P. Campagnola

Fecal Elastase-1 Is Useful in the Detection of Steatorrhea in Patients with Pancreatic Diseases But Not After Pancreatic Resection

BACKGROUND Fecal elastase-1(FE-1) has been suggested as an alternative to steatorrhea quantification to evaluate pancreatic insufficiency, but its diagnostic performance has not been compared with steatorrhea in chronic pancreatitis or after pancreatic resection. METHODS The relationship between steatorrhea and FE-1 was studied in patients with chronic pancreatic disorders or pancreatic resection. Students t test and ANOVA were used for statistical analysis, accepting 0.05 as limit for significance. RESULTS Eighty-two patients were studied (42 non-operated; 40 previously submitted to pancreatic resection). Fat output was higher in operated than non-operated patients (29.2 ± 3.1 vs 9.9 ± 2.2 g/day, p < 0.001) FE-1 was more severely reduced in operated patients (202 ± 32.3 μg/g in non operated vs 68.6 ± 18.2 in operated patients; p < 0.001). Steatorrhea was significantly more severe in operated patients across different levels of FE-1. The relationship between FE-1 and steatorrhea was described by a power regression model, with a regression line significantly different in operated and non-operated patients (p < 0.001). A steatorrhea of 7 g (upper limit of normal range) was calculated by this regression line when FE-1 is 15 μg/g in non-operated, but as high as 225 μg/g in operated patients. CONCLUSION FE-1 is useful to identify pancreatic insufficiency. Steatorrhea is anticipated in non-operated patients only when FE-1 is below the limit for a confident measurement of our assay. In operated patients, steatorrhea may be present even if FE-1 is only slightly reduced, that suggests a role for non pancreatic factors. FE1 is not useful to identify operated patients at risk of malabsorption.

Azathioprine maintenance therapy to prevent relapses in autoimmune pancreatitis

Objectives:Steroids are used to induce remission in autoimmune pancreatitis (AIP). Low-dosage steroid therapy or immunosuppressant (IMs) has been proposed as maintenance therapy to prevent AIP relapse. Few and conflicting data have been published on the efficacy of azathioprine (AZA) in preventing AIP relapse. The aim of this study was to evaluate the indication and efficacy of AZA as maintenance therapy to prevent disease relapse in AIP.Methods:Patients suffering from AIP diagnosed according to the ICDC in type 1, type 2, and not otherwise specified (NOS) were divided in those treated with AZA (AZA+ group) as maintenance therapy and not treated with maintenance therapy (AZA− group). Exclusion criteria were: previous pancreatic surgery, other autoimmune diseases as indication for AZA treatment, and use of IMs different from AZA. Drug safety, clinical and instrumental outcome of AZA+ patients were evaluated.Results:A total of 23 patients (18 Males and 5 Females, mean age 54±11 years) in AZA+ group and 97 (58 Males and 39 Females, mean age 45±18 years) in AZA− group were compared. In AZA+ group, patients were significantly older (P=0.043), type 1 AIP was more frequently diagnosed (87 vs. 51%, P=0.006), sIgG4 higher (758±625 vs. 311±409 mg/dl, P<0.001), other organ involvement (OOI) more frequently observed (83 vs. 48%, P=0.002), with higher frequency of relapse before AZA treatment (78 vs. 14%, P<0.001). Three patients in AZA+ group required drug discontinuation because of adverse events. Twenty patients were therefore evaluated for outcome. Six out of 20 patients (30%) relapsed after 24±15 months (5 in pancreas and 1 on biliary tract). They were retreated with steroids and continued AZA. Two out of 6 patients (33%) had a second relapse,after respectively 11 months (in pancreas and kidney) and 22 months (in kidney).Conclusions:AZA is an effective and safe treatment to prevent AIP relapses.

Impedance pH Monitoring: Intra-observer and Inter-observer Agreement and Usefulness of a Rapid Analysis of Symptom Reflux Association

Background/Aims Symptom reflux association analysis is especially helpful for evaluation and management of proton pump inhibitor (PPI) refractory patients. An accurate calculation requires manual editing of 24-hour multichannel intraluminal impedance-pH (MII-pH) tracings after automatic analysis. Intra- and inter-observer agreement as well as reliability of rapid editing confined to the time around symptomatic episodes are unknown. Aim of this study was to explore these topics in a prospective multicenter study. Methods Forty consecutive patients who were off PPI therapy underwent MII-pH recordings. After automatic analysis, their tracings were anonymized and randomized. Three experienced observers, each one trained in a different European center, independently performed manual editing of 24-hour tracings on 2 separate occasions. Values of symptom index and symptom association probability for acid and non acid reflux were transformed into binary response (i.e., positive or negative). Results Intra-observer agreement on symptom reflux association was 92.5% to 100.0% for acid and 85.0% to 97.5% for non-acid reflux. Inter-observer agreement was 100.0% for acid and 82.5% to 95.0% for non-acid reflux. Values for symptom index and symptom association probability were similar. Concordance between 24-hour and rapid (2 minutes-window before each symptomatic episode) editings for symptom reflux association occured in 39 to 40 patients (acid) and in 37 to 40 (non-acid), depending on the observer. Conclusions Intra- and inter-observer agreement in classifying patients with or without symptom reflux association at manual editing of 24-hour tracings was high, especially for acid reflux. Classifying patients according to a rapid editing showed excellent concordance with the 24-hour one and can be adopted in clinical practice.

Clinical and Morphological Features of Paraduodenal Pancreatitis: An Italian Experience With 120 Patients

Objectives This study aimed to evaluate the clinical and radiological features and clinical outcomes of paraduodenal pancreatitis (PP). Methods A final diagnosis of PP was based on surgical specimens in resected patients and on imaging in nonoperated patients. Clinical, radiological, and pathological data were collected and reevaluated. Results We studied 120 patients, 97.5% of whom were drinkers and 97.5% were smokers. Symptoms at clinical onset were acute pancreatitis in 78 patients (65%) and continuous pain in 68 patients (55.8%). Other symptoms were vomiting (36.7%), weight loss (25.8%), and jaundice (11.7%). Cystic variant was diagnosed in 82 patients (68.0%), and solid variant was diagnosed in 38 patients (32.0%). Pure and diffuse forms were observed in 22 (18.3%) and 98 (81.7%) patients, respectively. Pancreatic calcifications were present at clinical onset in 5.0% of the patients and in 61.0% at the end of follow-up. Somatostatin analogs were used in 13 patients (10.8%), and 81 patients (67.0%) underwent surgery. Conclusions The clinical profile of PP was found to be middle-aged men who were heavy drinkers and smokers with painful pancreatitis and was associated with vomiting and weight loss. In nonresponders, alcohol withdrawal and medical therapy can be proposed as a first-line treatment, and surgery as a second-line treatment.

Sacral nerve stimulation for intractable constipation: was it really an intractable constipation?

We read with interest the paper by Kamm and coworkers on the effect of sacral stimulation on intractable constipation.1 The paper reports the results of an open multicentre study on the effect of this procedure in patients who proved refractory to the standard medical treatments of constipation. We think that some biases limit the application of the study to real-life patients with constipation. First, the authors correctly report that, in the original paper of the Rome III commission, functional constipation was defined only by the presence of at least two out of five different symptoms.2 A reduced number of bowel movements was simply one of the …

P.18.3 EXOCRINE PANCREATIC FUNCTION IN THE FOLLOW-UP OF PATIENTS SUFFERING FROM AUTOIMMUNE PANCREATITIS

Background and aim: Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis with typical histological features, fully responding to steroids. Pancreatic exocrine function can be studied by dosage of fecal elastase 1 (FE1). Aim of this study was to evaluate pancreatic exocrine and endocrine function in patients suffering from AIP before and after steroid therapy, and in the follow-up. Material and methods: FE1 was evaluated both before and after steroid therapy and in the follow-up (1, 2 and 3 years) in 37 patients (24 males, 13 females, mean age at onset of the disease 45.7±15.5 years) diagnosed as having AIP between 2008 and 2012. Results: FE1 was 144.6±166.6 μg/g stool at clinical onset. 20 patients (54%) showed severe pancreatic exocrine insufficiency ( 200 μg/g stool). Before steroids, diabetes was diagnosed in 6 patients (16%) with low levels of FE1 (66.4±107.3 μg/g stool). Following steroids, FE1 increased in all patients (232.1±193.9 μg/g stool) (p<0.0001). However 40% of patients still showed severe pancreatic exocrine insufficiency after steroids. Predictive factors of low levels of FE1 are advanced age, weight loss, jaundice and steatorrhea. In short follow-up exocrine and endocrine pancreatic function remained stable. Conclusions: Patients suffering AIP show exocrine pancreatic insufficiency at clinical onset that improves after steroid therapy and remains stable during a 3-years follow-up.

NMR and MRCP After Secretin Infusion in a Long-Term Comparison Study of Pancreogastro- vs. Pancreojejuno-Duodenopancreatectomy

Context After pylorus-preserving pancreaticoduodenectomy the anastomosis of pancreatic remnant may be done with the stomach (pancreogastric, PGA) or the jejunum (pancreojejunum, PJA). Recently, we have found that, in the long-term, PGA is associated with a more severe impairment of the residual pancreatic function. No data are available on the RNM ability to demonstrate an impairment of the residual pancreatic secretion or morphological changes after surgery. Methods Patients who 6 years ago entered a controlled short term comparison of PGA and PJA were studied by RNM and MRCP after secretin infusion (quantification of residual pancreatic volume, pancreatic duct diameter immediately proximal to the anastomosis, qualitative impairment of secretion), and tests of exocrine (fecal elastase-1, fecal fat balance) function. Two radiologists, blinded to the results of functional parameters, independently scored the residual pancreatic volume, duct diameter and secretin-stimulated secretion. Mean±SEM are shown. The Student’s t test was used. Results We studied 34 patients (16 PGA, 18 PJA; age 56.6±2.7 vs . 57.5±2.5 years; time from surgery 81±5 vs . 80±3 months). PGA was associated with a more severe impairment of steatorrhea than PJA (26.6±4.1 vs . 18.2±3.6 g/day; reference range: 0-7; P<0.01) and of fecal elastase-1 (70.2±25.5 vs . 121.4±6.7 µg/g; P<0.001). RNM showed in PGA a more marked dilatation of the pancreatic duct (diameter 4.63±0.91 vs . 2.50±0.18 mm, P<0.05) and non significant tendency to a smaller residual pancreas (26.3±3.0 vs . 35.9±4.1 mL; P=0.069). There is a power correlation between residual pancreas and steatorrhea. After secretin infusion, the secretion was consistently considered by two different radiologists to be more frequently impaired in PGA (42%) than in PJA (18%; P=0.05, Fisher test). Conclusion The pancreo-gastric anastomosis is associated, in the long run, with more severe morphological and functional impairment of exocrine function than the pancreo-jejunal one. Normal 0 false false false EN-GB X-NONE X-NONE

OC.11.6: IN PATIENTS WITH PANCREO-DUODENAL RESECTION, PANCREO-GASTRO ANASTOMOSIS PRODUCES A MORE SEVERE PANCREATIC DERANGEMENT THAN PANCREO-JEJUNAL ANASTOMOSIS. RESULTS OF A LONG TERM RANDOMISED STUDY

tissue acquisition (EUS-FNTA) utilizing a 19-gauge needle to obtain tissue samples for histological diagnosis and Ki-67 expression in patients with suspected PETs. Material and methods: 25 consecutive patients (mean age 54±15 yrs; M/F 11/14) with suspicious of PETs on previously performed imaging studies who, between August 2009–September 2010, underwent attempted EUS-FNTA using a 19G needle. The collected specimens were placed directly in formalin for histological examination. Results: All patients had a single lesion localized in the pancreatic head in 5, in the uncinate process in 2, in the isthmus in 4, in the body in 5, in the tail in 6, and at the body-tail junction in 3. In 18 patients EUS-FNTA was performed using the conventional linear echoendoscope, while in the other 7 patients the newly developed forward viewing echoendoscope was used. The mean size of the biopsied lesions was 15.6±7.3 mm (range 7-100mm). Overall, EUS-FNTA could be performed in all patients without complications. A mean of 2.7±0.5 passes per patient were performed. Tissue samples for histological examination were retrieved in 23 out of the 25 patients (92%) and were sufficient to make a diagnosis of NETs in all these patients. Ki-67 determination could be performed in 21 of the 23 patients (91.3%) with available tissue from EUS-FNTA. In the 6 patients who underwent surgery, preand post-surgical Ki-67 values were concordant in 4, while in 2 patients upgrading of the Ki-67 in the post-surgical specimen occurred. Conclusions: In patients with suspected PETs, retrieval of tissue specimens with EUS-FNTA using a 19G needle is safe and feasible, with a high diagnostic accuracy even in those with small lesions localized in difficult segment of the pancreas to be sampled. Determination of Ki-67 on tissue samples acquired through this technique can be of help in guiding further management decision.