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A356 AGA ABSTRACTS GASTROENTEROLOGY,Vol. 108, No. 4 FUNCTIONAL AND NUTRITIONAL RESULTS OF PYLORUS PRESERVING PANCREATICODUODENECTOMY FOR CHRONIC PANCREATrI'IS. L Gambiez, A. Wurtz, A. Foumier, H. Porte, J.P. Chambon, P. Quandalle. Clinique Chirurgicale Ouest, - H6pital Claude Huriez - 59037 Lille cedex - France The main advantage of pylorus preservation (laP) during pancreaticoduodenectomy (PD) is to avoid functional and nutritional consequences of the gastreetomy. For 22 patients with a chronic pancreatitis (CP), we evaluated the functional results of this procedure. Between 1984 and 1992, a PD + PP was performed for 22 patients with at least one mechanical complication of a serious PC (19 males, 3 females, mean age : 39, follow up : 42 month). The functional results were assessed by a score including : pain, weigh gain, dyspepsia, professional activity, diabetes and steatorrhea. The possibility of a jejuno-gastric reflux was systematically checked using Tc - HIDA scintigraphy associated with a normal meal. Statistical analysis : Fisher Exact test. Five patients had an early post operative complication with 2 death (9 %). A delayed gastric emptying (< 24 days) occurred in 6 cases and regressed spontaneously. Two margina! ulcerations healed under medical therapy. Three patients (13 %) died belatedly (> 18 month) of extra pancreatic diseases. Presently, 14 patients (82 %) are back to their previous weigh. Functional results are scored as follows : excellent (n = 9), good (n = 5), fair (n = 3). A jejuno-gastric reflux was observed in 5 cases (29 %), all of them occurred among 10 patients who had a duodenal compression pre operatively (p = 0,044). This nutritional results are encouraging. DP + PP may be a good solution to treat particular forms ofCP : with predominant pain or when there is a doubt about an added pancreatic carcinoma. IN VITRO DISSOLUTION PROFILES OF ENTERIC COATED MICROSPHERE PANCREATIN PREPARATIONS AT DIFFERENT pH VALUES. KI-] Gan I, Vc'P Geus 2'3, HGM Heijerman 1, W Bakker I, CBHW Lamers 3. 1Adult CF Centre and 2Dept of Intensive Care, Leyenburg Hospital, The Hague, 3 Dept o f Gastroenterology, University Hospital Leiden, The Netherlands Pancreatic enzyme supplen~ts (pancrcatin), given as enteric coated micrnspbere (~-'m) preparations, are the mainstay of therapy in pancreatic insufficiency as it occurs in cystic fibrosis. These preparations arc designed to survive in acidic gastric juice and to dissolve in the alkaline duodenum. Fat is absorbed in the proximal jejunum and enzyme supple- ments need to be released in the distal duodenum. Slowly dissolving preparations, in combinationwith very high dosages (> 40.000 U lipasc/kg/day) raise the risk of colonic strictures, as reported recently (Lancet 1994; 343: 615-6). There is little objective data on dissolution times of corn preparations at different pH levels. In healthy individuals, post-pmndial pH in the distal duodenum is 5.67 (our observations), lntralummal pH in the distal part of the duodenum of pancreatic insufficient patients will be considerably lower than 5.6 because of low or absent pancreatic bicarbonate production. Aim of this study was to measure dissolution time in buffer solutions of different pH, for 5 eem pancreatin preparations: 3 new high-strength and 2 regular strength preparations. Materials and methods: The following preparations were tested: Croon, Creon Forte (Solvay-Duphar), Panerease, Paneresse-HL (Cilag) and Panzytrat (Knoll). Two capsules were placed in buffer solution at 37°C in a British Phannaccpein (BP) dissolution testing apparatus. Fresh acetic acid / sodium'acetate buffer solutions with pH between 4.0 and 6.0 (intervals of 0.2 pH units) were used. Solutions were stirred at 125 rpm and the rate of dissolutien was monitored by taking 2 ml samples at m~ular intervals and measunng exlmctien at 280 nm, as described in BP. Measurements were repeated 6 times. Results: All preparations failed to dissolve at pH 4.0. Panzytrat and Pancrease-HL shmved within 1 hr: 40 and 55% dissolution at pH 5.0, rising to 67 and 79% dissolution at pH 5.2, and > 90% dissolution at pH > 5.4. Creon and Creon Forte Showed within 1 hr: < 25% dissolution at pH < 5.2, with sharply rising rate of dissolution to > 90% dissolution at pH 5.,:I. Panerease showed within 1 hr: < 25% dissolution at pH < 5.2, rising to 55% within 1 hr at pH 5.4, aad > 90% at pH > 5.6. All preparations dissolved completely(>90%) within 30 minutes at pH 6.0. Concluswns : Pancreatic enzyme preparations that survive in gastric acid but dissolve rapidly at pH 5.2 - 5.6 are probably more effective. Of the preparations tested Panzytrat and Pancrease-HL best meet this criterium. • THE IMPORTANCE OF THE PANCREATIC DUCT SEGMENT OF THE SPHINCTI~ OF ODDI (SO): WHY CONVENTIONAL SPHINCTEROPLASTY MAY FAIL IN RECURRENT PANCREATITIS. DJ Geenen, WJ Hogan, JE Geenen, J Kruidenier. Pancreatic B'diary Center of St. Lukes Hospital, Milwaukee, WI Sphincteroplasty is used in the treatment of patients with acute recUi'rent pancreatitis (ARP) secondary to suspected sphincter of Oddi (SO dysfunction. Some of these patients have recurrent attacks of pancreatitis despite apparently adequate sphincteroplasty, We have evaluated both the common bile duct (CBD) segment and pancreatic duct (PD) segment of the SO in a group of these patients. Methods: Nine patients (ages 38-72; mean 55 yrs) with recurrent episodes of panereatitis after previous sphincteroplasty (mean 18-24 mos) and nine age-matched control patients with prior endoscopic sphincteroplasty for CBD stones had manometric pressure measurement of both CBD/PD segments of the SO. If abnormalities in either segment of the SO was detected in ~the ARP patients at SOM, endoscopic therapy was performed. ~ Results: The CBD/duodenal pressure gradient and basal pressure of the CBD segment of the SO were ablated in all 18 patients. The basal pressure of the PD segment of the SO was intact (14.0+2.0 mmHg) in the 9 control patients; however, it was elevated in 8 of the 9 ARP patients (70 + 11 mmHg). The other ARP patient had elevated phasic wave pressure in the PD segment of the SO. Subsequently, the 9 ARP patients had PD sphineterotomy and/or dilation with stent placement. Seven of 9 ARF patients had repeat SOM within one year. Mean basal SO pressure in the PD segment was significantly reduced in the seven patients (12.5+2.0 mmHg). No further attacks of pancreatitis occurred during a mean follow-up of 7 years (range 2-13 yrs). Two patients did not improve; 1 patient had persistent basal pressure elevation of the PD segment of the SO; the other patient refused SOM. Both patients have experienced episodes of recurrent panereatitis. Conclusions: Recurrent attacks of panereatitis in ARP patients may be caused by SO dysfunction. Conventional sphincteroplasty may not ablate the PD segment of the sphincter of Oddi. SO manometry is necessary to identify a subgroup of patients with acute recurrent panereatitis who will benefit from endoscopic therapy of the pancreatic duct segment of the sphincter of Oddi. DOES THE USE OF OCTREOSCANNING ALTER MANAGEMENT IN PATIENTS WITH ZOLLINGER-ELLISON SYNDROME: A PROSPECTIVE STUDY.'? F. GibriL I.C. Reynolds, J.L. Doppman, C.C. Chela, B. Termanini, C.A. Stewart, R.T. Jensen. National Institutes of Health, Bethesda, MD Determination of the extent and location of the tumor is important in patients with pancreatic endocrine minor such as those With Zollinger-Ellison syndrome (ZES), both to determine resectability, increase the possibility of cure and evaluate responses to treatment in patients with advanced disease. Recently [mln-DTPA=DPhel]octreotide (OCTREOSCAN) has been released for this purpose in the U.S. Experience with this test is limited in the U:S., the test is expensive and itJs unclear how much additional information it adds to existing methods. To attempt to address this we prospectively studied 46 patients with ZES. Patients underwent standard imaging methods [(ultrasound, CT scan, MR], selective angiography (ANGLO)], and then had an octreoscan performed at 4 and 24 hrs poSt IV injection (6 mCi) of [mIn-DTPA-vPhel]octreotide (planar and SPECT images, Trionix Dual Head Gamma Camera). All octreoscan images were read without knowledge O f the results of the other imaging studies. The 46 patients had a mean age (.t_SEM) of 51+1.5 yrs, 57% were males, and 21% had MEN-I. Ultrasound, CT scan, MR] and ANGIO localized tumors in 23%, 36%, 47% and 49% of patients, with at least one of these modalities positive in 60% of patients. Octreoscan was positive in 76% of patients. 14 patients had liver metastases proven by biopsy or surgery and the octrenscan was positive for liver metastases in all patients, whereas at least one other imaging study was positive for liver metastases in 13/14 (92%). The octreoscan changed management in 47% of all cases. In 8 patients (17%) without metastatic liver disease it was the only modality to localize the primary tumor, in 7 patients it clarified the tumor status in a patient with a questionable result on another imaging study, and in 7 patients it demonstrated additional metastatic foci that altered management: 10 of the patients were new patients and in 8 of the 10, surgery or liver biopsy confirmed the octreosean results. These results demonstrate that the addition of the octreosean to existing tumor localization methods resulted in an alteration in clinical management in 47% of patients. It is concluded that the octreoscan is a valuable tumor localization method and should be routinely used in all patients with ZES.

Does the use of octreoscanning alter management in patients with Zollinger-Ellison syndrome: A prospective study?

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A356 AGA ABSTRACTS GASTROENTEROLOGY, Vol. 108, No. 4

FUNCTIONAL AND NUTRITIONAL RESULTS O F PYLORUS PRESERVING PANCREATICODUODENECTOMY FOR CHRONIC PANCREATrI 'IS. L Gambiez, A. Wurtz, A. Foumier, H. Porte, J.P. Chambon, P. Quandalle. Clinique Chirurgicale Ouest, - H6pital Claude Huriez - 59037 Lille cedex - France

The main advantage of pylorus preservation (laP) during pancreaticoduodenectomy (PD) is to avoid functional and nutritional consequences of the gastreetomy. For 22 patients with a chronic pancreatitis (CP), we evaluated the functional results of this procedure.

Between 1984 and 1992, a PD + PP was performed for 22 patients with at least one mechanical complication of a serious PC (19 males, 3 females, mean age : 39, follow up : 42 month). The functional results were assessed by a score including : pain, weigh gain, dyspepsia, professional activity, diabetes and steatorrhea. The possibility of a jejuno-gastric reflux was systematically checked using Tc - HIDA scintigraphy associated with a normal meal. Statistical analysis : Fisher Exact test.

Five patients had an early post operative complication with 2 death (9 %). A delayed gastric emptying (< 24 days) occurred in 6 cases and regressed spontaneously. Two margina! ulcerations healed under medical therapy. Three patients (13 %) died belatedly (> 18 month) of extra pancreatic diseases. Presently, 14 patients (82 %) are back to their previous weigh. Functional results are scored as follows : excellent (n = 9), good (n = 5), fair (n = 3). A jejuno-gastric reflux was observed in 5 cases (29 %), all of them occurred among 10 patients who had a duodenal compression pre operatively (p = 0,044).

This nutritional results are encouraging. DP + PP may be a good solution to treat particular forms o fCP : with predominant pain or when there is a doubt about an added pancreatic carcinoma.

IN VITRO DISSOLUTION PROFILES OF ENTERIC COATED MICROSPHERE PANCREATIN PREPARATIONS AT DIFFERENT pH VALUES. KI-] Gan I, Vc'P Geus 2'3, HGM Heijerman 1, W Bakker I, CBHW Lamers 3. 1Adult CF Centre and 2Dept of Intensive Care, Leyenburg Hospital, The Hague, 3 Dept of Gastroenterology, University Hospital Leiden, The Netherlands

Pancreatic enzyme supplen~ts (pancrcatin), given as enteric coated micrnspbere (~-'m) preparations, are the mainstay of therapy in pancreatic insufficiency as it occurs in cystic fibrosis. These preparations arc designed to survive in acidic gastric juice and to dissolve in the alkaline duodenum. Fat is absorbed in the proximal jejunum and enzyme supple- ments need to be released in the distal duodenum. Slowly dissolving preparations, in combination with very high dosages (> 40.000 U lipasc/kg/day) raise the risk of colonic strictures, as reported recently (Lancet 1994; 343: 615-6). There is little objective data on dissolution times of corn preparations at different pH levels. In healthy individuals, post-pmndial pH in the distal duodenum is 5.67 (our observations), lntralummal pH in the distal part of the duodenum of pancreatic insufficient patients will be considerably lower than 5.6 because of low or absent pancreatic bicarbonate production. Aim of this study was to measure dissolution time in buffer solutions of different pH, for 5 eem pancreatin preparations: 3 new high-strength and 2 regular strength preparations. Materials and methods: The following preparations were tested: Croon, Creon Forte (Solvay-Duphar), Panerease, Paneresse-HL (Cilag) and Panzytrat (Knoll). Two capsules were placed in buffer solution at 37°C in a British Phannaccpein (BP) dissolution testing apparatus. Fresh acetic acid / sodium'acetate buffer solutions with pH between 4.0 and 6.0 (intervals of 0.2 pH units) were used. Solutions were stirred at 125 rpm and the rate of dissolutien was monitored by taking 2 ml samples at m~ular intervals and measunng exlmctien at 280 nm, as described in BP. Measurements were repeated 6 times. Results: All preparations failed to dissolve at pH 4.0. Panzytrat and Pancrease-HL shmved within 1 hr: 40 and 55% dissolution at pH 5.0, rising to 67 and 79% dissolution at pH 5.2, and > 90% dissolution at pH > 5.4. Creon and Creon Forte Showed within 1 hr: < 25% dissolution at pH < 5.2, with sharply rising rate of dissolution to > 90% dissolution at pH 5.,:I. Panerease showed within 1 hr: < 25% dissolution at pH < 5.2, rising to 55% within 1 hr at pH 5.4, aad > 90% at pH > 5.6. All preparations dissolved completely (>90%) within 30 minutes at pH 6.0. Concluswns : • Pancreatic enzyme preparations that survive in gastric acid but dissolve rapidly at pH

5.2 - 5.6 are probably more effective. • Of the preparations tested Panzytrat and Pancrease-HL best meet this criterium.

• THE IMPORTANCE OF THE PANCREATIC DUCT SEGMENT OF THE SPHINCTI~ OF ODDI (SO): WHY CONVENTIONAL S P H I N C T E R O P L A S T Y M A Y F A I L I N R E C U R R E N T PANCREATITIS. DJ Geenen, W J Hogan, J E Geenen, J Kruidenier . Pancreatic B'diary Center of St. Lukes Hospital, Milwaukee, WI

Sphincteroplasty is used in the treatment of patients with acute recUi'rent pancreatitis (ARP) secondary to suspected sphincter of Oddi (SO dysfunction. Some of these patients have recurrent attacks of pancreatitis despite apparently adequate sphincteroplasty, We have evaluated both the common bile duct (CBD) segment and pancreatic duct (PD) segment of the SO in a group of these patients. Methods: Nine patients (ages 38-72; mean 55 yrs) with recurrent episodes of panereatitis after previous sphincteroplasty (mean 18-24 mos) and nine age-matched control patients with prior endoscopic sphincteroplasty for CBD stones had manometric pressure measurement of both CBD/PD segments of the SO. I f abnormalities in either segment of the SO was detected in ~the ARP patients at SOM, endoscopic therapy was performed. ~ Results: The CBD/duodenal pressure gradient and basal pressure of the CBD segment of the SO were ablated in all 18 patients. The basal pressure of the PD segment of the SO was intact (14.0+2.0 mmHg) in the 9 control patients; however, it was elevated in 8 of the 9 ARP patients (70 + 11 mmHg). The other ARP patient had elevated phasic wave pressure in the PD segment of the SO. Subsequently, the 9 ARP patients had PD sphineterotomy and/or dilation with stent placement. Seven of 9 ARF patients had repeat SOM within one year. Mean basal SO pressure in the PD segment was significantly reduced in the seven patients (12.5+2.0 mmHg). No further attacks of pancreatitis occurred during a mean follow-up of 7 years (range 2-13 yrs). Two patients did not improve; 1 patient had persistent basal pressure elevation of the PD segment of the SO; the other patient refused SOM. Both patients have experienced episodes of recurrent panereatitis. Conclusions: Recurrent attacks of panereatitis in ARP patients may be caused by SO dysfunction. Conventional sphincteroplasty may not ablate the PD segment of the sphincter of Oddi. SO manometry is necessary to identify a subgroup of patients with acute recurrent panereatitis who will benefit from endoscopic therapy of the pancreatic duct segment of the sphincter of Oddi.

DOES THE USE OF OCTREOSCANNING ALTER MANAGEMENT IN PATIENTS WITH ZOLLINGER-ELLISON SYNDROME: A PROSPECTIVE STUDY.'? F. GibriL I.C. Reynolds, J.L. Doppman, C.C. Chela, B. Termanini, C.A. Stewart, R.T. Jensen. National Institutes of Health, Bethesda, MD

Determination of the extent and location of the tumor is important in patients with pancreatic endocrine minor such as those With Zollinger-Ellison syndrome (ZES), both to determine resectability, increase the possibility of cure and evaluate responses to treatment in patients with advanced disease. Recently [mln-DTPA=DPhel]octreotide (OCTREOSCAN) has been released for this purpose in the U.S. Experience with this test is limited in the U:S., the test is expensive and itJs unclear how much additional information it adds to existing methods. To attempt to address this we prospectively studied 46 patients with ZES. Patients underwent standard imaging methods [(ultrasound, CT scan, MR], selective angiography (ANGLO)], and then had an octreoscan performed at 4 and 24 hrs poSt IV injection (6 mCi) of [mIn-DTPA-vPhel]octreotide (planar and SPECT images, Trionix Dual Head Gamma Camera). All octreoscan images were read without knowledge O f the results of the other imaging studies. The 46 patients had a mean age (.t_SEM) of 51+1.5 yrs, 57% were males, and 21% had MEN-I. Ultrasound, CT scan, MR] and ANGIO localized tumors in 23%, 36%, 47% and 49% of patients, with at least one of these modalities positive in 60% of patients. Octreoscan was positive in 76% of patients. 14 patients had liver metastases proven by biopsy or surgery and the octrenscan was positive for liver metastases in all patients, whereas at least one other imaging study was positive for liver metastases in 13/14 (92%). The octreoscan changed management in 47% of all cases. In 8 patients (17%) without metastatic liver disease it was the only modality to localize the primary tumor, in 7 patients it clarified the tumor status in a patient with a questionable result on another imaging study, and in 7 patients it demonstrated additional metastatic foci that altered management: 10 of the patients were new patients and in 8 of the 10, surgery or liver biopsy confirmed the octreosean results. These results demonstrate that the addition of the octreosean to existing tumor localization methods resulted in an alteration in clinical management in 47% of patients. I t is concluded that the octreoscan is a valuable tumor localization method and should be routinely used in all patients with ZES.