Belgian Pancreatic Club Session

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1 Pancreatology 2006;6:75 79 Published online: February 8, 2006 DOI: 0.59/ The abstracts are only available online, free of charge, under Belgian Pancreatic Club Session at the 8th Belgian Week of Gastroenterology February 9, 2006, Oostende, Belgium Abstracts Guest Editor Myriam Delhaye, Brussels Basel Freiburg Paris London New York Bangalore Bangkok Singapore Tokyo Sydney

2 Abstracts Idiopathic Recurrent Acute Pancreatitis: Assessment by S-MRCP before Pancreatic Sphincterotomy M. Arvanitakis, M. Delhaye, M. Bali 2, C. Matos 2, N. Schoofs, A. Hittelet, M. Cremer, O. Le Moine, J. Deviere Department of Gastroenterology, 2 Department of Radiology, Erasme University Hospital, Brussels, Belgium Background: Idiopathic Recurrent Acute Pancreatitis (IRAP) may be due to a persistent or transient obstruction to pancreatic juice flow into the duodenum. An abnormal response at secretin enhanced MRCP (S-MRCP) defined as a persistent dilatation of the main pancreatic duct has been shown to correlate with an abnormal pancreatic sphincter manometry and may be associated with papillary stricture. Up to now, there is no pre-therapeutic, non-invasive procedure predictive of the effectiveness of pancreatic sphincterotomy (PS) in patients with IRAP. Aim: The aim of this retrospective study was to evaluate the predictive value of S-MRCP in IRAP patients having undergone PS. Patients and Methods: Patients who had IRAP ( 2 episodes), without severe chronic pancreatitis (CP) nor identified biliary stones, and had undergone PS were identified retrospectively from an endoscopic data base. Patients who had pre-therapeutic S-MRCP were selected. Follow-up data included AP recurrence and further S-MRCP. Results: Thirty-one patients were identified. Median age at the time of PS was 45 (8 80) years. Patients had a median ratio of 2 (0.4 6) AP episodes/year before PS. Duration of disease before PS was 24 (6 20) months. Nineteen patients had a complete (n 6) or an incomplete (n 3) pancreas divisum and 8 patients had minimal changes of CP. Abnormal response at S-MRCP was observed in 9 patients. Treatment included major PS (n 4), minor PS (n 6) or both (n ). A 6F stent (n 5) or a nasopancreatic catheter (n 20) was inserted in all but 6 patients in order to prevent post- ERCP AP. Three patients had post-ercp AP (9.6%). There was no treatment associated mortality. Twenty-four patients (M:2/F:2) were followed-up during a period of 32 (6 04) months after PS. Fifteen patients (63%) presented no further AP during follow-up and the ratio of AP episodes/year after PS was significantly decreased for the remaining 9 patients (2 vs. 0.63, p 0.005). One 75-year old patient died from a further attack of AP (48 months after PS). Seven patients required further endoscopic treatment; PS recut (n 5) and/or pancreatic stenting (n 5). Male gender (p 0.04) and older age (p 0.0) seem to be associated with a positive outcome (no further AP during follow-up). An abnormal response at pre-therapeutic S-MRCP was associated with the need for pancreatic stenting during follow-up (p 0.05). Conclusion: PS is an effective treatment for IRAP and an abnormal response at S-MRCP is predictive for the need of further pancreatic stenting. This finding might reflect the difference between functional and organic stricture, the latter requiring complementary endoscopic treatment besides PS. 2 Proximal Double-Balloon Enteroscopy as a Risk Factor for acute Pancreatitis T. Moreels, M. Groenen 2, J. Haringsma 2, E. Kuipers 2 University Hospital Antwerp, Belgium and 2 Erasmus Medical Centre Rotterdam, The Netherlands The concept of double-balloon enteroscopy (DBE) consists of the combined use of a balloon-loaded enteroscope and overtube. By consecutively inflating and deflating the two balloons and straightening the endoscope with the overtube, a stepwise progression of the enteroscope throughout the small intestine is achieved. This newly developed method enables the endoscopic investigation of the entire small intestine through the combination of a proximal and a distal approach. In addition, interventional endoscopy is possible through the working channel. Few complications have been reported up until now. We present two cases of acute pancreatitis one day after proximal DBE for suspected small-bowel disease. The first case presented with selflimiting acute oedematous pancreatitis after proximal DBE for a jejunal carcinoid tumor. The second case presented with severe acute hemorrhagic pancreatitis after proximal DBE for obscure gastrointestinal bleeding. In both cases there was a clear relationship between the DBE procedure and the development of acute pancreatitis. It is hypothesised that straightening of the enteroscope in the fixated duodenum causes long-lasting compression of the pancreatic head, leading to acute pancreatitis. Abdominal pain after the procedure is mentioned as a complication in the early reports of DBE and is generally assigned to the inflated air entrapped within the bowel lumen. It is however likely to assume that post-dbe pain due to mild pancreatitis is mistaken as abdominal cramps due to intraluminal air. It would be interesting to determine pancreatic enzymes before and after proximal DBE to fully appreciate the risk of post-dbe pancreatitis. Fax Karger@karger.ch S. Karger AG, Basel and IAP /06/ $23.50/0 Accessible online at:

3 3 Evaluation of Somatostatin Inhibitory Effect on Pancreatic Exocrine Function using Secretin-Enhanced Dynamic Magnetic Resonance Cholangiopancreatography: A Cross Over, Randomized, Double Blind, Placebo-Controlled Study M. Bali, P. Golstein 2, T. Metens, N. Chatterjee 3, J. Deviere 2, C. Matos Departments of Radiology and 2 Gastroenterology, Erasme University Hospital, 3 UCB, Brussels, Belgium Purpose: Somatostatin inhibitory effect on the exocrine pancreas has been demonstrated by clinical and experimental studies performed with invasive investigative methods. The aim of this study was to quantify the inhibitory effect of low doses of somatostatin (62.5, 25 and 250 g) on secretin-stimulated pancreatic exocrine secretions using magnetic resonance cholangiopancreatography (MRCP). Materials and Methods: Ten healthy volunteers underwent four MRCP at one week interval. At each MRCP one of the three doses of somatostatin or the placebo was given by the IV route for a period of 40min. After 20min from the beginning of drug infusion, secretin was injected (0.3 CU/kg). MRCP was performed before and every sec for 5 min after secretin administration. Pancreatic exocrine secretions were quantified by the measurements of pancreatic flow output (PFO) and total excreted volume (TEV), derived from a linear regression between MRCP calculated volumes and time. Results: For the three doses of somatostatin PFO was significantly reduced compared to placebo (p 0.05). TEV was significantly reduced only for the doses of 62.5 and 250 g. No statistical significant differences were observed among the three doses. Conclusions: Low doses of somatostatin inhibit pancreatic exocrine secretions as demonstrated non invasively with MRCP. mostly done (Beger or Frey techniques), or surgery directed among more localized complications (group B). Material and Methods: From March 993 to September 2004, 29 p suffering from chronic complicated pancreatitis were operated in our institution (22 males, 7 females). Population: ASA: I(5 p), II(3 p), III(8 p), IV(3 p). Age from 3 67 years old (m 44.48). Preop. weight: mean 59.9 kg. Aetiology: alcohol intoxication 28 p (93.3%). Co-morbidities: diabetes 7 p, cirrhosis 2 p, tobacco intoxication 28 p, denutrition p, history of abd. surgery 3 p. Preoperative CP complications: disabling pain 26 p, morphin consuming patients 7 p, malabsorption 9 p, biliary stenosis 3 p, duodenal stenosis 6 p, HTP 2 p, pseudocysts 8 p (3 complicated with haemorrhage), splenic involvement 2 p, haemorrhage 4 p, pancreaticopleural fistula p, history of pancreatic surgery 4 p. Number of preoperative hospital admissions: 5 (m 4.5). Surgical procedures: group A: Beger 6 p, Frey 7 p, Whipple 2 p group B: cystojejunostomy 6 p, corporeocaudal pancreatectomy 7 p (3 with splenic preservations), choledoco-jejunal derivation p. 6 patients were operated on emergency ( splenic rupture, 2 hemorrhages, 3 sepsis). Results: Mean follow up: 36 months. Group A (n 5) Group B (n 4) Hospital stay (days) Morbidity 53% 35% Mortality Continuing alcohol abuse 3 3 Pain control 87% 86% Morphin consumtion De novo diabetes 4 2 De novo malabsorption 4 0 Late mortality 2 pancreatic unrelated causes!!! Conclusion: Even in very selected, highly morbid patients, the results of a tailored surgery, including duodenum-preserving local pancreatic resections for the more complex cases, remain good ( 85% patients pain-free), however at the price of a certain deterioration of pancreatic endocrine and exocrine function. 4 Surgery for Chronic Pancreatitis: Results of a Series from the Last Decade with Special Reference to Duodenum-Preserving Local Pancreatic Resections C. Bertrand, A. Dili, B. Mansvelt, G. Molle, N. Tinton CH Jolimont, Belgium Backround: In chronic pancreatitis, the goals of surgery is to treat severe, intractable pain, pancreatitis-associated complications of adjacent organs, endoscopically unmanageable pancreatic pseudocysts with ductal pathology, internal pancreatic fistulas, exclusion of malignancy. In this study, we reviewed the results of surgical procedures tailored to the disease : treatment of the head of the pancreas, regarded as the pacemaker of the chronic inflammatory process (group A) for which duodenum-preserving pancreatic resection were 5 Two Stage Treatment of Liver Metastasized Neuroendocrine Tumor of the Pancreas G. Roeyen, T. Chapelle, P. Abrams 2, S. Francque 3, P. Michielsen 3, P. Jorens 4, D. Ysebaert Hepatobiliary, Endocrine and Transplantation Surgery, 2 Endocrinology, 3 Gastroenterology and Hepatology, 4 Intensive Care Medicine, University Hospital Antwerp, Belgium Background: Diffuse inoperable liver metastases of neuroendocrine tumors (NET) of the pancreas have previously been considered an indication for liver transplantation. Long-term results however were poor, because of recurrent disease. This can partly be attributed to incomplete clearance of the tumor mass during a one-stage tumor resection and transplantation. Nowadays, the only accepted indication for liver transplantation in this setting, is complete tumor mass Abstracts Pancreatology 2006;6:

4 removal in young patients without persistent extrahepatic disease. Therefore we adopted a two stage surgical treatment modality for these NETs with diffuse liver metasases. The first operation consists of a radical resection of the primary NET, the second consists of an orthotopic cluster liver-pancreas-transplantation. Case Reports: 3 patients were treated in this two stage modality. Patient is a 46-year old women, with two foci of a proinsulinoma in the pancreas due to MEN syndrome. The patient underwent first a subtotal (95%) pancreatectomy. During this procedure the diffuse liver metastases were confirmed. Nine months later, when persistent extrahepatic disease had been excluded, this patient underwent an orthotopic cluster liver-pancreas-transplantation. At two years followup, this patient is still tumor free. Patient 2 is a 36-year old man, with a large pro-insulinoma ( cm) of the pancreatic tail due to MEN syndrome, invading the left kidney and with liver metastases. He underwent a total pancreaticoduodenectomy with splenectomy, a left nephrectomy and extended lymph node clearance. Four months after this radical resection, no extrahepatic disease could be diagnosed, and therefore this patient underwent a similar cluster orthotope liverpancreas-transplantation. At one year follow-up, this patient is also considered free of tumor and has returned to work. Patient 3 is a 44-year old man with a somatostatinoma (5 cm) in the pancreatic head and liver metastases, treated with a pancreaticoduodenectomy. Extrahepatic disease has been excluded with MRI of the abdomen, CT-scan of the thorax, octreoscan, bone scintigraphy (with radioguided biopsy of a hot spot), PET-scintigraphy and laparoscopy. Since no extrahepatic disease could be confirmed, this patient too has been listed for a liver transplantation. He is still on the waiting list. Conclusion: In our opinion, this aggressive two step modality in treating these liver metastasized NETs has the advantage of a primary radical resection of the primary target organ, the pancreas, because there is the option of pancreas transplantation afterwards. Second, when extrahepatic disease can be excluded during a waiting time of several months, the patient undergoes an orthotope cluster liver-pancreas-transplantation, treating in the same time the diffuse liver metastases and also the exocrine and endocrine insufficiency, a consequence of the radical pancreatic resection. This attitude selects and excludes candidates that develop extrahepatic metastatic disease during waiting time. Third, the orthotopic cluster liver-pancreastransplatation has proven to be a safe procedure as no postoperative complications occurred, related to the transplantation. However, this treatment modality has to be reserved for young patients who can be cured by this aggressive approach. 78 Pancreatology 2006;6:75 79 Belgian Pancreatic Club Session

5 Author Index for Abstracts Numbers refer to abstract number Abrams, P. 5 Arvanitakis, M. Bali, M., 3 Bertrand, C. 4 Chapelle, T. 5 Chatterjee, N. 3 Cremer, M. Delhaye, M. Deviere, J., 3 Dili, A. 4 Francque, S. 5 Golstein, P. 3 Groenen, M. 2 Haringsma, J. 2 Hittelet, A. Jorens, P. 5 Kuipers, E. 2 Le Moine, O. Mansvelt, B. 4 Matos, C., 3 Metens, T. 3 Michielsen, P. 5 Molle, G. 4 Moreels, T. 2 Roeyen, G. 5 Schoofs, N. Tinton, N. 4 Ysebaert, D S. Karger AG, Basel and IAP Fax karger@karger.ch Accessible online at:

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