QS267. Groove Pancreatitis: A Case Series

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