP. The number of days between admissionand ERCP were calculated.
Results: Approximately 2.5 ERCPs were performed per 100,000population per year in patients admitted with AP. Only 20%, i.e. 0.5ERCPs per 100,000 population per year, were performed within 2 daysof admission. Most Trusts did not undertake early ERCP.
Conclusions: Early ERCP for predicted severe gallstone AP isnot widely practiced in UK.
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The Role of Routine Serum AmylaseEstimation After ERCPD.W.J. Howcroft, A. Hames, H. Gray, S.D. Mansfield, G. Sen, M. Hudson, K.E. Oppong, R.M. Charnley
Hepato-Pancreato-Biliary Unit, Freeman Hospital,Newcastle upon Tyne, UK
Aims: To determine the value of routine estimation of serum amy-lase after ERCP to enable identification of patients with post-procedurepancreatitis before clinical signs develop.
Methods: Details of consecutive patients undergoing ERCPfrom May 2002 to May 2003 were recorded including the incidence ofhyperamylasaemia (�5x upper limit of normal) and the subsequentdevelopment of pancreatitis. Due to individual consultant preferences,we were able to compare the relative incidence of diagnosed pancre-atitis between 2 groups of patients: those who had, and those who didnot have, routine amylase estimation 4 hours following the procedure.
Results: Of 321 patients undergoing ERCP, 193 (60%) hadamylase measured, 175 (55%) routinely. Of 17 (8.8% of patientschecked) with raised amylase, 5 (1.6%) developed clinical acutepancreatitis. Hyperamylasaemia (present in all 5) was detected byroutine measurement in 3 and following onset of pain in 2 (after 3 and
�70 (n � 22) �70 (n � 25)
Age-mean (range-years) 59.5 (40–69) 78 (70–93)Follow up-median (IQR-months) 71.7 (17.9–82.4) 48.8 (20.2–74.4)Death/Biliary cause 2/0 12/0Median time to RBS (IQR-months) 16.6 (5.2–75.5) 28.4 (9.4–78.2)
106 Pancreatology 2005;5:97–107 30th Annual Meeting of the PancreaticSociety of Great Britain and Ireland
8 hours). There was no significant difference in the incidence ofrecorded pancreatitis between those patients who had routine amylasemeasurement (3/175) and those who did not (2/146).
Conclusions: Routine amylase estimation is a sensitive, butnon-specific marker of impending pancreatitis which may have a rolein day case ERCP.
25
Current Status of Laparoscopic Resection ofBenign Pancreatic LesionsW.M. Elsaify
Department of General Surgery, Ipswich General Hospital,Ipswich, UK
Aims: This review summarises current data on laparoscopicpancreatic resection (LPR) of benign lesions of the pancreas.
Methods: A Medline review identified articles published since1992 summarising patients who underwent laparoscopic pancreaticresection.
Results: Laparoscopic enucleation (LE) is ideal for small andsolitary insulinomas, while laparoscopic distal pancreatectomy (LDP)is more suitable for insulinomas located in the pancreatic tail in closeproximity to the pancreatic duct. Such techniques are not suitable forlesions located in the head of the pancreas adjacent to important ves-sels and major pancreatic duct. There is no reduction in the risk ofpancreatic fistula following laparoscopic approach. Magnificationand enhanced laparoscopic visualisation of the operative field oftenfacilitates preservation of the spleen. Laparoscopic ultrasonographyprovides an effective technique for accurate intraoperative localiza-tion of insulinomas. The reported experience to date with laparo-scopic hand-assisted pancreatic resection is limited, but the results areencouraging.
Conclusions: Laparoscopic resection of benign lesions of thepancreas has gained wide acceptance as a safe and successful treat-ment for benign lesions of the body and tail of the pancreas, with allthe potential benefits of minimally invasive surgery.
26
Early Experience of Endoscopic Ultrasoundin Predicting the Resectabillity ofPeriampullary TumoursC.M. Pring, S. Khulusi, K.R. Wedgwood
Pancreatic Surgical Unit, Castle Hill Hospital, Cottingham, Hull, UK
Aims: The resectability rate at our institution for periampullarytumours, following dedicated CT imaging alone, was 67%. We wantedto assess whether this would improve with the addition of EUS.
Methods: We assessed our early single unit experience of CTand EUS in predicting tumour resectability, by assessing 10 consecu-tive patients on whom attempted curative or palliative surgery wasperformed.
Results: 6/10 patients had resectable lesions, as predicted on CTand EUS. One patient had a liver secondary demonstrated on CT andEUS, confirmed at laparoscopy. A second patient had a resectabletumour on CT, however EUS and operative findings demonstrated anirresectable tumour. The CT and EUS of the third patient indicated anirresectable lesion, confirmed at operation. The CT and EUS of thefinal patient demonstrated a resectable tumour which was irresectableat operation.
CT and EUS concurred in 8 cases. In one case the CT did notmatch EUS and operative findings. In the final case the CT and EUSconcurred, but they did not match the operative findings.
Conclusion: The sensitivity of CT and EUS are 80% and 90%respectively. CT appears to have improved and EUS offers an oppor-tunity for further improvement in assessing resectability.
Deakin, M. 23Denley, S.M. 11, 15Diamond, T. 22Di Paola, M. 2Douglas, F.S. 3Dudding, T. 21
Elsaify, W.M. 25
Ghaneh, P. 20Gillams, A. 7Gould, K. 10Gray, H. 24Grossman, A.B. 4
Hall, A. 1Hall, R. 17Hames, A. 24Hanson, M. 4Howcroft, D.W.J. 24Hudson, M. 24Husain, L. 19Huscher, C. 2Hutchins, R. 4
Imrie, C.W. 5, 9, 18
Jaques, B.C. 10Jiao, L.R. 13Jibawi, A. 23
Khulusi, S. 26Kilner, A.J. 10Knowles, C.H. 8Koeppen, H. 1Korbonits, M. 4Krukowski, Z.H. 16Krysa, J. 12
Larvin, M. 17Lees, W. 7Limongelli, P. 13Lochan, R. 10Lord 19Luce, P. 12
Manas, D.M. 10Mansfield, S.D. 24Marron, C. 22Mathew, S. 22McDonald, H. 18McKay, C.J. 5, 9, 11, 15, 18McKay, D. 22McKie, L. 22Moug, S.J. 15Murray, L. 5Murray, W.R. 9
Nadarajah, R. 8Neoptolemos, J.P. 20
O’Dair, L.C. 3O’Suilleabhain, C. 10Oommen 19Oppong, K.E. 10, 24
Pai, M. 13Pain, J. 21Pambu, G. 13Pereira, S.P. 7, 14Ponzano, C. 2Pring, C.M. 26
Ravindran, R. 16Refson, J. 8Reid, A. 18
Roy, S.D. 23Russell, R.C.G. 6
Scott, J. 10Sen, G. 24Shanmugam, V. 16Shearer, C. 11Shore, S. 20Slavin, J.P. 23Smith, D.B. 20Srivastava, P. 23Steger, A. 12Sultana, A. 20
Talbot, M. 9Talwar, A. 21Tam, W. 14Theis, B.A. 6
Verbeke, C. 1Vijaynagar, B. 8Villatoro, E. 17Vimalachandran, D. 20Vinjamuri, S. 20
Wedgwood, K.R. 26Williamson, R.C.N. 13Wittmann, J. 14
