42nd European Pancreatic Club (EPC) Meetingukb.lf1.cuni.cz/abstrakta/epc2010_abstr.pdf · 264 Pancreatology 2010;10:259–400 42nd European Pancreatic Club (EPC) Meeting Antitrypsin-Gene

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Pancreatology 2010;10:259–400 Published online: May 18, 2010DOI: 10.1159/000314328

The abstracts are only available online, free of charge, underwww.karger.com/doi/10.1159/000314328

42nd European Pancreatic Club (EPC) Meeting

Contents

Oral Sessions Acute Pancreatitis Abstracts O1–O12 262Cancer Host Interaction Abstracts O13–O21 267Chronic Pancreatitis Abstracts O22–O33 271Autoimmune Pancreatitis Abstracts O34–O39 275Pancreatic Cancer Abstracts O40–O51 278

Nordic Light Oral Sessions Nordic Light Session I Acute Pancreatitis 1 Abstracts NLS1–NLS3 283Acute Pancreatitis 2 Abstracts NLS4–NLS6 284

Abstracts June 16–19, 2010,Stockholm, Sweden

Guest EditorsJ.-Matthias Löhr, StockholmRalf Segersvärd, StockholmJohan Permert, Stockholm

Pancreatology 2010;10:259–400260 42nd European Pancreatic Club (EPC) Meeting

Chronic Pancreatitis 1 Abstracts NLS7–NLS9 286Chronic Pancreatitis 2 Abstracts NLS10–NLS12 287Physiology 1 Abstracts NLS13–NLS14 288Surgery 1 Abstracts NLS15–NLS17 289

Nordic Light Session II Quality of Life Abstracts NLS18–NLS19 290Autoimmune Pancreatitis Abstracts NLS20–NLS22 291Cell Biology Abstracts NLS23–NLS25 292ERCP Abstracts NLS26–NLS28 293Heredity & Genetics Abstracts NLS29–NLS30 294Surgery 2 Abstracts NLS31–NLS33 295

Nordic Light Session III Endoscopy Abstracts NLS34–NLS36 297Expression Profiling Abstracts NLS37–NLS38 298Pancreatic Cancer Abstracts NLS39–NLS40 299Pathology Abstracts NLS41–NLS43 300Physiology 2 Abstracts NLS44–NLS46 302Surgery 3 Abstracts NLS47–NLS49 303

Oral-Poster Sessions Oral-Poster Session I Abstracts OP1–OP10 305Oral-Poster Session II Abstracts OP11–OP20 309Oral-Poster Session III Abstracts OP21–OP30 313Oral-Poster Session IV Abstracts OP31–OP34 317Oral-Poster Session V Abstracts OP35–OP44 319

Poster Sessions Poster Session I Basic Science – Physiology, Cell Biology & Development Abstracts P1–P6 323

Pancreatology 2010;10:259–400 261Contents

Basic Science – Acute Pancreatitis Abstracts P7–P20 325Basic Science – Chronic Pancreatitis Abstracts P21–P22 331Basic Science – Pancreatic Cancer Abstracts P23–P52 331Clinical Science – Acute Pancreatitis Abstracts P53–P85 343Clinical Science – Chronic & Autoimmune Pancreatitis Abstracts P86–P97 356

Poster Session II Clinical Science – Pancreatic Cancer Abstracts P98–P132 360Clinical Science – Endocrine & Rare tumors Abstracts P133–P145 375Clinical Science – Endoscopy, Techniques & Imaging Abstracts P146–P173 380Clinical Science – Miscellaneous Abstracts P174–P180 391

Author Index 394

ErratumIn a previous version, abstracts O47 and P99 are identical. Abstract O47 has been replaced in this publication by the correct abstract.

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Oral Sessions

Acute Pancreatitis

O1

The Molecular Role of the Unfolded Protein Response in PancreatitisE.N. Fazio1, C.L. Pin1

1Department of Physiology and Pharmacology, University of Western Ontario; Children’s Health Research Institute and Department of Paediatrics, London Health Sciences Centre

Introduction: Accumulation of unfolded proteins in the endo-plasmic reticulum (ER) leads to activation of compensatory signaling cascades, collectively termed the unfolded protein response (UPR). Activation of the UPR enhances cell survival by alleviating protein load through decreased translation and increased degradation. Previous studies revealed activation of the UPR in the pancreas dur-ing L-arginine- or cerulein-induced pancreatitis (CIP). However, the role of the UPR during pancreatitis is currently unknown.

Objectives: The aim of this study was to determine the role of the UPR following initiation of pancreatitis by assessing a link to MIST1, a transcription factor required for acinar cell terminal differ-entiation.

Materials and Methods: C57Bl/6 mice were treated with ceru-lein (50 mg/kg) or tunicamycin (1 mg/kg) for up to 8h. Pancreatic tissue, protein and RNA were isolated for immunofluorescent, west-ern and northern blot analysis, respectively. Primary cultures of aci-nar cells were treated with the ER stressor tunicamycin, and chromatin immunoprecipitation (ChIP) performed.

Results: Analysis of MIST1 expression during CIP revealed decreased MIST1 protein concomitant with the loss of junctional complexes and apical PKC localization. Pancreatic MIST1 expres-sion was also decreased after in vivo treatment with tunicamycin, illustrating a link between Mist1 expression and the ER stress response. ChIP analysis determined that XBP1, a mediator of the UPR, occupies the Mist1 promoter in primary acinar cells during tunicamycin treatment.

Conclusion: Our studies indicate that CIP results in the loss of acinar cell differentiation characteristics at the same time that MIST1 expression is decreased. This change may be due, in part, to transcrip-tional activity of the UPR.

O2

Deletion of the Serine Protease Cathepsin G Ameliorates Systemic but Not Local Injury of Experimental PancreatitisA.A. Aghdassi1, M. Sendler1, C. Storck1, F.U. Weiss1, M.M. Lerch1, J. Mayerle1

1Department of Medicine A, University of Greifswald, Germany

Introduction: Neutrophils significantly contribute to the sever-ity of acute pancreatitis and can directly induce premature intracellu-lar protease activation and necrosis. Cathepsin G, a serine protease stored in azurophilic granules of neutrophils, could mediate local and systemic injury in acute pancreatitis.

Objectives: We studied the course of experimental pancreatitis in cathepsin G (CTSG)-deleted animals (Blood 1999;94:4282-4293).

Materials and Methods: Pancreatic acini were assessed for cathepsin G expression. Acute pancreatitis was induced by repetitive caerulein injections in CTSG-deficient mice. Over 24 hours we stud-ied serum lipase and amylase, histology, myeloperoxidase and trypsin activation, as well as cytokine levels. Direct effects of CTSG were investigated by co-incubation of purified CTSG as well as spleno-cytes from CTSG-/- mice with isolated acini.

Results: Cathepsin G was not expressed in acinar cells. Experimental pancreatitis of CTSG-deficient animals was character-ized by an ameliorated systemic inflammatory response characterised by decreased MPO levels in pancreas and lung as well as serum TNFa. However, local injury was not affected. Serum lipase and amy-lase levels as well as pancreatic histology were not influenced by CTSG knock-out. Incubation of isolated pancreatic acini with puri-fied CTSG did not result in intracellular trypsin activation or acinar cell necrosis nor did co-incubation of splenocytes from CTSG-/- ani-mals result in reduced intracellular zymogen activation.

Conclusion: CTSG is neither synthesized nor secreted by acinar cells. We rule out a direct effect of CTSG on intracellular premature protease activation as the earliest event in pancreatitis. The beneficial effect of CTSG deletion might be exerted by the prevention of neutro-phil transmigration into the pancreas during experimental pancreatitis.

Pancreatology 2010;10:259–400 263Abstracts

O3

LFA-1 Regulates Leukocyte Recruitment in Severe Acute PancreatitisD. Awla1, A. Abdulla1, H. Hartman1, S. Zhang1, S. Regnér1, H. Thorlacius1

1Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden

Introduction: Leukocyte infiltration and trypsinogen activation are crucial events in the pathophysiology of pancreatitis. Lymphocyte function-associated antigen 1 (LFA-1) is found on T cells, B-cells, macrophages and neutrophils and it has an essential role in their recruitment to the site of inflammation.

Objectives: Our aim is to show whether LFA-1 has effect on leukocyte recruitment, trypsinogen activation and tissue damage in severe acute pancreatitis.

Materials and Methods: Pancreatitis was induced by retro-grade infusion of sodium taurocholate into the pancreatic duct in C57BL/6 & LFA-1 knock out mice. C57BL/6 were treated with either saline or anti-LFA-1 antibody before induction of pancreatitis.

Results: Taurocholate infusion caused an obvious increase in serum amylase, pancreatic leukocyte infiltration, acinar cell necrosis, oedema formation & pancreatic haemorrhage. Levels of pancreatic myeloperoxidase (MPO), pancreatic & serum macrophage inflamma-tory protein-2 (MIP- 2), pancreatic trypsinogen activation peptide (TAP) and lung MPO were significantly increased confirming local and systemic disease. Both genetically cancelling & biologically antagonizing LFA-1 resulted in significantly lower levels of pancre-atic oedema, acinar cell necrosis, haemorrhage, pancreatic & lung MPO and serum amylase as well as serum and pancreatic MIP-2 lev-els compared to C57BL/6 mice. However, TAP levels were similar in all groups.

Conclusion: Our novel data suggests that LFA-1 has a critical role in leukocyte recruitment but not in trypsinogen activation in acute pancreatitis.

O4

PKC Delta Mediates Pro-inflammatory Responses in a Mouse Model of Caerulein Induced Acute PancreatitisM. Bhatia1, R. Ramnath2

1University of Otago, Christchurch, 2National University of Singapore

Introduction: Acute pancreatitis is an inflammatory disorder of the pancreas. Protein kinase C (PKC) delta plays an important role in mediating chemokine production in mouse pancreatic acinar cells.

Objectives: This study aims to investigate the role of PKC delta in the pathogenesis of acute pancreatitis and to explore the mechanisms through which PKC delta mediates pro-inflammatory signaling.

Materials and Methods: Acute pancreatitis was induced in mice by 10 hourly intra-peritoneal injection of caerulein. PKC delta translocation inhibitor peptide (delta V1-1) at dose of 1.0 mg/kg or Tat (carrier peptide) at a dose of 1.0 mg/kg was administered to mice

either 1 h before or 1 h after the first caerulein injection. 1 h after the last caerulein injection the mice were sacrificed and pancreas, lungs and blood were collected for further analysis such as plasma amylase activity, pancreatic water content, tissue myeloperoxidase (MPO) activity, and ELISA and Western blot analysis.

Results: Prophylactic and therapeutic treatment with delta V1-1 attenuated caerulein-induced plasma amylase levels and pancreatic edema. Treatment with delta V1-1 decreased myeloperoxidase activ-ity and monocyte chemotactic protein-1 levels in both pancreas and plasma.

PKC delta mediated acute pancreatitis by activating pancreatic nuclear factor kappaB, activator protein-1 and mitogen-activated pro-tein kinases. Moreover, blockade of PKC delta attenuated lung myeloperoxidase activity and edema. Histological examination of pan-creatic and lung sections confirmed protection against acute pancreati-tis. Treatment with Tat had no protective effect on acute pancreatitis.

Conclusion: These results suggest that blockade of PKC delta represents a promising prophylactic and/or therapeutic tool for the treatment of acute pancreatitis.

O5

Constitutive Activation of RelA/p65 in the Pancreas Protect from Acute Pancreatitis by Upregulating the Serine Protease Inhibitor Spi2AM. Treiber2, P. Neuhöfer2, C. Schwerdtfeger2, Z. Hong2, H. Schulz4, T. Wartmann3, H. Witt1, W. Halangk3, R.M. Schmid2, H. Algül2

1Else-KrönerElse-Kröner-Fresenius-Zentrum für Ernährungsmedizin, Technical University of Munich, 2II. Medizinische Klinik, Klinikum rechts der Isar, Technical University of Munich, 3Department of Experimental Surgery, Otto-von-Guericke-University of Magdeburg, 4Department of Surgery, Otto-von-Guericke-University of Magdeburg

Introduction: The transcription factor NF-κB/Rel is rapidly activated during the onset of acute experimental pancreatitis.

Objectives: Its role in this disease, however, is discussed con-troversially.

Materials and Methods: Here we studied the role of the inhib-itor protein IB during acute pancreatitis using the Cre-loxP strategy in mice.

Results: Selective deletion of the ikba gene in pancreatic exo-crine (ikbaF/F)cells resulted in nucleartranslocation of endogenous RelA/p65. Acute experimental pancreatitis in these mice (ikba panc) turned out to be attenuated with respect tolocal and systemic injury. The protective effect in these mice depends onnuclear RelA/p65 in the acinar cells. Micro-Array-analysis in wildtype, IkBa or RelA/p65 deficient pancreas revealed differentially regulated genes, among which serpina 3g (protein Spi2A) was significantly upregulated in ikbapanc and downregulated in relapanc compared to wildtype. Further analyses revealedthat Spi2A is directly regulated by RelA/p65. In line with this observation, trypsin activity in IB deficient mice was dramatically reduced. Tofurther elucidate the role of serpina 3g we identified several SNPs in Exon 2 of the human analogue Alpha1-


Antitrypsin-Gene. However, none of the SNPs was associated with severityof acute pancreatitis or chronic pancreatitis in human.

Conclusion: Our data therefore suggest for the first time thatp-reactivation of NF-B inthe pancreas might serve as novel and protec-tive preconditioning maneuver thatmight be of therapeutic relevance in clinical settings. Moreover, we provideevidence for a cross-link of the IKK/NF-B/Rel pathway to conversion of trypsinogen to trypsin.

O6

Water, Fire and Burning Ashes: May Aquaporin Kinetic and Gene Expression Help Figuring Out Further Understanding of Acute Edematous Pancreatitis?F. Marotta1, Y. Naito2, H. Yadav3, R. Daccò1

1Emergency Unit, SG Hospital, Milano, Italy, 2Immunology Res Center & Clinic, Nagoya, Japan, 3Regenerative Medicine Section, NIDDK, National Instiute of Health, Bethesda, USA

Introduction: The clinical course in some cases of oedematous form of acute pancreatitis (AP) seem to follow pathophysiological mechanisms to be fully predicted and unfolded as yet. In virtually all cases marked oedema of the parenchyma is observed and such changes are displayed by the classical experimental caerulein-induced AP. Aquaporins (AQP) are widely distributed in mammals and repre-sent a family of membrane proteins controlling water channel, regu-lating cellular permeability and transport in health as well as in disease. To the best of our knowledge, there is a paucity of data regarding AQPs status in acute pancreatitis.

Objectives: The aim of the present investigation was to study and to monitor ACQs localization and functional genomic expression in early caerulein-induced AP in view of getting further insights into their possible role in phenotypic expression of the disease.

Materials and Methods: Male Wistar rats weighing 200-230g and aged 8 months were housed in individual cages in an environmen-tal-controlledvivarium. Under phenobarbital anaesthesia 10ug/kg/h of caerulein was infusedfor 3h to induce AP and sacrifice were made at 3h and 72h afterwards. Pancreases were excised and examined for histology. In particular, the expression of AQP1 and AQP8 was exam-ined by specificRT-PCR (AQP1: 5’-CTGGGTGGGACCATTCATTG-3’ and 5’TGCGGTCTGTAAAGTCGC TG-3’; AQP8:5’-GCCTAAT GAGCAGTCCCACAA-3’ and 5’-TGGATCTCACTGGCTGGG CCCAGCTC-3’).

Results: Control pancreases showed AQP1 and AQP8 localized in pancreatic ductal cells together with capillaryendothelia and in aci-nar cells, respectively. During early phase (3h) of AP, AQP1 expres-sion significantly decreased in all sites and further worsened lateron (72h) despite overall histological improvement of AP. The same pat-tern wasobserved with AQP8 at 3h but this level remained stable at 72h observation. Onthe other hand, immunoblot showed unchanged band densitometry for protein levelof AQP1 but decreased for AQP8 (at 3h and 72h). At immunohistochemistry AQP1 disappeared induc-tal cells (looking normal at histology) but strongly increased in capil-laryendothelia. AQP8 disappeared in the apical membrane of acinar cells at 3h butless than 50%was detected at 72h.

Conclusion: The gene expression/protein level discrepancy noted for AQP1 and AQP8 are likely due to different turnover and half life. On the other hand, “normal” histology may still hide signifi-cant prolonged epigenomic abnormalities which warrant further stud-ies aimed in view of possible implication for the clinical course of AP.

O7

The Effect of Early vs. Delayed Enteral Nutrition on Gastrointestinal and Immune Function of the Patients with Severe Acute Pancreatitis. A Randomized Controlled Clinical TrialW. Li1, F. Qiu1, Z. Tong1, X. Wang1, W. Yu1, N. Li1, J. Li1

1SICU Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China,

Introduction: Many studys indicated that enteral nutrition is beneficial to maintain the gut barrier function and improve prognosis. We supposed that early enteral nutrition (EEN) have more advantages on gastrointestinal and immune function of the patients with severe acute pancreatitis (SAP) over the delayed enteral nutrition (DEN).

Objectives: To compare EEN VS DEN on the gastrointestinal function and immune function in patients with SAP.

Patients and Methods: 40 patients with SAP were random-ized into EEN and DEN group. Patients in EEN were laid nasal-intes-tine feeding tube under X ray or endoscope in the jejunum, began enteral nutrition within 4 days after the onset of rhe disease. Wile patiens in DEN group received TPN for 7 days, and then were switched to enteral nutrition (same as the EEN group). The gastroin-testinal motility (gastrointestinal function score, intra-abdominal pressure, MTL, CCK), intestinal barrier function (the rate of lactulose / mannitol), and immune function (HLA-DR) were observed.

Results: The mortality and the CT score were not different between two groups. But the surgery rate(5% vs 30%, P < 0.01) were significantly lower in the EEN group;. the intra-abdominal pressure, gastrointestinal score were significantly lower in EEN group; the serum motilin levels was significantly higher in the EEN group . HLA-DR levels in EEN group were significantly higher than DEN group (60.39±15.33% vs 46.44±21.77%, P < 0.05).

Conclusion: Compare with DEN, EEN significantly improved the intestinal barrier function, improve the gastrointestinal motility and immune function.


O8

Genetic Variant (c.760 C > T; R254W) in the Chymotrypsinogen C (CTRC) Gene is Not Associated with Pancreatitis in a US PopulationA. Lozano-Leon1, B. Diergaarde2, V. Muddana3, M. O’Connell4, D.C. Whitcomb5

1University Hospital of Santiago de Compostela, Santiago de Compostela, Spain, 2Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh PA, USA

Introduction: Mutations in the Chymotrypsinogen C (CTRC) gene have been reported to be associated with chronic pancreatitis (CP).

Objectives: Our aim was to determine if genetic variants in CTRC exon 2, 3 or 7 are associated with recurrent acute pancreatitis (RAP) or CP in the United States.

Materials and Methods: Subjects from the North American Pancreatitis Study 2 (NAPS2) cohort were studied (RAP, n = 412; CP, n = 455; control, n = 601). Exon 2-3 and exon 7 were amplified for sequencing (CP, n = 348; control, n = 303) and screening using RFLP for R254W [c.760 C > T] (CP, n = 455, RAP, N = 412; control, n = 601).

Results: Four previously reported variants were detected; G60G (180 C > T); A73T (217 G > A); R254W (c. 760 C > T) and c. 811 G > T. There was no difference in frequency of variants between CP and con-trols for G60G (21.3 vs 19.8, p = 0.12), A73T (0.5% vs 0%), c.811 (40% vs 47%, p = 0.30) or R245W (0.6% vs 0.5%, p = 1.0). Likewise, there was no association between RAP and CTRC variants.

Conclusion: The most common CTRC variants associated with CP in Europe and India were not associated with CP or RAP in the USA. Deep sequencing of the CTRC gene will be necessary to deter-mine if risk of CP or RAP is associated with rare variants.

O9

TNFB Polymorphism in Patients with Acute Pancreatitis (AP) in Association with Cytokine Level and Disease SeverityD. Baczewska-Mazurkiewicz1, B. Stpien1, J. Rutkowska3, W. Olszewski3, M. Zagozda3, G. Rydzewska1, A. Rydzewski2

1Gastroenterology Dept. CSK MSW i A, Warsaw, Poland, 2Nephrology Dept. CSK MSW i A, Warsaw, Poland, 3Intitute of Experimental and Clinical Medicine, Polish Academy of Sciences, Warsaw, Poland

Introduction: Polymorphisms in the regulatory regions of cytokine genes can affect the level of cytokine production, and may be associated with predisposition to diseases and different clinical outcomes. Recently we have found higer frequency of TNFalfa G-308A(GG), TLR2 G-2259A(GG) and TLR2 G-2259A(GA) geno-types in AP patients.

Objectives: The aim of present study was to evaluate plasma level and its association with different cytokine polymorphisms and disease severity.

Patients and Methods: We investigated, in a prospective man-ner, 300 AP patients and 108 controls.

The severity of AP was stratified according to Ranson and Balthazar scale, CRP level and Atlanta criteria. Genomic DNA was isolated from the whole blood. Polymorphisms to TGFß1 (T29C, G74C) were genotyped using PCR-RFLP. Blood samples were taken on 1,3 and 7 day after admission in AP patients and in 40 controls. We examined serum level of TGF1 by ELISA.

Results: Frequency of TGF1 T29C (CC and TT) genotypes were significantly higher (3,5 vs 0,0% and 77,5 vs 12,3%) (p‹0,0001), whereas CT genotype was less frequent (6,1 vs 32,1%) (p‹0,0001) in AP patients as compared to control group. No association with AP was found for TGF1 G74C polymorphism. No differences between mild and severe AP were observed. TGF1 serum level were signifi-cantly elevated in AP group compared with controls (p‹0,001). No diffirence however was found in TGF1 level between severe and mild acute pancreatitis.

Conclusion: The TBF1 T29C TT and CC genotypes may be a risk factor for the development of AP. No differences however were found in genotypes frequency and serum level of TGF1 between mild and severe AP.

O10

Minimally Invasive Step-up Approach versus Open Necrosectomy in Necrotizing Pancreatitis: A Randomized Controlled Multicenter TrialH.C. van Santvoort1, M.G. Besselink1, O.J. Bakker1, H.S. Hofker2, M.A. Boermeester2, C.H. Dejong2, H. van Goor2, A.F. Schaapherder2, C.H. van Eijck2, T.L. Bollen2, B. van Ramshorst2, V.B. Nieuwenhuijs2, R. Timmer2, P.M. Kruyt2, E.R. Manusama2, E. van der Harst2, G.P. van der Schelling2, C.J. van Laarhoven2, E. Buskens2, H.G. Gooszen1

1University Medical Center Utrecht, The Netherlands, 2Other hospitals from the Dutch Pancreatitis Study Group

Introduction: Standard treatment for infected necrotizing pan-creatitis in most centers is open necrosectomy. Outcome may be improved by a minimally invasive step-up approach.

Objectives: To compare open necrosectomy with a step-up approach in patients with (suspected) infected necrotizing pancreati-tis in terms of clinical and economic outcomes.

Patients and Methods: We randomized 88 patients with (sus-pected) infected necrosis to primary open necrosectomy or a step-up approach in 19 hospitals. The step-up approach consisted of percuta-neous drainage followed, if necessary, by minimally invasive retro-peritoneal necrosectomy. The primary endpoint was a composite of major complications (new onset multi-organ failure, perforation of a visceral organ or enterocutaneous fistula, bleeding) and death. Secondary endpoints included other complications and total costs.

Results: The primary endpoint occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%)


assigned to the step-up approach (RR 0.57; 95%-CI 0.38-0.87; P = 0.006).

In the step-up approach group, 35% of patients were treated with percutaneous drainage only and did not require necrosectomy. New onset multi-organ failure occurred less often in the step-up approach group (12% versus 40%; P = 0.002). At 6 months follow-up, patients in the step-up approach group had a lower rate of incisional hernias (7% versus 24%; P = 0.03) and new onset diabetes (16% versus 38%; P = 0.02). Mean total costs per patient were €10,839 (12%) lower with the step-up approach.

Conclusion: A minimally invasive step-up approach, as com-pared to open necrosectomy, reduced the rate of the composite end-point of major complications and death, and long-term morbidity and costs in patients with (suspected) infected necrotizing pancreatitis.

O11

Changes in Pancreatic Endocrine and Exocrine Function After First Acute Alcoholic PancreatitisJ. Sand1, R. Lappalainen-Lehto1, S. Järvinen1, H. Pelli1, S. Räty1, I. Nordback1

1Department of Gastroenterology and Alimentary Tract Surgey, Tampere University Hospital, Finland

Introduction: Acute pancreatitis may cause diabetes and impaired exocrine function, but especially after mild pancreatitis the possible changes in pancreatic function are poorly documented.

Objectives: The cohort of patients (Gastroenterology 2009;136:848-55.) were further followed for their pancreatic function after first acute alcoholic pancreatitis.

Patients and Methods: Patients were followed up to 7 yrs. Patients were interviewed for possible recurrent acute pancreatitis and offered faecal elastase tests and tests for glucose metabolism.

Results: 49/119 initial patients were continuing in March 2010. 33/119 patients developed recurrent pancreatitis. 7 patients had dia-betes already prior to acute pancreatitis. New onset diabetes was observed in 24 patients and tended to be more common in patients with recurrent attacks (41% vs. 21%; p = 0.08). The number of patients with impaired glucose metabolism increased throughout the follow up. In patients without recurrent pancreatitis the mean faecal elastase activity increased up to 3 yrs and then slowly decreased. Although the mean elastase activities were in normal range throughout the follow up, the proportion of patients with abnormally low elastase values (< 100 ug/g) was also at its lowest 3 yrs after the initial pancreatitis. Of the patients who developed diabetes but did not suffer from recurrent pancreatitis 23% developed exocrine pancreatic insufficiency whereas 60% of patients with low elastase activity had also diabetes. The pan-creatic function during the follow up did not correlate with the sever-ity of the initial pancreatitis.

Conclusion: The risk for new onset diabetes increases during years after acute alcoholic pancreatitis whereas the pancreatic exo-crine function improves for the first 2 - 3 yrs and impairs thereafter. Most of the patients with exocrine insufficiency also have diabetes.

O12

Intravenous Procaine and Clinical Course of Acute PancreatitisJ. Keller1, H. Bronisch3, U.M. Henniges1, I. Koop4, M. Kahl1, A. Dignass5, C. Ell6, M. Freitag2, P. Layer1

1Dept. Internal Medicine, Israelitic Hospital, Hamburg, Germany, 2Dept. Anaesthesiology and Intensive Care Medicine, Israelitic Hospital, Hamburg, Germany, 3Dept. Internal Medicine, Katholisches Krankenhaus St. Nepomuk, Erfurt, Germany, 4Dept. Internal Medicine, Amalie Sieveking-Krankenhaus, Hamburg, Germany, 5Dept. Internal Medicine, Charite Berlin, Campus Virchow Klinikum, Berlin, Germany, 6Dept. Gastroenterology, Dr. Horst Schmidt-Kliniken, Wiesbaden, Germany

Introduction: Intravenous (IV) local anaesthetics have been reported to induce significant improvements of clinical course in severe abdominal alterations including major abdominal surgery. Beneficial effects have been attributed to a combination of anti-inflam-matory, antiinfectious, neuroprotective, and motility-modulating effects that are highly attractive for therapy of acute pancreatitis (AP).

Objectives: We aimed to investigate whether IV procaine improves the clinical course in patients with AP.

Patients and Methods: 46 consecutive patients with AP received IV infusion of procaine (2g/24h) or placebo for 72h in a randomized, double blind fashion. Serum CRP levels, number of complications, gastrointestinal motility disturbances, duration of hos-pitalization and occurrence of adverse events were monitored at base-line, every 24h over 3 days and/or on hospital discharge.

Results: No deaths occurred in either group and no severe adverse events unrelated to pancreatitis. Serum CRP and motility dis-turbances were similar in both groups. On admission, 23% of patients assigned to placebo, and 42% patients assigned to procaine, presented with a complication of pancreatitis. During the first 72 hours, preva-lence of complications nearly doubled in the placebo group (to 42%); by contrast, it decreased in the procaine group (to 35%; p = 0.085 vs placebo). The median length of hospital stay did not differ between groups (placebo, 9.6 days; procaine, 10.6 days). However, the propor-tion of patients still hospitalised after 14 days was 38% following placebo treatment, but only 8% after procaine treatment (p = 0.012).

Conclusion: IV procaine appears to mitigate the severity of AP and to improve the clinical course of the disease. Thus, larger clinical trials should be encouraged.


Cancer Host Interaction

O13

Tumor Protein 53 Induced Nuclear Protein 1 (TP53INP1) in Pancreatic Cancer Cell MigrationM. Seux1,2, S. Peuget1,2, M.P. Montero3, C. Siret3, V. Rigot3, L. Pouyet1,2, P. N’guessan1,2, S. Garcia1,2, J.L. Iovanna1,2, A. Carrier1,2, F. André3, N. Dusetti1,2

1INSERM, U624 «Stress cellulaire», Marseille, 2Aix-Marseille Université, Campus de Luminy, Marseille, 3INSERM U911, CRO2, Aix-Marseille Université, Marseille, France

Introduction: TP53INP1 is a p53 target gene that modulates cell growth and apoptosis. TP53INP1 is able to suppress pancreatic tumor development.

Objectives: The aim of this work is to characterize a potential role for TP53INP1 in pancreatic cancer cell migration.

Materials and Methods: In order to study the role of TP53INP1 in migration, an in vivo mouse model of skin wound healing and two in vitro assays (wound healing and Boyden chamber assays) were performed. Two complementary cell lines were analyzed:TP53INP1+/+ or -/- transformed Mouse Embryonic Fibroblasts (MEF) and the TP53INP1-null human pancreatic adenocarcinoma.

MiaPaCa2 cell line, modified to have an inducible expression of TP53INP1.

Results: In order to analyze the role of TP53INP1 in migration, skin wounds were made on the backof TP53INP1+/+ or -/- mice. We showed that wound repair was faster in TP53INP1-/-mice compared to TP53INP1+/+ mice. This phenotype seemed to be linked to decreased fibroblasts migration. In vitro, we showed that TP53INP1 expression reduced cell migration. Using transcriptomic analyses on TP53INP1-expressing or -null tumors, we showed that TP53INP1 reduces SPARC (Secreted protein acidicand rich in cysteine) expres-sion. SPARC is a secreted protein implicated in cell migration and has an increased expression in pancreatic tumors and metastasis. Given that TP53INP1 expression decreases during pancreatic tumorigenesis, SPARC is an interesting candidate to explain TP53INP1 implication in cell migration. Modulation of SPARC expression showed that TP53INP1-induced SPARC repression leads to migration reduction.

Conclusion: We describe here a novel function for TP53INP1 in regulation of pancreatic cancer cell migration via modulation of SPARC expression.

O14

Early Fractalkine Receptor (CX3CR1) Expression in Pancreatic Ductal Adenocarcinoma and Neural InvasionL. Laghi1, P. Bianchi1, F. Marchesi1, A. Destro1, L. Piemonti2, D. Rahal1, A. Zerbi1, M. Roncalli1, M. Montorsi1, A. Mantovani1, A. Malesci1, P. Allavena1

1IRCCS Istituto Clinico Humanitas, 2IRCCS Istututo San Raffaele

Introduction: Ductal pancreatic adenocarcinoma (PAD) exp-resses chemokine receptors, which can promote migration, invasion and metastasis. The fractalkine receptor CX3CR1, involved in neural adhesion, is a candidate mediator for PAD neural invasion (NI).

Objectives: To assess whether 1) PAD expresses CX3CR1, and 2) neural invasion correlates with CX3CR1 expression.

Materials and Methods: The study series included 85 consec-utive pancreatic cancers (65 PAD, 14 ampullary, and 6 endocrine), of known stage (TNM classification), grade and NI (27 PAD+). 15 PAD specimens also contained early ductal neoplastic lesions (Pancreatic Intraductal Neoplasia, PanIN). CX3CR1 expression, assessed by immunohistochemistry, was scored as negative/low (L) and high (H).

Results: 30 (46%) PAD showed H-CX3CR1, but 2 (14%) amp-ullary (p = 0.02), and 0 endocrine (p = 0.03) cancers did. In the 15 PAD with PanIN (13 H-CX3CR1), the H-expression rate increased from normal ducts and PanIN1 (19/66, 29%), to PanIN2 (27/41, 66%) and PanIN3 (29/38, 76%) (p < 0.001). NI was seen in 15 (50%) H- and in 12 (34%) L-CX3CR1 PAD (p = 0.02). Among 25 PAD with no lymph-node metastasis (N0), NI was present in 8 of 12 (75%) high- but in 3 of 13 (23%) LCX3CR1 (p = 0.03).

Conclusion: CX3CR1 expression increases selectively in PAD, and anticipates malignant transformation and invasion, potentially contributing to neoplastic progression. Our data also suggest that H-CX3CR1 participates to PAD NI early, before lymph-node inva-sion. CX3CR1 contribution to local PAD progression and NI deserves further investigation in the light of its potential to discriminate a sub-group of locally, neural-invasive PAD.

O15

Tenascin-C Affects Pancreatic Cancer Cell Migration and Invasion and Interferes with Fibronectin Adhesive FunctionI. Paron1, S. Berchtold1, M. Tost1, M. Shamarla1, I. Esposito1

1Institute of Pathology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany

Introduction: Pancreatic cancer (PDAC) is characterized by an abundant fibrous tissue rich in extracellular matrix (ECM) proteins. Tenascin-C (TNC) is a large ECM glycoprotein whose levels of expression increase in the progression from low-grade precursor lesions (PanIN) to PDAC.


Objectives: Aim of this study was the validation of the pro-posed role of TNC in the early steps of pancreatic carcinogenesis using a genetically engineered mouse model, as well as the functional characterization of the effects of exogenous TNC on the properties of pancreatic cancer cell lines.

Materials and Methods: Immunohistochemistry was made on LSL-KRASG12D/+;Ptf1a+/Cre(ex1) mice to determine the expres-sion of TNC in PanINs and PDAC. To study the effects of TNC on cancer cells, in vitro assays such as wound healing assays, adhesion assays and viability tests were performed. In addition, immunoblot-ting and immunofluorescence experiments were done to examine if TNC may activate the integrin signalling pathway.

Results: TNC stromal expression is increased in mouse pancre-atic stroma starting from the early phases of carcinogenesis. TNC promotes cell migration, invasion as well as adhesion of pancreatic cancer cells to the uncoated growth surface. In contrast, cell adhesion to fibronectin is significantly decreased in the presence of TNC. The effects of TNC on cell adhesion are paralleled by changes in the acti-vation state of Akt and paxillin proteins.

Conclusion: Our data suggest that TNC plays a role in PDAC spreading and metastasis in vivo by affecting cell motility, invasive-ness and adhesion, these effects being different depending on the microenvironment.

O16

Notch2 Is Required for Panin Progression and Development of Pancreatic Ductal AdenocarcinomaP. Mazur1, H. Einwächter1, M. Lee1, B. Sipos2, H. Nakhai1, R. Rad3, U. Zimber-Strobl4, L. Strobl4, F. Radtke5, G. Klöppel6, R.M. Schmid1, J. Siveke1

1II. Med. Dep., Technical University of Munich, Germany, 2Dep. of Pathology, University Hospital Tübingen, Germany, 3The Wellcome Trust Sanger Institute, Cambridge, UK, 4Dep. of Gene Vectors, Helmholtz Center Munich, Germany, 5Ecole Polytechnique Federale de Lausanne, SV/ISREC, Lausanne, Switzerland, 6Institute of Pathology, Technical University of Munich, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most fatal malignancies lacking effective therapies. Novel ther-apeutic approaches include targeting of developmental pathways. Notch signaling is a key regulator of cell fate specification and pan-creatic cancer development, however, the role of individual Notch receptors and downstream signaling events is largely unknown.

Objectives: Characterization of Notch signaling in pancreatic carcinogenesis using genetically engineered mouse models.

Materials and Methods: Genetically engineered mice with pancreas-specific activation of oncogenic KrasG12D and subsequent development of PanIN lesions and PDAC were crossed with condi-tional Notch1, Notch2 and Myc knockout mice. Phenotypic analysis was carried out using expression profiling, quantitative RT-PCR, western blot, immunohistochemistry, isolation of cancer cells, ChIP and luciferase reporter assays among others.

Results: We show that Notch2 is predominantly expressed in ductal cells and pancreatic intraepithelial neoplasia (PanIN) lesions, while Notch1 is mainly expressed in acinar cells.

Deficiency of Notch2 but not Notch1 blocked PanIN progression, prolonged survival and led to a phenotypical switch in tumor differen-tiation towards anaplastic pancreatic cancer with epithelialmesenchy-mal transition. By expression profiling we identified downregulation of Myc signaling in Notch2-deficient cancer cells. Myc was found activated during PanIN progression and in PDAC. In vitro analysis revealed transcriptional regulation of Myc by Notch2. In vivo, condi-tional deletion of Myc in the PDAC mouse model resembled the phe-notype of Notch2-deficient mice.

Conclusion: Our data reveal a pivotal role of Notch2 during pancreatic carcinogenesis placing Notch2 as a central regulator of PanIN progression and malignant transformation through modulation of Myc signaling.

O17

Inactivation of Vhl in Adult Acinar Cells Induces Panin FormationJ. Speicher1, F. Esni1

1Department of Surgery, University of Pittsburgh, Rangos Research Center, Pittsburgh, PA

Introduction: The tumor suppressor gene von Hipple-Lindau (Vhl) is involved in regulating HIFs, CyclinD1 and p53. In humans, Vhl is expressed in normal exocrine pancreas but is absent in pancre-atic ductal adenocarcinomas. Furthermore, in Ptf1Cre;LSL-Kras mice, we could demonstrate a temporal correlation between loss of Vhl expression and progression from early metaplastic lesions to mPanINs. The gradual loss of Vhl expression suggests a potential link between Vhl loss and cancer progression.

Objectives: To study the role of VHL during pancreatic cancer initiation and progression.

Materials and Methods: In order to study the roleof VHL dur-ing pancreatic tumorigenesis, we have conditionally deleted Vhl in pancreatic progenitor cells in Ptf1aCre;Vhlfl/fl mice, or specifically in the adult acinar cells in ElaCreERT2;Vhlfl/fl mice.

Results: Our analyses revealed the presence of metaplastic lesions in 8 weeks old Ptf1aCre;Vhlfl/fl pancreas, whereas ElaCreERT2;Vhlfl/fl pancreas displayed signs of pancreatitis, and also Alcian blue-positive mPanINs, which expressed high levels of Ck-19, Sox9, Pdx-1, Hes1 and sonic hedgehog.

Conclusion: The phenotype observed in ElaCreERT2;Vhlfl/fl pancreas indicates that i) lack of Vhl in adult acinarcells leads to pan-creatitis, and ii) downregulation of Vhl may be a relatively early event during pancreatic tumorigenesis. In addition, the absence ofmPanINs in Ptf1aCre;Vhlfl/fl pancreas suggests that inactivation of Vhl during pancreatic development may induce mechanisms that would compen-sate for the lack of Vhl in the adult acinar cells. In summary, the ElaCreERT2;Vhlfl/fl may be the first mouse model which display mPanIN formation in the absence of ectopic oncogenic Kras expres-sion.


O18

Validation of the IKK/NF-kappaB/Rel Signalling Pathway as Therapeutic Target in a Mouse Model of Pancreatic CancerM. Lesina1, G. Kolb1, K. Dlubatz1, B. Sipos2, M. Treiber1, R.M. Schmid1, H. Algül1

12nd Department of Internal Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany, 2Department of Pathology, University of Tuebingen, Tuebingen, Germany

Introduction: Constitutive activation of NF-kappaB and muta-tions in TP53 are the important oncogenic drivers of pancreatic ductal adenocarcinomas (PDAC).

Objectives: The aim of the present study was to explore the role of RelA/p65 during pancreatic tumor development in vivo.

Materials and Methods: We used the Ela-TGFalpha trans-genic murine model of pancreatic tumor. Overexpression of trans-forming growth factor alpha under the control of the elastase promoter in the pancreas causes the formation of ductal lesions and the devel-opment of ductal adenocarcinoma in 40% of cases. Crossbreeding these mice with p53 floxed mice (Ela-TGFalpha Trp53panc) greatly accelerated tumorigenesis. In both murine models rela-gene was spe-cifically inactivated in the pancreas using Cre/loxP system (Ela-TGFalpha relapanc; Ela-TGFalpha Trp53panc relapanc).

Results: Our previous observations indicate that functional inac-tivation of RelA/p65 led toprolonged survival of Ela-TGFalpha trans-genic mice (720 days vs. 450 days). RelA/p65 regulates proliferation and apoptosis. This effect seems to be p53-independent. Both Ela-TGFalpha Trp53panc relapancund Ela-TGFalpha relapanc develop pancreatic carcinoma in 100% of cases. However, RelA/p65 inactiva-tion is involved in the differentiation of carcinomas. While 75% of the tumors in Ela-TGFalpha Trp53panc relapanc mice display ductal phe-notype (25% are undifferentiated), 18% of developed tumors in Ela-TGFalpha Trp53panc mice are PDAC (82% are undifferentiated).

Conclusion: IKK/NF-kappaB/Rel pathway plays an importan-trole in pancreatic carcinogenesis. Functional inactivation of RelA/p65 increased significantly median survival. Its protective function seems to be p53-independent. This study reveals the IKK pathway as interesting therapeutic target.

O19

Inactivation of TP53INP1 Accelerates KrasG12D Mediated Pancreatic Carcinogenesis and Promotes Malignant TransformationP. Clerc1, V. Gigoux1, T. Al Saati2, A. Carrier3, N. Dusetti3, M. Dufresne1

1Inserm U858/Institut de Médecine Moléculaire de Rangueil, Toulouse, France, 2Inserm, IFR150, Plateau technique d’histopathologie expérimentale, Toulouse, France, 3Inserm U624, Marseille, France

Introduction: TP53INP1 (Tumor Protein 53 Induced Nuclear Protein 1) is a stress response gene whose expression is lost at the PanIN1b/PanIN2 stages of pancreatic cancer. Several data support that TP53INP1 has an anti-tumoral activity.

Objectives: To know whether TP53INP1 loss of expression contributes to pancreatic cancer formation and to determine in vivo whether TP53INP1 is a tumor suppressor gene.

Materials and Methods: LSL-KrasG12D+/-, Pdx1Cre+/- and TP53INP1-/- mice were interbred to generate KrasG12D+/-/Pdx1cre+/-/TP53INP1-/- triple mutant mice (KrasINP1) and control littermates. Paraffin sections of mouse pancreas were stained with H&E and scored for the presence of preneoplasic and neoplasic lesions.

Results: Survival of KrasINP1 was less than that of KrasG12D+/-/Pdx1cre+/- and TP53INP1-/- mice. Analysis of pan-creas showed more advanced PanIN (PanIN1b, PanIN2) as compared with age-matched KrasG12D+/-/Pdx1cre+/-. PanIN3 and locally invasive carcinoma developed in mice at 5 months of age, an age at which they are not found in KrasG12D+/-/Pdx1cre+/- mice. We also observed that in the presence of activated Kras, TP53INP1 deficiency induced cystic lesions resembling IPMN in 50% of the mice. Cystic lesions developed as early as two months of age.

Macroscopic tumors developed in 40% of animals at 10-15 months of age. The sole inactivation of TP53INP1 failed to produce any neoplasic lesions in the pancreas.

Conclusion: Homozygous deletion of TP53INP1 in the context of an activating KrasG12D mutation significantly accelerates neopla-sic changes in the ductal epithelium. Our data also provide in vivo confirmation that TP53INP1 functions to block progression of pan-creatic cancer. KrasINP1 have potential interest for the study of pan-creatic cancer pathobiology.


O20

Pancreas Cancer Cell Cannibalism Results from a Novel Type of TGFbeta-induced Phagocyte-directed Epithelial-tomesenchymal Transition Allowed by the Absence of the Stress Protein p8C. Cano1, M. Sandi1, T. Hamidi1, E. Calvo2, O. Turrini3, V. Secq1, S. Garcia1, G. Lomberk4, R. Urrutia4, J.L. Iovanna1

1INSERM U.624, Stress Cellulaire, Parc Scientifique et Technologique de Luminy, Marseille, France., 2Molecular Endocrinology and Oncology Research Center, CHUL Research Center, Quebec, Canada., 3Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France., 4Laboratory of Epigenetics and Chromatin Dynamics, Gastroenterology Research Unit, Departments of Biochemistry and Molecular Biology, Biophysics, and Medicine, Mayo Clinic, Rochester, USA

Introduction: Epithelial-to-mesenchymal transition (EMT) allows the transdifferentiation supporting pancreas cancer metastasis and is believed to yield a unique fibroblastic phenotype. Since EMT renders cancer cells more invasive and resistant to treatment, it can be assimilated to an efficient stress response. p8 stress protein is a tran-scription cofactor implicated in tumor progression and a target of TGFb, which triggers EMT.

Objectives: We explored the role of the p8 protein during EMT in pancreas cancer.

Materials and Methods: siRNA-mediated p8 inactivation in Panc-1 cells was performed for in vitro studies of EMT andcell can-nibalism upon TGFb, using immunofluorescence, flow-cytometry, DNAmicroarray and qRT-PCR. Human and murin (Pdx1-KrasG12D/Ink4aKO mice in p8KObackground) were analyzed using immuno-chemistry and immunofluorescence.

Results: p8 inactivation causes impaired TGFb-induced fibro-blastic EMT in vitro. In vivo, p8-deletion provokes an EMT blockade in murine pancreatic tumors. EMT-related gene profile upon TGFb is altered in p8-deficient cells with downregulation of fibroblast mark-ers and overexpression of phagocytosis-related genes. p8-deficient cells become capable of cannibalizing each other upon TGFb treat-ment. Inactivation of phagocytosis-related CDC42 and CXCL1 genes in p8-deficient cells inhibits cannibalism. A fraction of p8-deficient cells in human and murine pancreas tumors do cannibalismand exhibit myeloid-markers (CD68 and F4/80, respectively), consistent with a repressive role of p8 on phagocyte-directed (P)-EMT. Finally, canni-balism ends with cell death in vivo and in vitro, suggesting that it is detrimental to tumor progression.

Conclusion: We show that p8 favors fibroblastic EMT over P-EMT. Since cannibalism leads to cancer cell death, enhancement of P-EMT through p8 targeting appears as a promising strategy for fight-ing pancreatic cancer.

O21

Retinoic Acid-induced Stellate Cell Quiescence Modulates Behaviour of Human Pancreatic Tumour CellsF.E.M. Froeling1, C. Chelala2, R. Dobson3, C.E. Mein3, I.R. Hart1, H.M. Kocher1

1Centre for Tumour Biology, Institute of Cancer, Barts & The London School of Medicine and Dentistry, John Vane Science Centre, Charterhouse Square, London, United Kingdom, 2Centre for Molecular Oncology, Institute of Cancer, Barts & The London School of Medicine and Dentistry, London, United Kingdom, 3Genome Centre, Barts & The London School of Medicine and Dentistry, London, United Kingdom

Introduction: Pancreatic cancer is characterized by a strong desmoplastic stroma. The main cell type responsible for this stroma is the pancreatic stellate cell (PSC), which in pancreatic cancer changes from a quiescent fat-storing phenotype to a myofibroblast-like cell secreting extracellular matrix (ECM) proteins.

Objectives: By targeting the tumour stroma with all-trans retin-oic acid (ATRA) we aim to identify a novel therapeutic strategy for this malignancy.

Materials and Methods: First, the effects of ATRA on PSCs were studied using cell-cycle analysis, gene expression microarray, immunostaining, western blotting and quantitative PCR. Subsequently, the consequences of changes in PSCs on pancreatic cancer cells were studied in 2D and novel 3D organotypic co-cultures.

Results: A characteristic change in morphology and expression profile, as well as a shift to the G1 phase of cell cycle demonstrated that on exposure to 1 micromolar ATRA stellate cells were rendered back into their quiescent phenotype. Gene-expression profiling iden-tified effects on numerous key canonical pathways of which the wnt-beta-catenin pathway was the most prominent. Organotypic co-culture of PSCs and cancer cells demonstrated an indirect effect of quiescent PSCs on cancer cell morphology, proliferation (decrease) and apopto-sis (increase) and confirmed the down-regulation of the canonical wnt-beta-catenin signalling, which we have demonstrated to be due to an increased expression of sFRP4 (secreted frizzled-related protein 4). Moreover, compared to activated PSCs (which stimulated cancer cell invasion), quiescent PSCs blocked invasion by forming a “wall” at the cancer-matrix junction.

Conclusion: Targeting the desmoplastic stroma with agents such as ATRA offers exciting opportunities for combinatorial therapy for pancreatic cancer.


Chronic Pancreatitis

O22

Substance P Pathway Is Alterated in Chronic PancreatitisF.F. di Mola1, F. Tavano1, G. Mascetta1, M. Carella3, R. Barbano2, P. Parrella 2, M.W. Büchler4, H. Friess5, P. di Sebastiano1

1Department of Surgery, IRCCS, Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy, 2Laboratory of Oncology, IRCCS Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy, 3Unit of Genetic, IRCCS Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy, 4Department of General Surgery, University of Heidelberg, Germany, 5Department of Surgery, Technische Universität of München, Klinikum rechts des Isar, Munich, Germany

Introduction: The pathophysiology of pain in chronic pancrea-titis (CP) is still not completely understood. Recent data suggest a role for neuropeptides such as substance P (SP) and the neuroimmune interaction in the inflammatory process of the pancreas. SP degrada-tion is mediated by the endogenous extracellular metalloenzyme called neutral endopeptidase (NEP). Further studies failed to detect NEP in patient with pancreatic disorders while increased expression of SP was detected.

Objectives: We aimed to investigate NEP pathway to better evaluate the SP pathway in CP patients.

Materials and Methods: SP and NEP mRNA levels were ana-lyzed by quantitative real time polymerase chain reaction (RT-PCR) in pancreatic tissue specimens from patients undergoing pancreatic resec-tion for CP and healthy organ donors. NEP gene mutation analysis, NEP methylation assay and miR-128a expression was also performed.

Results: Quantitative RT-PCR demonstrated increased SP mRNA expression in CP tissues (P < 0·05) compared to controls, while NEP mRNA showed no significant changes between CP and healthy controls. Screening did not reveal any mutation of interest but only the presence of seven intronic polymorphisms located down-stream or upstream of several exons. MSP analysis suggests a light tendency to NEP hypermethylation for one promoter CpG islet in about half of chronic pancreatitis samples when compared with donor group meanwhile NEP loos of function was associated to mir-128a significant over-expression in CP patients

Conclusion: In the SP pathway, it would appear that NEP is unable to sufficiently degrade the increased amount of SP, which may in part explain the perpetuation of pancreatic inflammation, due to mir-128a over-expression

O23

A Lymphoblast Protein Assay to Detect Subclinical Johanson-Blizzard-Syndrome in Patients with Exocrine Pancreatic InsufficiencyJ. Mayerle1, N. Kumar2, S. Bauhuber3, F.U. Weiss1, L. Steils2, U. Völker2, M. Zenker3, M.M. Lerch1

1Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, 2Institute of Functional Genomics, Ernst-Moritz-Arndt-Universität, Greifswal, 3Institute of Human Genetics, Otto-von-Guericke-University Magdeburg, Germany

Introduction: A rare cause of exocrine pancreatic insufficiency is Johanson-Blizzard-Syndrome (JBS), an autosomal recessive disor-der caused by mutations in the UBR-1-gene.

Objectives: We developed a protein-based diagnostic assay to detect subclinical JBS and identified disease-relevant signalling path-ways by proteomics.

Patients and Methods: Lymphoblast homogenates from 14 patients with 13 UBR-1 mutations and variable phenotype and 11 controls underwent 2D-proteome analysis. Principal component anal-ysis (PCA) was combined with quantification of Ubr-1 expression by Western blotting. Hierarchical clustering of patients and controls was employed for spots displaying lowest p-levels derived from Golubs algorithms. 20 spots specific for JBS on ROC analysis were identified by mass-spectroscopy.

Results: In lymphoblast extracts 1295 proteins were differen-tially expressed between patients and controls. PCA analysis clearly discriminated JBS-patients. Four patients resembling controls had residual Ubr-1 expression and a milder phenotype. Hierarchical clus-tering of controls and patients with our without residual Ubr-1 expres-sion showed marked differences in the gene-tree. A five spot proteinpanel of Interferon-induced-GTP-binding- protein, HLA-class-II-histocompatibility-antigen, Annexin-A6, FK506-binding-protein-4, and GRP78 permitted identification of JBS-patients irrespective of phenotype (predictive strength 1, area under ROC-curve). Of note, the molecular chaperones GRP78 (BiP) and FK506BP were consistently upregulated in JBS-patients and confirmed as Ubr-1 substrates.

Conclusion: Using proteomics we identified 5 lymphyoblast proteins which allow diagnosing JBS without sequencing all 47 UBR-1-gene exons - even in phenotypically mild cases. The identification of GRP78 and FK506BP as Ubr-1-substrates suggests an ER-stress-related pathogenesis of JBS. Employing this 5-protein-panel-test may lead to the identification of many subclinical JBS-cases among patients with exocrine pancreatic insufficiency.


O24

Expression of a Novel Transcription Factor SOX-9 in Chronic PancreatitsF. Shek1, S. Al-Maamari 2, M. Patel1, A. Bateman1, R. Benyon1, T. Adrian2, D. Fine1

1Pancreatic Fibrosis Research, Southampton University., 2Department of Physiology, Faculty of Medicine & Health Sciences, United Arab Emirates University

Introduction: The SOX-9 gene is a member of transcription factor genes involved in embryogenesis and is involved in the devel-opment of pancreas. SOX-9 regulates the expression of type 2 colla-gen in the neural crest of developing avian embryos. Pancreatic Stellate Cell (PSC) plays a central role in pancreatic fibrosis which is the main feature of chronic pancreatitis. It has been demonstrated that the induction of SOX-9 expression occurred during the activation of hepatic stellate cells in hepatic fibrosis.

Objectives: This study examined the expression of SOX-9 in human chronic pancreatitis, early fibrosis and normal pancreas tissue.

Materials and Methods: We used human archival resected pancreatic tissue in paraffin sections. Two samples of normal pancreas tissues were obtained from resection of gastric cancer where normal pancreata were also resected. Two samples of early fibrotic tissues were obtained in patients who underwent Whipple’s procedure for cholangiocarcinoma. Two samples of severe chronic pancreatitis were included. Standard method of immunohistochemistry was performed using a polyclonal SOX-9 antibody and -SMA monoclonal antibody.

Results: Preliminary results show that SOX-9 was strongly expressed in the nuclear of centroacinar cells and the ductal epithelial cells which are adjacent to the fibrotic bands. The expression was more apparent with the progression of the fibrosis with strong posi-tive expression in the chronic pancreatitis sections as compared to the normal and early fibrosis. However, the fibrotic bands show no expression of the SOX-9 protein.

Conclusion: Our preliminary results suggest that SOX-9 may exerts an increasing influence on the PSC from surrounding tissues as the fibrosis progresses in chronic pancreatitis.

O25

Pancreatic Stellate Cells Express IGF-1 and Insulin Receptors: Implications for Treatment of Pancreatic FibrosisM. Patel1, J. Collins1, C. Benyon1, D. Fine1

1Pancreatic Research Group, Southampton University, Southampton

Introduction: Pancreatic stellate cells(PSC) are exposed to sup-raphysiological concentrations of insulin via the islet-acinar portal system and is known to have a trophic effect on acinar tissue. Insulin-like growth factor-1 (IGF-1) has been shown to increase following pancreatitis and pancreatic regeneration. These related molecules may therefore be involved in regulation of PSC numbers by effects on proliferation or apoptosis. This effect could be mediated via insulin or IGF-1 receptors.

Objectives: 1. Demonstrate the expression of IGF-1 and insulin receptor by PSC. 2. Determine whether PSC secrete IGF-1. 3. Determine the effects of IGF-1 and insulin on PSC proliferation and apoptosis.

Materials and Methods: Activated rat PSCs were used between passages 1-4. Proliferation was determined by [3H]-thymidine incorporation. Apoptosis was determined with acridine orange and caspase 3 activity assays. Western blotting and immunocytochemistry were used to demonstrate insulin and IGF-1 receptors. Real time quantitative PCR was used to detect receptor mRNA. ELISA was used to determine the secretion of IGF-1.

Results: Activated PSC express protein and mRNA for IGF-1 and insulin receptors. IGF-1 is secreted by activated by PSC, which is upregulated 2.4 fold following serum withdrawal. Exogenous IGF-1 (100ng/ml) and insulin(10000 ng/ml) prevented cycloheximide induced PSC apoptosis, 63% at 24hrs, and 71% at 24hrs respectively. There was moderate effect on PSC proliferation following exposure to IGF-1 but not with insulin.

Conclusion: These data suggest a potential autocrine role for IGF-1 in reducing PSC apoptosis on serum withdrawal. Targetting IGF-1 or its receptor may increase PSC susceptibility to apoptosis. This represents a potential therapeutic target for prevention or treat-ment of pancreatic fibrosis.

O26

Evaluation of a Modified Method for Pancreatic Stellate Cell Isolation and CultureN. Dadabaeva1, O. Strobel1, N.A. Giese1, K. Felix1, A. Heller1, D. Thereska1, J. Werner1

1Department of General Surgery, University of Heidelberg, Heidelberg, Germany

Introduction: Pancreatic stellate cells (PSC) are important in the microenvironment in pancreatitis and pancreatic cancer. In vitro stud-ies involving PSC are a central tool in pancreatic research. Activation and differentiation of PSC that occur during isolation and culture may result in an alteration of the PSC phenotype. This may impair the reli-ability of in vitro studies in modelling in vivo contexts.

Objectives: To evaluate a modified method for PSC isolation and culture and its ability to produce cultured PSC of a phenotype that reflects the phenotype of the original tissue.

Materials and Methods: Trypsin-EDTA was used for diges-tion and allowed to easily obtain cell suspensions. Growth media with reduced serum content were used to maintain PSC in culture and to avoid PSC activation. Commonly used markers for PSC activation were used to characterize and compare original tissue and matched PSC cultures.

Results: PSC isolation was successful in 13/15 tissue samples irrespective of the extent of fibrosis. Reduction of serum concentra-tion in the modified culture media resulted in a reduced growth rate of PSC if compared to conventional methods. However, comparison of the expression of -SMA, desmin, and of lipid droplets content revealed a great extent of similarity in the phenotypes of cultured PSC and their original tissues.

Conclusion: The modified technique is useful to isolate PSC in a standardized manner from pancreatic tissue specimens indepen-


dently of their grade of desmoplasia. Together with culture media with reduced serum content the method results in PSC of a phenotype that more closely reflects the phenotype of the original tissue.

O27

Chronic High-fat Diets Induce Oxide Injuries and Fibrogenesis of Pancreatic Cells in RatsX. Zhang1, Y. Cui1, L. Fang2, F. Li1

1Department of General Surgery, Xuanwu Hospital, Capital Medical University, 2Department of Surgery, Division of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas, USA

Introduction: Previous studies have reported that long-term intake of high-fat diets (HFD) may lead to chronic pancreatic injuries. However, the mechanism of pancreatic damages induced by chronic high-fat diets(HFD) remains unknown.

Objectives: The current study was to detect the involvement of free fatty acids (FFA) and lipid peroxidation in pancreatic injuries in rats induced by a long-term HFD.

Materials and Methods: Rats of HFD groups (n = 12) were fed with an HFD for 2, 4, 6, 10, and 18 weeks respectively. Pancreatic Malondialdehyde (MDA) content and the concentration of FFA were measured. Histopathologic changes were observed by Sirius Red staining for fibrosis and immunostaining of the pancreatic stellate cells (PSC) for desmin, smooth muscle actin (-SMA), platelet-derived growth factor receptor type (PDGFR), and transforming growth fac-tor 1 (TGF1).

Results: Pancreatic MDA content, the number of desmin and -SMA positive cells significantly increased in all the HFD groups (p < 0.05). The levels of pancreatic FFA, PDGFR, and TGF1 increased in rats of 2-, 4-, and 6-week HFD groups (p < 0.05). These enhance-ments were accompanied with tissue edema, focal acinar degenera-tion, vaculation of acinar and islet cells in pancreas. In groups of the 10- and 18-week HFD treatment, remarkable acinar cellular atrophy, fatty replacement, deposition of hemosiderin, and interstitial collagen deposition were observed.

Conclusion: The results indicate that chronic HFD increased pancreatic FFA and lipid peroxidation associated with pancreatic injuries and collagen synthesis by activated PSC in rats.

O28

Smoking and the Course of Chronic Pancreatitis: A Dose Dependent RelationshipV. Rebours1, M.P. Vullierme2, P. Hammel1, P. Ruszniewski1, P. Lévy1

1Pancreatology Unit, Beaujon, Clichy, 2Radiology Unit, Beaujon Clichy

Introduction: Smoking has recently been shown to affect the course of alcoholic chronic pancreatitis (ACP).

Objectives: To assess a dose-dependent relationship between tobacco consumption and the course of ACP.

Patients and Methods: All patients with ACP who were smok-ers were included in this prospective study. Thresholds were defined at 10, 15, 20 and 30 packs.years (p.y) in order to assess the relation-ship between tobacco intake and the course of ACP. Statistical adjust-ment on alcohol intake was performed.

Results: 108 pts were included, with a median alcohol intake of 145 (40-500) g/day since 15 (3-40) years. Median tobacco intake was 30 (3-90) p.y. Pancreatic calcifications and ductal changes were seen in 70 and 73% of the pts. Pancreatic exocrine insufficiency and diabe-tes were observed in 36 and 30% of the pts. 33% of the pts had chronic, opioid-dependent pain. No differences in ACP outcome were seen at the 10 p.y threshold. However, diagnosis of ACP and acute pancreatitis was made significantly earlier (p = 0.005 and 0.005 resp) from the 15 p.y threshold. Chronic pancreatic pain was also more fre-quent (p = 0.05). At 20 p.y threshold, ACP and acute pancreatitis occurred earlier (p = 0.0002 and <0.0001), and the pts hade more often PC, calcifications and ductal changes (p = 0.02, 0.05 and 0.005 resp). Similar results were observed at the 30 p.y threshold, but additionally pancreatic exocrine insufficiency occurred earlier (p = 0.04).

Conclusion: Tobacco intake accelerates the course of ACP in a dose-dependent fashion. A major threshold effect is seen at 20 p.y.

O29

The N34S Mutation of Serine Protease Inhibitor, Kazal Type 1, in Patients with Chronic Pancreatitis and Pancreatic CancerA. Gasiorowska1, R. Talar-Wojnarowska1, B. Smolarz2, H. Romanowicz-Makowska2, A. Kulig2, E. Malecka-Panas1

1Departament of Digestive Tract Diseases, Medical University of Lodz, Poland, 2Laboratory of Molecular Genetics, Department of Pathology, Institute of Polish Mother’s Memorial Hospital, Lodz, Poland

Introduction: The N34S mutation of the SPINK1 gene has been reported to have a connection with idiopathic chronic pancreatitis (ICP), but the association with alcoholic chronic pancreatitis (ACP) and pancreatic cancer (PC) has been controversial.

Objectives: The aim of the study was to determine the fre-quency of SPINK1 mutation in patients with ACP, ICP and with PC. We also reviewed the clinical data of chronic pancreatitis (CP) patients and analyzed the differences of the clinical course of CP between patients with and without SPINK1 mutation.

Patients and Methods: The diagnosis of CP and PC was based on clinical examination, ultrasound, computed tomography and pathology. DNA was isolated from 33 patients with ACP, 14 patients with ICP and 24 patients with PC. 46 healthy individulas were enrolled as control. The N34S mutation of SPINK1 have been detected with PCR-RFLP.

Results: Among CP group, in 6 patients (18%) with ACP and 4 patients (28.6%) with ICP N34S mutation of the SPINK1 was detected. The frequency of SPINK1 mutation was significantly higher (p < 0.024) than in controls (6.5%); OR was 5.733 (95%CI 1,218-26,959). There was no difference in the frequency of the N34S muta-tion between patients with ACP and controls (p = 0.108; OR 3,185


(95% CI 0.745-12,606). No relations have been detected between those mutation presence and clinical features of the CP patients. Among the 24 patients with PC, the N34S mutation was present in 1 patient (4%). There was no difference in the frequency of the N34S mutation between patients with PC and controls (p = 0,687; OR 0,623 (95% CI 0,085-4,696).

Conclusion: Those preliminary data suggest the high incidence of N34S SPINK1 mutation in Polish population generally, as well as in CP. The SPINK1 N34S mutation was significantly associated with an increased risk of ICP. Further studies are needed to explore the role of SPINK1 in the carcinogenesis of PC.

O30

Is Chronic Pancreatitis Really a Patchy Disease? A Prospective Study Based on Quantitative Pancreatic ElastographyJ. Iglesias-Garcia1,2, M. Castiñeira-Alvariño2, J. Lariño1,2, M. Luaces-Regueira2, R. Ferreiro1, E. Domínguez-Muñoz1,2

1Gastroenterology Department. University Hospital of Santiago de Compostela, 2Foundation for Research in Digestive Diseases (FIENAD)

Introduction: Chronic inflammation, pancreatic fibrosis and atrophy are criteria for diagnosing chronic pancreatitis (CP). These features are considered to have a patchy distribution, making unreli-able the pathological diagnosis based on pancreatic biopsy. Nevertheless, studies defining the patchy distribution of CP are based on surgical specimens, not representative of the natural history of CP.

Objectives: Aim of this study was reevaluate the concept of patchy distribution of CP in patients at different stages

Materials and Methods: 92 consecutive patients (mean age 48-years, [21-76], 72 male), who underwent an endoscopic ultrasound (EUS) to confirm the diagnosis of CP were prospectively included. 99 patients with healthy pancreas were included as controls. EUS-elastography was performed with radial Pentax and Hitachi-900. EUS criteria of CP were evaluated, and patients were classified according to Rosemont Classification(RC). Pancreatic stiffness was quantified by EUS-elastography at head, body and tail. Two areas were selected for quantitative elastographic analysis: A, pancreatic parenchyma and B, soft peripancreatic area. B/A (strain-ratio) was considered the result of elastographic evaluation. Data are shown as median (95%CI) and compared by ANOVA test.

Results: 22(23.9%) patients were indeterminate for CP, 40(43.5%) suggestive of CP, and 30(32.6%) consistent with CP. Strain-ratio was similar in the head (2.84;95%CI:2.63-3.05), body (3.09;95%CI:2.88-3.31) and tail of the pancreas (2.98;95%CI:2.77-3.19) (p = 0.9). No differences in strain-ratio of different pancreatic areas were found at different stages of the disease according to RC.

Conclusion: The analysis of tissue stiffness by quantitative EUS-elastography in patients with different stages of CP doesn’t sup-port the concept of CP as a patchy disease

O31

Surgery Remains the Best Option for Management of Patients with Chronic PancreatitisC. Kyriakides1, A.E. Frampton1, P. Limongelli1, D. Westaby2, P. Vlavianos2, L.R. Jiao1

1HPB Surgical Unit, Dept. of Surgery & Cancer, Hammersmith Hospital, Imperial College, London, UK, 2Dept. of Gastroenterology, Hammersmith Hospital, Imperial College NHS Trust, London, UK

Introduction: Controversy related to endoscopic or surgical management of patients with chronic pancreatitis (CP) remains due to a lack of adequately powered randomised control trials.

Objectives: A systematic review of the published data was car-ried out to address issues related to the outcome and choice of treat-ment for CP.

Materials and Methods: Search of published articles on endo-scopic or surgical treatment of chronic pancreatitis from January 1994 to December 2008 using the search engines of Medline, Embase and the Cochrane Collaboration database was carried out. Keywords such as CP, endoscopic, stenting, surgical, drainage, resection, pancreati-cojejunostomy and Whipple’s were used in various combinations. Meta-analysis was performed on studies fulfilling the selection crite-ria with data on morbidity, mortality and pain control.

Results: A total of 19 articles were included in the statistical analysis which fulfilled the selection criteria. Only two articles were randomized trials (RCT). Analysis of these two RCTs (n = 180) revealed that surgical treatment was significantly better than the endoscopic option for either complete pain resolution or partial pain resolution (P < 0.0001). Seventeen were non-RCT publications with a total of 2496 patients were identified. The result showed that the com-plete and partial pain control was achieved in 33.16% and 13.42% patients respectively in the surgical group whilst 25.31% and 4.79% respectively in the endoscopic group. Complications were higher (11.03%) in the surgical group compared to the endoscopic group (5.83%) including cholecystitis, pancreatitis, bleeding, leakage, infec-tion and death.

Conclusion: Surgery remains the most effective treatment for CP, with a higher proportion of patients achieving lasting pain relief.


O32

Managment of Alcohol Addiction in Chronic PancreaitisJ.A. Tsai1, M. Grundsten1, M. Sjölund1, O. Wisén2, M. Segerdahl3, J. Permert1, J.M. Löhr1, R. Segersvärd1

1Dept. of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden, 2Dept. of Addiction Medicine, Karolinska University Hospital, Stockholm, Sweden, 3Dept. of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden

Introduction: Patients with chronic pancreatitis may benefit from management of addiction and pain in parallell with pancreato-logical problems.

Objectives: To evaluate intervention against alcohol addiction in patients with chronic pancreatitis.

Patients and Methods: Since 2005 patients referred to our clinic with chronic pancreatitis undergo separate and joint assessment by 1) pancreatologist, 2) addiction specialist and 3) pain specialist.

Results: Forty-three patients with chronic pancreatitis who underwent multi disciplinary assessment were evaluated regarding alcohol addiction, defined according to DSM-IV. These patients were classified as follows: 1) no history of alcohol abuse - 19, 2) alcohol abuse in remission - 7, 3) ongoing alcohol abuse - 15, 4) harmful alcohol intake without addiction - 2. Twelve patients under-went intervention against alcohol abuse through outpatient contact with an addiction specialist. After this, 10 patients were in remission from abuse for at least 6 months of follow-up. Five of these patients underwent pancreatic resection. One developed delirium after a postoperative bile leak while the remaining 4 had an uneventful postoperative course both from a surgical and a psychiatric point of view.

Conclusion: In this selected group of patients with chronic pan-creatitis, we found that intervention against alcohol addiction appears to be effective. The high proportion of patients with addiction that could stop drinking, suggests that this type of multi disciplinary man-agement of patients with chronic pancreatitis may be a feasible con-cept for optimizing their condition before surgery, while the basic problem behind the development of chronic pancreatitis also is addressed.

O33

Digestive Venous Thrombosis Occuring During Chronic Pancreatitis is Caused by Local Inflammation and Not by ThrombophiliaV. Rebours1, M.P. Vullierme2, O. Hentic1, F. Maire1, M.H. Denninger3, P. Hammel1, P. Ruszniewski1, P. Lévy1

1Pancreatology Unit, Beaujon, Clichy, 2Radiology Unit, Beaujon, Clichy, 3Hematology Unit, Beaujon, Clichy

Introduction: Thrombosis of digestive veins occurs in up to 13% of the pts with alcoholic acute (AP) or chronic (CP) pancreatitis.

Objectives: To assess an overexpression of thrombophilic factors.

Patients and Methods: All pts with alcoholic AP or CP were included in this prospective study. Every pt had a CT scan and an exhaustive search for thrombophilia.

Results: 119 pts (male 84%, median alcohol intake: 120 (40-500) g/day for 15 (3-40) years) were included. 93% of the pts were smokers (median intake 30 packs.years). Calcifications, exocrine insufficiency and diabetes were observed in 70, 35 and 30%, respec-tively. Median follow-up from the diagnosis was 3 (0.5-17) years. Pseudocysts were present in 55% (pancreatic head 69%, infected 20%). Median CT severity index in pts with AP was 4 (1-9). DVT was found 35% of the pts. The portal, superior mesenteric and splenic veins were involved in 34, 24 and 93% of the pts, respectively. Thrombophilia was evidenced in 29% of the pts: antiphospholipid antibodies, lupic antibodies, activated C protein deficiency, V Leiden R506Q mutation, factor II G20210 mutation in 17, 5, 2, 1 and 1% respectively. The factors associated with DVT thrombosis were smok-ing (RR = 1.6 (1.38-1.85), p = 0.03), pseudocyst (RR = 2.91 (1.29-6.56), p = 0.008), localisation of pseudocyst in the pancreatic tail (p = 0.03), high CT severity index for AP (p = 0.007) and pancreatic necrosis (p = 0.02). The presence of coagulation anomalies did not increase the risk of DVT.

Conclusion: DVT is seen in 1/3 of the pts with acute/chronic alcoholic pancreatitis. Smoking and local inflammation are the major predisposing conditions.

Autoimmune Pancreatitis

O34

A Mouse Model for Autoimmune Pancreatitis: Investigation of the Mechanisms Driving Chronic Pancreatitis Induced Tissue DestructionG.M. Seleznik1, L.K. Sun3, T. Reding-Graf3, A. Weber2, A. Mildner4, S. Regenass5, T. Rülicke6, R. Graf3, M. Heikenwalder1

1Institute of Neuropathology, Department of Pathology, University Hospital Zurich, Switzerland, Institute of Clinical Pathology, Department of Pathology, University Hospital Zurich, Switzerland, Swiss HPB (Hepato-Pancreatico-Biliary) Center, Department of Surgery, University Hospital Zurich, Switzerland, 4Institute of Neuropathology, Department of Pathology, University Hospital Freiburg, Germany, 5Clinical Immunology, Department of Internal Medicine, University Hospital Zurich, Switzerland, 6University of Veterinary Medicine, Vienna, Austria

Introduction: Chronic pancreatitis (CP) is an inflammatory dis-ease with irreversible and progressive destruction of the pancreas, resulting in severe exocrine and endocrine insufficiency. Destruction of acinar cells coincides with immune-cell infiltration and fibrosis.


Among different entities of CP, autoimmune pancreatitis (AIP) repre-sents a distinct and increasingly frequently detected form with char-acteristic clinical and histological features. Which processes trigger and maintain the inflammatory response underlying CP or AIP is not fully understood yet.

Objectives: We demonstrate upregulation of the pro-inflamma-tory cytokines lymphotoxin alpha and beta (LTab) in patients with chronic pancreatitis when compared to healthy controls. We aimed at generating a mouse model to mimic chronic pancreatic inflammatory changes and tissue destruction dependent on the presence of lympho-toxin.

Materials and Methods: Consequently, we generated trans-genic mice with targeted overexpression of LTab in the exocrine pan-creas (ElaLTab).

Results: Two independent double transgenic lines were gener-ated which developed early onset of CP. Already at the age of 5 weeks transgenic mice showed elevated serum amylase and lipase levels. Pancreatic histology shows typical features of inflammation - mostly macrophages, T- and B-cell infiltrates, increased acinar cell prolifera-tion, acinar to duct metaplasia and fibrosis. At an age older than 6 months, indirect immunfluorescence microscopy with serum of trans-genic mice was positive for autoreactive anti-nuclear antibodies (ANA) - indicative of an autoimmune phenotype.

Conclusion: The ElaLTab mouse model might be suitable to investigate the mechanisms of chronic pancreatic inflammation and nonimmune- or autoimmune-induced tissue destruction.

O35

Serum Biomarkers for the Diagnosis of Autoimmune Pancreatitis and in Distinguishing it from Pancreatic CancerK. Felix1, O. Hauck1, F. Fakelman1, M. Schnölzer2, T. Kempf2, M.W. Büchler1, J. Werner1

1Department of General Surgery, University of Heidelberg, INF 110, Heidelberg, Germany; 2Protein Analysis Facility, German Cancer Research Center, INF 580, Heidelberg, Germany

Introduction: Autoimmune pancreatitis (AIP) is a form of CP defined by a characteristic lymphoplasmacytic infiltrate and pancre-atic enlargement or mass that can mimic pancreatic cancer. In pres-ence of new onset of diabetes and weight loss the distinction between AIP and pancreatic cancer can be challenging.

Objectives: It is extremely important to diagnose AIP to choose the appropriate treatment and avoid unnecessary surgery.

Materials and Methods: Mass spectrometry (MS), and 2D-DIGE has been applied to analyze serum protein alterations associ-ated with AIP and PaCa, and to identify biomarkers indicative for the diseases. Patients sera were either equalized using peptide library beads analyzed onto CM-10 arrays or immunodepleted from the 20 promi-nent proteins prior 2D-DIGE analysis. The analysis of protein spectra and the patterns that may correlate with PaCa or AIP was performed with the CiphergenExpressProgram. The identity of the biomarkers was determined by a combination of protein fractionation techniques, chromatographic purification steps, gel electrophoresis, and MS.

Results: Data analysis revealed 24 differentially expressed pro-tein peaks able to discriminate between the groups. Seven proteins were purified and chracterized by peptide mapping and PSDMALDI-TOF-MS. Apo A-II, apo-A-I, TTh were identified and found as 3-fold decreased in PaCa sera. Identification of proteins that emerged from our 2D-PAGE/WB and MS-analysis revealed procarboxypeptidase-A2, a-enolase, succinyl-CoA-synthetase b-subunit and transferrin-precursor as AIP-autoantigens. The identified proteins were validated by ELISAs.

Conclusion: Procarboxypeptidase A2, a-enolase, succinyl-CoA-synthetase b-subunit, transferrinprecursor, TTh and apolipopro-teins found as novel AIP markers can easily be assessed by simple tests of patient sera and can be used to ensure that PaCa is not misdi-agnosed.

O36

Autoantibodies to the Antigens of Acinar Cells, Hepatocytes, IgG1-4 in the Patients with Chronic PancreatitisN. Zhivaeva, V. Sagynbaeva, L. Vinokurova

Central Scientific Research Institute of Gastroenterology

Introduction: The violations of immune functional activity has serious role in the development and course of chronic pancreatitis.

Objectives: To study the blood content and prognostic signifi-cance of autoantibodies to the antigens of acinar cells, hepatocytes, IgG1-4 in the patients with chronic pancreatitis (CP).

Patients and Methods: 85 patients with CP were examined. 43 patients were with CP with complications. 40 patients –CP without complications. 2 patientswith autoimmune pancreatitis (AP). Twenty persons - control group. Autoantibodies, IgG1-4 were examined by immunoenzime method with test-system «Euroimmun», «Orgentec, DRG-Diagnostics».

Results: Increase of the different immunoglobulin types was revealed in 85 patients with the exacerbation of CP. IgG1 22,3±2,1 mg/ml (N 4,9-11,4 mg/ml). IgG2 21,6±1,7 mg/ml (N 1,5-6,4 mg/ml). IgG3 3,8±0,3 mg/ml (N 0,2-1,1 mg/ml). IgG4 3,0±1,4 mg/ml (N 0,08-1,4 mg/ml). High blood level IgG4 was revealed in the patients with AP. IgG4: 24 mg/ml (N 0,8 -1,4 mg/ml). It reflects intensity anti-gen stimulation, processes of inflammation. The maximal increase of autoantibodies concentration 32,4±10,6 U/ml (N < 20 U/ml) was revealed in the patients with AP. The moderate increase 24,2±3,8 U/ml in the patients with CP with complications. The minimal one 18,6±2,6 U/ml in the patients with CP without complications, in con-trol group –10,5±2,5 U/ml.

Conclusion: The increase of autoantibodies, IgG1-4 was revealed in the blood of patients with CP. It is depends on the etiology disease and stage, complications. It reflects the intensity of autoim-mune processes as well as disease’s activity.


O37

Comparison of the Mannheim Diagnostic Criteria of Autoimmune Pancreatitis with Other Diagnostic Criteria SystemsA. Schneider1, J.M. Löhr2, M.V. Singer1

1Dept. of Medicine II, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany, 2Dept. of Surgical Gastroenterolgy, Karolinska Institute, Stockholm, Sweden

Introduction: Different diagnostic criteria for autoimmune pan-creatitis (AiP) have been developed in various centers from Europe, USA and Asia. We recently developed the Mannheim AiP Diagnostic Criteria. A consensus about the different diagnostic systems has not been reached.

Objectives: To compare the Mannheim AiP Diagnostic Criteria with other diagnostic systems.

Patients and Methods: Mannheim AiP Diagnostic Criteria define “definite”, “probable” and “possible” AiP. “Mannheim Definite AiP” is diagnosed in patients fullfilling Mayo HISORt or Asian AiP Criteria; or simultaneously presenting with pancreatic disease, other autoimmune disease and/or elevated autoantibodies, and disease response to steroids. “Mannheim Probable AiP” is diagnosed with pancreatic disease, elevated IgG4 and/or other autoantibodies, and other autoimmune disease. “Mannheim Possible AiP” is diagnosed with pancreatic disease and either elevated IgG4 and/or other autoan-tibodies, or other autoimmune disease. Patients with non-alcoholic pancreatitis from our clinic (1997-2009) were studied. In patients with “Mannheim Definite AiP”, we compared the Mannheim AiP Diagnostic Criteria with Japan-, Korean-, Asian-, Mayo HISORt-, Revised Mayo HISORt- and Italian-Criteria.

Results: We detected “Mannheim Definite AiP” in n = 21 patients. In n = 5/21 patients, pancreatic histology was obtained by surgery. In only these patients, diagnosis of AiP could be established by any diagnostic system. In n = 8/21 patients, the diagnosis of AiP was only achieved with the Mannheim AiP Diagnostic Criteria. In this cohort of patients, all individuals responded to steroid medica-tion.

Conclusion: The Mannheim AiP Diagnostic Criteria are supe-rior to other criteria systems and allow the diagnosis of AIP in atypi-cal forms of the disease.

O38

Long Term Outcome of Patients with Autoimmune Pancreatitis (AIP)F. Maire1, Y. Le Baleur1, V. Rebours1, M.P. Vullierme1, A. Couvelard1, A. Sauvanet1, O. Hentic1, P. Lévy1, P. Ruszniewski1, P. Hammel1

1Beaujon Hospital, Clichy, France

Introduction: Long term outcome of patients with AIP is still poorly understood.

Objectives: To analyse the long term outcome of AIP pts and to compare HISORt+ pts and pts with normal serum IgG4.

Patients and Methods: Two groups were defined: HISORt+ (meeting HISORt criteria) and HISORt– (typical imaging and response to steroids with normal serum IgG4). AIP-related events and pancreatic exo/endocrine insufficiency were looked for during fol-low-up.

Results: 44 pts were included: 29 (66%) in HISORT+ group and 15 (34%) in HISORt- group. Median followup was 41 months [5-130]. Steroids were effective in all treated pts. Relapse was observed in 27% of pts, after a median delay of 6 (1-70) months. Four pts received azathioprine due to steroid resistance/dependence. Elevated serum IgG4 and pain/jaundice at time of diagnosis were associated with relapse at univariate analysis (p = 0.04 and <0.01 respectively). At long term, pancreatic atrophy/duct abnormalities on imaging, exo/endocrine insufficiency were observed in 35%, 34% and 39% of pts, respectively. No factor was associated with exocrine insufficiency, while female gender (p = 0.04), increasing age (p = 0.006) and HISORt+ (p = 0.001) were associated with diabetes. HISORt– AIP was more frequently associated with inflammatory bowel disease than HISORt+ AIP, but relapse rates were similar in both groups.

Conclusion: Relapse occurs in 27% of pts and is more frequent in pts with initial elevated serum IgG4 levels. Pancreatic atrophy and insufficiency occur in >1/3 pts within 3 years of diagnosis. The out-come of AIP in pts with normal serum IgG4 -often associated with inflammatory bowel diseaseis not different from that of HISORt+ pts.

O39

Corticosteroids Correct Aberrant Cystic Fibrosis Transmembrane Conductance Regulator Localization in the Duct and Regenerate Acinar Cells in Autoimmune PancreatitisS. Ko1, N. Mizuno2, Y. Yatabe3, T. Yoshikawa1, H. Ishiguro4, A. Yamamoto4, S. Azuma1, S. Naruse1, K. Yamao2, S. Muallem5, H. Goto1

1Department of Gastroenterology, Nagoya University Graduate School of Medicine, 2Department of Gastroenterology, Aichi Cancer Cener Hospital, 3Department of Moleculer Diagnostics, Aichi Cancer Center Hopital, 4Department of Human Nutrition, Nagoya University Graduate School of Medicine, 5Department of Physiology, UT Southwestern Med Ctr at Dallas

Introduction: Corticosteroids are now widely accepted as a treatment for autoimmune pancreatitis (AIP). However, the molecular mechanism by which steroid treatment improves AIP remains largely unknown.

Objectives: The aim of this study was to elucidate cellular mechanisms by which corticosteroids improve both pancreatic exo-crine function and histopathology in AIP.

Patients and Methods: Pancreatic exocrine function was eval-uated by the secretinstimulatedfunction test and pancreatic biopsy


specimens were processed forhistologic analysis at the time of diag-nosis and 3 months afterinitiation of steroid treatment. Expression and localization of proteins was assayed by immunohistochemistry. Analysis ofimmunoglobulin (Ig)G4-positive plasma cells was used to verifyinflammation in AIP.

Results: The number of IgG4-positive plasma cells in pancre-atic sections wasdecreased by steroid treatment, indicating reduced inflammation. Fluid, bicarbonate (HCO3-), and digestive enzyme secretions all wereimpaired in most patients with AIP. Corticosteroids improved bothHCO3- and digestive enzyme secretion. A large frac-tion of thecystic fibrosis transmembrane conductance regulator (CFTR), which playsa central role in pancreatic duct HCO3- secre-tion, was mislocalizedto the cytoplasm of duct cells before treatment. Corticosteroidscorrected the localization of CFTR to the apical mem-brane, accountingfor the improved HCO3- secretion. Steroid treat-ment resulted inregeneration of acinar cells, accounting for restored digestive enzymesecretion.

Conclusion: Corticosteroids reduce inflammation and restore both digestive enzymeand HCO3- secretion in patients with AIP by regenerating acinarcells and correcting CFTR localization in pancre-atic duct cells. Mislocalization of CFTR may explain aberrant HCO3- secretion inother forms of pancreatitis.

Pancreatic Cancer

O40

Role of the 18F-FDG PET for the Preoperative Diagnosis of Malignant Transformation of Intraductal Papillary Mucinous Tumors of the Pancreas (IPMT)C. Pery1, N. Regenet1, C. Ansquer2, E. Frampas3, A. Couvelard4, F. Montravers5, M.P. Vullierme6, P. Lévy7, A. Sauvanet8, P. Hammel7

1Chirurgie Digestive et Endocrinienne, Centre Hospitalier Universitaire, Nantes, France, 2Médecine Nucléaire, Centre Hospitalier Universitaire, Nantes, France, 3Radiologie, Centre Hospitalier Universitaire, Nantes, France, 4Anatomo-pathologie, Hôpital Beaujon, AP-HP, Clichyla-Garenne, France, 5Médecine Nucléaire, Hôpital Tenon, AP-HP, Paris, France, 6Radiologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France, 7Pancréatologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France, 8Chirurgie Hépatique et Pancréatique, Hôpital Beaujon, AP-HP, Clichyla-Garenne, France

Introduction: Conventional imaging is insufficiently sensitive/specific to assess malignancy in IPMT thus the therapeutic decision can be difficult in these patients.

Objectives: The aim of this study was to assess whether 18F-FDG-PET could help to detect a malignant component in IPMT.

Patients and Methods: 18 patients who had an IMPT treated by surgical resection in two centers were reviewed. All underwent CT

scan, MRI, endoscopic ultrasonography (EE) and PET before surgery. The histological examination was performed by two experienced pathologists.

Results: The overall sensitivity, specificity, positive and nega-tive predictive values of PET for the diagnosis of invasive carcinoma were 75%, 85%, 60% and 92%, respectively, vs 50-75%, 61-77%, 28-50% and 77-88% using CT/MRI/EE. Two subgroups could be distinguished : group 1 with a pancreatic mass on CTscan (n = 8) which was highly suggestive of malignancy, and group 2 without mass but with risk factors of malignancy (i.e. mural nodules >=3 mm, main duct or combined type, enlargement of the main duct >=10 mm or branch ducts >=30 mm) (n = 10). In the group 2, sensitivity, specificity, positive and negative predictive values of PET for the diagnosis of invasive carcinoma were 100%, 100%, 100% and 100% respectively.

Conclusion: PET was more efficient than conventional mor-phological techniques to diagnose invasive carcinoma in IPMT. The good negative predictive value could help to decide a limited resec-tion (enucleation or medial pancreatectomy) by excluding invasive carcinoma. Additional data are needed to determine the role of PET in the detection of metastases or tumour recurrence after a pancreatic resection for malignant IPMT.

O41

Identification of Serum Protein Biomarkers for Early Stage Pancreatic CancerS. Murray1, M. Aspinall O-Dea1, S. Tonack1, V. Elliot1, R. Jenkins2, C. Lane3, S. Camuzeaux4, U. Menon4, A. Gentry-Maharaj4, J. Sinclair4, S. Pereia5, J.F. Timms4, J.P. Neoptolemos1, B. Greenhalf1, E. Costello1

1Liverpool CR-UK Centre, Division of Surgery and Oncology, University of Liverpool, UK, 2Department of Pharmacology and Therapeutics, University of Liverpool, UK, 3Applied Biosystems, Warrington, UK, 4Institute for Women’s Health, University College of London, UK, 5Institute of Hepatology, University College of London, UK

Introduction: During pancreatic cancer progression as the tumour invades surrounding tissues, proteins are released into the cir-culation. Proteins are released from cancer cells and from cells in the surrounding tissues in response to the tumour.

Objectives: The aim of this study was to detect and identify these tumour specific proteins and evaluate their use as biomarkers for pancreatic cancer.

Patients and Methods: Serum was taken from 5 patients with early stage pancreatic cancer (EC:T1/3N0), 5 with later stage cancer (LC:T3N1), 5 with chronic pancreatitis (CP) and 5 healthy controls (HC). The serum samples were pooled, depleted of 20 abundant serum proteins, digested with trypsin and labeled with iTRAQ reagents. Strong cationic exchange chromatography was performed followed by reversed phase LC-ESI-MS/MS. From the proteins identi-fied, potential biomarkers were selected for validation based on fold change calculations and antibody availability.

Results: Over 250 proteins were identified with greater than 95% confidence and relative quantification data were obtained for 234 of these proteins. One potential biomarker was elevated 9.6-fold


in EC compared to HC and 25-fold compared to CP. In validation set 1, this protein was elevated 5-fold in EC compared to HC and 2-fold compared to CP. In validation set 2, the amount of this protein increased in 3 out of 5 patients over a 5 year time period leading up to a diagnosis of pancreatic cancer.

Conclusion: We have identified a potential biomarker for early stage pancreatic cancer. This protein is elevated 5-fold in EC com-pared to HC and 2-fold compared to CP.

O42

Deciphering of Pre-validated Serum Biomarker Signatures for Pancreatic Cancer Using Affinity ProteomicsC. Wingren1, R. Segersvärd2, A. Sandström1, A. Carlsson1, R. Andersson3, J.M. Löhr2, C. Borrebaeck1

1Dept. of Immunotechnology and CREATE Health, Lund University, Lund, Sweden, 2Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institutet at Karolinska University Hospital Stockholm, Sweden, 3Dept. of Surgery, Clinical Sciences, Skane University Hospital, Lund, Sweden

Introduction: Pancreatic Cancer (PC) is an aggressive disease with an incidence of 10/105 inhabitants/year, of which 96% will die within 5 years. Using current clinical tests, PC is very difficult to diagnose at an early stage, and when the cancer is finally confirmed, it is mostly already at an advanced level. By finding PC early, the odds of saving the patients by individually optimized surgical and/or therapeutic interventions will increase dramatically, resulting in an improved survival, improved quality of life and reduced costs, setting a novel standard for PC healthcare.

Objectives: To de-convolute PC-associated serum portraits for improved diagnosis based on a simple blood test using affinity proteomics.

Materials and Methods: Using an in-house designed recombi-nant antibody microarray technology platform, we have performed multiplexed protein expression profiling of 103 serum samples, including 34 PC, 16 chronic pancreatitis, 23 autoimmune pancreati-tis, and 30 healthy controls.

Results: In this study, we have deciphered PC-associated serum biomarker signatures. In more detail, we have for the first time pre-validated a serum biomarker signature composed of 18 analytes enabling us to discriminate between PC and healthy controls with high specificity and sensitivity. Further, we have successfully extended these findings and delineated a second 25 analyte-based serum biomarker signature uniquely allowing us to distinguish PC vs. a combined patient cohort composed of healthy controls, chronic pancreatitis and autoimmune pancreatitis.

Conclusion: Taken together, the data showed that a simple blood sample harboured sufficient information for enabling PC diag-nosis in a highly specific and sensitive manner.

O43

Molecular Analysis of p53, K-ras and CDKN2A Promoters Methylated in Intraductal Papillary Mucinous NeoplasmsL. Yan1, J. Butler1, S. Harrison1, C. Grocock1, M. Harcus1, H. Smart1, M. Lombard1, J. Evans1, R. Sutton1, J.P. Neoptolemos1, W. Greenhalf1

1Division of Surgery and Oncology, The University of Liverpool

Introduction: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are benign lesions but often develop or are associated with carcinoma.

Objectives: To investigate the feasibility of screening pancre-atic juice for molecular markers indicative of malignancy associated with IPMN

Patients and Methods: Pancreatic juice was extracted from patients with pancreatic ductal adenocarcinoma (51), chronic pan-creatitis (21), biliary tract stones (44) and IPMN (14). p53 mutations were analysed using a modified yeast functional assay, K-ras status was analysed using mutation specific real-time PCR and the propor-tion of CDKN2A promoters methylated at CpG islands was estimated by using comparative methylation specific real-time PCR. Tissue samples were tested for p53 mutations by direct sequencing.

Results: p53 mutations were detected in 4 (29%) of 14 patients with IPMN compared with 20 (39%) of 51 cases of pancreatic ductal adenocarcinoma, none of 40 controls and 2 (10%) of 20 patients with chronic pancreatitis (p < 0.001). K-ras mutations were detected in 8 (57%) of 14 patients with IPMN comparing with 29/51 (57%) cancer patients, 10/44 (23%) controls and 8/21 (38%) patients with chronic pancreatitis (p < 0.005). Four (31%) of 13 IPMN patients had CDKN2A promoter methylation levels >12% compared to 27 (61%) of 44 can-cer patients, 1/21 (5%) controls and 2/19 (11%) with chronic pancrea-titis (p < 0.0001). None of the IPMN lesions had p53 mutations.

Conclusion: Combination molecular analysis in pancreatic juice identifies patients with IPMN even without associated malignancy. The associated mutations do not seem to be associated with the IPMN lesion itself and so could be identifying pre-malignant lesions within or associated with the mucinous neoplasia.

O44

Low Frequency of Microsatellite Instability Among European Patients with Pancreatic CancerL. Laghi1, A. Spinelli1, P. Bianchi1, A. Brecht2, G. Schumacher2, C. Röcken2, I. Gräntzdörffer2, P. Neuhaus2, M. Roncalli1, M. Montorsi1, A. Malesci1

1IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy; 2Charitè Campus Virchow, University of Berlin, Berlin, Germany

Introduction: Inherited and acquired defects of the mismatch repair (MMR) genes are responsable for gastrointestinal cancers with


microsatellite instability (MSI), which account for 10-15% of the cases. However, the reported prevalence of the MSI phenotype among pancreatic tumors varies widely from 1% to 10%, and the contribu-tion to the inherited burden of pancreatic tumors remains to be determined.

Objectives: To assess the prevalence of tumors with the MSI phenotype among pancreatic neoplasms in Caucasian patients.

Patients and Methods: We studied the prevalence of the MSI phenotype among 135 consecutive pancreatic tumor resections per-formed at an Italian and at a German referral center. Speci mens from Italy comprised 10 ampullary cancers, 6 endocrine tumors and 57 pancreatic ductal adenocarcinoma (PDAC), and those from Germany 62 PDAC. MS-status was determined by taking advantage of mono-nucleotide repeat markers (BAT25 and BAT26), which are almost monomorphic in Caucasians.

Results: Only one out 119 (0.8%) PDAC showed MSI, and was identified in a 77 years old Italian patient (1.7%), as compared to 1 out 10 ampullary cancers (10%, P = 0.2), and 1 out of 6 endocrine tumors (17%; p = 0.09; MSI in PDAC vs other histotypes, p = 0.04)

Conclusion: The prevalence of MSI was higher in pancreatic tumors other than PDAC in European patients. In PDAC MSI is a rare phenomenon, which likely does not contribute to the burden of pancreatic cancer, while it might be encountered in less frequent, sus-ceptible to radical surgery, pancreatic neoplasms which might arise in the context of HNPCC.

O45

Parallelized Functional Characterization of Pancreatic Cancer Candidate Genes on Reverse Transfection Cell MicroarraysS. Melchisedech1, T. Honstein1, R. Kreider1, T.M. Gress1, M. Buchholz1

1Clinic for Gastroenterology, Marburg, Germany

Introduction: In previous high-throughput analyses, we gener-ated expression profiles of ~2000 candidate genes in primary tissues and model systems of pancreatic cancer. 80 candidate genes with a high probability of being biologically relevant or to be suited as target genes for diagnosis or therapy were selected for further characterization.

Objectives: This project aims to functionally analyze the 80 genes in transformed and nontransformed cell lines to select highly relevant candidates for further in-depth characterization. In parallized assays, the candidates are overexpressed as well as downregulated in different cell lines and the effects on differentiation, proliferation, apoptosis-resistance evaluated.

Materials and Methods: The parallelized analyses are per-formed in the “reverse transfection” format. In this technique, overex-pression- and knockdown-constructs are spotted in regular arrays together with transfection reagents on glass slides. Cells are then cul-tivated on the slides, incorporating and expressing the different con-structs. Overexpressionor knockdown effects are analysed by fluorescence-based assays.

Results: Candidates and controls were expressed as fusion con-structs with fluorescence proteins in carcinoma cell lines (PANC-1, SUIT007, EPras) as well as non-transformed cells (HEK293, EP4) in the presence or absence of serum. Several candidates were identified

as target genes for serum stimulation (alteration of subcellular locali-sation) and/or showed influence on proliferation (Ki67-staining) or apoptosis resistance (cleavedcaspase 3-assay). Analysis of the effects on cell differentiation (staining forE-Cadherin or Vimentin) as well as experiments in knockdown format are ongoing.

Conclusion: ‘Reverse transfection arrays’ are a highly efficient technology to identify tumor-relevant genes and characterize impor-tant functional roles with high throughput.

O46

Surgical Resection for Local Recurrence of Pancreatic CancerO. Strobel1, W. Hartwig1, T. Hackert1, J. Debus2, M.W. Büchler1, J. Werner1

1Department of General Surgery, University of Heidelberg, Heidelberg, Germany, 2Radiation Oncology, University of Heidelberg, Heidelberg, Germany

Introduction: Local recurrence of pancreatic ductal adenocarci-noma occurs in up to 80% of patients within 2 years after a potentially curative resection. In general, these patients only receive palliative chemotherapy or chemoradiation, and have a poor survival.

Objectives: To evaluate the outcome and potential value of sur-gical resection in locally recurrent pancreatic cancer.

Patients and Methods: 111 patients underwent exploration for locally recurrent pancreatic cancer between 10/2001 and 10/2009. Analysis included perioperative morbidity and mortality as well as was evaluation of survival rates determined by Kaplan-Meier estima-tion and log-rank tests.

Results: Median time between the initial resection and recur-rence was 14.0 months. 54 (49%) patients underwent resection, 57 (51%) of patients either underwent palliative bypass or exploration only. The in-hospital morbidity and mortality rates of resected patients were 25.8% and 3.2% compared to 13.2% and 0% of patients who underwent palliative bypass or exploration only. The overall median survival of patients with recurrent disease after the resection of the recurrence was 21.6 months (44.7% 2-year survival) and significant longer than survival after palliative surgery (10.7 month, 12.2% 2-year survival, p = 0.0010). Patients with a prolonged interval from resection to recurrence were more likely to benefit from re-resection compared with patients with early recurrence.

Conclusion: Resection for recurrent pancreatic cancer can be carried out safely. While differences in survival between resected and non-resected patients may be based on patient selection, the survival observed after resection justify the attempt of resectipn. A close fol-low-up of patients with pancreatic resections and an aggressive man-agement of local recurrences are recommended.


O47

Radiofrequency Ablation for Advanced Ductal Pancreatic Carcinoma: Is This Approach Beneficial for Our Patients? A Systematic ReviewR. Pezzilli1, C. Ricci1, R. Casadei1, F. Monari1, M. D’Ambra1, F. Minni1

1Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy

Introduction: It has recently been claimed that radiofrequency ablation (RFA) may be beneficial for patients with locally advanced or metastatic ductal pancreatic adenocarcinoma (PC).

Objectives: To obtain information on the demographic and clin-ical outcomes in patients who underwent RFA for locally advanced or metastatic PC.

Materials and Methods: A systematic review of the literature using Medline was carried out on February 26, 2010. The MESH terms used were “pancreatic neoplasms” (explanatory variable) and “catheter ablation” (outcome variable). We identified additional stud-ies through hand searches of bibliographies from primary studies, review articles and key journals; the search yielded 49 hits.

Results: Of the 49 papers, 7 no randomized studies involving 106 patients with PC treated using RFA were examined. The median age of the patients was 62 years (range 27–85). PC was mainly located in the pancreatic head (66.9%) with a median size of 4.6 cm (range 3–1). RFA was carried out in 85 patients (80.1%) with locally advanced PC and in 21 (19.9%) with metastatic disease. Palliative surgical procedures were carried out in 41.5% of the patients. The temperature used was 90°C (range 30–105) and the ratio between the number of passes of the probe and the size of tumor was 0.5 (0.36–1). The median postoperative morbidity and mortality were 27.3% and 7.5%, respectively; the median survival was 6.5 months (range 1–33).

Conclusion: RFA is feasible, even if both its safety and long-term results are disappointing. At present, an RFA procedure should not be recommended for patients with locally advanced PC.

O48

One Hundred Consecutive Patients Treated with Radiofrequency Ablation for Stage III Pancreatic Cancer: Results from a Single InstitutionI. Frigerio1, A. Giardino1, R. Girelli1, R. Salvia2, S. Partelli2, P. Pederzoli2, C. Bassi2

1HPB Unit, Pederzoli Clinic - Peschiera del Garda (Verona), 2Surgical and Gastroenterological Department, Policlinico GB Rossi - Verona

Introduction: Radiofrequency ablation (RFA) is an accepted procedure for unresectable solid tumors and we recently demonstrated its applicability in stage III pancreatic carcinoma.

Objectives: Here we present our series of patients.

Patients and Methods: Patients with Stage III ductal carci-noma were prospectively enrolled for the study. RFA was performed during laparotomy and associated to palliative surgery when needed. Pancreatic fistula, duodenal injuries and thrombosis of portal vein or SMV were considered as RFA-related complications. After surgery all patients were sent to the oncologist to receive chemo and radio-therapy (CTRT) and follow up was updated every three months.

Results: Between February 2007 and March 2010, 100 patients were treated with RFA in our institution. Males were 57 and the median age was 64 yrs. Tumor was located in the head/uncinate process in 67 cases and palliative surgery was associated in 51 pts. RFA as up front treatment was carried out in 51 cases and 87 pts were sent for adiuvant CTRT after RFA. RFA-related morbidity was 16% and mortality was 3%. Thirteen pts had early progression and died of the disease within 3 months after RFA. Sixty nine pts are alive and 45 of them are, at this time, progression free. Median follow up is 7 months.

Conclusion: RFA might be a new option to treat patients with Stage III pancreatic cancer and must be associated with chemo and radiotherapy. Further studies are needed to investigate its possible role as part of a multimodal neoadiuvant treatment.

O49

Metastatic to Resected Lymph Node Ratio Is an Important Prognostic Factor in Pancreatic Ductal AdenocarcinomaA. Rahman1, S. Robinson1, B. Haugk2, J. French1, D. Manas1, B. Jaques1, S. White1, R. Charnley1

1Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle Upon Tyne, UK, 2Department of Histopathology, Freeman Hospital, Newcastle Upon Tyne, UK

Introduction: Positive lymph node status is a recognised pre-dictor of survival in those undergoing pancreaticoduodenectomy for ductal adenocarcinoma.

Objectives: To identify further factors related to patient prognosis.Patients and Methods: A prospective database of all patients

undergoing pancreaticoduodenectomy between April 2002 and June 2009 was analysed to identify all patients with proven pancreatic duc-tal adenocarcinoma. All other histological groups were excluded from analysis. Tumour characteristics and patient survival were analysed by uni-variate and multi-variate analysis to identify those factors pre-dicting long-term outcome.

Results: 134 patients (60% male; median age 64 years (range 34-80)) underwent pancreaticoduodenectomy for ductal adenocarci-noma over this time period. Overall 5 year survival was 18.6%. Univariate analysis identified nodal status, metastatic to resected lymph node ratio, vascular invasion and resection margin status as predictors of survival. T stage was not a predictor of survival. Using multivariate Cox regression analysis only nodal status and metastatic to resected lymph node ratio were identified as independent predic-tors of survival (p < 0.001). Nodal status alone identified a group (10%) of lymph node negative patients with 5 year survival of 55.6% compared with 12.9% for N1 disease. Metastatic to resected lymph node ratio, however, was able to stratify the remaining lymph node


positive patients, identifying a poor prognostic group of >15% nodes positive with 5 year survival of 5.2% versus 21.7% for those with <15% resected nodes positive, (p = 0.0017).

Conclusion: The metastatic to resected lymph node ratio can provide significant prognostic information in those with node posi-tive disease after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

O50

Intratumoral Vascular Growth Determines R1-rate and Lymph Node Status in Pancreatic CancerR. Segersvärd1, A. Leifler1, S. Ghazi2, F. Jonsson1, M. Nilsson1, J. Permert1

1Dept. of Surgical Gastroenterology, CLINTEC Karolinska Institutet at Karolinska University Hospital Stockholm, Sweden, 2Dept. of Pathology, Lab Med, Karolinska Institutet at Karolinska University Hospital Stockholm, Sweden

Introduction: The rate of microscopic residual disease (R1) and lymph node (LN) yield after pancreaticoduodenectomy (PD) for pan-creatic cancer (PC) are regarded a function of surgical technique and high quality pathology. The role of intrinsic tumoral factors such as and lymphatic (L), vascular (V) or perineural (PN) growth are less studied.

Objectives: To evaluate the impact of intrinsic tumor factors on R1-rate and LN-status.

Patients and Methods: From our prospective registry, 100 consecutive PD for PC were analysed regarding R1-rate, tumor size (Ts), differentiation (diff), and the presence (1) or absence (0) of L, V, PN growth, regional (N) and extra regional LN-metastases (M1 LN). LN-ratio (LN-met/LN) was calculated.

Results: Median Ts 30 mm, 54% poor diff. L1 51%, V1 56%, PN1 87%. R1-rate 62%. Median LN-yield 21 and LN-met 3. N1 82%, M1LN 30%. Venous resection (VR) 31%. In univariate analysis V1 and PN1 increased R1-rate. L1, V1, and PN1 increased number of LN-met and N1-stage. L1 and V1 increased LN-ratio and M1LN. In multivariate regression analysis (adjusted for Ts, diff, VR), V1 was an independent risk factor for R1 (OR 7.2), N1 (OR 12.8) and M1LN (OR 10.2). PN1 was a contributing risk factor for N1 (OR 8,4). No impact of L1 was observed.

Conclusion: This study shows that intratumoral vascular growth is an independent factor for nonsuccessful surgical resection as well as spread to regional and extra regional lymph nodes. We suggest that all pancreatic cancers should be considerad “biologically non-resectable” and that pretreatment should be given before surgical resection.

O51

Familial Pancreatic Cancer – Results of Screening of Individuals at RiskP. Langer1, P.H. Kann2, V. Fendrich1, N. Habbe1, E.P. Slater1, J. Heverhagen3, T. Gress4, D.K. Bartsch1

1Department of General Surgery, Philipps-University Hospital, Marburg, Germany, 2Division of Endocrinology and Diabetology, Philipps-University Hospital, Marburg, Germany, 3Department of Radiology, Philipps-University Hospital, Marburg, Germany, 4Department of Gastroenterology, Philipps-University Hospital, Marburg, Germany

Introduction: First-degree relatives of familial pancreatic can-cer (FPC) - patients have an up to 32-fold increased risk for the devel-opment of pancreatic cancer (PC). Individuals at risk (IAR) from FPC-families should undergo PC screening.

Objectives: To evaluate the diagnostic yield of a prospective screening program in FPC.

Patients and Methods: IAR of FPC families of the German Collection for FPC (FaPaCa) were enrolled in a prospective PC screening program including clinical examination, lab-tests, endo-scopic ultrasound (EUS) and magnetic resonance imaging (MRI).

Results: Between 6/2002 and 12/2009 72 IAR of 94 FPC-families took part in the program. Fortysix IAR (63.9%) had a normal pancreas based on EUS and MRI. Twenty-six (36.1%) IAR had lesions, of whom 10 were operated on and 16, including 5 with poten-tial side branch IPMN, are under observation. Nine IAR underwent pancreatic resection revealing the following: PC (n = 1), PanIN3 + IPMN (1), serous cystadenoma (n = 3), IPMN (n = 2), PanIN1/2 lesions (n = 2). One patient with IPMN also revealed multifocal PanIN2 lesions. These resulted in a diagnostic yield of malignant (PC) or potentially malignant precursor lesions of PC (IPMN, PanIN3, multifocal PanIN2,) between 5,5% (4 of 72) to 12,5% (9 of 72), depending on inclusion of the 5 IAR with branch duct IPMNs on imaging.

Conclusion: In FPC an EUS-based screening program leads to the detection of potential precursor lesions of PC. Since the yield of the program is comparably low and its value is still not defined, screening of IAR should only be performed under board approved scientific protocols and not on a health care basis.


© 2010 S. Karger AG, Basel and IAP


Nordic Light Oral Sessions

Nordic Light Session I

Acute Pancreatitis 1

NLS1

Rho-kinase Inhibition Regulates CXC Chemokine Formation, Leukocyte Recruitment and Trypsinogen Activation in Severe Acute PancreatitisD. Awla1, H. Hartman1, A. Abdulla1, S. Zhang1, M. Rahman1, S. Regnér1, H. Thorlacius1

1Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden

Introduction: Severe acute pancreatitis is characterized by infiltration of leukocytes, trypsinogen activation and tissue necrosis, but the intracellular signalling mechanisms remain elusive.

Objectives: Rho kinase is a regulator of specific cellular pro-cesses in several pro-inflammatory activities. Herein, we examined the role of Rho-kinase signalling in acute pancreatitis.

Materials and Methods: Pancreatitis was induced by infusion of taurocholate into the pancreatic duct in C57BL/6 mice. Animals were treated with a Rho kinase inhibitor Y-27632 (0.5-5 mg/kg) or saline before induction of pancreatitis.

Results: Taurocholate infusion caused clear-cut increase in serum amylase, pancreatic leukocyte infiltration, acinar cell necrosis and oedema formation. Levels of pancreatic myeloperoxidase (MPO), macrophage inflammatory protein-2 (MIP-2), trypsinogen activation peptide (TAP), Mac-1 expression on neutrophils and lung MPO was significantly increased confirming local and systemic disease. Inhibition of Rho-kinase dose-dependently protected against pancrea-titis. For example, 5mg/kg Y-27632 reduced acinar cell necrosis, leu-kocyte infiltration and pancreatic oedema by 90%, 89% and 58%, respectively as well as tissue levels of MPO by 75% and MIP-2 by 84%. Moreover, Rho-kinase inhibition decreased lung MPO by 75% and serum amylase by 83%. Pancreatitis induced TAP levels were reduced by 61% in Y-27632-treated mice.

Conclusion: Our novel data suggests that Rho-kinase signalling plays an important role in acute pancreatitis by regulating CXC chemokine formation and subsequent leukocyte infiltration. Thus, these results indicate that Rho-kinase may constitute a novel target to treat severe acute pancreatitis.

NLS2

IL-6 Links NF-B and STAT3 in Different Compartments to Regulate Acute Lung Injury in a Mouse Model of Acute PancreatitisZ. Hong1, M. Lesina1, M. Treiber1, T. Wortmann1, S. Rose-John2, W. Halangk2, R.M. Schmid3, H. Algül1

1II. Medical Clinic, Klinikum rechts der Isar, Technical University of Munich, 2Department of Experimental Surgery, Otto-von-Guericke-University of Magdeburg, 3Institute of Biochemistry, Christian-Albrechts-University of Kiel

Introduction: Acute lung injury (ALI) defines the most severe complication in acute pancreatitis (AP) and is associated with high mortality.

Objectives: Specific therapeutic approaches for this complica-tion are hampered by the lack of knowledge about the pathophysio-logical mechanisms.

Materials and Methods: By using genetic and pharmacologi-cal approaches in mice, we unravel a crosstalk of transcription factors in different compartments that regulate AP and ALI.

Results: Rapid NF-B activation in the pancreas results in recruit-ment of myeloid cells which secret IL-6 NF-B dependently. Released IL-6, in turn, induces p-STAT3Y705 in the acinar cells thereby ampli-fying local inflammation. Interestingly, the axis of NF-B dependent IL-6 production in myeloid cells and pancreatic p-STAT3Y705 is a prerequisite for AP-associated ALI. Pharmacological intervention prove the NF-B/IL-6/STAT3 axis as a valuable target in management of ALI.

Conclusion: This study identifies for the first time the pathophysiological mechanism of AP and associated ALI thereby defining a novel therapeutic rationale in treatment of inflammation associated ALI.


NLS3

A Novel Model of Acute Alcoholic Pancreatitis by Concomitant Administration of Ethanol and Fatty AcidW. Huang1, R. Mukherjee1, V. Elliott2, D.M. Booth3, A.V. Tepikin3, D.N. Criddle3, R. Sutton2

1Division of Surgery and Oncology, Royal Liverpool University Hospital, Liverpool, UK, 2NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK, 3Physiological Laboratory, University of Liverpool, Liverpool, UK

Introduction: At present no simple, reliable model of murine alcoholic pancreatitis exists. Nonoxidative metabolites of alcohol, fatty acid ethyl esters, are synthesized in the pancreas by enzymes which conjugate ethanol (EtOH) to fatty acids and have been impli-cated as mediators of acute pancreatitis.

Objectives: To characterise a novel acute pancreatitis model induced by concomitant administration of EtOH and fatty acid (palm-itoleic acid: POA) in mice.

Materials and Methods: CD1 mice (30-35 g) were injected intraperitoneally twice one h apart, either with normal saline (50 μl), or 1.32 g/kg pure EtOH, or 1.32 g/kg EtOH + 0.25 mg/kg POA, or 1.32 g/kg EtOH + 2 mg/kg POA. The severity of acute pancreatitis was assessed at 2, 6, 12, 24 and 48 h after the first injection. The peak serum EtOH concentration was quantified by enzymatic assay.

Results: The peak serum EtOH concentration achieved was 35.6 ±4.9 mM in the EtOH alone group. Saline, EtOH alone, or EtOH with the lower concentration of POA caused no discernable pancreatic injury. In contrast, EtOH with the higher concentration of POA induced significant increases of serum amylase (peak at 12 h), pan-creatic trypsin and myeloperoxidase activity, accompanied by marked histopathological changes that peaked at 24 h. All parameters decreased at 48 h.

Conclusion: Our results indicate that concomitant administra-tion of EtOH and POA causes acute pancreatitis. Since this novel model may parallel clinical acute alcoholic pancreatitis, it could be a useful tool to study alcohol-induced acute pancreatitis.

Acute Pancreatitis 2

NLS4

Prognostic Value of Blood Urea Nitrogen (BUN) in the Early Assessment of Acute Pancreatitis: An International StudyB. Wu1, O. Bakker2, G. Papachristou3, K. Repas1, M.G. Besselink2, H.C. van Santvoort2, V. Muddana3, V. Singh1, D.C. Whitcomb3, H.G. Gooszen2, P. Banks1

1Brigham and Women’s Hospital Boston, 2Utrecht University Medical Center, 3University of Pittsburgh Medical Center

Introduction: An accurate approach to monitor early disease course is a critical step to improve treatment in acute pancreatitis (AP).

Objectives: To evaluate the accuracy of early changes in BUN for prediction of mortality in a series of rigorously defined prospec-tive AP cohort studies.

Patients and Methods: Data were collected from 3 prospec-tive AP cohort studies: Brigham and Women’s Hospital (BWH), University of Pittsburgh Medical Center (UPMC) and from 15 Dutch hospitals (Dutch Pancreatitis Study Group [DPSG]). All centers used standardized criteria for diagnosis of AP. Early BUN trajectories were compared between survivors and fatal cases of AP (univariate analy-sis). Multivariate logistic regression was used to obtain age- and gen-der-adjusted estimates for elevation in BUN at admission and/or rise in BUN at 24 hours. Accuracy of BUN was compared with APACHE II using area under ROC curves (AUC).

Results: Data from 1,407 AP cases were included from the 3 study cohorts (642 BWH, 579 DPSG and 186 UPMC). Mortality ranged from 3.4-6.4%. Both the BUN at admission and subsequent change in BUN at 24 hours were independent predictors of mortality. In particular, a BUN >=25 mg/dL at admission was associated with 13% mortality while rise in BUN of >=10 mg/dL in 24 hours was associated with mortality as high as 30%. Accuracy of a two-variable BUN model (admission and change in BUN) ranged from AUC = 0.82 to 0.95. Overall accuracy of the BUN model was comparable to APACHE II (AUC = 0.80).

Conclusion: Serial BUN measurement is a simple and accurate method for monitoring early disease course in acute pancreatitis.


NLS5

EuroPEPs-European Post ERCP Pancreatitis Study: A Pancreas 2000 ProjectS. Regnér1, K. Kull2, L. Kylänpää3, H. Pelli4, R.H. Pfützer5, H. Simán6, J.M. Löhr7

1Dept of Surgery, Institution of Clinical Sciences, Malmö, SUS, Lund University, 2Dept of Endocrinology and Gastroenterology, Internal Medicine Clinic, Tartu University Hospital, Estonia, 3Dept of Surgery, Helsinki University Central Hospital, Finland, 4Dept of Surgery, Helsinki University Central Hospital, Helsinki and Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland, 5Dept. of Internal Medicine, Evangelisches Krankenhaus Kalk, Cologne, Germany; Dept. of Medicine II, Universitätsmedizin Mannheim, Mannheim, Germany, 6Dept of Medicine, Central Hospital Växjö, Växjö, Sweden, 7Dept of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sweden

Introduction: ERCP may lead to acute post ERCP pancreatitis (PEP) in 5-15% of all cases. The role of patient related risk factors such as hypertriglyceridemia, alcohol consumption, smoking or genetic variations remain elusive. Furthermore, ERCP pancreatitis is the only form of human pancreatitis where pathophysiological events can be investigated from the very beginning.

Objectives: To study patient related risk factors and the early pathophysiology in PEP.

Patients and Methods: Patients undergoing ERCP in 5 differ-ent European centers were included. Known risk factors (procedure related factors, indication for ERCP, age) as well as potential risk factors (alcohol consumption, smoking habits, dietary factors) were collected prospectively. Blood and urine samples were drawn before and at 2, 6 and 24 hours after ERCP for analysis of genetic factors as well as for markers of protease activation, enzyme leakage and inflammation.

Results: In all, 172 patients were included. Most common indi-cations for ERCP were stone disease (57%), icterus (12%), tumour (9%), and pancreatic pseudocyst (4%). 17 patients (10%, mean age 67 years) developed PEP. In this group, distribution of indications was not different from the overall group. Frequency of precut or EST to the bile duct was not significantly higher in patients developing PEP. EST in pancreatic duct was significantly more common in patients developing pancreatitis (27% versus 6%, p < 0.03).

Conclusion: Analysis of patient related risk factors and of mediators of protease activation and inflammation will give better knowledge about post ERCP pancreatitis and the pathophysiology of acute pancreatitis. Currently, further analysis of some of these factors is underway.

NLS6

Angiotensin II Receptor Blockers and Risk of Acute Pancreatitis – A Population Based Casecontrol Study Using the Prescribed Drug Register in SwedenT. Sjöberg Bexelius1, F. Mattsson1, R. Ljung2, Y. Lu1, M. Lindblad1

1Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, 2National Board of Health and Welfare, Stockholm, Sweden

Introduction: Acute pancreatitis is a potentially lethal disease, with a rising incidence in the Western world. Yet, no pharmacological prevention exists. Experimental and epidemiological research sug-gests a protective effect of angiotensin II receptor blockers.

Objectives: Do exposure to angiotensin II receptor blockers protect against development of acute pancreatitis?

Materials and Methods: During 2006 we performed a nation-wide case-control study on Swedish residents aged 40-84 years. First-time cases with acute pancreatitis were identified in the National Patient Register and data on dispensed prescriptions was retrieved from the Prescribed Drug Register. Control persons were randomly selected from the corresponding background population in Sweden frequency matched on sex and age. To estimate relative risk of acute pancreatitis among users of angiotensin II receptor blockers, as com-pared to non-users, we used multivariable regression analysis to cal-culate odds ratios (OR) with 95% confidence interval (CI) adjusting for potential confounding by sex, age, education, alcohol related dis-ease, cardiovascular disease, and number of distinct medications.

Results: Among 1,961 cases of acute pancreatitis and 20,000 controls, current use of angiotensin II receptor blockers was followed by a decreased OR of acute pancreatitis, compared to non-users (adjusted OR 0.81, 95% CI 0.69-0.97). No association was found with past use, and no doseresponse effect was identified. No associa-tion was found for users of angiotensin-converting enzyme inhibitors (OR 1.05, 95% 0.91-1.22), analyzed for comparison reasons.

Conclusion: This large case-control study suggests that current use of angiotensin II receptor blockers prevents the development of acute pancreatitis.


Chronic Pancreatitis 1

NLS7

Pain Remission After Placebo in Randomized Conrolled Trials of Chronic Pancreatitis: A Meta-analysisL. Cocomello1, G. Capurso1, C. Cammà2, G. Delle Fave1

1Digestive and Liver Disease Unit, II Medical School, Sapienza University, Rome, Italy, 2Gastroenterology Unit, University of Palermo, Palermo, Italy

Introduction: Abdominal pain is the main clinical manifesta-tion of chronic pancreatitis (CP). The benefit of available therapy for its management is uncertain. Knowledge of the placebo outcomes and understanding specific study features that influence these outcomes may prove relevant for designing future clinical trials.

Objectives: The aim of this meta-analysis was to investigate the placebo effect on abdominal pain remission rate in CP and to identify factors influencing this rate.

Materials and Methods: Medline, Embase and Scopus were searched (through September 2009). Randomized placebo-controlled trials with at least 2 weeks’ duration in patients with CP that provided data on abdominal pain remission rate in the placebo arm were included. Pooled estimate of the placebo rate were calculated using random-effects logistic regression analysis. To deal with heterogene-ity, stratum-specific rates for different patient and study-level covari-ates were calculated.

Results: Six randomized controlled trials met the predefined cri-teria and included 172 placebotreated patients. The pooled estimate of the placebo rate of abdominal pain remission was 19% (95%CI 8%-39%; range 2.4%-50%; p = 0.005). There was a statistically sig-nificant heterogeneity among the studies (I2 = 78%; p < 0.001). Studies that had a longer run-in period (>2 weeks) had lower placebo rates of remission (10% versus 35%; p = 0.014). Subgroup analysis found wash-out and run-in periods as variables influencing placebo-remis-sion rate.

Conclusion: This meta-analysis confirms the heterogeneity of abdominal pain remission in the placebo arm of CP randomized pla-cebo-controlled trials. Wash-out and run-in period seemed to explain this heterogeneity. These data provide a sound basis for designing future placebocontrolled clinical trials evaluating abdominal pain in CP patients.

NLS8

Altered Cerebral Pain Processing in Chronic PancreatitisS.S. Olesen1, J.B. Frøkjær2, D. Lelic1, M. Valeriani3, A.M. Drewes1

1Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, Denmark, 2Department of Radiology, Aalborg Hospital, Aarhus University Hospital, Denmark, 3Division of Neurology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy

Introduction: Pain is a prominent symptom in chronic pancrea-titis, but the underlying mechanisms remains to be elucidated. Altered pain processing in the central nervous system has been reported in various chronic pain disorders and may be important in painful chronic pancreatitis.

Objectives: The aim of the present study was to investigate cerebral pain processing in patients suffering from pain due to chronic pancreatitis.

Patients and Methods: Twenty-four patients suffering from painful chronic pancreatitis and 14 healthy volunteers were included. The rectosigmoid colon was stimulated electrically at the pain thresh-old with simultaneous recording of event related brain potentials (EPs) from 64 surface electrodes. EPs were analyzed with reconstruc-tion of the underlying brain sources by inverse modelling. Source coordinates were projected to individual MR images of the brains.

Results: As compared with healthy volunteers the patients showed prolonged latencies of EPs in the frontal region (P < .01), while no differences were seen in the central (P = .1) or temporal regions (P = .5). No differences was seen in peak-to-peak amplitudes (all P > .05). Source analysis showed that in both patients and controls the dipolar activities were located consistently in bilateral insula, anterior cingulate gyrus, and bilateral in secondary somatosensory area. The bilateral insular dipoles were localized more posterior in the patients than in healthy subjects (P = .02).

Conclusion: The findings indicate that sustained pain in chronic pancreatitis leads to changes in cortical projections of the nociceptive system. This could reflect a neuropathic-like component in pancreatic pain, which may influence the approach to treatment.

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Pain Control Systems Is Impaired in Chronic PancreatitisS.S. Olesen1, C. Brock1, J.B. Frøkjær2, A.L. Krarup1, A.M. Drewes1

1Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, Denmark, 2Department of Radiology, Aalborg Hospital, Aarhus University Hospital, Denmark

Introduction: Pain is a prominent symptom in chronic pancrea-titis (CP), but the underling mechanisms are incompletely understood. Descending pain modulation from brainstem structures has been


reported to be of importance for maintaining pancreatic pain in an animal model of CP.

Objectives: The aims of the study were to investigate the role of descending pain modulation from supraspinal structures as well as nervous system sensitization in patients with pain due to CP.

Patients and Methods: Twenty-five patients with CP and 15 healthy volunteers were included. Inhibition of pain from the brain-stem (diffuse noxious inhibitory control (DNIC)) was induced experi-mentally by immersing the hand into ice water for three minutes (cold pressor test) and quantified as changes in pain thresholds before and after its induction. Pain processing was investigated as the responses to multimodal (electrical, thermal, and mechanical) stimulations of the rectosigmoid colon (i.e. a gastrointestinal organ remote to the pancreas).

Results: Compared with healthy volunteers, the efficacy of DNIC was reduced in patients with CP (13%±21% vs. 39%±22%, respectively; P = .01). Sensitization of the nervous system was indi-cated by remote hyperalgesia in the rectosigmoid to electrical (21±15mA vs. 27±15mA; P = .02) and heat stimulation (51±5C vs. 53±4C; P = .02).

Conclusion: Patients with CP have impairments in normal pain control systems and evidence of sensitization of the nervous system, likely on the central level. The findings support a growing body of evidence suggesting changes in central nervous system pain process-ing to be of importance in chronic pancreatic pain.

Chronic Pancreatitis 2

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Analysis of the Etiology in 458 Pancreatitis Patients According to the M-ANNHEIM Multiple Risk Factor ClassificationA. Schneider1, J.M. Löhr2, M.V. Singer1

1Dept. of Medicine II, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany, 2Dept. of Surgical Gastroenterology, Karolinska Institute, Stockholm, Sweden

Introduction: Chronic pancreatitis (cP) represents a complex disorder with interaction of various risk factors. The M-ANNHEIM classification addresses this issue and stratifies multiple (M) etiologi-cal risk factors such as Alcohol (A), Nicotine (N), Nutrition (N), Heredity (H), Efferent duct factors (E), Immunity (I), Miscellaneous factors (M), differentiates various disease stages and defines different degrees of disease severity.

Objectives: To identify the interaction and frequency of known etiological risk factors in pancreatitis patients.

Patients and Methods: Patients (n = 458 with sufficient data, exclusion of biliary pancreatitis) from our clinic in Germany (1997-2008) were classified according to the M-ANNHEIM classification.

Results: In n = 172/458 patients (38%, n = 49 borderline cP, n = 123 definite or probable cP), only up to one etiological risk factor

was found. In n = 286/458 patients (62%, n = 62 borderline cP, n = 224 definite or probable cP), two or more risk factors were identified. Alcohol was observed as a risk factor in n = 266/465 (58%) patients. Nicotine was found in n = 311/458 (68%) individuals. Alcohol was found in n = 25/172 (15%) and Nicotine in n = 44/172 (26%) patients with up to one risk factor. Alcohol was detected in n = 241/286 (84%) and Nicotine in n = 267/286 (93%) patients with multiple risk factors. Interaction of Alcohol with Nicotine was found in n = 236/286 (83%) patients with multiple risk factors. Idiopathic disease without any known etiological risk factor was identified in only n = 56/458 (12%) patients.

Conclusion: Nicotine is more frequently found as a risk factor of pancreatic inflammation than Alcohol. Idiopathic pancreatitis with absence of any known risk factor is rare.

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Chronic Pancreatitis and Acute Recurrent Pancreatitis: Two Faces of the Same Coin or Two Different Diseases?R.A. Zuppardo1, L. Frulloni2, S. Bertolini1, C. Calzolari1, S.K. Singh3, A. Bertelè4, V. Corrente4, F. Di Mario1, A. Franzè4, G.M. Cavestro1

1University of Parma, Italy, Department of Clinical Science, Section of Digestive Diseases, 2University of Verona, Italy, Department of Surgical and Gastroenterological Sciences, 3Boston University School of Medicine and Boston Medical Center, Section of Gastroenterology, 4Azienda Ospedaliero Universitaria di Parma, Italy, Unità Operativa di Gastroenterologia ed Endoscopia Digestiva

Introduction: Clinical differences between chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) are controversial.

Objectives: To investigate the clinical phenotype of ARP and CP patients as two distinct group of patients.

Patients and Methods: Eighty-one ARP and 162 CP patients were consecutively enrolled. We classified ARP patients on the basis of recurrence of acute pancreatitis in the absence of radiological find-ings of CP (ductal dilation/alteration and/or pancreatic calcifications). Clinical features analyzed were gender, age at diagnosis, alcohol intake, smoking habit, incidence of dyslipidemia, diabetes mellitus, colelithiasis and pancreas divisum.

Results: ARP and CP are characterized by differences in clinical course and associated factors. When compared to CP patients, ARP subjects had a significantly higher incidence of pancreas divisum (ARP = 11,1%; CP = 3,7%; p = 0,02). With respect to mean alcohol intake, the percentage of drinkers in ARP was lower (ARP = 27,1%; CP = 40,1%; p = 0,04). Smoking habit was significantly higher in CP patients (ARP = 22,2%; CP = 66%; p = 0,006) even if the amount of cigarettes/die was similar (ARP = 23,7±14,2; CP = 23,6±12,1). Moreover, ARP patients had a minor incidence of type II diabetes (p = 0,0001) and dyslipidemia (ARP = 3,7%; CP = 14,8%; p = 0,008).

Conclusion: CP and ARP patients are characterized by distinct endogenous (incidence of pancreas divisum, pancreatic calcifications and/or ductal lesions, methabolic features) and exogenous factors (smoking habit and alcohol intake). We do believe ARP may progress to CP as final epiphenomenon: chronic pancreatitis could be the final


endpoint of different pancreatic inflammatory diseases much as cir-rhosis is the common late manifestation of a variety of chronic liver diseases.

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Recurrent and Chronic Pancreatitis in Children and Adolescents at a Tertiary Center in SwedenF. Lindgren1, T. Casswall1, N. Albin2, E. Beijer1, E. Granlund1, L. Gustavsson1, U. Arnelo3, J.M. Löhr3

1Dept. of Pediatric Gastroenterology, Hepatology and Nutrition, 2Dept. of Radiology, 3Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden

Introduction: Chronic and recurrent pancreatitis in children is a rare and serious illness.

Objectives: To determine the clinical picture, etiological fac-tors, investigational methods and outcome of recurrent and chronic pancreatitis at a pediatric gastroenterology referral center.

Patients and Methods: A retrospective chart review (2004-2010) of children with recurrent or chronic pancreatitis based on symptoms, radiology and/orlaboratory parameters (>=2 episodes with enzymes >=3 x upper level).

Results: 27 patients (17 girls, 10 boys) fulfilled the criteria. Median age at diagnosis was 9.25 years. (0.67-15). Female to male ratio was 1.7:1. Mean duration of illness was 5.1 years. Common eti-ologies were: hereditary (36%), biliary tract disease (20%), idiopathic (12%); structural anomalies, metabolic disorders, and suspected auto-immune pancreatitis (all, 8%). All patients were examined with mag-netic resonance imaging (a special pancreas program including MRCP 89% and MR with secretin stimulation 59%). Other methods used: CT-scan (36%), EUS (32%) and ERCP(20%). 36% needed surgical/therapeutical intervention, mainly papillotomy and pancreatic stents. 48% needed medical treatment with pancreatic enzymes. 11/25 had a “clinical picture” and laboratory tests showing exocrine insufficiency (32%) or diabetes/pathological glucose tolerance test (12%).

Conclusion: This is the first cohort study presented in Scandinavia of children with recurrent and chronic pancreatitis. Hereditary and biliary tract diseases were common etiologies. MR is the preferred investigational method. 72% were treated medically or surgically and 44% had evidence of pancreatic insufficiency. These children should be evaluated at a tertiary center with experience in pediatric pancreatology, surgery, and radiology.

Physiology 1

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Important Role of Apical maxi-K+ Channels in the Stimulation of Pancreatic Ductal Bicarbonate by Bile AcidsV. Venglovecz1, P. Hegyi2, Z. Rakonczay Jr.2, L.V. Kemény2, L. Tiszlavicz3, M. Grunet4, A. Nardi4, M.A. Gray5

1Department of Pharmacology and Pharmacotherapy, University of Szeged, 2First Department of Medicine, University of Szeged, 3Department of Pathology, University of Szeged, 4NeuroSearch A/S, Ballerup, Denmark and National Research Foundation Centre for Cardiac Arrhythmia, University of Copenhagen, Copenhagen, Denmark, 5Institute for Cell & Molecular Biosciences, Newcastle University, Newcastle upon Tyne, UK

Introduction: Our group has previously shown that luminal administration of chenodeoxycholate (CDC) at a low concentration (100 ÂμM) stimulated HCO3- secretion in intact guinea pig pancre-atic ducts (Venglovecz et al., Gut 2008). Our preliminary experiments suggested that CDC caused a rise in cytosolic calcium which acti-vated calcium-dependent K+ channel in pancreatic ductal epithelial cells (PDEC).

Objectives: Therefore, the aim of this study was to investigate the role of K+ channels in the CDC-stimulated pancreatic ductal bicarbonate secretion.

Materials and Methods: We used patch clamp and microspec-trofluorimetry techniques to measure whole cell currents and rates of HCO3 - secretion, respectively, from isolated guinea pig PDEC. Immunohistochemistry was performed for detection of ion channels in pancreatic ducts.

Results: Exposing PDEC to CDC (100 μM) reversibly increased whole cell K+ currents and hyperpolarised cell membrane potential. Bile acid-stimulated K+ currents were inhibited by Ba2+ (2 mM), iberiotoxin (100 nM), and suppressed by strong intracellular Ca2+ buffering. Luminally applied iberiotoxin also blocked CDC-stimulated HCO3- secretion from microperfused ducts. Moreover, the maxi-K+ channel activator NS11021 (3 μM) induced a similar increase in HCO3- secretion to CDC. Immunohistochemical analysis showed strong maxi-K+ channel protein expression on the apical membrane of PDEC.

Conclusion: We show for the first time that maxi-K+ channels are expressed in the apical membrane of guinea pig PDECs, and that they play a crucial role in regulating HCO3- secretion in response to bile acids. We speculate that maxi-K+ channels represent a novel therapeutic target for acute pancreatitis.

Supported by OTKA, MTA, Royal Society International Grant, NKTH.


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Inducible Effect of Dachengqi Decoction on Pancreatic Acinar Cell Apoptosis from Rats: In Vivo and In Vitro studyT. Wenfu1, W. Jia1, G. Hanlin1, L. Juan1, C. Guangyuan1, X. Qing1, W. Meihua1

1Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China

Introduction: The famous hinese herbal prescription of Dachengqi Tang(DCQD), composed of ahuang (Radix et Rhizoma Rhei), houpu (Magnolia officinalis Rehd.), zhishi(Fructus Aurantii Immaturus) and mangxiao (NatriiSulfas), has been particularly used to treat acute pancreatitis for more than 30 years in China and its clinical efficacy on acute pancreatitis is obvious and has been acknowledged nationwide. Recent studies have shown that treated with DCQD of acute pancreatitis can suppress systemic inflammatory response, improve pancreatic microcirculation. However, there have seldom studies involving the effect and mechanism of DCQD on the pancreatic acinar cell apoptosis in rats with acute pancreatitis.

Objectives: To probe the effects of traditional Chinese herbal medicine Dachengqi Decoction (DCQD) in inducing the apoptosis of pancreatic acinar cell.

Materials and Methods: In vivo experiments, a total of 18 Sprague-Dawley rats were randomly divided into sham-operated group, control group and DCQD-treated group with taurocholatein-duced pancreatitis(6 rats in each group). The spray-dried DCQD (2g/mL of crude drugs) were orally administered to rats. The amylase activity in serum, nitrogen monoxidum (NO) content and inducible NO synthetase (iNOS) activity in pancreatic tissue were measured respectively. The pancreatic acinar cell apoptosis and pathological scores of pancreatic tissues were determined. In vitro experiments, the effect of DCQD on the cerulein-stimulated pancreatic acinar cell line AR42J was evaluated through measuring the cell’s survival rate, Lactate dehydrogenase (LDH), the production of reactive oxygen species(ROS) and the cell viability and apoptosis.

Results: In vivo experiments, it revealed that DCQD could markedly decreased serum amylase(1489±176 U/N, Sham-operated; 8099±1722 U/N, Control-AP; 4183±880 U/N, DCQD-Treated), increased NO(30.5±1.5mol/ L, Sham-operated; 8.3±0.4mol/ L, Control-AP; 58.6±3.7mol/ L, DCQD-Treated) and iNOS activity (0.59±0.03 U/ mg, Sham-operated; 0.37±0.03 U/ mg, Control-AP; 0.42±0.02 U/mg, DCQD-Treated) in tissues and apoptosis rate com-bining with decreasing pathological scores of pancreatic tissues com-paring DCQD-treated group (5.7 ± 1.9) with AP group (9.2 ± 2.7) (P < 0.05). In vitro experiments, DCQD markedly increased pancrea-titis acinar cells activity, decreasing LDH releasing rate and reducing the generation of ROS as well as enhancing apoptosis rate comparing DCQD-treated group with AP group (P < 0.05).

Conclusion: DCQD can induce pancreatitis acinar cell apopto-sis through increasing NO content and iNOS activity in the pancreas of experimental acute pancreatitis or reduce intracellular ROS gener-ation in isolated cells, leading to the pathological improvement of the pancreatic tissue lesions.

Surgery 1

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34 Robotic Pancreatectmoies: Short Term ResultsM. Del Chiaro1, C. Moretto1, C. Croce1, F. Costa1, R. Pisano1, V.G. Perrone1, N. De Lio1, S. Signori1, F. Vistoli1, U. Boggi1

1Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy

Introduction: The âDa Vinci Surgical Systemâ (DSS) is a promising minimally invasive technique in pancreatic surgery. Today few data are available on literature on it.

Objectives: To analyze the short term results of robotic pancre-atectomies (RP) on the basis of a single center experience.

Patients and Methods: From October the 1st 2008 to February 28, 2010, 34 PR were performed at our Institution. Twenty-four (70.6%) were females and 10 (29.4%) males. The mean age was 59.4 yrs (range 24-80 yrs). The mean BMI was 25 kg/m2. Twelve patients (35.3%) underwent pancreaticoduodenectomy, 15 (44.2%) distal pan-createctomy, one (2.9%) total pancreatectomy, 3 (8.8%) central pan-createctomy, 3 (8.8%) enucleation.

Results: An histological diagnosis of IPMN was found in 7 cases (20.6%), serous adenoma in 6 (17.6%), periampullary neo-plasms in 5 (14.8%), mucinous adenoma in 5 (14.8%), neuroendo-crine tumor in 5 (14.8%), ductal adenocarcinoma in 2 (5.8%), Frantz tumors in 2 (5.8%), mucinous carcinoma, and chronic pancreatitis in 1 (2.9%). There were no post-operative death. The post-operative course was complicated in 16 patients (47%) including 12 (36.4%) cases of pancreatic fistula. One patient (2.9%) required a relaparo-tomy for pancreatic remnant pancreatitis. The mean postoperative stay was 13.9 days. The mean post operative stay was significantly short in patients without post-operative complications on respect to patients with post-operative complications (9.8 vs 17.2 days; p = 0.005).

Conclusion: From this paper RP seems to be safe and feasible. Patient with uneventful post-operative course may have the biggest advantages from this approach. The real role of RP should be ana-lyzed in larger prospective randomized trials.

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Laparoscopic Versus Open Distal Pancreatectomy: A Comparative Casematched StudyA. Kausar1, D. Sherlock1, D. O’Reilly1, B. Ammori1

1North Manchester General Hospital, England, UK

Introduction: The laparoscopic approach to distal pancreatec-tomy (DP) for benign and malignant diseases is becoming increas-


ingly popular; however the potential benefits in comparison to open surgery have not been conclusively proved

Objectives: The aim of this study was to compare the open and laparoscopic approaches to elective DP.

Patients and Methods: A prospective maintained database was used to identify patients who underwent laparoscopic and open pancreaticoduodenectomy between 2007-2009. Patients were matched for age, sex and size of the tumour. One surgeon adopted the laparo-scopic approach for all comers while the others performed open sur-gery. The two approaches were compared on an intention-to-treat basis.

Results: 30 patients underwent 15 laparoscopic and 15 open DP. One laparoscopic procedure was converted to open surgery. The lap-aroscopic and open groups were comparable for age (57 vs. 59 years, p = 0.590), sex distribution, level of fitness as well as size (4.6 vs. 4.4 cm, p = 0.751) and nature of tumour. Laparoscopic surgery was asso-ciated with longer operating time (281 vs. 227 minutes, p = 0.064) and similar blood loss (253ml vs. 451, p = 0.15) but significantly higher spleen preservation rate (12.5% vs. 50%, p = 0.027). In the post oper-ative period the laparoscopic group had a shorter critical care stay (1.4 vs. 8.4, p = 0.005) and a shorter postoperative hospital stay (6.7 vs. 24.2 days, p<0.0001), but comparable morbidity rates (43.7% vs. 50%)

Conclusion: The laparoscopic approach to elective distal pan-creaticoduodenectomy is associated with a higher rate of splenic pres-ervation and a more rapid recovery compared with open surgery.

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Total Pancreatectomy: Indications, Different Timing, Perioperative and Longterm OutcomesS. Crippa1, D. Tamburrino1, S. Partelli1, G. Barugola1, S. Germenia1, R. Salvia1, C. Bassi1, P. Pederzoli1, M. Falconi1

1Department of Surgery, University of Verona, Italy

Introduction: Total pancreatectomy (TP) was rarely performed in the past because of its high morbidity and mortality. Since outcomes after pancreatic surgery and management of pancreatic insufficiency have significantly improved, TP had an increased reappraisal.

Objectives: To evaluate indications, timing, perioperative and long-term results after TP

Patients and Methods: Between 1996 and 2008, 65 patients (33 females, 32 males, median age 63 years) underwent TP at a sin-gle, high-volume centre

Results: 25 patients (38.5%) underwent a planned elective TP, 25 patients had a single-stage unplanned TP after an initial partial pancreatectomy that turned into TP because of intraoperative haemor-rhage (n = 1) or positive pancreatic resection margin (n = 24). The remaining 15 patients (23%) underwent a two-stage pancreatectomy for tumor recurrence in the remnant. No completion TP for postopera-tive complications were performed. There was no mortality, overall morbidity was 38.5% and reoperation rate 5%. Overall, 48% of patients had intraductal papillary mucinous neoplasms (IPMNs), and 29% pancreatic ductal adenocarcinoma. R1 resections rate was 12%. 4/23 patients (17%) who underwent single-stage unplanned TP for

positive resection margin had R1 resection (positive retroperitoneal margin). Median follow-up was 30 months. Five-years overall sur-vival was 71%. No deaths due to hypoglycaemia were observed. Median insulin units/day was 32, median lipase units/day 80000.

Conclusion: TP can be performed safely with no mortality and acceptable morbidity. In order to achieve an R0 TP, both the resection and retroperitoneal margin should be evaluated intraoperatively. TP is an effective operation is selected patients.

Nordic Light Session II

Quality of Life

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Significant Weight Gain After Long-term Treatment with CREON in Chronic Pancreatitis (CP) or Pancreatic Surgery (PS) Patients with Exocrine Pancreatic Insufficiency (EPI), Despite Previous Oral Enzyme TherapyD.C. Whitcomb1, E. Malecka-Panas2, G.A. Lehman3, G. Vasileva4, N. Gubergrits5, S. Caras6, Y. Shen6, S. Sander-Struckmeier7

1University of Pittsburgh, Pittsburgh, USA, 2Medical University of Lodz, Lodz, Poland, 3Indiana University Medical Center, Indianapolis, USA, 4MHAT Rousse AD, Rousse, Bulgaria, 5Donetsk National Medical University, Donetsk, Ukraine, 6Solvay Pharmaceuticals, Inc., Marietta, USA, 7Solvay Pharmaceuticals GmbH, Hannover, Germany

Introduction: Pancreatic enzyme replacement therapy is vital to prevent severe maldigestion and undesired weight loss in patients with EPI due to CP or PS.

Objectives: To assess long-term efficacy and safety of CREON in this population.

Patients and Methods: A 6-month, open-label extension of a double-blind, placebo-controlled study enrolling patients >18 years old with confirmed EPI due to CP or PS who were previously taking oral enzymes. Patients received individualized CREON doses as directed by investigators. Outcome measures included safety, clinical symptoms, and quality of life (QoL; SF-36 survey).

Results: 48 of 51 patients completed the open-label phase (one withdrew due to an unrelated treatment-emergent adverse event [TEAE] of burns; two were lost to follow-up). Mean age was 50.9 years, 70.6% were male, 76.5% had CP, and 23.5% PS. The mean ±SD dose was 186,960 ±74,640 lipase units/day. From baseline to study end subjects achieved a mean 2.7 ±3.35 kg increase in body weight (p < 0.0001). Mean change in stool frequency/day was –1.0


±1.3 (p < 0.001). Improvements in abdominal pain, flatulence, and stool consistency were observed; QoL scores did not change. TEAEs were reported by 22 patients (43%); only 7.8% were considered treat-ment-related. Serious TEAEs were reported by 13.7% (none treat-ment-related); no deaths were reported.

Conclusion: CREON significantly increased weight, signifi-cantly reduced stool frequency, and improved maldigestion symp-toms over 6 months in patients with CP and PS previously managed with standard treatments. CREON was well tolerated over 6 months, confirming the low incidence of treatment-related TEAEs in short-term studies.

Supported by Solvay Pharmaceuticals GmbH, Hannover, Germany.

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The Dependance of Quality of Life and Pain Intensity from the Width of the Main Pancreatic DuctM. Kuhayeu1, A. Shchastny1, A. Siatkouski2, S. Lyarski2, R. Petrov3, V. Egorov3

1The Vitebsk State Medical University, Vitebsk, Belarus, 2The Vitebsk Regional Clinical Hospital, Vitebsk, Belarus, 3The Vishnevsky Institute of Surgery, Moscow, Russian Federation

Introduction: The dependence of pain intensity and quality of life (QLQ) from the pancreatic duct width in patients with chronic pancreatitis (CP) is unclear.

Objectives: To compare the QLQ and pain intensity with the main pancreatic duct width in patients with CP.

Patients and Methods: 201 patients with chronic pancreatitis (176 men and 25 women aged between 43,5±8,5 years on average) were operated. PD was executed 59 times, the Frey procedure 13, the Beger operation 102, and the Bern modification 27 times. From them, 45 patients in the preoperative period had an estimation of quality of life and the intensity of the pain syndrome by means of the question-naire SF-36 and a visual analogue scale (VAS). Patients were divided into 2 groups depending on the width of the main pancreatic duct (MPD) (<6 mm –24, >6 mm - 21). Statistical processing of the results was conducted with a definition of a median (Me), 25th and 75th per-centile. To compare several independent sizes, the Mann-Whitney criterion (U) was used.

Results: In comparing patients on 8 scales of the questionnaire SF-36, no statistically significant difference between groups depend-ing on the width of the MPD (p > 0,05) was revealed. In estimating the intensity of the pain by VAS, no statistically significant difference was revealed either in both groups (p > 0,05).

Conclusion: According to our data, there is no statistically sig-nificant interrelation between the quality of life, intensity of the pain syndrome and the width of the main pancreatic duct in patients with CP.

Autoimmune Pancreatitis

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Investigation of the PRSS1 and SPINK1 Genes in Patients with Autoimmune Pancreatitis from GermanyA. Schneider1, S. Belle1, J.M. Löhr1, M.V. Singer1

1Dept. of Medicine II, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany, 2Division of Surgery, Karolinska Institute, Stockholm, Sweden

Introduction: Genetic mutations in the PRSS1, SPINK1 and CFTR genes have been associated with chronic pancreatitis. The fre-quency of genetic variations in these genes has not been determined in patients with autoimmune pancreatitis (AiP) from Germany.

Objectives: To identify the frequency of PRSS1 and SPINK1 mutations in patients with AiP from Germany.

Patients and Methods: Mannheim AiP Diagnostic Criteria define “definite”, “probable” and “possible” AiP. “Mannheim Definite AiP” is diagnosed in patients fullfilling Mayo HISORt or Asian AiP Criteria; or simultaneously presenting with pancreatic disease, other autoimmune disease and/or elevated autoantibodies, and disease response to steroids. “Mannheim Probable AiP” is diagnosed with pancreatic disease, elevated IgG4 and/or other autoantibodies, and other autoimmune disease. “Mannheim Possible AiP” is diagnosed with pancreatic disease and either elevated IgG4 and/or other autoan-tibodies, or other autoimmune disease. Patients with non-alcoholic pancreatitis from our clinic in Germany (1997-2009) were studied. Exons 2 and 3 of the PRSS1 gene and the entire coding region of the SPINK1 gene were investigated by direct DNA sequencing in patients with “Mannheim Definite AiP” in which DNA was available.

Results: We detected “Mannheim Definite AiP” in n = 21 patients. Genetic testing of the PRSS1 and SPINK1 genes was per-formed in n = 14/21 patients. We found a heterozygous SPINK1 N34S mutation in n = 2/14 (14%) patients. We did not detect a genetic varia-tion in the PRSS1 gene.

Conclusion: Genetic mutations in the SPINK1 gene are found in patients with AiP and may predispose to the development of the disease.


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Autoimmune Pancreatitis in Hungary. A Multicenter Nationwide StudyL. Czakó1, T. Takács1, T. Gyökeres2, Z. Dubravcsik3, A. Szepes3, L. Topa4, Á. Pap5, I. Földesi1, L. Tiszlavicz6, T. Wittmann1

1First Department of Medicine, University of Szeged, 2Department of Gastroenterology, State Health Centre, 3Department of Gastroenterology, Bács-Kiskun County Hospital, 4Department of Gastroenterology, Szent-Imre Hospital, 5Department of Gastroenterology and Endoscopy, National Cancer Institute, 6Department of Pathology, University of Szeged

Introduction: Most cases of autoimmune pancreatitis (AIP) have been reported from Japan.

Objectives: To assess the clinical features and management of AIP cases in Hungary.

Patients and Methods: The demographics, clinical presenta-tion, laboratory and imaging findings, extrapancreatic involvement, treatment response and recurrence were assessed in the first 10 patients diagnosed with AIP in Hungary.

Results: The median age at presentation was 44 years (range: 19-74); 50% were men. Newonset mild abdominal pain (90%), weight loss (50%) and jaundice (30%) were the most common symptoms, with biliary strictures and ulcerative colitis as the most frequent (30%) extrapancreatic manifestations. Diffuse pancreatic swelling was seen in 7 patients (70%), and a focal mass in 3 (30%). Pancreatic duct strictures were present in all 10 patients. The serum immunoglobulin-G4 level was elevated in 66% at presentation. All the percutaneous core biopsies (3 patients) and surgical specimens (2 patients) and in 2 out of 4 cases the biopsy of the papilla of Vater revealed the typical histological findings of AIP. A complete response to steroid treatment was achieved in all treated patients. Because of the suspicion of pan-creatic tumor, 2 patients with focal AIP underwent partial pancreatec-tomy, Recurrences were not observed. The Japanese Pancreas Society diagnostic criteria for AIP were fulfilled in 80% of these cases.

Conclusion: In this first Hungarian series, we have confirmed several findings previously reported in AIP. The occurrence in young patients and the lack of a male preponderance were interesting fea-tures of AIP in this series. The response to immunosuppressive ther-apy was excellent.

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Autoimmune Component on Chronic PancreatitisL. Lazebnik1, L. Vinokurova1, I. Trubicina1

1Central Research Institute of Gastroenterology Russia, Moscow

Introduction: Chronic pancreatitis is characterized with con-stant presence both of acute and chronic inflammation in pancreas tissue (PT) that creates conditions for accumulation of decay products having antigen properties and for accumulation of immune complexes

(IC). Disturbance of phagocytosis and excretion of IC causes inflam-matory tissue damage with elements of autoimmune response.

Objectives: Determination of autoimmune component presence in patients with chronic pancreatitis (CP) of alcoholic etiology.

Materials and Methods: 67 patients with CP and 15 healthyvol-unteers were examined. Content of INF, IgG, IgA, antibodies to pari-etal andacinar cells were determined in blood serum by means of immune-enzyme method. C-reactive protein (CRP) was determined by means of biochemical method.

Results: CP patients with complicateddisease course have increased content of CRB - by 78%, IgG, IgA - by 40-50%, INF 287.48±39.5 pg/ml (p < 0.05), control 54.1±6.8 pg/ml in blood serum bothin remission period and on exacerbation (more significant). After 3-4 CPexacerbations antibodies to parietal cells appear in 70% of patients. In 5-6years, on severe disease course antibodies to acinar cells appear in 38% ofcases.

Conclusion: Autoimmune response on CP ofalcoholic etiology and complicated disease course is activated throughincreased content of INF, IgG and IgA. Increased content of these biologicallyactive substances causes immune inflammation and decreases tolerance of damagedorgan.

Cell Biology

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The Loss of MIST1 Increases Acinar to Duct Cell TransdifferentiationC. Pin1, S. Volante1, J. Peat1, C. Johnson1

1The University of Western Ontario, London Ontario, Canada, 2Children’s Health Research Institute

Introduction: Pancreatic Ductal Adenocarcinoma (PDA) is the 4th leading cause of cancer related death in North America. Recent work suggests that PDA can arise from pancreatic acinar cells; how-ever, it is unclear what predisposes acinar cells to undergo transdif-ferentiation to duct cells. Work from our laboratory identified that acini lacking the transcription factor MIST1 is required for complete acinar cell differentiation suggesting a possible role for MIST1 in dic-tating acinar to duct transdifferentiation.

Objectives: To determine how an absence of MIST1 affects aci-nar to duct transdifferentiation ex vivo and following injury.

Materials and Methods: Acini were isolated from C57Bl/6 mice or mice lacking MIST1 (Mist1-/-), and cultured in collagen. In some cases, inhibitors of PKC and the MAPK pathway, ERK1/2, were included. The morphology and gene expression were examined by histological and immunofluorescent analysis. Alternatively, acute or chronic pancreatitis was induced in mice through cerulein injec-tions. To confirm transdifferentiation, molecular lineage tracing was performed using temporal activation of a ROSA26-LacZ reporter in acini prior to culture or injury.

Results: Mist1-/-acini showed extensive development of cyst-like structures and increased expression of PDX1 and cytokeratin 20


that was not observed in wild type cultures. Changes in morphology were dependent on activity of ERK1/2 and PKC. Lineage tracing confirmed that duct cells were derived from acini. Similar findings were also observed in vivo following pancreatic injury.

Conclusion: The absence of MIST1 leads predisposes acinar cells to increased transdifferentiation to duct cells. Future studies are needed to identify events that promote an unstable acinar cell pheno-type that enhances susceptibility to pancreatic disease.

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Pancreas Atrophy in Adult Mice Following Conditional Inactivation of the Coxsackie and Adenovirus Receptor (CAR) GeneT. Sultana1, M.A. Zaini1, K. Sollerbrant1

1Dept. of Women & Child Health, Pediatric Endocrinology Unit, Karolinska Institutet, Stockholm, Sweden

Introduction: The Coxsackievirus and Adenovirus Receptor (CAR) is known for its role in virus uptake and as a protein of tight junctions and other intercellular complexes. Disruption of the CAR gene is embryonic lethal.

Objectives: To investigate the role of CAR in adult mice.Materials and Methods: A conditional CAR knockout mouse

was constructed in which the CAR gene is disrupted at any chosen time point in a broad spectrum of celltypes and tissues.

Results: Several interesting and previously unknown pheno-types with high penetrance were found. Knockout mice displayed enlarged intestines and pancreas atrophy with specific loss of exo-crine tissue and appearance of tubular complexes characteristic of acinar-to-ductal metaplasia. In addition, knockout mice showed a complete atrioventricular heart block with temporal dissociation between atrial and ventricular depolarisations.

Conclusion: These results demonstrate important roles of CAR in the physiology of pancreas, intestines and heart in vivo.

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A Mouse Line Expressing Spink3-driven Cre RecombinaseM. Ohmuraya1, M. Hirota2, K. Yamamura1

1Institute of Resource Development and Analysis, Kumamoto University, 2Department of Surgery, Kumamoto Regional Medical Center

Introduction: Serine protease inhibitor Kazal type 1 (SPINK1), which was originally isolated from the pancreas, is produced within acinar cells of the exocrine pancreas. Previous studies have suggested that the SPINK1 gene is expressed in a wide range of tissues, although a complete characterization of SPINK1 gene expression in the adult organism has not been described.

Objectives: To further our understanding of SPINK1/Spink3 (In mouse, the homologous gene is designated Spink3), we analyzed the spatiotemporal expression profile of Spink3.

Materials and Methods: We generated a mouse line express-ing Cre recombinase under the control of the endogenous Spink3 pro-moter (Spink3-Cre), using the Spink3 deficient mice via a Cremediated recombination system. These mice were crossed with Rosa26 reporter mice (Spink3-Cre-R26R), and X-gal staining was performed. We compared X-gal staining profiles between Spink3-Cre-R26R and Spink3-lacZ knock-in mice (Spink3-lacZ).

Results: In Spink3-Cre-R26R mice at 8-wk-old, nearly 100% of acinar cells expressed bgalactosidase (b-gal). The expression was specific for acinar cells in the adult pancreas. A small part of cells in the gastrointestinal track, liver, lung, kidney, and seminal vesicle expressed b-gal in Spink3-Cre-R26R mice at 8-wk-old. In Spink3-lacZ mice, b-gal activity could be found in the pancreas, kidney, and seminal vesicle, but not in the gastrointestinal track, liver and lung at same age. These data suggest that Spink3 is widely expressed in endo-dermal tissues during embryonic stage, but only in the pancreas after birth.

Conclusion: Spink3-Cre knock-in mouse is a powerful tool for conditional knockout mice studies.

ERCP

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Intraoperative Rendezvous Endoscopic Retrograde Cholangiography Minimizes Post ERCP PancreatitisR. Noel1, L. Enochsson1, F. Swahn1, J.M. Löhr1, J. Permert1, U. Arnelo1

1Division of Surgery, CLINTEC at Karolinska Institutet, Stockholm, Sweden

Introduction: The removal of common bile duct stones during the era of laparoscopic cholecystectomy is still controversial. Intraoperative ERC (IOERC) facilitated by rendezvous cannulation technique is one of the one-seance-options available to manage com-mon bile duct stones.

Objectives: To investigate our experience with rendezvous IOERC with respect to stone clearance rate and procedure related complications, foremost post ERCP pancreatitis (PEP).

Patients and Methods: All patients subjected to IOERC between January 2000 and December 2009 were identified from our hospital registry. The patients medical charts and ERC reports were studied and descriptive statistics were obtained.

Results: 280 (190F/90M) consecutive IOERC patients were included. Mean age (range) was 48 (13-93) years. In 240 IOERC the rendezvous cannulation technique was used and in the remaining 40 IOERC, conventional cannulation techniques were used (non-rendez-vous). Stone clearance rate at first attempt was 87.9% (246/280). In total PEP occurred in 2.5% (7/280) patients. However, only one of the


PEP cases occurred in the rendezvous group (0.4%) whereas six patients developed PEP in the non-rendezvous group (15%). No mor-talities occurred. One case of retroperitoneal perforation occurred which was treated conservatively.

Conclusion: IOERC with the rendezvous cannulation technique is a safe method to manage CBDS during laparoscopic cholecystec-tomy. The stone clearance rate is high and the frequency of post ERCP pancreatitis is low provided that the IOERC rendezvous technique was used.

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Factors of Pain Recurrence After Endoscopic Stenting for Painful Chronic PancreatitisL. Heyries1, O. Jeanniard-Malet1, X. Lagrange1, J. Sahel1

1Department of Gastroenterology and Pancreatology, Hopital de la Conception, Marseille, France

Introduction: Treatment of painful chronic pancreatitis remains controversial. Recent papers prone superiority of surgical treatment compared to endoscopic methods.

Objectives: We tried to determine factors of recurrence of pain after a successful endoscopic treatment

Patients and Methods: From January 1996 to December 2008, 287 patients were endoscopically treated for a painful chronic pan-creatitis in our department: 96 were excluded (previously pancreatic surgery (n = 36), pancreatic cancer during the follow-up (n = 11), fail-ure of endoscopic bridging the stenosis (n = 49)). Among 191 patients of whom stenosis could be stented, 147 were improved and 44 pre-sented with a persistent (n = 17) or a recurrent (n = 27) pain. Our retro-spective study concerned those 44 patients.

Results: 44 patients (38 males and 6 females), mean age 42 ys, presented a painful chronic calcifying pancreatitis. Aetiology was alcoholic addiction (n = 38), hyperparathyroidism (n = 1), familial (n = 1), idiopathic (n = 4). All the patients suffered of pain which was sustained in 20 (45% of cases). Main pancreatic duct presented a stenosis (n = 39) and/or obstructive stone(s) (n = 18). Endoscopic treatment was a pancreatic sphincterotomy followed by insertion of a plastic pancreatic stent (7-11,5 Fr) exchanged every 4 months for a mean duration of 10 months (0.5 - 40). Number of ERCP per patient was 3.6 (1-5). Eight patients were not improved by stenting, 8 had an increasing pain, 27 were improved but presented a recurrence of pain after 20 months (2-74 months). One patient died from haemorrhage after pseudo-cyst drainage. Treatment of recurrence of pain was endo-scopic (n = 29) with improvement in 29% of cases, or surgical (n = 8) with improvement in 10% of cases. Statistic analysis showed that fre-quency of portal hypertension and diabetes mellitus were significantly increased between the beginning of endoscopic treatment and the recurrence of pain: respectively 2/44 versus 8/43 (p = 0.031) and 5/44 versus 9/43 (p = 0.063).

Conclusion: Sustained pain, portal hypertension, diabetes mel-litus seem to be predictive factors of recurrence of pain after a suc-cessful endoscopic treatment of painful chronic pancreatitis.

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Preoperative Biliary Drainage and Biliary Contamination in PancreatoduodenectomyA. Kausar1, M. Manu1, D. Sherlock1, D. O’Reilly1

1North Manchester General Hospital, England, UK

Introduction: Preoperative biliary stents have been implicated in biliary tract contamination and post operative complications after pancreatoduodenectomy (PD). As most patients have biliary obstruc-tion presentation, preoperative drainage remains common practice.

Objectives: To determine the prevalence of biliary tract coloni-zation and its impact on post operative complications.

Patients and Methods: Review of our prospectively main-tained database and hospital computerised records of patients who had a PD for all indications in 2007-2009 with an intraoperative bile culture swab sent at the time of division of the common bile duct.

Results: 79 patients were identified 65 (82%) had prior biliary instrumentation (ERCP/PTC) and 59 (75%) had a stent in situ. 69 (87%) of bile cultures had positive results of whom 57 had a stent in situ. Of the 10 cultures with no growth, only 2 had been stented (p = 0.0001). Infective organism included escheria coli (9), enterobacteriaceae (12), candida (5), clostridia (2), streptococci (8), stenotrophomona (1) as well as mixed coliforms and skin organisms. All infective complications were in the patients who had positive biliary cultures. The risk of an infective complication with a stent was 24% (14/59) versus 10% (2/20) without a stent (p = ns). However only in 4 wound infections was the same organism found as had grown on the bile culture. Neither the pres-ence of a biliary stent nor biliary colonization had any statistically sig-nificant impact on length of hospital stay or total complication rate.

Conclusion: Preoperative biliary stenting increases the risk of biliary colonization which may increase infective post operative com-plications.

Heredity & Genetics

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Effect of Severe CFTR Mutations on the Age of Diagnosis, Clinical Presentation and Progression of Chronic PancreatitisM. Luaces-Regueira1, W. Zabala2, J. Iglesias-Garcia1,3, M. Castiñeira-Alvariño1, P. Raña2, A. Lozano-León1, L. Nieto1, F. Barros2, J. Lariño-Noia3, J.E. Domínguez-Muñoz1,3

1Foundation for Research in Digestive Diseases, 2Galician Public Foundation of Genomic Medicine, 3Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain

Introduction: CFTR gene mutations are classically associated to the development of cystic fibrosis (CF). Over 1000 mutations and


variants of CFTR gene have been identified. Mutations affecting pro-duction and processing of protein (class 1 and 2) are considered severe mutations and are associated to pancreatic damage.

Objectives: To study the implication of severe CFTR mutations on diagnosis, clinical presentation and complications of chronic pan-creatitis (CP).

Materials and Methods: Prospective cohort study including patients diagnosed of CP. Clinical data (age at diagnosis, exocrine pancreatic insufficiency (EPI), diabetes and calcifications) were eval-uated. Morphology severity of the disease was assessed by endo-scopic-ultrasound (EUS). 180 CFTR mutations were analyzed by mass spectrometry. Data were analyzed by logistic regression. Results are shown as OR (95%CI).

Results: 82 patients (73 males, mean age 52.3 years, [8-82]) were included. Age at diagnosis was 44.8 years (range 8-77). 53% were alcoholic. 39 presented as acute pancreatitis (AP), 27 EPI and 22 diabetes. Two patients suffered a CF. 27(32.9%) patients carryied a mutation or variant in the CFTR. 15 carried a severe mutation. Presence of CFTR severe mutations was associated with an increased risk of IPE (OR = 5,505; 95%CI: 1.571-19,361, p = 0.0024), but no diabetes (OR = 0.48; 95%CI: 0.148-1.556, n.s.), no pancreatic calcifi-cations (OR = 1.11; 95%CI: 0.35-3.51, n.s.), no AP (OR = 1.247; 95%CI: 0.386-4.0324, n.s.). Severe CFTR mutations don’t determine an earlier age of diagnosis (45.1±15.6 vs. 43.7±19.0 years, n.s.) or more advanced CP according to EUS.

Conclusion: Frequency of CFTR mutations is high in patients with CP. Patients with CFTR mutations from Class 1 and 2 have an increased risk of EPI, but no other complications of CP.

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Does R122C Mutation in PRSS1 Always Determine the Development of Hereditary Pancreatitis? Analysis of Genetic, Clinic and Morphological VariablesM. Luaces-Regueira1, W. Zabala2, J. Iglesias-García1,3, P. Raña2, M. Castiñeira-Alvariño1, A. Lozano1, L. Nieto1, F. Barros2, J. Lariño1,3, E. Domínguez-Muñoz1,3

1Foundation for Research in Digestive Diseases, 2Galician Public Foundation of Genomic Medicine, 3Gastroenterology Department, University Hospital of Santiago de Compostela

Introduction: Hereditary chronic pancreatitis (HCP) is an auto-somic-dominant disease with high penetrance associated to R122C mutation in exon 3 of cationic-trypsinogen-gen (PRSS1). Mutations in this gene cause a super-trypsin, which tends to self-activating within acinar cell and cannot be inactivated by hydrolysis.

Objectives: Analyze clinical implications of pancreatic R122C mutation in families whith at least one individual suffering HCP.

Materials and Methods: Prospective cohort study including individuals from families with at least one CP patient and carrying R122C mutation (index case). Symptoms, presence of exocrine pan-creatic insufficency (EPI), diabetes, recurrent acute pancreatitis (RAP), use of toxic and morphological severity by endoscopic ultra-sound were evaluated. Exons regions of PRSS1 were analyzed by direct secuentation.

Results: 3 families were identified with a total of 18 individuals. 7 carried R122C mutation and only 4 had CP (penetrance = 57%). Two cases had moderate CP (5 EUS-criteria) without IPE and RAP. The remaining two cases had severe CP (7 and 10 EUS criteria), childhood-onset and RAP. The most serious case, of 8 years, had pancreatic calci-fications, EPI and also a F1052V mutation in CFTR. None of cases had diabetes. 3 individuals with the mutation, do not present CP (0 EUS criteria at the EUS), but suffered a non-specific epigastric discomfort.

Conclusion: This study demonstrates that R1212C mutation have an incomplete penetrance of 57%. Other factors beside R122C mutation must be involved in the development of CP. Association of R122C mutation and F1052V mutation of CFTR determine the devel-opment of severe CP.

Surgery 2

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Intraoperative Texture-/Duct Size Assessment of the Pancreatic Remnant Predicts Pancreaticojejunostomy-associated Morbidity After PancreaticoduodenectomyC. Ansorge1, L. Strömmer1, Å. Andrén-Sandberg1, R. Segersvärd1

1Dept. of Surgery and CLINTEC, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden

Introduction: Morbidity after pancreaticoduodenectomy (PD) with pancreaticojejunostomy (PJ) remains high (30-60%); postopera-tive pancreatic fistula (PF) is a major underlying factor. Several stud-ies have reported an association between pancreatic remnant fibrosis and a lower PFincidence after PD.

Objectives: To evaluate whether a classification based on intra-operative texture- and duct sizeassessment of the pancreatic remnant can predict the risk of developing postoperative pancreaticojejunos-tomy-associated morbidity (PJAM).

Patients and Methods: Single-center prospective-observational study including PD’s performed 2008-2009. A standardized duct-to-mucosa end-to-side PJ-construction technique was used. Pancreatic texture and duct size were intraoperatively assessed and classified. Four texture (from normal to very hard; 1-4) and four duct size catego-eries were used (from <2 mm to >5 mm; 1-4). PJAM was defined as PF (ISGPF grade B/C), and/or symptomatic PJ-connected abscess/fluid collection. Severe PJAM was defined as grade IIIb or higher according to the Clavien-classification of surgical complications.

Results: Of 121 cases PJAM was observed in 26% and PF in 15%. Texture and duct size were associated with PJAM-incidence (p < 0.01). In multivariate analysis combining texture and duct size the risk estimation for PJAM was stratified as “high” (normal texture/normal duct, PJAM-incidence 47%), “intermediate high” (normal texture/dilated duct, 27%), “intermediate” (hard texture/normal duct, 17%), and “low” (hard texture/dilated duct, 2%). Severe PJAM was only observed in high-risk cases.


Conclusion: High-risk PJ has a 20 times higher PJAM-risk than low-risk PJ. Only high-risk cases develop severe PJAM. This easily usable classification can predict and quantify the risk for major pan-creaticojejunostomy-associated morbidity and has in our experience contributed to the surgeon’s level of alertness during the postopera-tive course.

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Vascular Reconstruction During Pancreatoduodenectomy for Ductal Adenocarcinoma of the Pancreas Improves Resectability But Not Achieve Patient CureM. Ouaissi1, C. Hubert1, D. Glineur2, R. Verhelst2, P. Astarci2, C. Sempoux3, P. Deprez4, I. Borbath6, L. Annet5, B.E. Van Beer5, Y. Humblet6, P. Scaillet7, G. El khoury2, P. Noirhomme2, A. Loundou8, J.F. Gigot1

1Division of hepatobiliary and pancreatic surgery. Clinique Universitaires Saint luc. Universitaire Catholique de lou-vain. Brussels., 2Department of Cardiovascular Surgery. Clinique Universitaires Saint luc. Universitaire Catholique de louvain. Brussels, 3Department of Pathology., 4Department of Gastroenterology., 5Department of Imaging., 6Department of Medical Oncology., 7Department of Radiotherapy., 8Faculty of Medicine. University Aix Marseille II.

Introduction: Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adeno-carcinoma of the pancreatic head.

Objectives: Compare the results of surgical resection in patients with pancreatic cancer with or without vascular resection. Late 10-year disease-free survival, being considered as an indicator of patientsâ disease cure.

Patients and Methods: 149 consecutive patients have under-gone pancreatoduodenectomy without vascular resection (Group 1:82 patients), with isolated venous resection (Group B:67 patients) or with arterial and/or venous resection (Group C: 8 patients).

Results: The duration of surgery and blood losses were signifi-cantly more important in Groups B and C compared to Group A, but postoperative morbidity and mortality rates were similar. R1 resec-tion was significantly more frequent in Group B (42%) and C (50%) compared to Group A (13%)(p = 0.0002), but there were more advanced tumours in these groups, as demonstrated by a lower Karnowsky index, a higher Ca 19-9 plasmatic level, a greater tumour size, a more advanced stage in the AJCC classification and more tumour location in the uncinate process of the pancreas. 10-year over-all and disease-free survival was significantly better in Group A (19% and 20%) compared to Group B (2.8% and 0%) and Group C (0% and 0%). Multivariate analysis proved vascular resection and metastatic nodal status as being independent predictive factors of disease-free survival.

Conclusion: Vascular resection combined to pancreatoduo-denectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates but does not improves patients’ disease cure rate. Neoadjuvant therapy should be considered in those patients.

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Results of 546 Consecutive Pancreatic Operations at Helsinki University Hospital, FinlandH. Pelli1, A. Juuti1, H. Mustonen1, S. Nordling2, J. Sirén1, C. Haglund1, T. Kiviluoto1

1Department of Surgery, Helsinki University Central Hospital, 2Department of Pathology, Helsinki University Central Hospital

Introduction: Pancreatic surgery has been associated with high postoperative mortality and morbidity. However, recent results in high-volume centres show low mortality rates (2.9%).

Objectives: The aim of our study was to evaluate the results of pancreatic operations in our hospital at era of centralisation.

Patients and Methods: In this retrospective study we included all patients undergoing pancreatic operation in Helsinki University Hospital 2000-2009. Survival data of the patients were obtained from patient records, the Statistics Finland and the Population Registry. The operations were performed by two operators. Diagnosis was obtained from pathologic records and pancreatic cancer diagnosis was re-evaluated from histological specimens by our pathologist. Life tables were calculated according to the Kaplan-Meier product limit method.

Results: There were 546 patients undergoing pancreatic opera-tion between that time period. 389 patients underwent pancreaticodu-odenectomy, 98 distal pancreatic resection, 19 total pancreatic resection and 40 other operation. Histological diagnosis was pancre-atic ductal adenocarsinoma in 192, invasive IPMN in 23 and adeno-carsinoma of papilla Vateri in 45 patients. Five patients died postoperatively and one during operation (heart attack) leading to 0.5% hospital mortality. Disease specific 1-, 2- and 3 year overall sur-vival for patients radically operated on pancreatic ductal adenocarsi-noma (n = 192) was 69%, [61-79], 45% [37-52] and 28% [21-36]. Patients who had ductal adenocarsinoma had significantly longer sur-vival when the operation was radical (R0) or there were no lymph node metastases.

Conclusion: Pancreatic surgery is safe operation in high volume centres. In our hospital the hospital mortality (0.5%) is comparable to the others reported from centralised hospitals.


Nordic Light Session III

Endoscopy

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Prospective Cohort Study Comparing Transient EUS Guided Elastography to EUSFNA for the Diagnosis of Solid Pancreatic Mass LesionsJ. Mayerle1, P. Simon1, E.J. Dickson2, M.M. Lerch1, C. Carter2, C.J. McKay2

1Department of Medicine A, Ernst-Moritz-Arndt-University, Greifswald, Germany, 2Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, Scotland, UK

Introduction: EUS-guided realtime-Elastography examines tis-sue stiffness. Calculation of the reconstructed strain field (stiffness) can be assessed quantitatively and is expressed as strain ratio (SR).

Objectives: We evaluated whether EUS-guided transient elas-tography would increase the diagnostic accuracy compared to EUS-FNA for pancreatic mass lesions.

Patients and Methods: In a prospective cohort study (10/2008-10/2009) we recruited 89 consecutive patients with a solid pancreatic mass and performed EUS, EUS-guided elastography with a linear Pentax EUS-scope and the HITACHI-EUB-7500 as well as EUS-guided-FNA using a 22G Cook needle. Definite diagnosis by cytol-ogy or histology was regarded as the gold standard.

Results: 71 patients had malignant lesions and 18 patients pre-sented with benign lesions. Median SR of benign lesions was 16 (±13.86 95%CI) compared to 44.4 (±8.8 95%CI) for malignant lesions (p < 0.001). Optimal Cut-Off as of ROC analysis was 24.8. Elastography detected malignant lesions with a sensitivity of 96%, a specificity of 42%. Overall accuracy was 84% with an AUC of 0.76. EUS-FNA detected malignant lesions with a sensitivity of 84%, a specificity of 100%. Accuracy was 88%. B-Mode EUS in the hands of an experienced endosonographer achieved a sensitivity of 93%, a specificity of 68% and overall accuracy here was 88%.

Conclusion: At present, elastography of pancreatic mass lesions has a low specificity for discriminating benign from malignant pan-creatic lesions and therefore cannot yet replace FNA. While elastog-raphy is a promising technique SR should not overrule the assessment by an experienced endosonographer. However, in less experienced hands SR might help in identifying malignant lesions.

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Looking Deep into the Pancreas: Endoscopic Ultrasound (EUS) as a Useful Diagnostic Tool in Asymptomatic Subjects with Chronic Benign Pancreatic HyperenzymemiaM. Gentile1, F. Perri1, F. Terracciano1, D. Scimeca1, A. Andriulli1

1Gastroenterology and Gastrointestinal Endoscopy Unit, “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo (FG), Italy

Introduction: Persistent increases of serum pancreatic enzymes in asymptomatic subjects, without pancreatic abnormalities at non invasive imaging tests, such as trans-abdominal-US, CTscan and MRCP, are a relatively common finding in clinical practice and usu-ally considered as benign idiopathic abnormalities: the condition is usually referred to as ânon-pathological chronic pancreatic hyperen-zymemiaâ (CPH).

Objectives: To evaluate pancreatic parenchyma and ductal mor-phology by EUS in subjects with CPH.

Patients and Methods: Over a 24-month period, 16 consecu-tive patients (10 males-6 females) were diagnosed as having CPH and scheduled to undergo EUS. Mean age was 48 years (range 21-72). The increase of pancreatic enzyme was found occasionally but its persistence was ascertained at repeat laboratory tests carried out every 6 months. In 12 patients hyperamylasemia was present with median levels of 111 U/L (range 68-172U/L-n.v.<53U/L); in the remaining 4 patients an increase of both amylase (median 164,5U/L, range 74-236U/L) and lipase (median 130,5U/L, range 90-211U/L–n.v.<60 U/L) was found. The EUS scan evaluated parenchyma echogenicity, ductal morphology and diameter.

Results: EUS showed abnormal pancreatic findings in 13/16 patients with CPH. 10 patients had subcentimetric pancreatic side branch dilation; multifocal dilation of ducts was detected in 8 of them, suggesting the occurrence of multifocal side branches IPMN. 3 had EUS findings reminiscent of pancreatic steatosis.

Conclusion: Our experience suggests the need for EUS as a first level diagnostic tool in patients affected by CPH, enrolling patients with abnormal features in pancreatic ducts or parenchyma morphol-ogy, in a follow-up program in order to diagnose early malignant evo-lution.


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Usefulness of Quantitative Endoscopic Ultrasound (EUS) Elastography for Diagnosing Chronic Pancreatitis (CP)J. Iglesias-García1,2, M. Castiñeira-Alvariño2, J. Lariño-Noia1,2, M. Luaces-Regueira2, R. Ferreiro1, E. Domínguez-Muñoz1,2

1Gastroenterology Department, University Hospital of Santiago de Compostela, 2Foundation for Research in Digestive Diseases (FIENAD)

Introduction: Endoscopic-ultrasonography (EUS) has become the method of choice for the diagnosis of chronic pancreatitis (CP), however diagnostic criteria are under debate. Analysis of tissue stiff-ness by quantitative EUS-elastography (Q-EUS-E) may provide addi-tional information.

Objectives: Aim of the study was to evaluate the usefulness of Q-EUS-E for the diagnosis of CP.

Materials and Methods: 191 consecutive patients (mean age 52 years, [21-85], 103 male), who underwent EUS with the suspicion of CP and follow-up of CP were prospectively evaluated. EUSelastography was performed with radial Pentax and Hitachi 900. EUS criteria of CP were evaluated, and patients were classified according to Rosemont Classification (RC). Two areas were selected for quantitative elastographic analysis: A, pancreatic parenchyma and B, soft peripancreatic area. B/A (strain-ratio) was considered the result of elastographic evaluation. Three determinations were per-formed in each patient (head, body and tail of the pancreas), and the mean was considered as final result. Data are compared by ANOVA test. Association between strain-ratio and number of EUS criteria was analyzed by linear regression.

Results: 99(51.8%) patients were considered normal, 22(11.5%) indeterminate for CP, 40(20.9%) suggestive of CP and 30(15.8%) consistent for CP. Strain-ratio was significantly different according to RC: 1.80 (95%CI:1.73-1.87) in normal pancreas, 2.41 (95%CI:2.23-2.60) in indeterminate CP, 2.89 (95%CI:2.73-3.05) in suggestive for CP, and 3.69 (95%CI:3.37-4.00) in consistent with CP (p<0.001). Correlation between EUS criteria and strain-ratio was 0.807 (p < 0.0001).

Conclusion: Q-EUS-E is a useful tool for the diagnosis of CP, supporting EUS findings. The three groups of the RC probably repre-sent different stages of CP.

Expression Profiling

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Identification of MicroRNA-21 as a Potential Biomarker of Clinical Outcome and a Target to Overcome Chemoresistance in Pancreatic Ductal Adenocarcinoma (PDAC)E. Giovannetti1, N. Funel3, E. Vasile5, L. Gonzalez Leon2, F. Mosca3, L.E. Pollina6, A. Falcone5, R. Danesi1, D. Campani4, G. Peters2, H. Verheul2, U. Boggi3, M. Del Chiaro3

1Dipartimento di Medicina Interna, Università di Pisa, Pisa, Italy, 2VU University Medical Center, Amsterdam, The Netherlands, 3U.O. Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy, 4U.O. Anatomia Patologica 3, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy, 5U.O. Oncologia 2 Universitaria, Azienda Ospedaliera-Universitaria Pisana, Polo Oncologico Area Vasta Nord-Ovest, Istituto Toscano Tumori, Pisa, Italy, 6Anatomia e Istologia Patologica I, Pisa, Italy, 7Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina, Università di Pisa, Pisa, Italy

Introduction: MicroRNAs are noncoding RNAs with key role in control of cellular proliferation and apoptosis. Recent data showed that miRNAs affect cancer prognosis, and influence response to che-motherapy. MicroRNA-21 (miR-21) was reported to be overexpressed and contribute to gemcitabine resistance in PDAC.

Objectives: This study was aimed to evaluate whether miR-21 is associated with overall-survival (OS) of PDAC patients and pro-vide mechanistic insights on its role in chemoresistance.

Patients and Methods: MiR-21 expression was evaluated in cells (7 PDAC cell lines, 7 primary cultures, and anormal pancreatic ductal cell line) and tissues (neoplastic specimens from 81PDAC patients treated with gemcitabine andnormal ductal samples) isolated by laser-microdissection. The role of miR-21 ongemcitabine activity was studied with a specific miR-21 precursor (pre-miR-21).

Results: Patients with high miR-21 expression had significantly shorter OS both in the metastatic and in the adjuvant setting. Multivariate analysis confirmed the prognostic significance of miR-21 (HR = 3.1, P = 0.003, for miR-21 expression above median). MiR-21 expression in primary cultures correlated with expression in their respective tissues, and with gemcitabine resistance. Pre-miR-21 trans-fection significantly decreased gemcitabine antiproliferative and pro-apoptoticeffects, while metalloproteinase-2/-9 and VEGF expression were up-regulated. Addition of inhibitors of PI3K andmTOR decreased phospho-Akt and prevented pre-miR-21 induced resistance to the proapoptotic effects of gemcitabine.

Conclusion: MiR-21 expression correlated with outcome in PDAC patients treated with gemcitabine. Modulation of apoptosis, Akt phosphorylation, and expression of genes involved in invasive behaviour, may contribute to miR-21 role in PDAC chemoresistance and to the rational development of targeted combinations.


NLS38

Widespread MicroRNA Down-regulation Characterizes Pancreatic Malignant TransformationA.E. Frampton1, J. Jacob2, N. Tsim1, P. Vlavianos3, N.A. Habib1, J. Stebbing2, L. Castellano2, L.R. Jiao1

1HPB Surgical Unit, Dept. of Surgery & Cancer, Hammersmith Hospital, Imperial College, London, 2Dept. of Oncology, Dept. of Surgery and Cancer, Cyclotron Building, Hammersmith Hospital, Imperial College, London, 3Dept. of Gastroenterology, Hammersmith Hospital, Imperial College NHS Trust

Introduction: MicroRNA (miRNA) expression profiles have been described in pancreatic ductal adenocarcinoma (PDAC), but a comparison with the premalignant cystic tumours (low and high malignant potential) of the pancreas is missing.

Objectives: We aimed to identify miRNA expression profiles in pancreatic cystic tumors with low malignant potential (serous micro-cystic adenomas) and high malignant potential (mucinous cystade-noma and intraductal papillary mucinous neoplasm (IPMN)) and compare these to pancreatic ductal adenocarcinoma (PDAC).

Patients and Methods: Tissue was obtained from patients with premalignant tumours (n = 25) and PDAC (n = 33). MiRNA microarray profiling was performed and validated using quantitative reverse transcription polymerase chain reaction (RT-qPCR). Differentially expressed miRNAs were further validated and normal pancreatic tissue (n = 9) was also studied. P values were calculated using Limma linear modelling adjusted for multiple testing and the parametric t-test.

Results: We observed widespread miRNA down-regulation in PDAC compared to low malignant potential tumours. MiR-21, a known oncogenic miRNA, was significantly down-regulated in PDAC compared to low malignant potential lesions, but in both groups it was upregulated compared to normal tissue (P < 0.001). A significant down-regulation of miR-16 (P = 0.05) and miR-126 (P = 0.003) in PDAC compared to low malignant potential lesions was also demonstrated.

Conclusion: MiRNA expression profiles revealed widespread down-regulation in PDAC compared to microcystic adenoma (the most benign lesion), especially of miRNAs that target crucial PDAC oncogenes. It appears that miR-21 up-regulation is an early event in the transformation from normal tissue. MiRNA expression can distin-guish PDAC from normal and low malignant potential pancreatic tumours.

Pancreatic Cancer

NLS39

CUX1 Stimulates Pancreatic Cancer Progression by Modulating Chemokine Expression in Tumor-associated MacrophagesB. Kuehnemuth1, H. Griesmann1, S. Ripka1, M. Buchholz1, T. Gress1, P. Michl1

1Dept. of Gastroenterology, University of Marburg, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is characterized by extensive infiltration of inflammatory stroma cells including tumor-associated macrophages (TAM). Previously, we could demonstrate high expression levels of the transcription factor CUX1 in both pancreatic tumor cells and tumor-associated mac-rophages. In addition, we identified CUX1 as important mediator of tumor progression and invasiveness in pancreatic cancer cells.

Objectives: In vivo and in vitro characterization of the effects of CUX1 in tumor-associated macrophages.

Materials and Methods: CUX1 expression in TAM was ana-lyzed by immunohistochemistry in PDAC tissues. The role of CUX1 in macrophages was evaluated using siRNA and overexpression tech-niques, and its effect on transcription of secreted chemokines was profiled using a multiplex quantitative RT-PCR approach. CUX1 tar-get genes were validated with RT-PCR, Western blotting, ELISA and luciferase assays. The functional impact of CUX1 and its targets was analyzed using proliferation, migration and angiogenesis assays.

Results: Immunohistochemical co-staining revealed strong expression levels of CUX1 in TAM of pancreatic cancer tissues. Profiling experiments showed that CUX1 downregulates several chemokines which have been associated with M1 differentiation and tumor suppression. The downregulation of CXCL10 and CCL5 was verified on RNA and protein level, and the transcriptional regulation of CXCL10 by CUX1 could be verified on promoter level. Functionally, we could show that suppression of CXCL10 led to enhanced angiogenesis. In addition, co-culture experiments of TAM with pancreatic cancer cell lines stimulated tumor cell proliferation and migration.

Conclusion: CUX1 promotes tumor progression of pancreatic cancer by modulating the chemokine profile in tumor-associated macrophages.


NLS40

Model-specific Effects of Pancreatic Stellate Cells on Pancreatic Cancer Cell Growth In VivoR. Jaster1, B. Fitzner1, H. Nizze2, J. Emmrich1, S. Liebe1

1University of Rostock, Department of Medicine II, Division of Gastroenterology, Rostock, Germany, 2University of Rostock, Institute of Pathology, Rostock, Germany

Introduction: Activated pancreatic stellate cells (PSC) have been implicated in the progression of pancreatic cancer (PC). The experimental data base, however, is still quite small.

Objectives: Using two different mouse models of PC, we directly compared the growth of PSCcontaining and PSC-free tumours in the same animal. Furthermore, the response of both types of tumours to chemotherapy was studied.

Materials and Methods: The PC cell lines DSL-6A and Panc02 were transplanted alone and together with PSC into opposite flanks of nude mice (DSL-6A) and C57Bl/6N (Panc02) mice, respec-tively. The mice were treated with gemcitabine and interferon-gamma (IFNgamma), and tumour growth and histology were analyzed.

Results: In nude mice, PSC-containing tumours grew faster and to a higher end volume than their corresponding controls. Gemcitabine and IFNgamma repressed the growth of both flank tumours to a simi-lar degree. In contrast, there was no growth advantage of PSC-containing tumours and no growth-inhibitory effect of IFNgamma inC57Bl/6N mice. Surprisingly, histological investigations did not reveal significant differences between tumours with and without co-injected PSC.

Conclusion: PSC accelerated the growth of PC in one of the two mouse models only. The efficiency of IFNgamma was indepen-dent of the presence of PSC, and also restricted to DSL-6A tumours. We hypothesize that in the nude mouse model PSC coinjection trig-gers the initiation of PC growth, whereas later on the stroma response is maintained by local fibroblasts. It needs to be studied further if the PSC-independent growth of Panc02 tumours is related to their lower differentiation grade.

Supported by the DFG.

Pathology

NLS41

How Accurate Is Size Asssessment of Pancreatic Head Cancers by Radiology and Pathology?C. Verbeke1, M. Sheridan2, A. Scarsbrook2, R. Albazaz2, A. Smith3, K. Menon3, A. Guthrie2

1Department of Histopathology, St James’s University Hospital Leeds, UK, 2Department of Radiology, St James’s University Hospital Leeds, UK, 3Department of Surgery, St James’s University Hospital Leeds, UK

Introduction: Preoperative assessment of tumour extent is a key factor in management algorithms for adenocarcinoma of the pan-creatic head.

Objectives: To compare the accuracy of tumour size measured on i) radiological imaging and ii) the macroscopic specimen with microscopic size assessment.

Materials and Methods: 41 consecutive patients (2008/9) undergoing pancreatoduodenectomy for adenocarcinoma were evalu-ated (19 pancreatic, 15 ampullary, 7 distal bile duct cancers). Maximal axial (MA-TS) and craniocaudal (CC-TS) tumour dimensions were recorded in consensus by retrospective review of radiological exami-nations on a PACS workstation, and compared with macro- and microscopic dimensions obtained from histopathology examination undertaken following a standardized methodology.

Results: Macroscopic assessment of tumours (both dimensions) was not significantly different from that of radiological measurement. In >70%, radiological assessment of the CC-TS differed significantly (>5 mm) from the microscopic size (table). In 70% of the cases, the CC-TS was underestimated. Radiological assessment of the MA-TS, though more accurate than the CC-TS (p = 0.02), underestimated 56% of cases. Radiological and macroscopic CC-TS and MA-TS assess-ment was more accurate for ampullary than pancreatic and distal bile duct cancers (p < 0.04). Radiology vs Microscopy Macro- vs Microscopy CC-TS MA-TS CC-TS MA-TS Discrepancy 0 mm 2 2 14 5 <5 mm 10 21 6 23 5 –10 mm 13 13 11 11 >10 mm 16 5 10 2.

Conclusion: Tumour size of pancreatic head cancers is signifi-cantly underestimated by pre-operative radiological (and macro-scopic) assessment compared to microscopy. This has important implications for neo-adjuvant treatment planning.


NLS42

Diagnostic Criteria for Pancreatic Ductal Adenocarcinoma Without Cytological or Histological MethodsM. Nilsson1, Å. Andrén-Sandberg1, C.W. Michalski3, N. Kartalis2, X. Molero5, N. Albiin2, P. Michl4, J.P. Neoptolemos6, F. Jonsson1, F.X. Real5, J. Permert1, J.M. Löhr1

1Dept. of Surgical Gastroenterology, Karolinska Institutet, 2Dept. of Diagnostic Radiology, Karolinska Institutet, 3Techical University, Munich, 4Dept. of Medicine II, Marburg, 5CNIO, Madrid, 6 University of Liverpool

Introduction: Verification of pancreatic ductal adenocarcinoma (PDAC) is difficult to accomplish. In clinical practice a definitive diagnosis is often not made in the large majority of cases that are not surgically resected.

Objectives: To establish diagnostic criteria for PDAC, based on non-cytological or histological methods, for the use in clinical and epidemiological studies.

Materials and Methods: An expert panel meeting was held in Stockholm on October 9, 2009, within the framework of the PanGen-MoldiagPaCa pancreatic cancer multi-centre case-control study. At this meeting non-histological-non-cytological diagnostic criteria were established through a consensus process.

Results: A 4 step categorization model was constructed. Category 1, very likely PDAC, optimized CT or MRI used and fulfil-ment of all of the following criteria: non-hypervascular mass, loss of lobulation, altered pancreatic contour, dilated main pancreatic duct, dilated main bile duct. Category 2, likely PDAC, also optimized CT or MRI used with non-hypervascular mass and at least one of the fol-lowing: altered pancreatic contour, dilated main pancreatic duct, dilated main bile duct. Category 3, possible PDAC, non-optimized CT or MRI or ultrasonography only used with finding of a mass lesion and at least one of the following: altered pancreatic contour, dilated main pancreatic duct, dilated main bile duct. Category 4, not PDAC, includes patients who do not fulfil requirements for categories 1 to 3. Criteria not applicable for patients with radiological signs or history of pancreatitis within 12 months.

Conclusion: Diagnostic consensus criteria for PDAC based on radiology have been established. A validation study is planned.

NLS43

Standardized Pathology Reporting of Pancreatic Specimens Has Implications for N-staging and Surgical StrategyA. Leifler1, S. Ghazi2, F. Jonsson1, M. Nilsson1, R. Segersvärd1

1Dept. of Surgery, CLINTEC, Karolinska Institute, Karolinska University Hospital Stockholm Sweden, 2Dept. of Pathology, Lab Med, Karolinska Institute, Karolinska University Hospital Stockholm Sweden

Introduction: Others and we have shown that the frequency of microscopically non-radical (R1) resection after pancreaticoduo-denectomy increases after the implementation of a standard protocol (SP) for pathologic examination of pancreatic specimens.

Objectives: To evaluate the effect of SP on the analysis of lymph nodes (LN) and circumferential resection margins (CRM), and their impact on survival.

Patients and Methods: All patients with pancreatic ductal adenocarcinoma subjected to pancreaticoduodenectomy 2003-2008 were analysed. The period beforeSP (non-SP) was compared to SP concerning R-rate, numbers of LN and LN metastases (LN-met) and positive CRMs. Survival for LN-status and CRMs adjusted for adju-vant chemotherapy, tumor differentiation, LN numbers and R-stage was analysed.

Results: 121 patients (49NonSP; 72 SP) were evaluated. LNs increased (SP 20 vs. Non-SP 15; P < 0,001) but LN-met did not. One single LN-met (i.e. N1) was not associated with poorer survival com-pared to N0 (OR 2,10; CI0,89-4,80) whereas 2 or more LN-met was (OR4,4; CI 1,64-11,71). The most frequent involved CRM was thep-osteriomedial (64%), that wasn’t evaluated in non-SP. More than one involved CRM did not affect the survival negatively.

Conclusion: Examination of 15 LNs is proposed as an optimal number for correct N-staging (1 or more LN-met) 1. However, the number of LN-met is more relevant parameter to study as adjusted survival only is affected negatively by 2 or more LN-met. SP increases the number of analyzed LN, making the premises for a more detailed LN-analysis better. SP also admits precise judgment of relevant CRM’s that may have implications for the surgical strategy in pancre-atic resections. 1 Tomlinson 2007.


Physiology 2

NLS44

Bicarbonate Secretion Is Inhibited by Trypsin via CFTR in Guinea Pig Pancreatic DuctsP. Pallagi1, B. Ózsvári1, Z. Rakonczay Jr1, T. Takács1, V. Venglovecz2, L. Judák1, T. Wittmann1, K. Borka3, M. Sahin-Tóth4, P. Hegyi1

1First Department of Medicine, University of Szeged, Szeged, Hungary, 2Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary, 3Department of Pathology, Semmelweis University, Budapest, Hungary, 4Department of Molecular and Cell Biology, Goldman School of Dental Medicine, Boston University, Boston, MA, USA

Introduction: Intraacinar activation of pancreatic enzymes is a key event in the pathogenesis of acute pancreatitis. Activated enzymes entering into the ductal system may influence the fluid and bicarbon-ate secretion of pancreatic ductal cells.

Objectives: Therefore, the aim of this study was to investigate the effects of trypsin on pancreatic ductal bicarbonate secretion.

Materials and Methods: Pancreatic protease-activated recep-tor 2 (PAR2) expression was determined by immunohistochemistry in guinea pigs. The activity of Cl-/HCO3- exchanger was measured on microperfused pancreatic ducts by microfluorimetry. CFTR (cystic fibrosis transmembrane conductance regulator) Cl- channel activity was investigated by whole cell patch clamp recordings on single pan-creatic ductal cells.

Results: PAR2 expression was found on the luminal membrane of intralobular ducts. Luminal administration of 10 M trypsin or 10 M PAR2 activating peptide (AP) had no effect on intracellular pH in HCO3--free solution; however, in the presence of HCO3-, a marked pHi elevation was observed suggesting inhibition of HCO3- efflux. Removal of extracellular Cl- from the HCO3-containing solution did not diminish the level of alkalosis caused by trypsin or PAR2-AP, but the 10 M CFTRinh-172 inhibitor reduced pHi elevation. Patch clamp experiments showed that both trypsin and PAR2-AP diminished the forskolin stimulated Cl- current of CFTR. 100 g/ml soybean trypsin inhibitor or 10 M PAR2 antagonist totally blocked the effect of trypsin and PAR2-AP on forskolin stimulated Cl-current.

Conclusion: Our results suggest that trypsin inhibits pancreatic ductal bicarbonate secretion via activation of PAR2 and inhibition of CFTR.

NLS45

A Novel Explant Outgrowth Culture Model of Mouse Pancreatic Acinar Cells with Longterm Survival and Preserved Secretory PhenotypeM. Bläuer1, I. Nordback1, J. Sand1, J. Laukkarinen1

1Dept. of Gastroenterology and Alimentary Tract Surgery, and Pancreas Laboratory, Tampere University Hospital, Tampere, Finland

Introduction: Despite many earlier attempts, no good long-term (over 2 days) acinar cell culture model, with a preserved amylase secretion, exists. For many mechanistic studies such a model would be of great advantage.

Objectives: Our aim was to develop a culture model with long-term survival and maintained secretory capacity of mouse acinar cells.

Materials and Methods: Explants of mouse pancreata were cultured in a serum-free medium on tissue culture inserts. Outgrowth of acinar cells was seen from day 4 onwards. On day 7, the outgrown primary cells were detached for secondary culture. The cellular com-position of the cultured explants and the identity of the outgrown cells in primary and secondary cultures were assessed by immunohis-tochemical means. Cell viability and caerulein-stimulated (10-12-10-8M) amylase release were studied in primary and secondary cultures.

Results: Immunohistochemical analysis revealed that the out-grown cells both in primary and secondary cultures were predomi-nantly acinar, whereas other cell types remained within the explants. Cell viability remained high during the follow-up. Basal and caeru-lein-stimulated amylase release sustained for a minimum of 7 days both in primary and secondary cultures.

Conclusion: We have developed a mouse acinar cell culture model with long-term cell survival and preserved secretory function.

NLS46

Structure-activity Relationships of Xanthines on Calcium Signalling in Murine Pancreatic Acinar CellsM. Cane1, W. Huang1, R. Mukherjee1, R. Sutton2, D.N. Criddle1

1Department of Physiology, University of Liverpool, UK, 2Liverpool Pancreatic Biomedical Research Unit, UK

Introduction: The inositol-1,3,4-trisphosphate receptor (IP3R) is an important Ca2+ release channel present on intracellular Ca2+ stores that is inhibited by caffeine. Preliminary data from our labora-tory have shown caffeine to be protective in experimental acute pan-creatitis (Huang et al. APA 2009), potentially via inhibition of cytosolic Ca2+ ([Ca2+]c) elevations. However, xanthines are also known phosphodiesterase (PDE) inhibitors. A systematic evaluation of caffeine and analogues on Ca2+ signalling in pancreatic acinar cells has not been performed.


Objectives: To determine structure-activity relationships of caf-feine on IP3-mediated (AChinduced) Ca2+ signals in pancreatic aci-nar cells and, for comparison, relative PDE inhibition.

Materials and Methods: Isolated murine pancreatic acinar cells were evaluated for changes of [Ca2+]c (fluo-4) using confocal microscopy. PDEI was determined using a PDE kit (Biomol) with 1mM 3-isobutyl-1-methylxanthine (IBMX) as standard. Compounds evaluated were caffeine (1,3,7-trimethylxanthine), theophylline, paraxanthine, theobromine, 1-methylxanthine and 7-methylxanthine.

Results: Acetylcholine induced [Ca2+]c oscillations (3.1 spikes/min) that were inhibited 41±7.5% and 86±5% by 500μM and 2mM caffeine, respectively. Dimethylxanthines evoked greater inhibition than caffeine, such that 500μM theobromine, theophylline and parax-anthine inhibited oscillations by 68±11% and 68±6.3% and 87±2.6%, respectively. Monomethylxanthines showed less inhibition of oscilla-tions than caffeine. All compounds evaluated inhibited PDE, how-ever, theophylline showed the greatest activity, being similar to the IBMX standard.

Conclusion: Dimethylxanthines possessed greater inhibitory activities on IP3-mediated Ca2+ signals than caffeine. Since ~80% of caffeine is converted to paraxanthine in the body, metabolism to dim-ethylxanthines may contribute to the beneficial effects of caffeine observed in models of acute pancreatitis.

Surgery 3

NLS47

Duodenum Preserving versus Pylorus Preserving Pancreatic Head Resection for Benign and Premalignant LesionsS. Pedrazzoli1, S.A. Canton1, M. Moro1, V. Beltrame1, C. Sperti1

1IV Surgical Clinic, Dept. of Medical and Surgical Sciences, University of Padova, Italy

Introduction: Pylorus preserving pancreaticoduodenectomy (PPPD) is the treatment of choice for benign or premalignant non-enucleable pancreatic head lesions. Duodenum preserving pancreatic head resection (DPPHR) was reported in only 132 patients in the eng-lish literature with a relatively short follow-up.

Objectives: The study was aimed to compare long-term results of DPPHR and PPPD.

Patients and Methods: Patients who underwent DPPHR or PPPD for benign or borderline disease between January 1991 and December 2008 were followed up until December 31st 2009 or their death. Endocrine and exocrine pancreatic function were evaluated at their last follow-up.

Results: Twenty-seven patients underwent DPPHR (Group 1) and 37 PPPD (Group 2). They were followed for a mean of 100 and 135 months respectively. There was no statistically significant differ-ence in postoperative complication rate (81.5% and 40.5%), pancre-atic fistula rate (40.1% and 18.9%), hospital mortality (0% and 2.7%).

Two patients died 3.3 and 97 months after DPPHR. There was also no statistically significant difference in treatment for biliary stricture (three patients in each Group), and in medical treatment for cholangi-tis (none Group 1 and 13 Group 2 patients). Diabetes mellitus was observed in eight Group 1 and 17 Group 2 patients (P > 0.05). Ten Group 1 and 21 Group 2 patients are taking pancreatic enzymes (P = 0.003).

Conclusion: DPPHR for benign or premalignant lesions is a dif-ficult procedure with a higher complication rate than PPPD, but with-out mortality. Its main advantage is the preservation of the entire duodenum and a normal biliary tree, allowing better long term results.

NLS48

Pancreaticoduodenectomy Versus Duodenum Preserving Pancreatic Head Resection in the Treatment of Chronic PancreatitisX. Liu1, Z. Zheng1

1West China Hospital, Sichuan University

Introduction: The surgical procedure for treatment of Chronic pancreatitis is different. For example, in north America the surgeons used to apply pancreaticoduodenectomy, while in Europe used to duodenum-preserving pancreatic head resection.

Objectives: In this study, we compared pancreaticoduodenec-tomy with duodenum-preserving pancreatic head resection in the treatment of chronic pancreatitis (CP) to assess the advantages of each type of procedure.

Patients and Methods: A retrospective review was performed in 123 consecutive patients undergoing pancreatic head resection for CP between January 2003 and June 2008.57 patients received PD and the other 66 patients received DPPHR. The clinical and morphologi-cal characteristics, operative data, hospitalization stay, postoperative complications, quality of life(QOL), pain relief, jaundice status, exo-crine and endocrine function were compared.

Results: There were no significantly differences with respect to clinical and morphological characteristics, pain relief, and jaundice status. In DPPHR group, The duration of operation was shorter (251.8±43.1 vs. 324.5±41.4 min, P < 0.001), and amount of blood loss was less(464.4±203.6 vs. 646.5±242.9 ml, P < 0.001). The overall postoperative morbidity for PD and DPPHR was 19% and 3% respectively(P = 0.006). Most functional and symptom scales revealed a better QOL in DPPHR group. At the end of follow-up, the propor-tion of patients with exocrine and endocrine insufficiency was higher in PD group compared with DPPHR group.

Conclusion: Both surgical procedures are equally effective in pain relief and jaundice reduction. However, DPPHR is superior to PD in terms of operative data, postoperative morbility, QOL, and preservation of exocrine and endocrine function. According to morg-hology and function of pancreas, consensual guide for the treatment of CP shoud be formulated to rationalize surgical strategy.


NLS49

Pancreas-preserving Procedures in Surgery of Duodenal DystrophyV. Egorov1, A. Vankovich1, I. Kozlov1, N. Yashina1

1The Vishnevsky Institute of Surgery, Moscow, Russia

Introduction: Duodenal dystrophy (DD) is infrequent disease, characterized by the chronic inflammation of the aberrant pancreatic tissue in the duodenal wall. DD management remains a topic of dis-cussion and pancreaticoduodenectomy (PD) is currently a method of choice when conservative treatment fails.

Objectives: To assess the results of pancreas-preserving proce-dures in surgery of DD.

Patients and Methods: Prospective analysis of the demo-graphic, clinical and instrumental data (35 pts), and results of surgical treatment of 22 patients with cystic forms of DD (2005-2009).

Results: Constant or relapsing abdominal pain was revealed in 100%, weight loss in 51%, vomiting in 26% and jaundice in 20% of cases. The most precise diagnostic methods were CT, MRI and endoUS. Twenty two patients were operated on by pancreatico - and cystoenterostomy (4), PD (10), total pancreatic head resection with the resection of the second part of the duodenum (2), duodenumpre-serving pancreatic head resection (2) and partial gastrectomy (1). In five cases pancreaspreserving technique was used: resection of the second part of the duodenum (RSPD) with direct duodeno-duodenoa-nastomosis (2), RSPD with jejunal interposition (2) and subtotal dudenectomy (1). Postoperative lethality was zero. Full pain control and all symptoms disappearance were achieved after pancreas-pre-serving procedures, in 91% of cases after PD and in 16% of cases after the pancreatic head resections and draining procedures. In two cases of severe chronic “orthotopic” pancreatitis the disturbance of glucose tolerance was detected after PD.

Conclusion: Pancreas-preserving procedures can be the optimal methods for duodenal dystrophy surgery and real alternative to PD.




Oral-Poster Sessions

Oral-Poster Session I

OP1

Updated Meta-analysis of Prophylactic Antibiotics for Severe Acute PancreatitisK. Jiang1, X.Z. Chen2, W. Huang3, X.N. Yang1, Q. Xia1

1Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, China, 2Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, China, 3Department of Surgery and Physiology, Royal Liverpool University Hospital, University of Liverpool, UK

Introduction: Prophylactic antibiotics have been used in the treatment of severe acute pancreatitis (SAP) for several decades in order to prevent complications associated with infected pancreatic necrosis, which correlates with significant mortality. However, recent randomized controlled trials (RCTs) and meta-analyses call the role of prophylactic antibiotic use into question.

Objectives: To investigate whether prophylactic antibiotics are beneficial to SAP patients.

Materials and Methods: We performed an updated compre-hensive meta-analysis of the RCTs based on PubMed. Mortality alone was considered for meta-analysis. Comparison was performed between prophylactic antibiotics, and placebo or no treatment. Cochrane RevMan 5.0 software was used for pooled estimates. Pooled mortality rate, risk ratio (RR), 95% confidence interval (CI) and number needed to treat (NNT) were calculated.

Results: In total 11 RCTs were included according to the criteria described. Subgroup analysis showed that during the period before 2000 (4 RCTs, 183 patients, RR = 0.31, 95% CI 0.12-0.79, P = 0.01, NNT = 8) there was a significant reduction of mortality by prophylac-tic antibiotics (5.26% vs 18.18%), whereas from 2000 to 2010 (7 RCTs, 439 patients, RR = 1.01, 95% CI 0.65-1.56, P = 0.98, NNT = 1429) no significant reduction was found (15.00% vs. 15.07%). Funnel plot analysis indicated an apparent publication bias during the period before 2000, probably, due to the lack of blinding method.

Conclusion: The overall sample size was insufficient to draw a definitive conclusion. However, at present the mainstream opinion on prophylactic antibiotic treatment for SAP is somewhat conservative. To ascertain whether certain SAP patients would benefit from antibi-otic prophylaxis requires further individual patient data analysis to uncover a potential sub-population.

OP2

Regulatory T-cells Mediate the Compensatory Anti-inflammatory Response Syndrome (CARS) in Severe Acute PancreatitisA. Dummer1, M. Sendler1, F.U. Weiss1, C. Pötschke2, T. Sparwasser3, W. Halangk4, B.M. Bröker2, M.M. Lerch1, J. Mayerle1

1Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, 2Department of Immunology, Ernst-Moritz-Arndt-University Greifswald, 3Institute of Experimental Immunology (Twincore), Medical University of Hannover, 4Division of Experimental Surgery, University of Magdeburg, Germany

Introduction: Severe acute pancreatitis is characterised by an early inflammatory immune response syndrome (SIRS) and a subse-quent compensatory anti-inflammatory response syndrome (CARS), both of which can determine severity and survival.

Objectives: We studied the role of regulatory T-cells (T-regs) in the course of severe experimental pancreatitis.

Materials and Methods: Depletion of T-regs in pancreatitis was achieved by using DEREG mice, which express a diphtheria toxin receptor-enhanced-GFP-fusion-protein under the control of the foxp3 gene locus (J.Exp.Med 2007, 204: 57-63) and CTLA-4 block-age by treatment with monospecific antibody against CTLA-4. In DEREG mice diphtheria toxin administration effectively depletes T-regs. Pancreatitis was induced in mice by intraductal administration of 2% taurocholate. Animal survival, flow cytometry, amylase, bacte-rial translocation and cytokines profiles were determined for up to 48h.

Results: During pancreatitis mice developed CARS as deter-mined by TNFa- and IL-10-secretion from LPSstimulated spleno-cytes, in parallel with CTLA-4 expression on Th-1 cells. T-reg depletion during pancreatitis reduced bacterial translocation, pre-vented CARS, increased T-cell activation, and increased survival. Blockage of CTLA-4 on alredy activated th-1 cells increased Th-1 activity while T-reg response was not affected. This decreased pan-creatic injury, systemic inflammation and bacterial translocation, and therefore increased survival.

Conclusion: These data indicate that T-regs play a dominant role in enhancing CARS with its associated immunosuppression dur-ing severe pancreatitis. Increasing Th-1-activation via CTLA-4-blockage can prevent infected pancreatic necrosis and CARS. CTLA-4 blocking treatment during pancreatitis represents a promis-ing therapy aimed at reversing the immune deficit during the most critical phase of pancreatitis.


OP3

Outcomes from Pancreatic Trauma in the UK 1989–2009A. Kausar1, O. Bouamra2, F. Lecky2, D. O’Reilly1

1North Manchester General Hospital, 2Trauma Audit & Research Network, England, UK

Introduction: Pancreatoduodenal (PD) trauma is rare but asso-ciated with a high mortality.

Objectives: To assess the incidence, mechanisms of injury, management and outcome of patients who sustained pancreatoduode-nal (PD) trauma in the UK over the period 1989-2009.

Patients and Methods: The Trauma Audit and Research Network (TARN) database is a collaboration of trauma data from over 50% of trauma receiving hospitals in the UK. The data base was searched for all patients with blunt or penetrating trauma to the pan-creas or duodenum.

Results: 657 of 267,000 (0.246%) trauma cases or of 13,513 (4.86%) abdominal trauma cases sustained PD trauma. Median age was 27 (IQR: 17-45) for blunt trauma and 28 (IQR: 21-38) for pene-trating trauma. The Male: Female ratio was 3:1. The Injury severity scores (ISS) were 26 (IQR: 17-36) for blunt trauma and 16 (IQR: 9-25) for penetrating trauma. The ratio of penetrating: blunt injury was 17:83. Road traffic collision was the commonest mechanism of injury, accounting for 393 (59.8%) of cases. 63.6% of cases under-went an initial operation for trauma in blunt PD trauma; 72.6% in penetrating PD trauma. For blunt trauma, mortality rates for pancre-atic, duodenal, both and total were 25.4%, 16.1%, 27.3%, 22.2%. For penetrating trauma, mortality rates for pancreatic, duodenal and total were 18.5%, 9.5% and 13.3%. Age, Glasgow Coma Scale and ISS were associated with mortality, Mann-Whitney test, all <0.001.

Conclusion: PD trauma is associated with a high mortality. A high proportion of pancreatic trauma in the UK is due to blunt trauma.

OP4

Platelets Regulate Macrophage Inflammatory Protein-2 Formation and Neutrophil Infiltration in Acute PancreatitisA. Abdulla1, D. Awla1, H. Hartman1, M. Rahman1, B. Jeppsson1, S. Regnér1, H. Thorlacius1

1Malmö University Hospital

Introduction: Recent data suggest that platelets not only con-trol thrombosis and haemostasis but may also regulate inflammatory processes. Acute pancreatitis (AP) is characterized by changes in both coagulation and pro-inflammatory activities; however, the role of platelets in AP is not known.

Objectives: To demonstrate the role of platelets in acute pan-creatitis.

Materials and Methods: AP was induced in C57BL/6 mice by repetitive caerulein administration (50 μg/kg, i.p.). Mice received a platelet-depleting or a control antibody prior to caerulein challenge. Neutrophil infiltration, myeloperoxidase (MPO) and macrophage

inflammatory protein-2 (MIP-2) levels, acinar cell necrosis and hae-morrhage in the pancreas as well as serum amylase activity quantified 24 h after caerulein injection while neutrophil-platelet aggregates quantified after 8 h.

Results: Caerulein administration caused pancreatic damage characterized by increased acinar cell necrosis, neutrophil infiltration, focal haemorrhage and serum amylase levels. Interestingly, we found that platelet depletion reduced acinar cell necrosis and haemorrhage by more than 64% as well as serum amylase by 42% in AP. Moreover, depletion of platelets reduced caeruleininduced MPO levels and neu-trophil recruitment by 56% and 72%, respectively, in the pancreas. Caerulein challenge increased local and systemic formation of MIP-2 and platelet depletion abolished MIP-2 generation in the pancreas and in the circulation.

Conclusion: These novel findings show that platelets play a critical role in AP by regulating neutrophil infiltration via MIP-2 for-mation in the pancreas. Thus, targeting platelet functions may be a useful approach to ameliorate pathological inflammation in the pan-creas.

OP5

Promotion of Non-oxidative Ethanol Metabolism Induces Pancreatic Acinar Mitochondrial Dysfunction and Cell DeathD.M. Booth1, W. Huang2, R. Mukherjee2, A.V. Tepikin1, R. Sutton2, D.N. Criddle1

1Physiological Laboratory, University of Liverpool, Liverpool, UK, 2Liverpool NIHR Pancreatic Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK

Introduction: Fatty acid ethyl esters (FAEEs), non-oxidative ethanol metabolites, are implicated in the pathogenesis of alcoholic pancreatitis. Previously we have shown that exogenous FAEEs induce Ca2+-dependant mitochondrial inhibition and pancreatic acinar necrosis. However, the extent to which the balance between oxidative and non-oxidative ethanol metabolism contributes to cellular damage is unclear.

Objectives: To investigate the effects of promotion of non-oxi-dative ethanol metabolism on cellular toxicity.

Materials and Methods: Isolated murine pancreatic acinar cells were assessed using confocal microscopy forchanges in [Ca2+]C (fluo4), mitochondrial function(NAD(P)H/TMRM) and cell death induced by ethanol, fat and/or metabolites.

Results: Low ethanol (10mM) with palmitoleic acid (POA; 20μM) produced predominantly oscillatory[Ca2+]C rises (61.5%) or had no effect (15.4%). However, when oxidative metabolism was concurrently inhibited with4-methylpyrazole (4-MP, 100μM), sus-tained [Ca2+]C elevations predominated, associated with NAD(P)H decrease (65.5%) and mitochondrial depolarization. This low etha-nol/POA combination did not stimulate necrosis or apoptosis, whereas these parameters were significantly increased when 4-MP was also present (4.3 and 3.7-fold, respectively). Prevention of FAEE hydro-lase activity with bis-(4-nitrophenyl)phosphate (BNPP; 200μM) pro-duced a 2-fold reduction in ethanol/POA/4-MP-induced necrosis, indicating the importance of fatty acid production to toxicity.


Palmitoleic acid ethyl ester (POAEE) orPOA (100-200 μM), applied alone, induced concentration-dependent increases of cell death whereas the oxidative metabolite acetaldehyde (100-200 μM) was without toxic effect.

Conclusion: When oxidative metabolism is compromised, low concentrations of ethanol with fatty acid induce toxic [Ca2+]C rises, mitochondrial dysfunction and necrosis, suggesting important delete-rious actions of non-oxidative alcohol metabolism in the pancreas.

OP6

The Epidemiological and Clinical Characteristics of 1934 Cases of Acute Pancreatitis in Gomel Region, BelarusV. Khokha1, D. Khokha1, A. Litvin2

1City Hospital, Mozyr, Belarus, 2Regional Clinical Hospital, State Medical University, Gomel, Belarus

Introduction: Over the last decade in Belarus acute pancreatitis as a cause of hospitalization ahead of acute cholecystitis and took second place after appendicitis.

Objectives: To explore the clinical characteristics and pathoge-netic patterns of acute pancreatitis (AP) in Gomel region, Belarus (to be compared it with international norms).

Materials and Methods: Analysis and summary of the clinical data of 1934 AP patients admitted into the Gomel Clinical Regional Hospital and Mozyr City Hospital between 2000 and 2009 were made.

Results: There were 1390 females and 544 males. The median age was –45.1 years. Episodes of pancreatitis were associated with alcohol consumption in 57% of cases and with gallstones in 12%; 19% of cases were associated with both gallstones and alcohol con-sumption, 12% cases detected as idiopathic. The median hospital stay was –25.6 days. 23% required admission in Intensive Care Unit. Most of the patients (n: 1489; 77.0%) presented mild episodes. In 23% of admissions local complications developed and 3,7% of admissions ended in death of the patient. Of the 71 deaths, 37% occurred in the first 2 weeks. Ultrasound and contrast-enhanced dynamic computed tomography were a precise imaging technique for diagnosis and severity grading as well as for complication detection. 175 patients received minimally invasive technique treatment with 10 deaths.150 patients received operative treatment with 45 deaths.

Conclusion: The incidence of AP increased in the recent 10 years. Alcohol consumption is the main etiology. Strictly handling the indications for surgery, avoiding early surgery and rationally using minimally invasive technique may help to gain satisfactory therapeu-tic efficacy.

OP7

The Non-conjugated Chenodeoxycholate Induces Intracellular ATP Depletion and Inhibits Bicarbonate Secretion in Pancreatic Duct CellsJ. Maléth1, Z. Rakonczay Jr.1, V. Venglovecz2, Z. Rázga3, L. Tiszlavicz3, P. Hegyi1

1First Department of Medicine, University of Szeged, 2Department of Pharmacology and Pharmacotherapy, University of Szeged, 3Department of Pathology, University of Szeged

Introduction: We have recently shown that a high contentration (1 mM) of non-conjugated chenodeoxycholate (CDC) has strong inhibitory effects on the activities of acid/base transporters (Na+/H+ exchanger (NHE), Na+/HCO3- cotransporter (NBC), Cl-/HCO3- exchanger (CBE)) of pancreatic ductal epithelial cells (PDEC).

Objectives: Our aim was to characterize the intracellular mech-anisms of the inhibitory effects of bile acids.

Materials and Methods: Intra/interlobular pancreaticducts were isolated from the pancreas of guinea pigs. Intracellular pH (pHi)and ATP level (ATP)i of PDEC were measured using microfluorom-etry. Toinvestigate the effect of CDC on glycolytic metabolism, we used 10 mM deoxyglucose (DOG)/5 mMidoacetamide (IAA). Morphological changes of PDECwere evaluated by transmission electron microscopy.

Results: 1 mM CDC strongly damaged themitochondria. For positive control we used the mitochondrial toxin carbonylcyanide 3-chlorophenylhydrazone (CCCP) (100 M) which mimicked the effect of CDC. Administrationof CDC and/or CCCP markedly and irreversibly reduced (ATP)i. DOG/IAAalso decreased (ATP)I, but to a lesser extent. CCCP or DOG/IAAadministered after high contentra-tion of CDC resulted in further (ATP)i depletion, however, their effects weresignificantly smaller after CDC than administered alone. CCCP stronglyinhibited NBC (recovery from acid load) and CBE (recovery from alkali load). Administration of DOG/IAA also inhib-ited the iontransporters. Significantly higher inhibition was evoked by paralleladministration of CCCP and DOG/IAA.

Conclusion: These resultssuggest that high contentration of the non-conjugated CDC causes mitochondrial damagefollowed by (ATP)i depletion and that CDC inhibits the glycolyticmetabolism of PDEC. We showed that the (ATP)i depletion by itselfcan be respon-sible for the impaired HCO3-secretion.


OP8

P-selectin Mediated Leukocyte Recruitment Plays an Important Role Downstream of Trypsinogen Activation in Acute PancreatitisH. Hartman-Magnusson1, D. Awla1, A. Abdulla1, B. Lindkvist2, H. Thorlacius1, S. Regnér1

1Department of Surgery, Institution of clinical sciences, SUS Malmö, Lund University, Sweden, 2Department of Gastroenterology, Sahlgrenska University Hospital, Sweden

Introduction: P-selectin is essential for leukocyte recruitment in inflammation.

Objectives: To study the role of P-selectin on chemokine expression, neutrophil recruitment and protease activation in a model of severe acute pancreatitis (AP).

Materials and Methods: C57BL/6-mice were subjected to ret-rograde intraductal pancreatic infusion of taurocholate or sodium chloride, or sham operated. Subgroups received an anti-P-selectin or control antibody. Animals were sacrificed 2, 6 and 24 hours post infu-sion. Pancreatic levels of myeloperoxidase (MPO), macrophage inflammatory protein-2 (MIP-2) and histological changes were deter-mined. Serum levels of trypsinogen and trypsinogen activation pep-tide (TAP) were analyzed in an inhouse RIA. P-selectin and Monocyte Chemoattractant Protein-1 (MCP-1) expression was measured by PCR.

Results: Taurocholate challenge caused a significant increase in MIP-2 and MPO levels as well as neutrophil infiltration, pancreatic necrosis and edema formation at 24 hours. Moreover, taurocholate enhanced serum levels of trypsinogen and TAP. Immunoneutralization of P-selectin reduced MPO levels, histological parameters and serum trypsinogen 24 hours post infusion but no effect of P-selectin inhibi-tion on MIP-2 formation or serum levels of TAP was observed. PCR in non anti-p selectin treated groups showed high expression of MCP-1 (24 times versus sham, 3.5-2.5 times versus sodium chloride) after 6 and after 24 hours whereas expression of P-selectin decreased after 24 hours (17 to 6 times vs sham and 6 to 1.5 times vs sodium chloride).

Conclusion: P-selectin plays an important role in regulating pro-inflammatory activities and tissue injury but not trypsinogen acti-vation in acute pancreatitis, suggesting that protease activation is a process upstream of leukocyte recruitment in AP.

OP9

Influence of Fluid Therapy on the Prognosis of Acute Pancreatitis: A Prospective Cohort StudyE. de-Madaria1, G. Soler-Sala1, I. López-Font1, J. Sánchez-Payá2, J. Martínez1, L. Gómez-Escolar1, L. Sempere1, P. Zapater3, C. Sánchez-Fortún1, M. Pérez-Mateo1

1Pancreatic Unit, Hospital General Universitario de Alicante, 2Preventive Medicine, Hospital General Universitario de Alicante, 3Clinical Pharmacology, Hospital General Universitario de Alicante

Introduction: The evidence about the benefits of an aggressive fluid therapy within the first days after admission in patients with acute pancreatitis (AP) is indirect and not supported by prospectively conducted studies.

Objectives: To evaluate influence of fluid therapy within the first three days after admission on the prognosis of AP.

Patients and Methods: Prospective cohort study. We included 246 nontransferred patients with AP. Organ failure and local compli-cations were defined according to the Atlanta Classification. Persistent organ failure (POF) was defined as any organ failure during >48 hours. A lower cut-off point (small amount of fluids as a poor progno-sis variable) and a higher one (greater amount of fluids associated with poor prognosis) within the first 24 and 72 hours and percentage of the total first 3 days fluid therapy administered in the first day (P24/72) was calculated by means of ROC curve.

Results: Administration of <2200mL in the first 24 hours was independently associated with POF and mortality. Administration of >4400mL in the first 24 hours was independently associated with acute collections, POF, higher hospital stay (HS), ICU admission and need for nutritional support (NS). Patients who received >14000 mL in the first three days had independently more local complications, POF, ICU admission, NS and higher HS. A P24/72 <28% was inde-pendently associated with POF and mortality.

Conclusion: Poor fluid therapy within the first 24 hours after admission and a high demand of fluids in the first 24 and 72 hours was associated with a worse prognosis.

OP10

Effects of Enteral Nutrition in Moderate to Severe Acute PancreatitisG. Poropat1, D. Stimac1

1Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka, Rijeka, Croatia

Introduction: Nutritional support as enteral preparations is thought to have positive effects on outcome of acute pancreatitis. However, only few trials performed on rather small number of patients showed no statistically significant effects on complications and mor-tality.

Objectives: To determine beneficial and harmful effects of enteral nutrition administered via a nasojejunal tube in comparison to


intravenous fluid replacement without nutritional support in patients with moderate to severe acute pancreatitis.

Patients and Methods: Hundred-eleven consecutive patients with acute pancreatitis and APACHE II score ³6 were randomized into one of two groups, enteral nutrition group (group I) and group with no nutritional support (group II). There were no significant dif-ferences in age, gender, BMI, etiology and disease severity between groups. Severity of acute pancreatitis was determined by APACHE II and Ranson scoring systems. Patients in group I received daily 105kJ (25kcal)/kg and 1,5g/kg of proteins, while patients in group II received only fluid replacement with crystalloid solutions. The nasojejunal feeding tube was placed within 24 hours of admission and confirmed radiographically. All cases were assessed by CT between days 5 to 10 after admission and graded according to CTSI classification.

Results: Fifty patients were randomized in group I and sixty-one patients in group II. There were no significant differences in local (p = 0,245) and systemic (p = 0,305) complications according to Atlanta criteria between the two groups. No significant difference in ICU admission (p = 0,111) and mortality (p = 0,743) was found either.

Conclusion: Our results could not confirm that nutritional support has beneficial or harmful effects on the outcome of acute pancreatitis.

Oral-Poster Session II

OP11

Activated Pancreatic Stellate Cells Express B7-H1 and B7-DC in Vitro and Suppress Proliferation of Activated CD4 T-cellsS. Karakhanova1, M. Löhr2, R. Jesnowski3

1Dept. of Surgery, Medical Faculty of Heidelberg, University of Heidelberg, Heidelberg, Germany, 2Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden, 3Dept. of Medicine II, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany

Introduction: Tumor cells have developed a series of mecha-nisms to escape the immune surveillance. Recently expression of B7-H1 or B7-DC molecules was demonstrated on pancreatic tumor cells. These members of the B7 family of co-stimulatory molecules are able to suppress host immunity by inhibiting T-cell function. B7-H1 expression thus was demonstrated to be an independent prog-nostic factor for poor prognosis in pancreatic carcinoma.

Objectives: To evaluate the expression and regulation of B7-H1 in pancreatic cells.

Materials and Methods: Expression of B7-H1 and B7-DC was monitored using conventional and quantitative RT-PCR and FACS analysis after stimulation and cocultivation experiments using pancreatic tumor cell lines and activated pancreatic stellate cells (PSC). Moreover the capability to suppress proliferation of CD3/CD28 stimulated CD4 T-cells was analysed in cocultivation experi-ments by [3H]-Thymidine incorporation.

Results: B7-H1 and B7-DC were expressed by some pancreatic tumor cells and surprisingly, also activated PSC demonstrated a marked expression of these two molecules. Stimulation of the cells with IFNa or IFNg markedly upregulated B7-H1 and B7-DC in pan-creatic tumor cells and activated PSC, TNFa had only marginal effects. Co-cultivation of PSC and pancreatic tumor cell lines strongly enhanced B7-H1 expression in PSC but not in the tumor cells. B7-DC expression was not affected by cocultivation neither in PSC nor in tumor cells. Cocultivation of activated PSC and CD4 T-cells nearly completely abrogated the proliferation of CD4 T-cells induced by CD3/CD28 costimulation.

Conclusion: Activated PSC in vitro express B7-H1/DC and suppress proliferation of activated CD4 T-cells and may therefore participate in the immune suppression observed in pancreatic carci-noma.

OP12

Gemcitabine Influences Drug Transporter Expression and MRP5 Contributes to Gemcitabine ResistanceW. Hagmann1, R. Jesnowski2, J.M. Löhr3

1CCU Molecular Gastroenterology, DKFZ, Heidelberg, Germany, 2Dept. of Medicine II, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany, 3Department of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden

Introduction: Gemcitabine represents a first line chemothera-peutic drug in the treatment of pancreatic cancer. Previous experi-mental chemotherapy studies using human pancreatic carcinoma cells have shown, that 5-FU treatment affects the expression profile of rel-evant cellular transporters including MRPs, and that MRP5 (ABCC5) influences chemoresistance of these tumor cells (Hagmann et al., 2009).

Objectives: To evaluate the influence of gemcitabine on the expression of uptake and export transporters in pancreatic carcinoma cells.

Materials and Methods: Expression of uptake and export transporters in pancreatic carcinoma cells after gemcitabine treatment was checked by RT-QPCR and immunoblot, and we studied by MRP5-overexpression and MRP5-specific RNA interference the role of MRP5 in cellular gemcitabine resistance.

Results: Exposure to gemcitabine (12 nM, 3 d) did not alter MRP1, MRP3, MRP5 and ENT1 mRNA expression, while high doses of the drug (20 μM, 1h) elicited upregulation of these transporters in most cell lines studied. In cells with acquired gemcitabine resistance (up to 160 nM gemcitabine), MRP5 and ENT1 mRNA or protein expression were upregulated in several cell lines. Combined treat-ment with 5-FU and gemcitabine caused a 5-40 fold increase in expression of the gemcitabine transporters MRP5 and ENT1. In addi-tion, our cytotoxicity studies with MRP5-overexpressing or MRP5-silenced cells demonstrated a contribution of MRP5 to gemcitabine resistance.

Conclusion: Our novel data may lead to improved strategies of future chemotherapy regimens using gemcitabine and/or 5-FU.


OP13

A novel GLI1-BRM chromatin complex mediates KRAS oncogenic function in pancreatic cancer cellsN. Hernandez-Alvarado1, L.L. Almada1, H. Huang1, S.F. Elsawa1, M.E. Fernandez-Zapico1

1Schulze Center for Novel Therapeutics, Mayo Clinic, Rochester, MN, USA

Introduction: The transcription factor GLI1 has elicited signifi-cant attention as key effector of multiple pancreatic oncogenic path-ways including KRAS. GLI1 mediates KRAS cancer-associated functions by regulating the expression of its downstream target genes. Therefore, knowledge of the mechanism underlying GLI-mediated transcription will further elucidate the contribution of KRAS to the initiation and progression of pancreatic cancer.

Objectives: Characterize GLI1 transcriptional mechanisms and its impact in KRAS-regulated function in pancreatic cancer cells.

Materials and Methods: We used expression, growth, luciferase, chromatin immunoprecipitation and pulldown assays in combination with deletion mutagenesis to examine the role this newly identified GLI1-Brahma (BRM) complex in KRAS-mediated transformation.

Results: We established the physical and functional interaction between GLI1 and BRM. Originally identified in yeast as part of the SWI/SNF complex, in mammals BRM regulates gene transcription by promoting nucleosomal remodeling. We showed that BRM pro-motes GLI activity in pancreatic cancer cells. This effect is indepen-dent of its nucleosomal remodeling function but requires its chromatin binding properties. Chromatin immunoprecipitation assays demon-strated that GLI1 and BRM are bound to KRAS targets gene (BCL-2 and Cyclin D1). Moreover, BRM acted in synergy with GLI1 to acti-vate KRAS target genes in pancreatic cancer cells. Finally, we showed that KRAS requires an intact GLI1-BRM complex to promote trans-formation in nontransformed cells and maintain an oncogenic gene expression in pancreatic cancer cells.

Conclusion: Thus, these findings identified a novel nuclear effector complex mediating KRAS oncogenic functions and provided novel mechanistic information into the biology of this pathway in pancreatic carcinogenesis.

OP14

Neural Cancer Cell Invasion Is Coupled with the Targeted Migration of Schwann Cells Towards Pancreatic Cancer CellsA. Boldis1, I.E. Demir1, T. Kehl1, H. Friess1, G.O. Ceyhan1

1Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

Introduction: Neural invasion (NI) in pancreatic cancer (PCa) is traditionally assumed to result from an affinity between pancreatic cancer cells (PCCs) and nerves. However, the main barrier on the way of cancer cells to nerve fibers are the fiber-ensheathing Schwann cells (hSC). The possibility of hSC being the actual attractive target for cancer cells in NI has not yet been investigated.

Objectives: To identify the potential role of hSC during NI.Materials and Methods: The PCC line T3M4 was simultane-

ously co-cultivated with hSC and dorsal root ganglia (DRGs) neurons in a 3-D extracellular-matrix-based migration assay. Cellular migra-tion was morphometrically analyzed via digital time-lapse-micros-copy. Temporal alterations in the expression of nerve growth factor (NGF) were quantified in all cell types via immunoblotting.

Results: When simultaneously confronted with hSC and DRGs, T3M4 cells preferentially migrated towards DRGs with a signifi-cantly higher velocity, mass migration and strict directionality. However, hSC reacted with a spindle-like conformational change and an even more targeted migration towards PCCs. Expression of NGF in PCCs gradually changed during migration. In contrast, the replace-ment of T3M4 with three different colorectal cancer cell lines (CCCs) did not entail any specific migratory activity of hSC or CCCs.

Conclusion: Neural invasion in PCa involves not only the inva-sion of nerves by PCCs, but also the targeted migration of hSC to can-cer clusters. The specific expression of neurotrophic factor receptors on PCCs points to the chemotactic effect of nerve-derived factors on NI progression. Therefore, the presented findings necessitate a funda-mental change in our understanding of neuro-cancer interactions.

OP15

PI3K-gamma Upregulation Promotes Proliferation and AKT Activation in Pancreatic CancerC. Edling1, F. Selvaggi2, T. Maffucci1, R. Buus1, P. di Sebastiano3, H. Friess4, P. Innocenti2, H.M. Kocher5, M. Falasca1

1Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Blizard Institute of Cell and Molecular Science, London, UK, 2Department of Surgical Sciences, G. d‘Annunzio University, Chieti, Italy, 3Department of Surgery, IRCCS - Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy, 4Department of Surgery, Technische Universität München, Munich, Germany, 5Queen Mary University London, Barts and The London School of Medicine and Dentistry, Tumour Biology Laboratory, Institute of Cancer, London, UK

Introduction: Mutations of the K-Ras oncogene are common in pancreatic ductal adenocarcinoma (PDAC). A key downstream medi-ator of Ras family signalling is the phosphoinositide 3-kinase (PI3K) family.

Objectives: The aim of our study was to determine which spe-cific PI3K isoforms are involved in PDAC and investigate the effects of these isoforms on proliferation, survival and induction of drug resistance in pancreatic cancer cells.

Materials and Methods: Immunohistochemical screening and scoring of PI3Ks in human pancreatic cancer tissue and normal coun-terparts. Proliferation assays, realtime PCR and western blot analyses of PDAC cell lines.

Results: Immunohistochemical screening revealed high specific expression of the PI3K class 1B isoform p110gamma. Scoring indi-cated that 72% of the PDAC tissue stained positive for PI3Kgamma, while no stain was detected in normal pancreatic ducts. Proliferation


analyses after selective inhibition and siRNA downregulation of PI3Kgamma demonstrated that PI3Kgamma, but not other PI3K iso-forms, is required for cell proliferation. Moreover, we showed that overexpression of PI3Kgamma indeed increases cell numbers and mediates activation of Akt in PDAC cell lines. Western blot analysis showed that PI3Kgamma induces Akt activation via stimulation of lysophosphatidic acid receptors. Additionally, our preliminary data suggests that PI3Kgamma might be involved in pancreatic cancer chemoresistance since PI3Kgamma expression is markedly upregu-lated upon Gemcitabine treatment in PDAC cell lines.

Conclusion: These data represent the first identification of a tumour-specific accumulation of the PI3K isoform p110gamma in human cancer. Further, our results signify a critical role for PI3Kgamma in pancreatic cancer and we hypothesise that PI3Kgamma overexpression is a key event in the disease progression.

OP16

Phosphatase PHLPP-1 Dephosphorylates AKT, Decreases Pancreatic Tumor Growth in the Mouse Orthotopic Model and Serves as a Prognostic Factor for Better Patients SurvivalC.J. Nitsche1, M. Edderkaoui2, P. Grippo5, G. Eibl3, N. Kasahara3, J. Mayerle1, K.D. Heidecke4, M.M. Lerch1, A.S. Gukovskaya2

1Department of Medicine A, Ernst Moritz Arndt University Greifswald, 2Pancreatic research Group, VA Greater Los Angeles Health care center Los Angeles, 3David Geffen School of Medicine, UCLA Los Angeles, 4Department of Surgery, Ernst Moritz Arndt University Greifswald, 5Feinberg School of Medicine Northwestern University, Chicago, IL

Introduction: Akt kinase is a potent pro-survival factor in pan-creatic cancer and its activity is regulated by phosphorylation. We have recently shown that PHLPP-1/2 are important phosphatases in regulating Akt phosphorylation and cell death mechanisms like apo-tosis, necrosis and autophagy. PHLPP-1 activity is furthermore regu-lated by ROS â important prosurvival factors in pancreatic cancer.

Objectives: In the following studies we investigated the role of PHLPP expression on survival and tumor growth in vivo.

Materials and Methods: An orthotopic tumormodel was applied by injecting lentiviral-transduced PHLPP-1/2 overexpressing or control MIAPaCa-2-cells into the pancreas of BALB/c mice. Tumor size was measured after 8 weeks. Samples were analyzed for PHLPP-1/2 expression, Akt phosphorylation, apoptosis and prolifera-tion. Human pancreatic adenocarcinoma samples were stained for PHLPP-1/2 expression and a survival analysis was performed.

Results: Immunostaining indicates a decreased expression of PHLPP-1/2 in human pancreatic adenocarcinoma. Low PHLPP-1 expression significantly correlated with poor survival in patients with pancreatic adenocarcinomas. The results on pancreatic cancer cells MiaPaCa-2 and PANC-1 demonstrate that knocking down PHLPP-1/2 stimulates Akt activity, whereas overexpression decreases Akt phosphorylation and stimulates apoptosis. Correspondingly, PHLPP-1

overexpression in MiaPaCa-2 cells decreases Akt phosphorylation, stimulates apoptosis and greatly decreases tumor growth in the mouse orthotopic pancreaticcancer model.

Conclusion: Our results indicate that PHLPP1 is a major phos-phatase inactivating Akt, a major anti-apoptotic molecule in pancre-atic cancer. Low PHLPP-1-expression correlates with a poor outcome in patients. PHLPP-1 overexpression decreases tumor growth and stimulates apoptosis in the orthotopic mouse model. The results sug-gest overexpressing of PHLPP1 as a promising strategy to stimulate pancreatic cancer cell death.

OP17

Role of ICAM-1, RAGE, Mac-1 and LFA-1 Adhesion Molecules in Leukocyte Recruitment in Experimental Pancreatic and Liver CancerP. Mosevicius1, T. Takeichi1, M.W. Büchler1, J. Schmidt1, E. Ryschich1

1Dept. of Surgery, University of Heidelberg

Introduction: Induction of cellular immune response against tumor cells has been proposed for development of new therapeutical approaches in pancreatic and liver cancer. Recruitment of activated leukocytes from peripheral blood into the tumor tissue is an important step of the immune reaction which is controlled by specific adhesion molecules.

Objectives: Disturbances of adhesion molecule expression down-regulate leukocyte recruitment and induce an escape of antitu-moral immune response. The present study is the first investigation of the role of adhesion molecules in leukocyte recruitment in pancreatic and liver cancer in vivo.

Materials and Methods: The dynamic immune response in orthotropic pancreatic and liver cancer was studied using intravital time-lapse microscopy in transgenic mice. The role of adhesion mol-ecules was studied using LFA-1-/-, ICAM-1-/-, Mac-1-/- and RAGE-/- mice.

Results: Leukocyte adhesion to endothelium and extravasation rates in tumor blood vessels were very low. Comparison between wild-type and knockout mice showed no significant differences of blood vessel density, leukocyte adhesion, extravasation, intratumoral migration and infiltration with Gr-1+ and CD68+ leukocytes. There was no difference of T cells infiltration of tumor tissue between wild-type, ICAM-1-/-and RAGE-/- mice. CD3+ and CD4+ leukocyte infil-tration in LFA-1-/- mice was significantly lower than in wild-type tumors, whereas CD8+ T cells were almost absent in LFA-1-/- mice in both tumor types.

Conclusion: Leukocyte recruitment in cancer is a low-speed process which may reflect low progress in inflammation in contrast to high-speed leukocyte recruitment during the acute inflammatory reaction. In contrast to normal tissue, only LFA-1 controls tumor infiltration with T cells, whereas other adhesion molecules (ICAM-1, Mac-1 and RAGE) do not participate in immune response against pancreatic and liver cancer in vivo.


OP18

Serum Biomarkers for Early Detection of Pancreatic CancerC. Jenkinson1, V. Elliott1, S. Tonack1, V. Shaw1, J.M.F. Tang1, S. Camuzeaux2, U. Menon2, A. Gentry-Maharaj2, J. Sinclair2, S. Pereira3, W. Greenhalf1, J.F. Timms2, J.P. Neoptolemos1, E. Costello1

1Liverpool CR-UK Centre, Division of Surgery & Oncology, University of Liverpool, UK, 2Institute for Women’s Health, University College of London, UK, 3Institute of Hepatology, University College of London, UK

Introduction: Late diagnosis of pancreatic ductal adenocarci-noma (PDAC) coupled with poor response to chemotherapy contrib-ute to a low overall 5 year survival rate of <4%. Identification of potential blood-borne biomarkers for pancreatic cancer could aid ear-lier detection of the disease and greatly improve prognosis.

Objectives: Samples collected, as part of a UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) from women who developed pancreatic cancer during the course of the 5 year trial (n = 304 pre-cancer and 304 control serum samples), along with late stage cancer samples and disease controls collected at the University of Liverpool, are being analyzed for potential protein and cytokine bio-markers using iTRAQ and Luminex technologies respectively.

Materials and Methods: Serum samples (n = 160) from pre-cancer and their matching control groups as well as separate PDAC groups (with and without biliary obstruction) were pooled and analy-sed using iTRAQ. Luminex analysis was performed to measure the levels of 27 different cytokines in serum of pre-cancer patients (n = 37) and controls (n = 37). The expression of potential biomarkers in indi-vidual samples was assessed using western blotting.

Results: Three cytokines were found to be significantly up-reg-ulated in pre-cancer samples compared to controls and 1 was signifi-cantly down-regulated. Initial iTRAQ analysis has detected 149 proteins (1% false discovery rate), with proteins identified as up/down- regulated in the prediagnosis groups, compared to controls. Validation studies so far have identified one of the candidate biomark-ers as up-regulated in the six month period prior to cancer diagnosis.

Conclusion: Initial data have identified promising candidates for early identification of pancreatic cancer.

OP19

Promoter Methylation of DNA Repair-related Genes in Pancreatic Ductal AdenocarcinomaC. Dutruel1, J. Chaisaingmongkol1, A. Bauer2, F. Bergmann3, J. Hoheisel2, N.A. Giese4, J. Werner4, C. Plass1, O. Popanda1, P. Schmezer1

1Division of Epigenomics and Cancer Risk Factors, German Cancer Research Center (DKFZ), Heidelberg, Germany, 2Division of Functional Genome Analysis, German Cancer Research Center (DKFZ), Heidelberg, Germany, 3Institute of Pathology, University Hospital Heidelberg, Germany, 4Surgical Clinic, University Hospital Heidelberg, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is usually incurable at time of diagnosis. New biomarkers are needed for early detection of the disease. Furthermore, improved understand-ing of mechanisms involved in pathogenesis will help developing more effective treatment options. Many genetic and epigenetic altera-tions have been reported to be involved in PDAC genesis and pro-gression, however, so far no study has focused on DNA repair-related genes (DRRGs), which protect cells from genomic instability. Impaired DNA repair mechanisms are known to contribute to malig-nant transformation.

Objectives: This study aims at identifying differentially methy-lated and silenced DRRGs in PDAC.

Materials and Methods: Preliminary DNA methylation screens in promoter associated CpG-islands (CGIs) of 160 DRRGs as well as mRNA expression data showing down-regulation of DRRGs in PDAC were used to select 35 candidate genes. CGI DNA methyla-tion status was quantitatively assessed by matrix-assisted laser des-orption/ionization time-of-flight mass spectrometry, after bisulfite conversion of genomic DNA and subsequent PCR amplification as previously described (Ehrich et al, PNAS 2005).

Results: We could identify two new target genes for significant hypermethylation in PDAC (n = 64) vs. normal (n = 7) tissues: SALL3 (mean tumor 17.9±0.9%, mean normal 10.4±0.9%, unpaired onetailed t-test with Welch’s correction p < 0.0001) and TACSTD2 (18±2%, 2.0±0.8%, p < 0.0001).

Conclusion: These genes display new putative target DRRGs for epigenetic alterations in pancreatic cancer, which could serve as biomarkers for PDAC early detection. Furthermore, the epigenetic silencing might point towards an important functional role in PDAC development. The association between promoter hypermethylation, mRNA and protein down-regulation is currently investigated in tissue samples and pancreatic tumor cell lines.


OP20

Pancreas Mini-tumours as Preclinical In Vitro Model for Medium-throughput Drug ScreeningP. Longati1, R. Jesnowski2, J.M. Löhr1, R. Heuchel1

1Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden, 2CCU Molecular Gastroenterology, German Cancer Research Center, Heidelberg, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is characterized by late diagnosis and therapy resistance. A major hurdle for therapy is the extremely fibrotic component formed by an exces-sive extracellular matrix deposition (ECM/desmoplasia). TGF-beta is the key player in the desmoplastic reaction, by activating pancreatic stellate cells to produce ECM/desmoplasia.

Objectives: Most drugs are currently tested in conventional 2D-culture before entering expensive in vivo experiments. Our idea was to provide a drug-screening in vitro model that considers the presence of the tumor stroma.

Materials and Methods: 3D-hetero-spheroids have been set up where PDAC cells are grown as avascular mini-tumors in combi-nation with a human pancreatic stellate cell line (PSCs). The PSCs were also ‘trained’ (PSCs-tr), under particular conditions, for improved spheroid growth. Interestingly, PSCs and PSCs-tr have dif-ferent localization (central/cortical) within the 3D-heterospheroid.

Results: PSCs are normally activated when cultured on plastic and they express the activation marker alpha-smooth muscle actin (asma). We observed that they do not express asma when grown as 3D-mono-spheroid. Nevertheless, asma is expressed in 3D-hetero-spheroid and colocalised with the PSCs, indicating that PDAC cells are able to activate the PSCs within the spheroid. We are also analysing the expression of ECM proteins within the spheroid. Finally, we show that 3D-minitumours, made up of PSCs and human PDAC cells, significantly increase the treatment resistance compared to conventional 2D-culture, thus more closely mimicking the in vivo situation.

Conclusion: Drug combinations/therapeutic approaches can be easily tested in minitumours and further analyses for prognostic bio-markers by different “omics”-approaches before/while entering pre-clinical (GEMM) studies can be pursued.

Oral-Poster Session III

OP21

Pancreatic Duct Changes Are Not Associated with Early Signs of Chronic Pancreatitis at Magnetic Resonance Imaging in Patients with Primary Sclerosing CholangitisK. Said1, N. Albiin2, B. Lindberg2, T.B. Brismar2, A. Karrar2, J. Permert3, A. Bergquist1

1Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden, 2Division of Radiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden, 3Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden

Introduction: The association between chronic pancreatitis (CP) and primary sclerosing cholangitis (PSC) has been reported pre-viously. The aims of the present study were to evaluate the presence of early pancreatic abnormalities and duct changes, using MRCP/MRI in PSC and to evaluate possible risk factors for these changes and their clinical importance.

Objectives: The aims of the present study were to describe the presence of pancreatic duct changes and early pancreatic abnormali-ties by evaluating the pancreatic parenchymal enhancement pattern using MRCP/MRI in a large cohort of PSC patients.

Patients and Methods: 103 patients with PSC were identified among all MRI liver/pancreas referrals in 2001–2005. MRCP was used to grade pancreatic duct changes in three groups; grade 0 (nor-mal); grade 1 (mild) and grade 2 (severe). For detection of early MRI signs of CP, the pancreas-spleen signal intensity ratio (SIR), the arte-rial and early venous phase ratio (A/PV ratio) and the age-related size of the pancreas were evaluated.

Results: Pancreatic duct changes were found in 24% of the PSC patients. The pancreatic duct changes were associated with extrahe-patic biliary involvement and long duration of PSC but not associated with pancreas-spleen SIR, A/PV ratio, pancreas size, previous post-ERCP or acute pancreatitis. Severe pancreatic duct changes were sig-nificantly associated to abdominal pain. Clinically significant CP was seen in one PSC patient (1%).

Conclusion: Pancreatic duct changes are associated with extra-hepatic bile duct strictures and not with the early MRI signs of chronic pancreatitis. Therefore, pancreatic duct changes seem to be part of the spectrum of PSC and should not be defined as chronic pancreatitis. Pancreatic duct changes are of limited clinical importance but may contribute to abdominal pain in PSC.


OP22

Patients with Tumor-like Chronic Pancreatitis (CP) might have Autoimmune Pancreatitis (AIP)S. Räty1, I. Nordback1, J. Sand1, K. Vasama1, J. Hagström2, S. Nordling2, J. Sirén2, T. Kiviluoto2, C. Haglund2

1Tampere University Hospital, 2Helsinki University Hospital

Introduction: Patients with chronic pancreatitis may need sur-gery for exclusion of cancer or because of severe symptoms. Only part of them benefit from surgery. It is well known that part of CP is autoimmune in nature. These patients might respond to corticosteroid treatment and surgery could be avoided.

Objectives: Our aim was to evaluate the proportion of AIP in patients operated on for CP.

Patients and Methods: 52 patients, who were operated on at Tampere and Helsinki University Hospitals for suspicion of cancer, but in whom final histopathological diagnosis revealed CP or for severe symptoms of CP. 35 patients underwent pancreaticoduodenec-tomy, 8 left pancreatic resection, 6 duodenum preserving pancreatic head resection (Beger`s procedure) and 3 lateral pancreatic drainage (Puestow). All 52 surgical specimens were re-evaluated by experi-enced pathologists, and representative samples were chosen for immunohistochemistry (ICH). Four micrometer thick sections from formalin-fixed and paraffin-embedded samples were stained for IgG-4 (MCA2098G) (Serotec, Oxford, UK, 1:100). For antigen retrieval, slides were treated in a PT-module (LabVision UK Ltd, UK) with Tris-EDTA for 20 min at 98°C. ICH was performed in Autostainer 480 (LabVision) using Dako REAL EnVision Detection System, Peroxidase/DAB+, Rabbit/Mouse (Dako, Glostrup, Denmark). Each sample was scored as positive or negative for IgG4 independently by two pathologists.

Results: Forty-four percent (23 out of 52; 44.2%) of specimens were positive for IgG4.

Conclusion: According to IgG4 IHC the proportion of AIP in our surgically treated CP material is much higher that expected, and suggests a possibility to treat certain patients with corticosteroids before decision to operate.

OP23

Results of Surgical Treatment of Chronic Pancreatitis with Pancreatic Head MassA. Shchastny1, S. Lyarski2, A. Siatkouski2, M. Kuhayeu1, R. Petrov3, V. Egorov3

1The Vitebsk State Medical University, Vitebsk, Belarus, 2The Vitebsk Regional Clinical Hospital, Vitebsk, Belarus, 3The Vishnevsky Institute of Surgery, Moscow, Russian Federation

Introduction: Controversies about the preferable surgical method for chronic pancreatitis treatment still persist.

Objectives: To assess short-term results of CP surgical treat-ment.

Patients and Methods: To analyze the results of different methods of CP surgical treatment on the basis of 201 operations exe-cuted at the Pancreas Surgery Center of Vitebsk, Belarus. (2002- 2009). Thirteen Frey, 102 Beger, 27 Bern procedures, and 59 pancreatoduodenectomies (PD) were performed.

Results: The average illness duration before diagnosis was 28.4 months. Pseudocysts were revealed in 51(25.3%), jaundice in 34(16.9%), biliary hypertension in 15 (7.4%), duodenal stenosis in 28(13.9%), portal hypertension in 37(18.4%), virsungolithiasis in 27(13.4%), and pancreatic calcification in 27(13.4%) cases. Diabetes was diagnosed preoperatively in 20(10%) cases. The postoperative lethality was 3.4%: acute heart failure 2(PD), pulmonary embolism 1(PD), pancreatonecrosis 2 (PD), cholangitis, liver abscesses, sepsis 1 (Beger), peritonitis, sepsis 1(Bern). The general complication rate was 34.3%. After Beger: 21.5%, after PD: 66.1%, after Bern: 25.9%, after Frey: 7.7%. The reoperation rate was 9.5%. The complication rate, blood transfusion rate and the time of ICU stay in case of PD differed negatively and significantly comparing to other groups.

Conclusion: Duodenum-preserving procedures can be the oper-ation of choice for CP with pancreatic head mass.

OP24

Iron Metabolism and Iron-Deficiency Anemia in Patients with Chronic PancreatitisE. Dominguez-Muñoz1,2, M. Castiñeira-Alvariño2, J. Lariño-Noia1,2, M. Luaces-Regueira2, J. Iglesias-García1,2

1Gastroenterology Department, University Hospital of Santiago de Compostela, 2Foundation for Research in Digestive Diseases (FIENAD)

Introduction: Iron metabolism doesn’t requiere normal pancre-atic secretion. Anemia hasn’t been studied in pancreatic diseases. Cephalic duodenopancreatectomy (CDP) is a surgical procedure for patients with chronic pancreatitis (CP). Iron-absorption may be impaired in patients after C.

Objectives: Evaluate iron-metabolism and iron-deficiency ane-mia in patients after CDP and CP, compared to non-operated CP patients.

Materials and Methods: Retrospective analysis of a prospec-tively collected data-base of patients diagnosed of CP. Exocrine pan-creatic function was evaluated by the optimized 13C-mixed triglyceride breath-test. Patients were classified according to previous CDP and exocrinepancreatic-insufficiency(EPI). Hemoglobin, mean-corpuscular-volume (MCV) and iron levels were quantified. Data are shown as mean 95%(CI), or percentage. Analysis was performed by ANOVA, Bonferroni-test and chi-square. Factors related with anemia were evaluated by multivariatestepwise-unconditional-logistic-regression analysis.

Results: 239 patients were included (mean age 50-years, [8-82], 199 male). 20 patients (8.4%) had a CDP. Among non-operated patients, 74(30.9%) had EPI, and 145(60.7%) no. Anemia was pres-ent in 9(45%) CDP-patients, 14(18.9%) EPI patients, and 16(11%) non-EPI patients (p = 0.016). Hemoglobin levels were lower in CDP-patients (12.8 g/dL;95%CI:12.1-13.7) than in non-operated patients (13.9 g/dL,95%CI:13.5-14.5 g/dL in EPI-patients and 14.4 g/dL,95%CI:14.1-14.4 g/dL in non-EPI patients (p = 0.001). MCV was


similar in three groups. Iron deficiency was present in 7(35%) CDP-patients, compared to 7(9.5%) patients with EPI and 19(13%) without EPI (p = 0.07). Serum-iron levels were lower in DPC-patients (p < 0.05). CDP was the only variable independently associated to anemia (OR 5.04, 95%CI: 1.87-13.58, p < 0.001) and iron-deficiency (OR 2.43,95%CI:0.82-7.15, p = 0.051) in patients with CP.

Conclusion: Anemia is not infrequent in CP patients. CDP is the main cause of iron-deficient anemia.

OP25

Tumor Necrosis Factor-alpha in Patients with Chronic Pancreatitis Having Biliary Pancreatic RefluxN. Shirinskaya1, T. Dolgich2

1Omsk State Medical Diagnostic Center, Omsk, Russian Federation, 2Omsk State Medical Academy, Omsk, Russian Federation

Introduction: –Objectives: Study of TNF-alpha in patients with chronic relaps-

ing pancreatitis, depending on presence in them biliary-pancreatic reflux.

Patients and Methods: 80 patients were examined in remis-sion (42 females; 38 males; mean age 39,7±4,9 years). Patients with gallstones were excluded from research. All patients underwent ultra-sound investigation by «Dynamic method of measuring revealing Wirsung’s duct reaction after the gallbladder stimulation» (Certificate 2512 on November 2002). Bile regurgitation to Wirsung’s duct explains a dilatation of its lumen at the contraction of the gallbladder. In healthy persons Wirsung’s duct lumen constriction was connected with normal functiong of Oddi’s sphincter and absence of obstacles to bile outflow.

Results: 60 patients had biliary-pancreatic refluxt; reaction 9 persons was characteristic for healthy people and at 11 patients bil-iary-pancreatic reflux was blocked by sclerotic changes in Wirsung’s duct. One should note an essential difference average values of tumor necrosis factor (TNF- alpha) in remission in patients with chronic relapsing pancreatitis, depending on presence or absence of the bil-iary-pancreatic reflux. Thus, for patiens with the reflux average TNF-alpha values were 96,82±5,68 pg/ml; and for persons without the reflux these values were 6,82±2,19 pg/ml.

Conclusion: The biliary-pancreatic reflux is a sign of high activity of an inflammatory processes in patients with chronic relaps-ing pancreatitis during a period of clinical remission and with bile reflux into Wirsung’s duct.

OP26

Results of Beger Procedure for Chronic Pancreatitis TreatmentA. Shchastny1, S. Lyarski2, M. Kuhayeu1, A. Siatkouski2, V. Egorov3, R. Petrov3

1Vitebsk Stete Medical University, Vitebsk, Belarus, 2Vitebsk Regional Clinical Hospital, Vitebsk, Belarus, 3The Vishnevsky Institute of Surgery, Moscow, Russian Federation

Introduction: The choice of the duodenum-preserving proce-dure for surgical treatment of chronic pancreatitis (CP) remains a dis-cussion point.

Objectives: To analyze the short-term results of the duodenum-preserving pancreatic head resection (DPPHR) by Beger.

Patients and Methods: From 2002 till 2009 102 consecutive Beger procedures were performed, demographic, clinical and periop-erative data were investigated.

Results: Men: 97, women: 5, the average age was 43.5±8.5yrs. Stenosis of the common bile duct was diagnosed in 22(21.5%) patients (in13 with mechanical jaundice), patients stenosis of the duo-denum in 6 (5.8%), portal hypertension in 19 (18.6%) and pseudo-cysts in 26 (25.5%) patients. Besides the specified complications, the following morphological changes of the pancreas were noted: pancre-atic calculi in 11 (10.7%) and virsungolithiasis in 11 (10.7%) patients. The decompression of the common bile duct as an addition to the standard resection led to the decompression of the constricted ductus choledochus without the necessity of imposing an additional biliodi-gestive anastomosis. The average postoperative hospital stay was 23,9±13 days, the duration of treatment in the ICU was 3,0±2,0 days. The operation time was 294±63 minutes. Hemotransfusion amounted to 690 ml on average. Out of 102 patients, 1(0,98%) patient died due to multiple bilobar liver abscesses on the background of the portal vein preoperative thrombosis.

Conclusion: The Beger procedure is safe operation for CP in specialized departments. Thia type of DDPHR provides good results in treating the pain syndrome and eliminating complications of CP.

OP27

Polymorphisms of IL-1beta and TNF-alpha Genes and Serum Levels in Patients with Chronic (CP) and Acute Pancreatitis (AP)I. Grigorieva1, T. Nikitenko1, T. Romanova1, Y. Ragino1, V. Maximov1, M. Voevoda1

1Institute of Internal Medicine SB RAMS

Introduction: Increase of IL-1beta serum levels is detected at AP and in acute stage of CP (Panek, 2006). Some studies reports about not increasing of TNF-alpha serum levels in pancreatitis (Paajanen, 1995).

Objectives: To investigate genes polymorphisms and serum levels of IL-1beta and TNF-alpha at patients with CP and AP.

Materials and Methods: 53 patients with CP and 40 patients with AP were examined. Serum levels of IL-1beta and TNF-alpha


was defined by ELISA; polymorphisms of these genes was studied by PCR.

Results: 511C/T polymorphism of gene IL-1 beta did not differ at CP and AP patients: genotypes T/T - 28,3% and 22,5%, T/C - 67,9% and 65%, C/C - 3,8% and 12,5% accordingly, and alleles T - 62,3% and 55%, C - 37,7% and 45% (p > 0,05). IL-1beta serum level in vari-ous genotypes at CP and AP patients did not differ: range T/T - 3,0- 6,6 pg/ml, T/C -2,7- 5,9 pg/ml, C/C -2,3-4,4 pg/ml (p > 0,05). G308A polymorphism of gene TNF-alpha genotypes and alleles frequencies did not differ at CP and AP patients: genotypes G/G –66,7% and 71,4%, G/A –31,7% and 26,2%, A/A –1,0% and 2,4% accordingly, and alleles G –82,5% and 84,5%, A –17,5% and 15,5% (p > 0,05). TNF-alpha serum levels in various genotypes at CP and AP patients did not differ: range G/G-4,1-4,9 pg/ml, G/A-3,7-6,6 pg/ml, A/A-1,0-2,7 pg/ml (p > 0,05).

Conclusion: polymorphisms of IL-1 beta and TNF-alpha genes at CP and AP patients did not differ. IL-1beta and TNF-alpha serum levels in various genotypes at CP and AP patients did not differ.

OP28

TNF-alpha Gene Polymorphism and Mutations of PRSS1, PSTI/SPINK1, ADH2 Genes, Smoking, Alcohol Abuse and the Clinical Course of PancreatitisI. Grigorieva1, T. Romanova1, T. Nikitenko1, V. Maximov1, M. Voevoda1

1Institute of Internal Medicine SB RAMS

Introduction: The course of genetically determined pancreatitis (P) is rather mild than at nonhereditary P (Keim V., 2001), and Rebours V., (2009) reports that mutations PRSS1 gene is not corre-lated with clinical/morphological expression in P.

Objectives: To evaluate TNF-alpha gene polymorphism and mutations of genes RSS1, PSTI/SPINK1, ADH2, smoking, alcohol abuse and its contribution to clinical course of P.

Patients and Methods: 128 patients (sex andage comparable) with an acute (AP) and chronic (CP) P have been surveyed. Diagnosis P has been verified by clinic methods, ultrasonography, CT. Polymorphisms of genes were studied by PCR.

Results: In 4 patients have PRSS1 gene R122H and N29I muta-tions, 3 patients - PSTI/SPINK1 gene N34S mutation, 8 patients - ADH2 gene rs1229984 mutation. Alleles and genotypes frequency G308A gene TNF-alpha didn’t differ in P and in Novosibirsk popula-tion (p > 0,05). ADH2 A allele met in 2,3times often in AP than in CP. PRSS1 and PSTI/SPINK1 mutations made significant contribution to P pathogenesis; in addition to these mutations smoking, alcohol abuse and ADH2 mutations clinical course of disease was the most severe. TNF-alpha gene polymorphism didn’t modify clinical course of P.

Conclusion: AP and CP patients with mutations of genes PSTI/SPINK1, PRSS1, ADH2 have intensive and frequent painful syn-drome and severe dyspepsia. These symptoms were the most expressed at accompanying smoking and alcohol abuse. Clinical course of P in different alleles and genotypes TNF-alpha gene was similar.

OP29

Causes, Types and Results of Surgical Treatment for Chronic Pancreatitis – A Single Center ExperienceM. Matejak-Gorska1, M. Durlik1

1The Department of Gastroenterology & Transplant Surgery, Central Clinical Hospital, Ministry of Internal Affairs & Administration, Warsaw, Poland

Introduction: Growing number of patients require hospitaliza-tion and surgery for chronic pancreatitis (CP). Surgical treatment for patients suffering from CP results in reduction of clinical symptoms and improves the quality of life (QoL).

Objectives: Aim of the study was to assess the effectiveness of surgical interventions in patients with CP treated in our department.

Patients and Methods: 1630 patients with diagnosis of CP were admitted to our hospital between 2001-2010.102 (6,25%) required surgical intervention. Indication for surgery was a lack of improvement following a period of medical treatment (40%) or suspi-cion ofmalignancy (60%). Type of surgery depended on clinical symptoms and suspicion of malignancy, and included drainage opera-tions or pancreatectomy for suspectedmalignancy. All patients were assessed for pain, biochemical parameters and QoL prior to surgery and one month thereafter.

Results: Increase inthe number of patients with CP, referred for surgical treatment, was observed over the study period. Perioperative mortality was 17,6%. In patients, who survived the perioperative period, complete or substantial release of pain was observed, as well as a progressive improvement in their general condition and QoL.

Conclusion: Surgical treatment for CP is an effective therapy which is recently becoming more accepted and popular. Surgical treatment, although not without complications, allows for a reason-ably quick improvement in general condition of patients with CP and a fast release of symptoms related to chronic pain, often associated-with chronic pancreatitis. The proper timing for the operation seems to be veryimportant, as well as an adequate preparation for surgery - both, medical and psychological.

OP30

Pancreatic Exocrine Function Post Esophagectomy, Gastrectomy and Pancreato-DuodenectomyS. Ward1, P. Gibson1, S. Mackay1, R. Cade2, S. Hassen2, S. Banting2

1Eastern Health Clinical School, Monash University, and 2Box Hill Hospital, Eastern Health, Melbourne, Australia

Introduction: Accurate testing of pancreatic exocrine function is difficult and currently available tests have significant disadvantages. Major upper gastrointestinal resections may be associated with signifi-cant ongoing nutritional difficulties and abdominal symptomatology.

Objectives: This study aims to document pancreatic exocrine function after various upper gastrointestinal resections using the Carbon 13 labeled mixed triglyceride breath test (C13-MTGBT).


Patients and Methods: Patients at least 3 months post oesophagectomy, gastrectomy and pancreato-duodenectomy were invited to undertake the C13-MTG-BT at Box Hill Hospital, Melbourne, Australia. Recruitment was conducted from August 2009 to March 2010 from public outpatient clinics, private consulting rooms and medical record searches. The primary outcome was cumu-lative percentage of ingested C13 exhaled as 13CO2 after 6 hours (cum.%C13-6hr). A secondary outcome was the time at peak rate of C13 excretion (peak-%C13/hr). Post-operative patients were statisti-cally compared with controls using the Mann-Whitney-U test.

Results: 10 control subjects and 26 post-operative patients were tested. The control group had a mean cum.%C13-6hr = 29.6 with 95% confidence limits 13.2 –46.1. The cum.%C13-6hr in each post-operative group compared with controls was not significantly differ-ent. However, the time of peak-%C13/hr was significantly earlier in the post-gastrectomy and post-oesophagectomy groups compared with controls.

Conclusion: This study documents the expected normal range of the C13-MTG-BT using our particular test protocol. In patients post upper gastrointestinal resections versus controls there was no significant difference in pancreatic exocrine function possibly due to low number of participants, but there was an earlier time of peak rate of excretion of C13 which may correlate with more rapid gut transit.

Oral-Poster Session IV

OP31

Neoadjuvant Therapy for Resectable Pancreatic Adenocarcinoma: An Interim Report of a Prospective Controlled Randomized StudyM. D’Ambra1, R. Casadei1, R. Pezzilli1, L. Calculli1, E. Barbieri1, M.C. Di Marco1, D. Rega1, C. Ricci1, M. Macchini1, B. Angelelli1, C. Serra1, A. Guido1, S. Lega1, D. Santini1, F. Minni1, R. Corinaldesi1

1Alma Mater Studiorum, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy

Introduction: High rate of R1 resection is reported after surgi-cal resection of pancreatic adenocarcinoma.

Objectives: To compare neoadjuvant chemoradiation (NAT) plus surgery versus surgery alone in patients with resectable pancre-atic adenocarcinoma in a prospective, controlled, randomized study. The primary end-point was to evaluate the R0 resection rate by ITT analysis; the secondary end-points were safety and efficacy of NAT, postoperative mortality, morbidity, and lymph noderatio.

Patients and Methods: Selection criteria: medical history, imaging findings, core biopsy. Eligible patients were randomized to receive either NAT (gemcitabine plus radiation therapy) and surgery (Group A) or surgery alone (Group B).

Results: From 2007 to 2009, 16 patients were randomized: 7 (43.7%) in Group A and 9 (56.3%) in Group B and data are available

for 14 subjects. R0 resection rate: Group A 60% (3/5); Group B 11.1% (1/9) (P = 0.095). NAT morbidity rate: 80% (4/5). One case (20%) after NAT had a progression of the disease, two cases had partial response (40%) and one had a stable disease (40%). Surgical resec-tion was performed in 4 patients of Group A (80%) and in 8 (88.8%) of Group B (1 case unresectable). Overall postoperative mortality: 1/12 (8.3%) (Group A vs. Group B: P = 1.000); overall postoperative morbidity: 5/12 (41.7%) (0% Group A vs. 62.5% Group B, P = 0.081). Mean number of lymph node metastasis was lesser (P = 0.051) in Group A (2±3) than in Group B (9±5).

Conclusion: Despite the small number of patients, preliminary data suggest that NAT plus surgery increases the R0 resection rate, reduces the lymph nodes-ratio and allows a better postoperative course.

OP32

Downstaging for Locally Advanced Pancreatic Cancer: Surgical and Pathological Outcomes After ResectionG. Barugola1, S. Partelli1, S. Crippa1, C. Bassi1, P. Pederzoli1, M. Falconi1

1Policlinico Universitario Borgo Roma Verona

Introduction: Chemo and chemoradiotheraphy in unresectable pancreatic cancer have mainly a role for palliation. Occasionally after treatment, the tumor become resectable and complete pathologic response has been reported.

Objectives: To compare outcomes and patterns of survival of patients who were resected after chemo or chemoradiation therapy (NT group) with those who underwent an upfront resection (US group).

Patients and Methods: Between 2000 and 2008, 403 patients with pancreatic cancer who underwent pancreatic resection were included. Fourty-one patients (10.1%) staged at first observation as having a locally advanced disease underwent surgical resection after neoadjuvant therapy. The remaining 362 patients (89.9%) had an upfront surgery. Univariate and multivariable analysis were per-formed.

Results: Mortality and morbidity rate were similar (2.4% and 31.7% in NT group, 1.1% and 28.2% in the US group, respectively). Frequency of nodal metastases resulted significantly lower in the NT group (31.7% vs 86.2%, respectively; p < 0.001). A complete patho-logical response was observed in 13.6% of NT patients. The median disease specific survival from resection was 34.9 months in the NT group compared with 27.0 months in the US group (p = 0.73). In the NT group, only R2 resection (HR 5.50) and a poorly differentiation (HR 4.00) correlated with survival. In NT group, N0 patients experi-enced a survival similar at N1 patients (p = 0.4).

Conclusion: Postoperative mortality and morbidity after pan-creatic resection for pancreatic cancer are not increased by neoadju-vant therapy. Neoadjuvant therapy in locally advanced pancreatic cancer can lead to an objective pathological response but this does not statistically improve survival after resection.


OP33

A Randomized Phase II Trial of Two Different Four-drug Combinations in Advanced Pancreatic Adenocarcinoma: Cisplatin, Capecitabine, Gemcitabine Plus Either Epirubicin or DocetaxelS. Cereda1, A. Rognone1, C. Belli1, L. Tondulli1, M. Ghidini1, S. Rezzonico1, P. Passoni1, G.P. Balzano1, A. Zerbi1, V. Di Carlo1, E. Villa1, M. Reni1

1S. Raffaele Scientific Institute, Milan, Italy

Introduction: PEFG regimen (P:cisplatin, E:epirubicin, F:5-fluorouracil, G:gemcitabine) significantly prolonged progression-free (PFS) and overall survival (OS) of patients with advanced pancreatic adenocarcinoma (PA) with respect to standard gemcitabine (Reni Lancet Oncol 2005).

Objectives: The current trial was aimed to assess whether the replacement of E with docetaxel (D) may improve 6 months PFS (PFS6).

Patients and Methods: Chemo-naive patients with stage III or metastatic PA received P (30 mg/m2 day 1), G (800 mg/m2 day 1) and capecitabine (1250 mg/m2/day days 1 to 14) and were randomized to receive either D at 25-30 mg/m2 day 1 (arm A: PDXG regimen) or E at 30 mg/m2 day 1 (arm B: PEXG regimen). Cycles were repeated every 14 days for a maximum of 6 months. The Fleming design was used to calculate the sample size on the probability of being PFS6. Assuming P0 = 40% and P1 = 60%, .05 and .10, the study was to enroll 52 patients per arm.

Results: Between July 2005 and September 2008, 105 patients were enrolled stratified by stage and randomized (53 arm A). Patients’ characteristics were (A/B): median age 61/59, KPS >70 92/88%, met-astatic disease 66/65%. PFS6 was 58/58%. Median OS was 11 months in both arms. A partial response was observed in 60/37% of patients. Main per cycle G3-4 toxicity was: neutropenia 4/13%, thrombocy-topenia 2/4%, anemia 4/4%, fatigue 6/4%.

Conclusion: The inclusion of D instead of E yielded more objective and less G3-4 neutropenia but did not improve PFS and OS. The present trial confirms the relevant impact on outcome of advanced PA of four-drug regimens.

OP34

Graft-versus-tumor Effect Against Pancreatic Ductal Adenocarcinoma After Treatment with Hematopoietic Stem Cell TransplantationB. Omazic1, Z. Hassan1, J. Mattsson1, R. Segersvärd2, J.M. Löhr3, J. Permert2, O. Ringdén1

1Center for Allogeneic Stem Cell Transplantation, 2Department of Surgical Gastroenterology, 3Department of Medical Gastroenterology, 4all at Karolinska University Hospital Huddinge, Stockholm, Sweden

Introduction: Allogeneic hematopoietic stem cell transplanta-tion (HSCT) is an established treatment for haematological malignan-cies. The curative effect of HSCT is mediated by a T-cell dependent graft-versus-leukemia effect which has also been demonstrated to control solid cancers. Mortality rates in patients with pancreatic duc-tal adenocarcinoma (PDAC) has only slightly increased the last 30 years. Even after curative resection and adjuvant chemotherapy, the 5-year survival remains poor.

Objectives: To study anti-tumor effect of HSCT in patients with PDAC.

Patients and Methods: We performed HSCT in two patients with PDAC after radical resection and adjuvant chemotherapy. Conditioning before HSCT consisted of fludarabine and cyclosphos-phamide. HLAidentical siblings were used as stem cell donors. Five controls, undergoing radical resection of PDAC and adjuvant chemo-therapy, were included.

Results: Both patients undergoing HSCT suffered from acute and chronic graft versus host disease (GVHD), with more extensive manifestations in one patient. They are both alive, 52 and 60 months after surgery, three years after HSCT. CT scans, performed in February 2010, did not show any signs of recurrence of PDAC. Among the controls, all patients died from progressive disease, mean survival was 29.4 months after surgery.

Conclusion: We here demonstrate two patients with radically resected PDAC that had beneficial anti-tumor effect from adjuvant treatment with HSCT. Even though only two patients were treated, the results are encouraging and more patients will be included.


Oral-Poster Session V

OP35

Neural Invasion in Pancreatic Cancer – A Critical Comparison with Other Gastrointestinal CancersF. Liebl1, J.G. D’Haese1, I.E. Demir1, K. Becker1, M. Maak1, A. Novotny1, R. Rosenberg1, H. Friess1, G.O. Ceyhan1


Introduction: Neural invasion (NI) is a major route of meta-static spread and a predictor of impaired survival in pancreatic cancer (PCa). Although NI has been included in the novel UICC classifica-tion, there is no data available which describes a unified definition of NI in all gastrointestinal malignancies.

Objectives: To provide a comprehensive characterization of NI in gastrointestinal malignancies, to establish a standardized novel NI-severity scoring system and to assess the impact of NI on patient survival in comparison to PCa.

Patients and Methods: A total of app. 12000 H&E-stained tis-sue sections from 100 patients with either an adenocarcinoma of the oesophago-gastric junction (AEG), squamous cell carcinoma of the esophagus (SCC), gastric, colon, rectum, biliary or pancreatic cancer were thoroughly examined for NI, and NI-severity was determined.

Results: NI was detected in 31% of colon and in 32% of rectal cancers, in 37% of SCCs, in 38% of AEGs, in 52% of gastric cancers, in 56% of cholangiocarcinomas and in 100% of PCa. NI severity was highest in PCa (24.9±1.9) followed by biliary cancer (9.5±1.7). Lowest NI severity was detected in AEG (0.8±0.3). In the multivari-ate analysis, NI was associated with an impaired survival in gastric (p = 0.045), rectal cancer (p < 0.001) and PCa (p = 0.02).

Conclusion: All patients with PCa demonstrate NI. The severity of NI is by far highest in pancreatic cancer in comparison to other gastrointestinal cancers. Additionally, NI is an independent prognos-tic factor only in patients with gastric, rectal and pancreatic cancer.

OP36

Application of the Software “PancPro” to Select Families Eligible to Screening for Pancreatic CancerG. Leonardi1, S. Presciuttini2, A. Zerbi3, M. Falconi4, S. Marchi1, U. Boggi2, M. Del Chiaro2

1Pisa University Hospital, Gastroenterology Unit, 2Pisa University Hospital, Division of General and Transplant Surgery, 3Department of Surgery, Humanitas Institute, Milan, 4Surgical and Gastroenterological Department, University of Verona

Introduction: Pancreatic cancer is the V cause of cancer death with a high mortality. The reason is the late diagnosis. Early detection is a strategy to improve the survival. It’s important to screen individu-als at high risk for pancreatic cancer to detect early cancer.

Objectives: The aim of this study was to use “PancPro” to select patients eligible to screening for pancreatic cancer.

Materials and Methods: We have applied “PancPro” to 570 families of patients presenting with pancreatic cancer: a model for pancreatic cancer risk prediction in individuals with familial pancre-atic cancer to identify high-risk subjects. It estimates the probability that an individual carries a pancreatic cancer susceptibility gene and the future probability that an asymptomatic individual will develop pancreatic cancer. We calculated the lifetime risk (Rc) of developing pancreatic cancer for a hypothetical 40 years-old son of each of the 570 probands. The lifetime risk for a subject of age 40 without family history of c ancer, Rp, was 0.011.

Results: The 570 Rc values were included between 0.01 and 0.13. The distribution was bimodal with the antimode located at Rc = 0.075. Considering the accepted threshold (Rc/Rp = 10) for including a relative in a surveillance program, 19 families out of the 570 were included. A total of 92 first-degree relatives with age >40 years of these probands would be selected for screening.

Conclusion: PancPro is a valid instrument to rank families based on familial risk for pancreatic cancer. It provides far more accu-rate risk assessment than summary counts of affected relatives, high-ligthing the clinical utility of this model.

OP37

The Role of Cyclooxygenase-2 Gene Polymorphisms in Pancreatic CarcinogenesisR. Talar-Wojnarowska1, A. Gasiorowska1, M. Olakowski2, A. Lekstan2, P. Lampe2, B. Smolarz3, H. Romanowicz-Makowska3, A. Kulig3, E. Malecka-Panas1

1Department of Digestive Tract Diseases, Medical University of Lodz, Poland, 2Department of Digestive Tract Surgery, Silesian University, Katowice, Poland, 3Laboratory of Molecular Genetics, Institute of Polish Mother’s Memorial Hospital, Lodz, Poland

Introduction: Cyclooxygenase-2 (COX-2) is a key enzyme involved in many biologic processes, such as cell proliferation, inva-


sion, metastases and angiogenesis, which are all relevant to cancer development and progression.

Objectives: The purpose of this study was to evaluate the clini-cal significance of -765G/C and -1195G/A COX-2 gene polymor-phisms in patients with pancreatic cancer.

Patients and Methods: The study included 201 patients: 85 with pancreatic cancer (PC) and 116 healthy controls. -765G/C and -1195G/A COX-2 genes polymorphisms have been studied in DNA isolated from blood samples. The associations of the analysed geno-types and clinical data at diagnosis have been evaluated.

Results: We found an increased frequency of the homozygous -1195AA COX-2 genotype in patients with PC (53,7%) compared with control group (21%) (p < 0,01). In contrast, the distribution of genotype and allele frequencies of the -765G/C COX-2 polymor-phism in the PC patients did not differ from those in control groups. The correlation between presence of homozygous -1195AA COX-2 genotype and tumor size >3 cm has been observed (p < 0,05). Analysed polymorphisms were unrelated to the patients sex and age as well as with the presence of regional or distant metastases.

Conclusion: These preliminary results indicate that -1195G/A COX-2 polymorphism may play important role in pancreatic carcino-genesis, however further studies are needed to investigate its possible association with PC prognosis.

OP38

Slower Recovery from Postoperative Complications Rather Than Complications Rate Dramatically Affects Length of Stay of Elderly Patients Undergoing PancreaticoduodenectomyF. Di Fabio1, S. Syed1, W. El Ghoul1, E. Johnston1, C. Johnson1, N. Pearce1, M. Abu Hilal1

1Hepatobiliary-Pancreatic Unit, Southampton General Hospital, Southampton University Hospitals NHS Trust, Southampton, UK

Introduction: The increased life expectancy of the general pop-ulation and dramatic improvements in postoperative care have extended the indications to perform pancreaticoduodenectomy (PD) in the elderly (e.g. over 75-80 years). However, this remains an area of debate.

Objectives: The aim of this study is to critically analyse the impact of age on postoperative complications, recovery, and length of hospital stay.

Patients and Methods: We reviewed a database of patients undergoing PD between January 2007 and November 2009, analysing surgical features and postoperative outcomes according to three age-classes: more than 80 years (5%), between 70 and 80 years (35%), less than 70 years (60%).

Results: In the study period 174 patients underwent PD. Patients over 80 years showed a trend toward increased postoperative bile leak (13% vs. 5% vs. 4%, p = 0.538), pancreatic leak (25% vs. 15% vs. 14%, p = 0.684), chest infection (50% vs. 30% vs. 28%, p = 0.428), and delayed gastric empting (63% vs. 16% vs. 14%, p = 0.002, chi-squared test) compared to the two younger classes of patients.

Complications substantially affected time to start regular feeding (median 17 vs. 11 vs. 10 days; p = 0.052, Kruskal-Wallis test) and sig-nificantly affected length of stay (median 29 vs. 20 vs. 18 days; p = 0.022, Kruskal-Wallis test) in patients over 80 years compared to the two younger classes of patients. No significant difference in mor-tality rate among the age-classes was detected.

Conclusion: A slower recovery from postoperative complica-tions seems to considerably influence length of stay after PD in the elderly. A comprehensive risk-benefit and cost-effective analysis should drive the surgical decision-making in the octogenarians.

OP39

A Molecular Prognostic Nomogram for Resectable Pancreatic CancerD. Chang1, E. Colvin1, C. Scarlett1, M. Pajic1, M. Pinese1, E. Muzgrove1, S. Henshall1, R. Sutherland1, J. Kench1, A. Biankin1

1Cancer Research Program, Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW, Australia, 2Departments of Surgery, Bankstown Hospital, Bankstown, Sydney, NSW, Australia

Introduction: Defining clinically and biologically relevant phe-notypes in some cancers has lead to substantial improvements in the overall outcomes through better patient selection and focusing novel therapeutic development on poor prognostic subgroups. About 80% of patients with pancreatic cancer (PC) succumb to the disease despite curative resection. However, relevant molecular phenotypes have not been defined.

Objectives: To evaluate the potential clinical utility of biologi-cally relevant molecules as prognostic factors in resected PC.

Patients and Methods: We assessed the relationship of aber-rant S100A4 calcium-binding protein expression, with survival in a cohort of 372 patients who underwent surgical resection for PC and derived a prognostic nomogram for resected PC using aberrant expression of S100A4 and S100A2.

Results: High S100A4 expression was an independent poor prognostic factor in both the training (n = 76; HR = 5.00, 95% CI = 2.29–10.9; P < 0.0001) and validation sets (n = 296; HR = 1.78, 95% CI = 1.29–2.46; P = 0.0004). Incorporating previously published data on S100A2, demonstrated that high expression of S100A4 was still an independent prognostic factor. Aberrant expression of these proteins stratified the cohort into 3 distinct prognostic groups. A pre-operative nomogram using only variables that could be measured pre-operatively (tumor size and molecular biomarkers), predicted survival better than nomograms derived using clinico-pathological variables, which are determined after examination of the resected specimen.

Conclusion: Aberrant expression of S100A4 and S100A2 strat-ifies PC into distinct prognostic groups, and improves the accuracy of prognostic nomograms using variables determined preoperatively. The development and application of such nomograms in routine clin-ical practice has the potential to improve patient selection and as a consequence overall outcomes for PC.


OP40

Intraperitoneal Increased Lactate-Pyruvate Ratio, Glycerol Release and Protease Activation Recognizes Significant Pancreatic Fistula Early After Whipple ResectionC. Ansorge1, S. Regnér2, R. Segersvärd1, C. Nylén1, L. Strömmer1

1Div surgery, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, 2Dept Surgery, UMAS, Malmö, Sweden

Introduction: Early diagnosis of clinically relevant pancreatic fistula (PF) would enable early intervention to reduce morbidity after Whipple resections (WR). A microdialysis (MD) catheter resembles a capillary blood vessel and can monitor tissue metabolic changes e.g. ischemia (increased lactate-pyruvate (L/P) ratio) and cell membrane injury (glycerol release).

Objectives: The aim if the current study was to use intraperito-neal MD after WR to identify early markers of clinically relevant PF.

Patients and Methods: WR were done in 52 patients. The MD catheter was placed behind (n = 12) or in front (n = 40) of the pancrea-ticojejunostomy (PJ). L/P ratio and glycerol levels were measured every 4th h postoperatively. Trypsin activation peptide (TAP) was analysed. Postoperative intraabdominal complications (IC) were clas-sified according to Clavien.

Results: Twenty patients developed 22 (42%) IC needing inter-vention: PF (IIIa n = 7, IIIb n = 2), intraabdominal haemorrhage (IIIb n = 6), gastroenteroanastomotic (GE) bleeding (IIIa n = 3), bile leak-age (IIIb n = 3) and GE leakage (IIIa n = 1). In the PF group increased L/P ratio (P < 0.05), glycerol levels (P < 0.001), and TAP were observed within 24 h postoperatively, preceding clinical symptoms. No such changes were observed in patients with other ICs, with an uncompli-cated course or if the MD catheter was placed behind the PJ.

Conclusion: Clinically relevant PF after WR appears to be asso-ciated with early ischemia, cell injury and protease activation. MD is a useful method for early detection of relevant PF encouraging post-operative vigilance and possibly earlier intervention. Furthermore, this method has great potential to increase our knowledge of the pathophysiology of postoperative PF and other intraabdominal com-plications after gastrointestinal surgery.

OP41

Cytokines, Chemokines and Growth Factors as Novel Biomarkers for the Detection of Resectable Pancreatic Adenocarcinoma (PDAC)J.M.F. Tang1, V. Shaw1, C. Jenkinson1, B. Greenhalf1, J.P. Neoptolemos1, E. Costello1

1Division of Surgery and Oncology, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK

Introduction: The initial diagnostic process for pancreatic can-cer can be difficult, especially when the presenting symptoms are

similar to other benign diseases such as chronic pancreatitis and obstructive jaundice. Clearly, there is a need for novel diagnostic techniques for the detection of PDAC.

Objectives: To examine the value of cytokines, chemokines and growth factors (CCGFs) as a non-invasive alternative for the detec-tion of resectable pancreatic cancer.

Patients and Methods: The Bio-Plex-Pro 27-Plex Luminex Assay was used to quantify human CCGFs in prospectively collected sera of patients with PDAC (n = 48), chronic pancreatitis (CP, n = 9), and healthy volunteers (HC, n = 10). A disease predicting formula was generated using stepwise regression and the Nominal Logistic Model. The resulting formula was then validated against an independent sample set (PDAC, n = 29; HC, n = 7; CP, n = 8).

Results: Five CCGFs were identified by stepwise regression as potential biomarkers for differentiating between PDAC and control subjects. In the discovery set, the disease predicting formula gener-ated by the Nominal Logistic Model yielded sensitivities and speci-ficities of 100% for PDAC against HC, CP and control subjects. In the validation set, sensitivities of 84.2% and relative specificities of 100%, 87.5%, and 93.3% were achieved for differentiating PDAC against HC, CP and control subjects respectively.

Conclusion: Results from this preliminary study suggest that CCGFs have the potential to differentiate between resectable PDAC and control subjects. However, further work, including increasing patient and control numbers in discovery and validation sets, is neces-sary before decisions are made on which CCGFs provide optimum sensitivity and specificity for differentiating between pancreatic can-cers and controls.

OP42

Polymorphism in the Hypoxia-Inducible Factor 1 Gene May Confer Susceptibility to Pancreatic Ductal AdenocarcinomaW. Xiuchao1, Z. Tianshuo1, R. He1, G. Chuntao1, H. Jihui1

1Key Laboratory of Cancer Prevention and Therapy, Tianjin Cancer Hospital

Introduction: Pancreatic cancer has one of the worst prognosis in gastrointestinal cancers, with a 5-year survival rate below 5%. It is necessary to find specific markers to predict risk of this cancer.

Objectives: The aim of the study was to investigate whether the polymorphisms of Hypoxiainducible factor 1 alpha (HIF1a) is involved in the susceptibility of pancreatic ductal adenocarcinoma (PDAC).

Patients and Methods: Genotypes of HIF1a were determined in 130 patients with pancreatic ductal adenocarcinoma and in a con-trol group of 162 healthy(frequency-matched by age and sex) . Epidemiological and clinical information was obtained. A uncondi-tional logistic regression model and log-rank tests were used for sta-tistical analysis.

Results: Our results demonstrate a significant difference in geno-type distribution for HIF-1a C1772T and G1790A polymorphism between PDAC patients and controls. we found an increase in both the C/T (30.8 vs. 14.2%, P = 0.001) and G/A(29.2 vs. 9.9%, P = 0.000) genotypes in our patients. Heterozygous genetype(CT) for the C1772T


polymorphism have a higher risk for developing PDAC compared to homozygous (CC) wild type (OR = 2.061, 95%CI: 1.369–3.104, P = 0.001). This signicant difference also evident in the HIF-1a G1790A polymorphism between two subjects (OR = 4.125, 95%CI: 2.604–6.532, P = 0.00).

Conclusion: In conclusion, this sudy suggests that the HIF-1a C1772T (P582S) and G1790A (A588T) polymorhisms in exon 12 is associated with Pancreatic carcinogenesis.

OP43

The Role of Environmental and Genetic Factors in Pancreatic CancerB. Mohelnikova-Duchonova2, D. Vrana1, I. Holcatova4, M. Ryska5, Z. Smerhovsky6, O. Havranek7, I. Hlavata1, L. Foretova8, Z. Kleibl7, L. Marsakova9, J. Novotny3, P. Soucek1

1Toxicogenomics Unit, National Institute of Public Health, Prague, Czech Republic, 21st Faculty of Medicine, Charles University in Prague, Czech Republic, 3Department of Oncology, 1st Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Czech Republic, 4Institute of Hygiene and Epidemiology, 1st Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Czech Republic, 5Department of Surgery, 2nd Faculty of Medicine, Charles University in Prague and Central Military Hospital, Czech Republic, 6Institute of Epidemiology, 2nd Faculty of Medicine, Charles University in Prague, Czech Republic, 7Institute of Biochemistry and Experimental Oncology, 1st Faculty of Medicine, Charles University in Prague, Czech Republic, 8Department of Cancer Epidemiology and Genetics, Masaryk Memorial Cancer Institute, Brno, Czech Republic, 9Faculty of Sciences, Charles University in Prague, Prague, Czech Republic

Introduction: Genetic variations in low penetrance genes may modify the risk of carcinogenesis.

Objectives: We have analyzed the associations of functionally relevant polymorphisms in carcinogen-metabolizing glutathione S-transferases (GSTM1, GSTT1, GSTP1), epoxide hydrolases (EPHX1), cytochromes P450 (CYP1B1 and CYP2A13), alcohol dehydrogenases (ADH1B and ADH1C), superoxide dismutases (SOD2 and SOD3), NADPH:quinine oxidoreductases (NQO1 and NQO2) and alterations in a genome integrity maintaining Checkpoint kinase 2 (CHEK2) with pancreatic cancer susceptibility.

Patients and Methods: A total of 953 Czech Caucasians (270 incident pancreatic cancer patients and randomly selected 683 unre-lated cancer-free controls) were included into the hospital-based case-control study. Epidemiological and clinico-pathological data were collected. Polymorphisms were determined in lymphocyte DNA by real-time PCR, RFLP, allele-specific PCR and high-performance liq-uid chromatography with sequencing verification.

Selected Results: The CYP2A13 variant allele*7 coding inac-tive enzyme was found in 7/265 controls and 0/235 cases. The GSTP1-codon 105 Val variant allele and the GSTT1-null genotype were associated with an elevated pancreatic cancer risk (OR = 1.38;

95%CI = 0.96-1.97 and OR = 1.56; 95%CI = 0.93-2.61). Combination of GSTT1-null and GSTP1-Val further increased the risk (OR = 2.50; 95%CI = 1.20-5.20). Carriers of the rare genotype Val/Val (recessive model) or the Val allele (dominant) in CYP1B1-codon 432 were under a significantly lower risk of pancreatic cancer than wild type carriers (p = 0.035 and p = 0.015). The pancreatic cancer risk was higher in individuals who inherited alterations in the CHEK2 region involving fork head-associated domain (OR = 5.14; 95%CI = 0.94-28.23) although the observed association was non-significant (p = 0.057).

Conclusion: Enzymes activating or detoxifying constituents of tobacco smoke (CYP1B1, CYP2A13, GSTP1 and GSTT1) may mod-ify pancreatic carcinoma etiology and their role should be further studied.

OP44

Resection of Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas: The Role of Intraoperative Ultrasonography (IOUS)E. De Raffele1, M. Mirarchi1, S. Vaccari1, L. Calculli2, D. Santini3, B. Cola1

1U.O. Chirurgia Generale, 2U.O. Radiologia, 3U.O. Anatomia e Istologia Patologica

Introduction: IPMNs are pancreatic neoplasms with malignant potential and can be multifocal. Segmental pancreatic resection are increasingly considered to be adequate for lesions with low malignant potential.

Objectives: The aim of the study was to define the role of IOUS in candidates to pancreatic resection for IPMNs.

Patients and Methods: Ten patients were included in the study (6 males and 4 females; mean age +SD was 71 +7 yrs, range: 61-84 yrs). All underwent preoperative CT-scan and MRCP for staging. 3 patients had invasive carcinoma and IPMNs, 2 had multifocal and 5 had unifocal IPMNs, respectively. IOUS was performed to explore the parenchyma, the tumour, the peripancreatic vessels, and to define resection margins before pancreatic division. Margins were submitted for intraoperative frozen section analysis.

Results: IOUS was useful to define resection margin in patients with invasive carcinoma: in one patient with carcinoma of the tail and multiple IPMNs, IOUS showed a 20 mm tumour of the isthmus which was included in the resected specimen and contained in-situ carci-noma. In patients with multifocal tumours, IOUS was useful to define resection margins of the dominant IPMN. In patients with unifocal tumour, IOUS was useful to obtain negative margins (2 DCP, 1 distal pancreatectomy, 2 resections of the tail with splenic preservation), as confirmed at intraoperative frozen section analysis in all cases.

Conclusion: IOUS should be routinely used in candidates to pancreatic resection for IPMN and should guide the surgeon, espe-cially in patients with multifocal neoplasms and in candidates to seg-mental conservative pancreatic resection.




Poster Sessions

Poster Session I

Basic Science – Physiology, Cell Biology & Development

P1

Galanin Receptors Are Highly Expressed in Isolated Pancreatic Islet Cells and Poorly Expressed in Isolated Pancreatic Acinar Cells in the MouseM. Bazargan1, S. Barreto1, D. Hussey1, M. Leong1, H. Peiris2, D. Keating2, C. Smith1, C. Carati3, J. Toouli1, G. Saccone1

1Departments of Surgery, 2Human Physiology, and 3Anatomy and Histology, Flinders University, Flinders Medical Centre, Bedford Park, SA, Australia

Introduction: Galanin, a neuropeptide found in the pancreas, modulates pancreatic endocrine and exocrine secretion. Galanin acts via three known receptors, galanin receptor 1(GALR1), GALR2 and GALR3. GALR expression throughout the pancreas however is not fully described.

Objectives: To establish if GALR are expressed in normal mouse pancreas, acinar and islet cells.

Materials and Methods: Pancreata were harvested and acinar and islet cells were isolated by standard techniques. Extraction of total RNA used a TrizolÔ protocol. The expression of GALR1, GALR2 and GALR3 mRNA was determined using real-time reverse transcription-polymerase chain reaction with primers designed spe-cifically for these transcripts. Hypoxanthine phophoribosyltransferase was used as a housekeeping gene for normalisation of expression data. In-situ hybridisation (ISH) studies using locked nucleic acid probes with sections of mouse pancreas were performed to localise the mRNA for each GALR.

Results: In whole pancreas (n = 5 mice), expression of the three GALRs was detected. GALR3 showed the highest expression fol-lowed by GALR1 then GALR2. In islet cells (n = 4 preparations), GALRs were highly expressed and at comparable levels. By com-parison with islet expression, acinar cell (n = 5 preparations) expres-sion of GALRs was very low. GALR3 displayed the highest expression whereas GALR1 and GALR2 were poorly expressed. These findings were supported by the ISH data.

Conclusion: The three GALRs are present in the mouse pan-creas, but their relative expression varies with the different cell types. The poor expression of GALRs by acinar cells is consistent with our finding that galanin does not modulate amylase secretion by directly acting on acinar cells.

P2

Galanin Potentiates Amylase Secretion from Mouse Pancreatic Lobules But Not from Isolated Acinar CellsM. Bazargan1, S. Barreto1, A. Schloithe1, C. Carati2, J. Toouli1, G. Saccone1

1Department of General and Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, SA, Australia, 2Department of Anatomy and Histology, Flinders University, Bedford Park, SA, Australia

Introduction: Galanin is implicated in the pathogenesis of acute pancreatitis. Many rodent models of acute pancreatitis use supramax-imal concentrations of caerulein to induce the disease. The effect of galanin on amylase secretion under these conditions is unclear. We hypothesised that galanin modulates pancreatic amylase secretion evoked by a supramaximal concentration of caerulein via a direct action on acinar cells (AC).

Objectives: To compare the effect of exogenous galanin on amylase secretion from pancreatic lobule and AC preparations evoked by a supramaximal concentration of caerulein.

Materials and Methods: Lobules and AC were prepared from mouse pancreata by standard techniques. Lobules or AC (n = 5-7 preparations) were incubated with galanin (10-13 –10-7M), caerulein (10-12 –10-7M), alone or in combinations for 60 min at 37oC. Control lobules or AC were incubated in medium alone. Amylase secretion was expressed as percent of control.

Results: Caerulein stimulated amylase secretion from lobules and AC in a dose-dependent manner (P < 0.05, Mann Whitney test). The peak secretion from lobules and AC was 170% and 330% of con-trol, respectively and evoked by 10-10M caerulein in both prepara-tions. Secretion then declined with increasing caerulein concentration in both preparations. Galanin alone did not influence basal amylase secretion from lobules or AC. Supramaximal caerulein (10-7M) alone stimulated amylase secretion from lobules to 124% of control and co-incubation with galanin potentiated amylase secretion to 160% of control (P < 0.05). In contrast, galanin had no effect on the supramaxi-mal caerulein-stimulated amylase secretion from AC.

Conclusion: Galanin does not act directly on AC to regulate pancreatic amylase secretion.


P3

Sodium Valproate Induced Functional and Structural Changes in Pancreatic Thiol Proteinase InhibitorM. Priyadarshini1, B. Bano1

1Dept. of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University

Introduction: Drug/ligand induced protein structure conforma-tional alterations are prime problems complicating drug medical ther-apy. Sodium valproate (VPA), an anti-epileptic agent has been associated with acute pancreatitis. Cathepsin mediated trypsinogen activation is one of the initiator points of acute pancreatitis. Thiol pro-teinase inhibitors (or cystatins), like the recently purified cystatin superfamily variant, pancreatic thiol proteinase inhibitor (PTPI) are prime endogenous regulators of cathepsin activity.

Objectives: Association of valproate and cathepsin mediated trypsinogen activation with pancreatitis provoked the interest in prob-ing the effects of valproate on PTPI.

Materials and Methods: PTPI was isolated and purified from pancreas of Capra hircus. Functional inactivation of PTPIwas esti-mated by loss of its antiproteolytic potential. Intrinsic fluorescence-and absorption difference spectroscopy, polyacrylamide gel electrophoresis(PAGE) were used to assess structural changes in PTPI induced upon drug complexation.

Results: The exposure of PTPI to varyingVPA concentrations caused substantial loss of its antiproteolytic potential. The inhibitor retained only 33% of its antipapain activity at 4 M VPA andbeyond this drug concentration, the inhibitor was barely active. Fluorescence and UV spectroscopy revealed only minor conformational changes in PTPI oncomplexation with VPA, which was further supported by absence of any grossconformational change in the protein band on subsequent analysis by PAGE. Thus, interaction with VPA might have caused subtle changes in conformation of PTPI’sactive site region resulting in functional loss.

Conclusion: On complexation with VPA, PTPIactivity was severely challenged suggesting cathepsin inactivation might be oneof the factors in VPA induced pancreatitis. The possible implication of thisstudy would be on designing therapeutic agents for efficient man-agement of VPAinduced pancreatitis.

P4

US and MRCP Findings in 23 Patients with Asymptomatic HyperenzimemiaG. Leonardi1, S. Marchi1, U. Boggi2, N. de Bortoli1, V.G. Perrone2, M. Del Chiaro2

1Pisa University Hospital, Gastroenterology Unit, 2Pisa University Hospital, Division of General and Transplant Surgery

Introduction: Persistent increases in serum concentrations<script type = ”text/javascript”src = ”http://epc2010.factory-dev.hu/sources/js/tinymce/themes/advanced/langs/en.js”></script> of pancreatic

enzymes (amylase and/or lipase) without clinical evidence of pancre-atic disease are a relatively common finding in clinical practice.

Objectives: Analize the spectrum of US and MRCP findings in patients with asymptomatic hyperenzimemia.

Patients and Methods: Over a 12-month period, 23 consecu-tive patients (12 females - 11 males) having chronic hyperenzimemia were scheduled to undergo US and MRCP. 7 (31%) patients had hyperamylasemia, 4 (17%) hyperlipasemia and 12 (52%) an increase of both enzymes. None of the subjects reported a daily alcohol intake >40 g.

Results: Only 9 patients (39%) had a pathological US imaging, while 14 (61%) had a completely normal US. 4 out of 23 patients (17%) had a normal pancreatic ductal three at MRCP. In the remain-ing 19 patients (83%), 6 patients (32%) showed pancreatic cysts, 5 (26%) pancreatic changes compatible with IPMN, 1 (5%) a dilated Wirsung with “Kinking”, 1 (5%) IPMN and chronic pancreatitis, 1 (5%) cancer arising from IPMN, 2 (11%) a chronic pancreatitis and 2 (11%) a “Pancreas Divisum”.

Conclusion: Patients with asymptomatic chronic hyperenz-imemia showed an abnormal US only in 39% of cases, but abnormal MRCP in 83% of cases. MRCP in the most effective and non invasive imaging technique in these patients because it gives more detailed morphological information about the pancreatico-biliary ductal sys-tem. In 19 subjects we found important pancreatic diseases. This means that all patients with asymptomatic chronic hyperenzimemia must undergo MRCP for detecting pancreatic diseases, some of which require follow-up.

P5

Structural and Functional Changes of the Gut Depend on Age When Total Exocrine Pancreatic Insufficiency Was Developed. Study in a Pig-modelO. Prykhod’ko1, O. Fed’kiv1, B. Weström1, S. Pierzynowski2

1Dept of Biology, Lund University, Sweden, 2Dept of Medical Biology, IMW, Lublin, Poland

Introduction: Exocrine pancreatic insufficiency (EPI) leads to maldigestion, malnutrition and growth deprivation in young individu-als. We have, however, shown in a pig model that EPI leads to growth arrest in young but not in older growing pigs.

Objectives: Present study focused on changes in the gut struc-ture and function of pigs with induced EPI at different ages.

Materials and Methods: Littermate pigs in order to develop EPI were subjected for pancreatic duct ligation in early (10kg bwt), or later life (50kg bwt), while un-operated pigs were used as a reference. The GI-tract was proceed for morphological and functional analyses and used for intestinal in vitro permeability measurements.

Results: The results showed a decreased mucosal thickness in the fundic stomach and atrophy of the small intestinal mucosa, i.e., a reduc-tion in villi height and crypt depth, in early EPI, but not in late EPI pigs. Though intestinal disaccharidases were unaffected, EPI resulted in an increased intestinal mucosal permeability to different-sized marker molecules compared to the un-operated pigs. Moreover, the gut-associ-ated lymphoid tissue was more developed in the late EPI pigs.


Conclusion: Apart from the similar compensatory changes in digestion/absorption in all EPI pigs, the changes in morphology of the gut indicate that some changes are age-related and possibly depend on maturity of gut at the point of induction of EPI.

P6

Smad7, the Major Negative Regulator of TGFbeta Signalling Is Not Required for the Development of the Mouse PancreasR. Heuchel1, Y.M. Lu1, I. Kleiter2, B. Hagman1, J.M. Löhr1

1Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sverige, 2Neurology Dept., University of Regensburg, Germany

Introduction: Transforming growth factor-beta (TGF-beta) plays multiple roles in pancreatic development and disease (fibrosis). Smad7 is induced by TGF-beta itself, blocks the receptor activity and thus acts in a negative feedback-loop. Transgenic overexpression of Smad7 in acinar cells of the mouse pancreas results in spontaneous pancreatic intraepithelial neoplastic lesions as a consequence of sup-pressing TGF-beta’s tumor suppressor activity (Kuang et al., PNAS (2006)). Furthermore, overexpression of Smad7 in pancreatic pro-genitor cells leads to beta-cell hypoplasia and neonatal lethality (Smart et al., PLos Biol. (2006)), supporting the importance of Smad7 for proper regulation of TGF-beta signalling during pancreas devel-opment and homeostasis.

Objectives: Since overexpression of Smad7 in pancreatic dif-ferent cells has such profound impact, we wanted to test what effect of the lack of Smad7 had on mouse pancreas development.

Materials and Methods: We have recently generated Smad7 partial knockout mice, in which the Cterminal part of Smad7 is still expressed (Li et al., J.Immun.176, 6777-84(2006)). In addition, we have crossed a conditional knockout of Smad7 (Kleiter et al., Brain, (2010)) with a mouse deleting Smad7 specifically and only in pan-creas progenitor cells.

Results: Partial knockout of Smad7 is viable and leads to increased fibrosis in liver and kidney wound healing models. No dif-ferences were observed in pancreas morphology and no spontaneous fibrosis was detected even in aged mutant mice. Furthermore, no macroscopic or microscopic changes can be detected in the pancreas development of mice with a complete lack of Smad7 function in pan-creatic progenitor cells.

Conclusion: Smad7 is not required for pancreas development in the mouse.

Basic Science – Acute Pancreatitis

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Protective Effects of Caffeine in a Murine Model of Caerulein-Induced Acute PancreatitisW. Huang1, R. Mukherjee1, M. Cane3, V. Elliott2, D.M. Booth3, A. Sim3, E. McLaughlin1, A.V. Tepikin3, O. Petersen4, D.N. Criddle3, R. Sutton2

1Division of Surgery and Oncology, Royal Liverpool University Hospital, Liverpool, UK, 2NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK, 3 Physiological Laboratory, University of Liverpool, Liverpool, UK, 4Cardiff School of Biosciences, Cardiff University, Cardiff, UK

Introduction: Coffee consumption is protective against acute alcoholic pancreatitis. Caffeine has multiple actions including inhibi-tion of the inositol 1,4,5-trisphosphate receptor (IP3R), adenosine receptor and of phosphodiesterase (PDE), although to what extent these actions are important in pancreatitis is unclear.

Objectives: To elucidate the effects of caffeine on pancreatic acinar cytosolic Ca2+ ([Ca2+]C) changes in vitro and in a caerulein-induced pancreatitis model in vivo, comparing its actions with those of rolipram (a PDE 4 inhibitor).

Materials and Methods: Confocal microscopy was used to assess changes in [Ca2+]C, in murine pancreatic acinar cells. Acute pancreatitis was induced in CD1 mice by repeated caerulein injec-tions. Caffeine at doses of 1, 5, 10 and 25 mg/kg/h ×7 was given hourly from 1 h, with serum concentrations determined at 130-720 minutes after the first caffeine injection by mass spectrometry, or 3 mg/kg rolipram was given at 30 min before the first caerulein injec-tion. The severity of pancreatitis was assessed by standard biomark-ers and histopathology.

Results: In vitro, 1 mM caffeine partially and 10 mM caffeine fully inhibited the [Ca2+]C plateau induced by hyperstimulation with cholecystokinin-8 (10 nM). In vivo, caffeine dose-dependently ame-liorated the severity of pancreatitis, with 25 mg/kg/h x 7 (~ 1 mM peak serum concentration) improving all parameters of pancreatitis remarkably except the associated lung injury. Rolipram reduced the overall histopathological score, but was less effective.

Conclusion: Caffeine is protective in caerulein-induced pan-creatitis, which may occur at least in part through IP3R and/or PDE inhibition.


P8

Administration of Ghrelin Accelerates Healing in Ischemia/Reperfusion-Induced Acute PancreatitisZ. Warzecha1, A. Dembinski1, P. Ceranowicz1, J. Cieszkowski1, B. Kusnierz-Cabala2, R. Tomaszewska3

1Department of Physiology, Jagiellonian University Medical College, Kraków, Poland, 2Department of Clinical Biochemistry, Jagiellonian University Medical College, Kraków, Poland, 3Department of Pathology, Jagiellonian University Medical College, Kraków, Poland

Introduction: Pretreatment with ghrelin, a 28-amino-acid poly-peptide originally isolated from the stomach, exhibits protective effect in the gut. This effect has been shown in the stomach and pan-creas. Also, administration of ghrelin exhibits therapeutic effect in the course of mild edematous acute pancreatitis.

Objectives: Aim of the study was to determine the influence of treatment with ghrelin on the course of severe necrotizing pancreati-tis. Additionally we have tested the effect of ghrelin on lipid peroxi-dation and antioxidant defense system in the pancreas.

Materials and Methods: Acute pancreatitis was induced in rats by severe pancreatic ischemia followed by reperfusion. Ghrelin was administered twice a day at the dose of 8 nmol/kg/dose, starting 24 h after the beginning of reperfusion. In this series, rats were sacri-ficed 2, 5, 9, 14 or 21 days after the start of reperfusion.

Results: Treatment with ghrelin after induction of acute isch-emia/reperfusion-induced pancreatitis accelerates normalization of pancreatic histology in this disease. This effect has been accompanied with improvement of pancreatic circulation and partial reversion of the pancreatitisevoked increase in serum activity of lipase and serum concentration of pro-inflammatory interleukin-1beta. Induction of acute pancreatitis reduced pancreatic activity of superoxide dismutase (SOD) and increased serum concentration of malondialdehyde. Administration of ghrelin reduced serum concentration of malondial-dehyde and partly reversed the pancreatitis evoked reduction in pan-creatic activity of SOD.

Conclusion: Ghrelin reduces oxidative stress and exhibit thera-peutic effect in severe necrotizing acute pancreatitis evoked by isch-emia followed by reperfusion.

P9

Pancreatic and Pulmonary Mast Cells Activation During Experimental Acute PancreatitisI. López-Font1, S. Gea-Sorlí2, E. de-Madaria1, L.M. Gutiérrez3, M. Pérez-Mateo1, D. Closa2

1Unidad de Patología Pancreática. Hospital General Universitario de Alicante. Alicante. España., 2Departamento de Patología experimental. IIBB-CSIC, IDIBAPS and CIBEREHD, Barcelona. España., 3Instituto de Neurociencias de Alicante. San Juan de Alicante. España

Introduction: Acute pancreatitis represents a substantial clini-cal problem with increasing incidence. The most important predictor of mortality is the development of multiple organ failure and the com-monest affected organ is the lung. Mast cells have been reported to contribute to several aspects of pancreatitis associated lung injury.

Objectives: To study the activation of pancreatic and pulmo-nary mast cells and the effect of mast cell inhibition on the activation of peritoneal and alveolar macrophages during acute pancreatitis.

Materials and Methods: Pancreatitis was induced by intraduc-tal infusion of sodium taurodeoxycholate in rats. The mast cell inhibi-tor Cromolyn was i.p. administered 30 min before pancreatitis induction. The pancreatic and pulmonar tissue damage was evaluated histologically and mast cells and their state of activation were evalu-ated. Peritoneal and alveolar macrophages were obtained and the expression of Tumor Necrosis Factor alpha was determined. The myeloperoxidase activity was measured to evaluate the effect of Cromolyn on the progression of inflammatory process. Finally, the effect of plasma on cultured mast cells or macrophages was evaluated.

Results: The Cromolyn significantly reduced the inflammation in pancreas and lung and the activation of alveolar macrophages. Mast cell degranulation was observed in pancreas during pancreatitis but not changes were observed in lung. Plasma from pancreatitis could activate alveolar macrophages but does not induced degranula-tion of mast cells.

Conclusion: Pancreatic mast cells play an important role in trig-gering the local and systemic inflammatory response in the early stages of acute pancreatitis. Lung mast cells are not involved in the inflammatory response to pancreatic damage.

P10

Effect of Dexamethasone and Nacetylcysteine on Lung Inflammation in Mild and Severe Acute PancreatitisL. Ramudo1, S. Yubero1, M.A. Manso1, I. De Dios1

1Department of Physiology and Pharmacology, University of Salamanca

Introduction: Lung injury is a feature in acute pancreatitis (AP) in which leukocyte recruitment is considered to play a critical role.

Objectives: To analyze the effect of dexamethasone (Dx) and N-acetylcysteine (NAC) on the expression of molecules involved in


leukocyte trafficking in lungs during AP and its consequences in neu-trophil infiltration.

Materials and Methods: Mild and severe AP was induced in rats by bile-pancreatic duct obstruction (BPDO) and 3.5% sodium taurocholate (NaTc), respectively. Dx (1 mg/kg) was administered 1 h after AP. NAC (50 mg/kg) was given 1 h before and 1 h after inducing AP. Amylase activity and IL-1 concentrations were analyzed in plasma. Myeloperoxidase (MPO) activity and mRNA expression of P-selectin, intercellular adhesion molecule (ICAM)-1, vascular adhe-sion molecule (VCAM)-1, monocyte chemoattractant molecule (MCP)-1, cytokine-induced neutrophil chemoattractant (CINC) were evaluated in lung.

Results: Hyperamylasemia and IL-1 plasma levels were reduced by Dx and NAC treatments. In both AP models, Dx completely avoided the overexpression of ICAM-1, MCP-1 and CINC and reduced Pselectin. VCAM-1 expression was reduced by Dx in mild but not in severe AP. Only in mild AP, NAC prevented the MCP-1 and CINC upregulation, reduced P-selectin and VCAM-1 expression, but it did not avoid ICAM-1 expression in both AP models. Neutrophil infiltration was decreased by NAC treatment in BPDO-AP, but none effect was found in NaTc-AP rats treated by either Dx or NAC.

Conclusion: The antioxidant effect of NAC was more effective than the anti-inflammatory action of Dx in reducing the neutrophil infiltration in lung during AP.

Supported by a grant from ISCIII (PI08/0035).

P11

Protective Effect of Obestatin in Ischemia/Reperfusion-Induced Acute Necrotizing PancreatitisA. Dembinski1, Z. Warzecha1, P. Ceranowicz1, J. Cieszkowski1, R. Tomaszewska2

Departments of 1Physiology, and 2Pathology, Jagiellonian University Medical College, Kraków, Poland

Introduction: Obestatin has been originally extracted from rat stomach, and the stomach is a major source of circulating obestatin. Previous studies have shown that administration of obestatin inhibits the development of mild edematous acute pancreatitis evoked by cerulein and protects pancreatic islet cells.

Objectives: Aim of the present study was to investigate the influence of obestatin administration on the development of severe necrotizing acute pancreatitis.

Materials and Methods: Acute pancreatitis was induced in rats by pancreatic ischemia followed by reperfusion. Obestatin was administered twice intraperitoneally at the dose of 8 nmol/kg/dose; the first dose was given 0.5h before exposure to ischemia, the second one 3h after the first injection. The severity of acute pancreatitis was assessed after 6-h reperfusion.

Results: Pretreatment with obestatin reduced morphological signs of acute pancreatitis such as pancreatic edema, pancreatic leu-kocyte infiltration, and vacuolization of acinar cells, necrosis, and number of foci of hemorrhages. These effects were accompanied with a decrease in the pancreatitis-evoked increase in serum activity of lipase. Also serum concentration of proinflammatory interleukin-1

and pancreatic activity of myelopeoxidase were reduced. The pancre-atitis-evoked decrease in pancreatic DNA synthesis was partially reversed by obestatin administration. Moreover, pretreatment with obestatin tended to reverse the pancreatitis-evoked decrease in pan-creatic blood flow, but this effect was statistically insignificant.

Conclusion: Administration of obestatin inhibits the develop-ment of inflammation and reduces the severity of ischemia/reperfu-sion-induced acute pancreatitis. This observation suggests that obestatin protects the pancreas independently to the primary cause of acute pancreatitis.

P12

Autophagy Is Neither a Prerequisite for – Nor a Consequence of – Early Trypsin Activation in Experimental PancreatitisS. Malla1, B. Krüger2, T. Wartmann3, M. Sendler1, F.U. Weiss1, F.S. Gorelick4, W. Halangk3, M.M. Lerch1, J. Mayerle1

1Department of Medicine A, Ernst-Moritz-Arndt- University, Greifswald, Germany, 2Division of Medical Biology, University of Rostock, Germany, 3Division of Experimental Surgery, University of Magdeburg, Germany, 4Yale University Medical School, New Haven, CT, USA

Introduction: Intracellular protease activation, an initiating event for pancreatitis, was suggested to begin in autophagosomes.

Objectives: We tested whether intracellular trypsin activation depends on autophagy, or autophagy on trypsin activation, in the early phase of pancreatitis.

Materials and Methods: We used mice expressing the fluores-cent autophagy marker LC-3-GFP to prepare acini and to induce pan-creatitis (7 i.p. caerulein injections, 50μg/kg). Organelles were separated by percoll gradient centrifugation at 50.000g (densities 1.03-1.16 g/ml) and identified using specific antibodies against ATG16 or a shift to membrane bound LC3-II (fluorescent on live imaging of acini) indicating autophagosomes. Trypsin activation after 10nM CCK was imaged confocally (Ile-Pro-Arg-AMC) with or with-out gabexate-mesilate.

Results: Autophagosome formation during pancreatitis was con-firmed by the appearance of fluorescent vesicles in the pancreas of LC3-GFP-mice and a shift of LC3 to its membrane-bound LC3-II form. Significant levels were reached at 4 h. Premature trypsin activa-tion also developed during pancreatitis. Simultaneous confocal imag-ing of autophagosome formation (LC3-fluorescence) and trypsin activation (Ile-Pro-Arg-AMC-fluorescence) in isolated acini indicated that the two events arise in different compartments. In subcellular frac-tions of 1 h pancreatitis animals the trypsin activation-compartment contained cathepsin-B but did not correspond to autophagosomes. Trypsin inhibition with gabexate-mesilate did not prevent autophago-some formation in response to supramaximal stimulation.

Conclusion: While autophagy has been shown to be important in regulating the ultimate levels of intrapancreatic protease activity and pancreatitis severity, the initial activation of trypsin develops neither in autophagosomes nor does it depend on autophagy. Onset of autophagy in the pancreas, in turn, does not require trypsin activation.


P13

Biochemical Changes of Small Intestine in Early Stages of Experimental Acute PancreatitisO. Rotar1, V. Rotar1

1Bukovinian State Medical University, Chernivtsi, Ukraine

Introduction: Infection of pancreatic necrosis is a major cause of morbidity and mortality in acute pancreatitis (AP). Bacterial trans-location occurs due to increase of intestinal permeability as a result of disorders of intestinal metabolism.

Objectives: To investigate the biochemical changes in small intestine (SI) in early stages of experimental AP.

Patients and Methods: In 70 Wistar rats AP was induced by intraperitoneal injection of 250 mg/100 g of 20% L-arginine solution. Changes of pro- and antioxydative status, connective tissue markers, proteolytic activity and nitric oxide metabolites concentration in SI have been investigated during the first 48 hours of AP.

Results: AP was accompanied by activation of oxidant stress. Concentration of diene conjugates, malone dialdehyde and nitric oxide metabolites increased after 12 hours after AP initiation and reached maximum in 24 hours: levels exceeded values of intact rats on 22%, 10% and 18% accordingly (<0,05). Their neutralization occurred after 48 hours as a result of activation of antioxidant defense: superoxide dismutase and the catalase concentrations has been raised in 1,6 and 1,7 times (<0,05). Under influence of oxidant stress col-lagenolytic activity raised in 1,5 times after 12 hours and remained high until the end of experiment. Simultaneously changes in proteo-glycans and glycoproteins structure appeared: concentration of sialic and hexuronic acids, hexosamine and fucose enlarged in 35-75% (<0,05).

Conclusion: In early terms of AP oxidant and nitrosative stress stimulate collagenolytic activity and destroy structure of proteogly-cans and glycoproteins in small bowel tissues that can influence on the rate of a bacterial translocation from the gut.

P14

Chymotrypsinogen and Trypsinogen Are Activated via Different Mechanisms and in Different Organelles During Caerulein Induced PancreatitisT. Wartmann1, B. Brandt-Nedelev1, H. Lippert1, J. Mayerle2, M.M. Lerch2, W. Halangk1

1Division of Experimental Surgery, Otto-von-Guericke-University Magdeburg, Germany, 2Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, Germany

Introduction: Premature activation of digestive zymogens is a triggering event for acute pancreatitis. It is thought to arise in a mem-brane-confined intracellular compartment and in a cascade-like man-ner, in which either the activities of trypsin or of lysosomal cathepsins play a central role.

Objectives: We have tested whether this hypothesis explains chymotrypsinogen activation during experimental pancreatitis in the mouse.

Materials and Methods: In wild-type NMRI, or cathepsin-B and cathepsin-L-deficient mice acute pancreatitis was induced by 7 hourly injections of caerulein (50 μg/kg i.p.). Control mice received i.p. saline. Subcellular pancreatic homogenate fractions were pre-pared by Percoll gradient centrifugation. Using the specific substrates Boc-QAR-MCA for trypsin and Suc-AAPF-AMC for chymotrypsin we determined enzyme activities fluorometrically. Subcellular com-partments were identified by Western blots for organelle markers or by marker enzyme activities.

Results: Neither trypsin nor chymotrypsin activity in the pan-creas rose in controls. During pancreatitis, and almost in parallel with trypsin, chymoptrypsin activity peaked between 30 min and 1h after disease onset. Unexpectedly, intracellular chymotrypsin activity developed completely independent of the presence or absence of cathepsin-B or cathepsin-L, in the absence of trypsinogen activation, but was inhibited by chymostatin. The subcellular secretory organ-elles of trypsin and chymotrypsin activation were distinct without overlap in densities.

Conclusion: During intestinal digestion and in vitro chy-motrypsinogen was clearly shown to be activated by trypsin-depen-dent limited proteolysis. During experimental pancreatitis in mice, however, chymotrypsinogen activation is independent of either trypsin activity or lysosomal cathepsins. It occurs through a separate activation mechanism and in a distinct compartment that both require further characterization.

P15

Differential Activation of Peritoneal, Alveolar and Lung Interstitial Macrophages During Acute PancreatitisS. Gea-Sorlí1, A. Serrano-Mollar1, D. Closa1

1Dept Experimental Pathology. IIBB-CSIC-IDIBAPS-CIBEREHD. Barcelona Spain

Introduction: Systemic inflammatory response syndrome is one of the major pathobiologic processes underlying severe acute pancreatitis and the degree of macrophage activation could be one of the factors that finally determine the severity of the disease. When activated, macrophages could show three different phenotypes: clas-sical or m1 activation, wound healing or m2a and immune regulation or m2b. These three basic macrophage populations are not strict but these populations can blend into various degree of activation.

Objectives: To characterize the phenotype activation of differ-ent macrophages populations during experimental acute pancreatitis and their relationship with the outcome of the disease.

Materials and Methods: In this work we have characterized the phenotype of peritoneal, alveolar and lung interstitial mac-rophages, on an experimental model of acute pancreatitis induced by intraductal administration of 3.5% sodium taurocholate. The expres-sion of m1, m2a and m2b markers was evaluated 3h, 6h and 24h after pancreatitis induction. lipase, as indicator of pancreatic damage and myeloperoxidase as indicator of tissue inflammation was measured.


Results: Results indicate that pancreatitis courses with an early m1 activation of peritoneal macrophages, followed by a late m1 acti-vation of alveolar macrophages and an inhibitory m2b activation of lung interstitial macrophages. These activations correlate with the progression of the inflammatory response in pancreas and lung.

Conclusion: We conclude that the progression and resolution of inflammation in distant organs during acute pancreatitis depends on the activation of the different macrophage populations.

P16

Risk of Recurrence with and without Preventive Measures After Biliary PancreatitisA. Popowicz1, E. Wirén1, G. Sandblom1, Å. Andrén-Sandberg1

1Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge

Introduction: According to guidelines at Karolinska University Hospital Huddinge patients suffering from biliary pancreatitis should be treated with ERCP with sphincterotomy or cholecystectomy imme-diately after the pancreatitis subsides to prevent recurrence. The aim of this study was to compare recurrence rates for patients treated according to the guidelines with those who were not.

Objectives: Does a standardised program for treatment of bil-iary pancreatits eliminate the risk of recurrence?

Patients and Methods: A review of patients treated with diag-nosis acute pancreatitis at Karolinska University Hospital in 2007 was performed. Patients with biliary pancreatitis were divided with regards to measures taken during hospital stay, i.e. ERCP with sphinc-terotomy or cholecystectomy, and measures taken after discharge with subdivision into measures scheduled before or after discharge.

Results: Altogether 52 patients were treated for biliary pancrea-titis, 31 women and 21 men. No significant association between age, gender or etiology was found. Mean age was 54 years. Fifteen patients underwent cholecystectomy and 33 ERCP during hospital stay. Some patients received both treatments. Eleven patients underwent chole-cystectomy and seven ERCP after discharge following decision before discharge. Ten patients underwent cholecystectomy and 40 ERCP after discharge following decision after discharge. Two cholecystec-tomies and two ERCP were planned but not performed. A total of 21 recurrences were noted, seven of which after ERCP or cholecystec-tomy was performed. In these seven relapses despite treatment according to guidelines etiology was biliary (n = 4), alcohol (n = 2) and other (n = 1). Two relapses were seen after cholecystectomy and five after ERCP.

Conclusion: A standardised program for management of biliary pancreatitis reduces most likely the recurrence risk, but doesn’t elimi-nate it completely.

P17

Late Changes of Pancreatic Polyamine Levels Are Involved in the Pathogenesis of Lornithine-Induced PancreatitisG. Biczó1, P. Hegyi1, R. Sinervirta2, S. Berczi3, S. Dósa3, A. Siska4, B. Iványi3, V. Venglovecz5, T. Wittmann1, T. Takács1, L. Alhonen2, Z. Rakonczay Jr.1

1First Department of Medicine, University of Szeged, 2Department of Biotechnology and Molecular Medicine, A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio Campus, Kuopio, Finland, 3Department of Pathology, University of Szeged, 4Department of Clinical Chemistry, University of Szeged, 5Department of Pharmacology and Pharmacotherapy, University of Szeged

Introduction: L-ornithine is a precursor of polyamine synthesis that is essential for cell survival. Paradoxically, intraperitoneal (i.p.) administration of L-ornithine results in severe acute necrotizing pan-creatitis in rats.

Objectives: Our aims were to investigate the changes in pancre-atic and extrapancreatic (lung and liver) polyamine homeostasis after injection of a large dose of L-ornithine and to test the effects of the stable polyamine analogue methylspermidine (MeSpd) on L-ornithine-induced acute necrotizing pancreatitis.

Materials and Methods: Male Wistar rats were injected intra-peritoneally (i.p.) with 3 g/kg L-ornithine and/or physiological saline and were untreated, pretreated or treated with 50 mg/kg MeSpd i.p. Rats were sacrificed after 0-168 h for determinations of pancreatic and extrapancreatic concentrations of spermidine, spermine, and putrescine, and activities of ornithine decarboxylase and spermidine/spermine N1-acetyltransferase (SSAT). The severity of pancreatitis was assessed by measuring standard laboratory and histological parameters.

Results: Intraperitoneal administration of 3 g/kg L-ornithine par-adoxically induced marked pancreatic spermidine catabolism, possi-bly via activation of SSAT, after appearance of first histological signs of acute pancreatitis. In contrast, polyamine levels were generally increased in the lung and liver with the exception of lung spermidine levels which decreased. Pretreatment or treatment with MeSpd did not influence the levels of natural polyamines and SSAT activity and did not alter the severity of L-ornithine-induced acute pancreatitis.

Conclusion: L-ornithine-induced acute pancreatitis was associ-ated with activation of pancreatic polyamine catabolism. Admin-istration of MeSpd did not affect disease severity.

Supported by OTKA, NKTH, MTA and Academy of Finland.


P18

Experimental Acute Pancreatitis Induced by Inhibition of NO-SynthasesO. Krylova1, A. Rudenko1, J. Gajdar1

1State Institution “Institute of Gastroenterology of Academy of Medical Sciences of Ukraine”

Introduction: The role NO in norm and at a pancreas pathology remains insufficiently studied.

Objectives: Our aim was to study the influence of inhibition NO-synthases on pancreas.

Materials and Methods: Male 20 rats (Wistar), 20-22 week old, middle-weight (201.2±3.5) g were used. NO-synthases were inhibited by Ng-nitro-L-arginin (Fluka) - 40 mg/kg, once a day, dur-ing 12 days. All rats were sacrificed, and pancreas was histologically examined. Tissue sections were fixed in 10% formalin and stained with hematoxylin-eosin and with reactant PAS.

Results: Histological examination of pancreas showed: the edema of acinus tissue of lobules around the periducts stroma, the stasis of blood in capillaries, the infiltration of acinus by inflamma-tory cells. The swelling and clarification of cytoplasm’s of acinuses, condensation of chromatin in nucleuses of acinuses were observed. The inflammation and dystrophy were found in epithelium of large ducts also. Macrophages were mainly distributed along the interlobu-lar/intralobular septa and acinar cells within necrotic regions. Preservation of islets was observed in that time. These data testified to development of an acute pancreatitis in rats at inhibition of NO-synthases.

Conclusion: The inhibition of NO-synthases leads to deficiency NO in pancreas, that conducts to infringement of mechanisms of reg-ulation, is accompanied by microcirculation changes, development of inflammation, dystrophy, apoptosis in pancreas.

P19

Changes of Intestinal Mucosal Microbiota During Acute Destructive Pancreatitis in RatsO. Rotar1, I. Sydorchuck1, D. Rotar1, V. Polevoj1

1Bukovinian State Medical University, Chernivtsi, Ukraine

Introduction: Gut is recognized as main source of bacterial translocation during acute destructive pancreatitis (ADP). Besides other factors changes of mucosal microbiota directly influence on rate of microorganisms spreading from intestine and may serve as prog-nostic factor of severity pancreatic infection.

Objectives: To investigate the changes of mucosal microbiota of gut during ADP.

Patients and Methods: In 70 Wistar rats ADP was induced by intraperitoneal injection of 250 mg/100 g of 20% L-arginine solution twice during 1 hour. Concentration of microorganism on mucosal sur-face of colon and distal ileum were investigated during 24-120 hours by bacteriological methods.

Results: In colon amount of autochtonous physiologically use-ful microflora decreased during all period of ADP: after 72 hours E.

feacalis eliminated, after 120 hours Bifidobacteria spp. disappeared and Lactobacteria spp. were found only in 2 from 7 animals. In such condition concentration of autochtonous facultative and allochtho-nous microorganisms Staphylococcus spp., Clostridia spp., Enterobacteria spp. and Candida spp. reached 3,5-4,5 log CFU/g. In distal ileum concentration of Lactobacteria spp., Bifidobacteria spp., E. feacalis felt from 6,51-6,81 log CFU/g till 3,57-4,8 log CFU/g after 24 hours, and they absolutely disappeared after 48 hours until 7 day. Due to profound deficit of physiologically useful microflora amount of Peptococcus spp., Staphylococcus spp., Clostridia spp. and espe-cially Enterobacteria spp. (Klebsiela, Edvardsiela, Proteus, toxic strains of E. coli.) reached higher level than in colon.

Conclusion: During ADP changes of distal ileal mucosal micro-biota were more significant than in colon. Thus bacterial transloca-tion from distal ileum may occur in a higher level than from the colon.

P20

Role of IAPP in Acute PancreatitisY.M. Lu1, R. Segersvärd1, U. Arnelo1, J.M. Löhr1, R. Heuchel1

1Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institutet & Karolinska Universitetssjukhuset Huddinge, Stockholm, Sverige

Introduction: Acute pancreatitis (aP) is associated with signifi-cant morbidity and a mortality rate of approximately 7-50%. High plasma IAPP levels have been proposed to be a prognostic factor pre-dicting complications whenever pancreatitis is secondary to alcohol or gallstones. IAPP has also been found in experimental studies to elicit effects that also are characteristics of aP, including hyperglyce-mia, insulin resistance, acute hypocalcaemia, and to increase acinar amylase secretion.

Objectives: The use of transgenic or knockout mice together with classic models of secretagogue-induced pancreatitis has pro-vided considerable insight into the role of individual cellular or humor factors in different stages of experimental pancreatitis. We therefore used IAPP knock-out mice (Gebre-Mehdin, BBRC, 1998) to further clarify the role of IAPP in aP.

Materials and Methods: aP was induced by 9-hourly i.p-injec-tions of 50mg/kg cerulein (or NaCl) in sex- and age-matched IAPP knock-outmice and corresponding wt controls. Sampling (blood, tis-sue) was 1-hour after last injection. This experiment was performed twice. Pancreatic tissue and serum was analyzed for pancreatic injury, inflammation (Myeloperoxidase MPO) activity, TNF, IL6, IL-10, MCP-1, Cxcl-1). Gene profiling of more than 35000 genes has been tested in Affimetrix array.

Results: aP was successfully induced by cerulein i.p.-injection in mice. Unexpectedly, there were no statistic differences between the IAPP knock-out and wild type mice withrespect to acinar injury, amy-lase, pancreatic tissue MPO, TNF, IL-6, IL-10, MCP1 and CxCl-1 levels. Affimetrix expression profiling supported these initial results. However, a number of novel genes specifically related to aP were uncovered.

Conclusion: The lack of IAPP does not change the early phase of cerulein-induced acute pancreatitis in mice.


Basic Science – Chronic Pancreatitis

P21

Tolerance of Gastroduodenal Zone, Organs on Acute and Chronic Pancreatitis in RatsI. Trubicina1, L. Vinokurova1, B. Chicunova1, L. Lazebnik1


Introduction: Autoimmune component connected with loss of ability to tolerate ‘self-antigens’ is in patients with chronic pancreati-tis (CP).

Objectives: Determination of disturbance of organs gastroduo-denal zone tolerance on reproduction of acute and chronic pancreati-tis in rats.

Materials and Methods: White rats were divided into fiveex-perimental and one-control groups. Experimental groups: the 1st -immunization by means of three-fold intraperitoneal introduction of pancreatictissue (PT) homogenate 3 days apart; the 2nd and the 3d -tissue damage with acetic acid; the 4th and the 5th -introduction of duodenum secretion into PT. Content of INFy, antibodies toparietal and acinar cells were determined in blood serum and PT extracts bymeans of immune-enzyme method.

Results: After preliminary immunizationantibodies to parietal 195.43±21 and acinar cells 67.5±6.8 were revealed inanimals’ blood serum; in control group they are absent. Content of INFy 145.6±7.8pg\ml is increased in blood and PT extracts; control 50.6±5.1; 186.7±8.3pg\ml of the tissue; control 30.2±2.5 pg\ml of tissue (p < 0.05). In the 2ndand the 3d groups (acute pancreatitis) antibodies to parietal andacinar cells are absent; INFy is increased both in blood and tissue. The 4th and the 5th groups - chronic pancreatitis. Antibodies toparietal and acinar cells are identified; level of antibod-ies content dependson depth of PT damage. Increased INFy content is kept in blood.

Conclusion: Autoimmune response has organ specificity, involves other organs injoint reaction - gastric mucous which has low immune tolerance.

P22

Experimental Research on the Therapeutic Effect of Cordyceps Mycelia Extracts on Chronic Pancreatitis in RatsN. Cui1, S. Zhang1, Y. Zhuo1

1Tianjin Institute of Acute Abdominal Disease, 2Tianjin Nankai University Hospital, Tianjing University, Tianjing, PR China

Introduction: Cordyceps Mycelia is one of Chinese traditional herbs and can enhance immunity of organism.

Objectives: To investigate the therapeutic effect of Cordyceps mycelia extracts (CME) on rats with chronic pancreatitis induced by dibutyltin dichloride.

Materials and Methods: 30 healthy male Wistar rats were ran-domly divided into 3 groups: model group were injected dibutyltin dichloride (DBTC) into the right jugular vein with a syringe at a dose of 7 mg/kg body weight, control group were treated only with sol-venttreatment group were administered CME once daily at a dose 0.2 g/(kg.d). After 28-day feeding, the n-benzoyl-tyrosyl para-aminoben-zoic acid (NBT-PABA) test was carried out to evaluate pancreatic exocrine function, Pancreatic tissues were harvested for hematoxylin and eosin staining and pathological evaluation, and the mRNA expres-sion of TGF-1 was detected by using immunohistochemistry and real-time PCR respectively.

Results: Compared with model group, the PABA recovery in 6-h urine, the pathologic scores of pancrease tissue and the expres-sion of TGF-1were all decreased in treatment group (P < 0.05).

Conclusion: CME can protects the pancreas against chronic injury and improve pancreatic exocrine function in DBTC induced rat chronic pancreatitis model, with probable mechanism of the inhibi-tion of overexpression of TGF-1.

Basic Science – Pancreatic Cancer

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P24

Subdiaphragmatic Vagotomy Promote Tumor Growth and Migration in Pancreatic CancerL.I. Partecke1, W. Keßler1, D. Nguyen Trung1, M. Sendler2, E. Lorenz1, C. Heidecke1, F.U. Weiss2, M.M. Lerch2, W. von Bernstorff1

1Universitätsklinikum Greifswald, Klinik für Chirurgie, Greifswald, Germany, 2Universitätsklinikum Greifswald, Klinik für Innere Medizin A, Greifswald, Germany

Introduction: Pancreatic cancer continues to have a very poor prognosis including residual disease and early recurrences in many cases. In the majority of resections a pancreaticoduodenectomy includes the transection of the vagus nerve. Thereby, the anti-inflam-matory actions of the vagus nerve on tumour-promoting tumour-asso-ciated macrophages (TAM) may get lost.

Objectives: To investigate the impact of vagotomies on pancre-atic cancer.

Materials and Methods: In an established orthotopic murine syngeneic pancreatic cancer model using 6606 PDA cells in C57BL/6 mice subdiaphragmatic vagotomies versus sham surgery were per-formed. The impact on tumour growth was monitored using small


animal MRI. TAMs as well as the levels of TNF-alpha wereanalyzed using immunohistochemistry. The role of TNF-alpha on tumour growth wasexamined in vitro by cell titer blueand BrdU assays. Migration of tumour cells was monitored using a scratch assay.

Results: Subdiaphragmatic vagotomies lead to significantly increased tumour growth and number of lymphnode metastases (p < 0.05). The loss of anti-inflammatory actions of the vagus nerve on macrophages increased levels of TNF-alpha in the tumour. Macrophages stimulated with tumour cells in vitro secreted increased levels of TNF-alpha. These, in turn, had a significant impact on tumour cells: 6606 PDA cells reacted with significantly increased in vitro tumour growth (p < 0.05) and migration (p < 0.05).

Conclusion: Vagotomies lead to increased tumour growth and migration in a murine pancreatic cancer model. This effect may be mediated by an increases secretion of TNF-alpha of TAMs. Hence, the suppression of TAMs could offer new perspectives in immuno-therapies of pancreatic cancer patients.

P25

Vacuole-Membrane-Protein-1 (VMP1) Mediated-autophagy Correlates with Loss of p21 Expression in Human Pancreatic CancerA. Ropolo1, A. Lozano-Leon2, V. Boggio1, J.E. Dominguez-Muñoz2, M.I. Vaccaro1

1University of Buenos Aires, Buenos Aires, Argentina, 2University Hospital Santiago de Compostela, Spain

Introduction: VMP1 is a pancreatitis-induced protein whose expression triggers autophagy. We previously showed that VMP1-autophagy pathway promotes apoptosis in pancreatic cancer cells.

Objectives: Here, we evaluate the expression of VMP1 and its relationship with p21 and p53 in human pancreatic ductal-adenocar-cinoma. We also investigated LC3 expression as a marker of autophagy.

Materials and Methods: Tissue microarrays were performed from tumor stage advanced; 50-pancreatic cancer and 7-control sam-ples were included.

Results: Immunohistochemistry revealed VMP1 expression in glandular cells in 10 (20%) of the tumor samples but none in controls. The same expression pattern was observed for LC3, suggesting VMP1-mediated autophagy. Tumor samples also showed loss expres-sion of p21, which correlated with VMP1 (p < 0.001) and p53 (p < 0.03) were observed. Interestingly, patient’s survival was higher in VMP1-expressing pancreatic cancer samples. In order to analyze the pathological role of the VMP1 and p21 relationship in tumor cells, we used HCT116 and HCT116 p21-/- cells. VMP1 expression was higher in p21-/- cells that showed autophagy activation evidenced by the recruitment of LC3. Flow cytometry of annexin V revealed sig-nificant reduction of apoptotic levels in HCT116 p21-/- cells after starvation-induced autophagy. Contrary, overexpression of VMP1 in HCT116 cells showed significant increase of apoptosis after autophagy induction.

Conclusion: Our results demonstrate that p21 expression allows apoptosis in tumor cells undergoing VMP1-mediated autophagy and the loss of p21 reduces apoptosis and favors autophagy, disassem-

bling VMP1-mediated autophagy from apoptosis. We propose that VMP1 and p21 expression are involved in the crosstalk between autophagy and apoptosis in human pancreatic cancer.

P26

High Glucose Stimulates HIF-1alpha Expression in Human Pancreatic Cancer Cells and Increases Cell MalignancyX. Jia1, Z. Liu2, J. Larsson1, K. Sundqvist2, J. Permert1, F. Wang1

1Department of Surgical Gastroenterology, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Sweden, 2Department of Clinical Immunology, Karolinska University Hospital, Huddinge, Sweden

Introduction: Cancer cells are found to express the transcrip-tion factor of hypoxia-inducible factor-1alpha (HIF-1a) as a result of intra-tumoral hypoxia and gene mutation. Benign cells are found to express HIF-1a in diabetes.

Objectives: We undertook this study to investigate whether excess glucose stimulates HIF-1a expression in pancreatic cancer cells.

Materials and Methods: We cultured MiaPaCa2, Panc-1, Bx-PC3, and HPAF-II human pancreatic cancer cells in hypoxic con-ditions and determined their HIF-1a expression using Western blots. Then, we characterized the cell biology of glucose-stimulated hypoxic MiaPaCa2 cells, using normoxic MiaPaCa2 cells and hypoxic MiaPaCa2 cells with HIF-1a siRNA as two HIF-1a-negative controls. In the different MiaPaCa2 cells, we examined phosphoinositide-3 kinase (PI-3K), the glycolytic enzyme hexokinase, the inhibitor of glucose oxidation pyruvate dehydrogenase kinase-1 (PDK1), and the products of glucose oxidation reactive oxygen species (ROS). We also assessed cell migration using a Boyden chamber.

Results: When MiaPaCa2, Panc-1, Bx-PC3, and HPAF-II cells were cultured in hypoxic conditions, their HIF-1a expression was all stimulated by excess glucose (11.1 mM or more). In hypoxic MiaPaCa2 cells, excess glucose increased PI-3K, hexokinase and PDK1 and decreased ROS. These data suggest that the glucose-induced HIF-1a expression in pancreatic cancer cells is mediated by PI3K and is associated with a switch in glucose metabolism from oxi-dation to glycolysis. Excess glucose also induced greater migration in HIF-1a-positive MiaPaCa2 cells than in HIF-1a-negative cells.

Conclusion: High glucose stimulates HIF-1a expression in human pancreatic cancer cells and increases cell malignancy.


P27

Trail Signaling Is Mediated by DR4 in Pancreatic Tumor Cells Despite the Expression of Functional DR5A. Trauzold1, J. Lemke1, H. Wajant2, S. Schütze3, H. Kalthoff1

1Division of Molecular Oncology, Kiel, 2Division of Molecular Internal Medicine, Würzburg, 3Institute of Immunology, Kiel

Introduction: TRAIL and agonistic receptor-specific antibodies are currently under clinical investigation for treatment of different malignancies. TRAIL activates DR4 and DR5 and triggers apoptotic and non-apoptotic signaling pathways.

Objectives: The objectives of our study were to find out which TRAIL receptor mediates TRAILinduced effects in pancreatic ductal adenocarcinoma cells as well as to compare side by side the response of these cells to TRAIL and agonistic antibodies against DR4 (mapa-tumumab) and against DR5 (lexatumumab).

Materials and Methods: Cell death and secretion of IL-8 were determined by cristal violett staining and ELISA, respectively. The cell surface expression of death receptors was measured by FACS analysis and NF-kappaB activity by EMSA. DISC composition was analyzed by immunoprecipitation.

Results: We show that TRAIL, mapatumumab and lexatu-mumab, all are able to activate cell death and proinflammatory sig-naling. DISC analysis revealed that mapatumumab and lexatumumab induce formation of homocomplexes of either DR4 or DR5, whereas TRAIL additionally stimulated the formation of heterocomplexes of both receptors. Notably, blocking of receptors using DR4- and DR5-specific Fab fragments indicated that TRAIL exerted its function pre-dominantly via DR4. Interestingly, inhibition of PKC by Goe6983 enabled DR5 to trigger apoptotic signaling in response to TRAIL and also strongly enhanced lexatumumab-mediated cell death.

Conclusion: We unraveled signaling differences between the natural ligand TRAIL and agonistic anti-DR4 and DR5 antibodies. We show that DR5 is silenced for TRAIL- but not for agonisticanti-body treatment. Interestingly, DR5 can be re-activated for TRAIL-mediated death signaling by the inhibition of PKC offering a novel chance for clinical translation.

P28

EGF Signaling: A Novel Regulator of GLI1 Oncogenic Activity in Pancreatic CancerA. Comba1, A. Artal1, L.J. Pena-Sanchez1, D. Billadeau1, M.E. Fernandez-Zapico1

1Schulze Center for Novel Therapeutics, Mayo Clinic, Rochester, MN, USA

Introduction: Understanding signal transduction from a net-work perspective allows an appreciation of different signaling inputs within the network that can lead to different cellular phenotypes, including neoplastic transformation. Mutations in different elements of the Hedgehog (HH) and EGF pathways, as well as their abnormal

activation, are implicated in the development of pancreatic cancer. Interestingly, evidence from genetic models predicts the existence of key regulatory steps needed by HH and EGF signaling to modulate pancreatic tumorigenesis.

Objectives: Determine the molecular mechanisms mediating the HH-EGF pathway interaction in pancreatic cancer.

Materials and Methods: We used reporter, growth, expres-sion, immunoprecipitation and ChIP assays in combination with geneticand pharmacological manipulations of the HH and EGF path-ways to dissect the interaction between these two oncogenic cascades in pancreatic cancer.

Results: Here, we demonstrated the ability of EGF pathway to functional interact with component of the HH cascade in pancreatic cancer cells. EGF activates GLI1, essential effector of the HH onco-genic function, even in the absence of an active HH signaling. Further analysis of this molecular interaction suggested that EGF-mediated activation of GLI transcription factors requires an intact activity of the SRC-VAV1 axis. Moreover, EGF promoted through this axis GLI1 chromatin binding and transcription of its cell growth-related target genes. Finally, we demonstrated that an active EGF-SRC-VAV1 axis is required to GLI1-mediated regulation of pancreatic cancer cell growth.

Conclusion: Taken together, these results provide a novel insight into the complex network involved in pancreatic carcinogen-esis and present new avenues for the development of therapeutics regimens for this dismal disease.

P29

Collagen-I Increases the Expression of Transgelin and Lumican (Regulators of Cell Migration) by Activated Pancreatic Stellate CellsP. Phillips*2, L. Yang*2, A. Vonlaufen2, W. Kaplan1, M. Cowley1, R. Pirola2, J. Wilson2, M. Apte2

1Bioinformatic Centre Garvan Institue for Medical Research, Sydney, Australia, 2Pancreatic Research Group, University of New South Wales, Sydney, Australia *Authors contributed equally to the study

Introduction: Activated pancreatic stellate cells (PSCs) play a central role in pancreatic fibrosis, a feature of chronic pancreatitis and pancreatic cancer. The fibrous matrix produced by PSCs can, in turn, regulate PSC function. Using microarrays, we have previously dem-onstrated that 146 genes were dysregulated (fold change>2, p < 0.001, q < 0.25, n = 3) in PSCs cultured on collagen-I (mimics fibrotic pan-creas) versus MatrigelTM (mimics normal pancreatic basement mem-brane). Interestingly, genes for transgelin and lumican (which code for proteins known to regulate cell migration) were upregulated in PSCs cultured on collagen-I compared to MatrigelTM.

Objectives: To assess transgelin and lumican mRNA and pro-tein expression in: i) PSCs cultured on matrigel versus collagen-I; ii) quiescent PSCs vs PSCs cultured on plastic.

Materials and Methods: Transgelin and lumican expression was assessed by real-time PCR and western blotting in quiescent rat PSCs (24 hours after isolation or grown on MatrigelTM and activated PSCs (cultured on collagen-I for 72h or on plastic; n = 5 preparations).


Results: Transgelin and lumican mRNA levels were upregulated by i) 45.5 and 24.7 fold (*p < 0.05) respectively in PSCs cultured on collagen-I vs MatrigelTM and ii) 20 and 4.2 fold (*p < 0.05) respec-tively in plastic-activated PSCs vs quiescent cells. Transgelin protein expression was also increased (% of control [mean±SE]: 295.7±28.92,*p < 0.05) in activated PSCs compared to quiescent PSCs.

Conclusion: Transgelin and lumican are significantly increased in PSCs cultured on fibrous ECM and associated with PSC activa-tion.

Implication: Characterisation of genes that may play a role in PSC transformation may allow the identification of specific therapeu-tic targets for the treatment of fibrosis.

P30

Beta-tubulin Mediates Sensitivity to Chemotherapeutic Drugs in Pancreatic Cancer CellsJ. Liu*1, J. McCarroll*2, M. Apte1, J. Youkhana1, M. Kavallaris2, P. Phillips1

1Pancreatic Research Group, University of New South Wales, Sydney, Australia, 2Pharmacoproteomics Program, Children’s Cancer Institute Australia for Medical Research, Sydney, Australia, *Authors contributed equally

Introduction: Pancreatic cancer (PC) has a poor prognosis, most commonly due to resistance to chemotherapeutics. Beta-tubulin isoforms (II, III and IVb) have been implicated in chemoresistance in other cancers. Recently, we demonstrated that silencing beta III-tubulin sensitizes lung cancer cells to both tubulin binding agents (TBAs) and DNA damaging agents (Cancer Res, 2007). Beta III-tubulin is highly expressed in pancreatic ductal adenocarcinoma sam-ples and in PC cell lines. However, the role of beta-tubulins in the known resistance of PC cells to chemotherapy drugs is unknown.

Objectives: To determine the effect of silencing beta II, beta III or beta IVb tubulin (using siRNA methodology), in PC cells on drug sensitivity.

Materials and Methods: MiaPaCa-2 cells ±beta-tubulin spe-cific siRNA were treated with gemcitabine, taxol or vincristine (n = 3). Seven days later colonies from clonogenic assays were counted (sur-viving fraction).

Results: Silencing beta III-tubulin significantly sensitized MiaPaCa-2 cells to the anti-metabolite gemcitabine (at doses of 1.25-10nM; p < 0.05) and to the TBAs, taxol (1.25-5nM; p < 0.05) and vin-cristine (0.25-1nM; p < 0.05). Silencing beta IVb-tubulin significantly sensitized the cells to vincristine (0.625-1.25nM; p < 0.05) and gem-citabine (0.625-1.25nM; p < 0.05). Silencing beta IItubulin had no effect on drug sensitivity of MiaPaCa-2.

Conclusion: This is the first study to show that suppression of beta III and beta IVb-tubulin increases drug sensitivity in PC cells. These novel data support the concept that each of the tublin isotypes has a unique function in regulating drug sensitivity in PC. Targeting beta III or beta IVb tubulin may improve chemotherapy response in PC.

P31

High Expression of S100A2 Calcium-Binding Protein Defines a Metastatic Phenotype in Pancreatic CancerC. Scarlett1, D. Chang1, E. Colvin1, A. Mawson1, M. Pajic1, A. Biankin1

1Cancer Research Program, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia

Introduction: High expression of S100A2 calcium binding pro-tein (S100A2) is associated with a poor response to pancreatectomy for pancreatic cancer. These data suggest that S100A2 may play a key role, in the development of a metastatic phenotype (PC)[1].

Objectives: This study aims to define the functional role of S100A2 in PC metastases in vitro and in animal models of PC.

Materials and Methods: The effects of altered S100A2 expres-sion on proliferation and motility was assessed in 17 PC cell lines. Tumour growth and metastases were assessed in subcutaneous xeno-grafts generated from S100A2 overexpressing MiaPaCa-2 cells in NOD/SCIDgc null(NOG) mice.

Results: Gain of function studies inboth MiaPaca-2 and Panc 10.05 cells revealed no difference in proliferation for S100A2 over-expressing PC cells compared to empty vector controls for both MTS and anchorage dependant colony forming assays. Wound healing assays assessing motility revealed that S100A2 overexpressing Panc 10.05 cells demonstrated increased wound closure compared to con-trols. Xenografts stably overexpressing S100A2, developed extensive liver metastases.

Conclusion: These data suggest that high S100A2 expression defines a specific pancreatic cancer phenotype and plays a key role in metastasis. S100A2 is a potentially important molecular target for the development of novel therapeutic strategies for PC.

1. Biankin, A.V., et al., Expression of S100A2 calcium-binding protein pre-dicts response to pancreatectomy for pancreatic cancer. Gastroenterology, 2009. 137(2): p. 558-68, 568 e1-11.

P32

Haplotypes in Melanoma Inhibitory Activity 2 Correlate with Survival and Chemoresistance in Pancreatic CancerB. Kong1, C.W. Michalski1, N. Valkovska1, S. Rieder1, X. Hong1, S. Streit1, H. Friess1, J. Kleeff1

1Department of Surgery, Technische Universität München, Munich, Germany

Introduction: Response rates of pancreatic ductal adenocarci-nomas (PDAC) to chemotherapy are low and potenitally affected by gentic factors.

Objectives: To define the influence of MIA2 haplotype on the chemotherapy response of PDAC patients.

Materials and Methods: Expression of melanoma inhibitory activity 2 (MIA2) was examined in pancreatic tissues and pancreatic cancer cell lines. MIA2 polymorphisms were defined by conventional


PCR sequencing and high-resolution melting curve analysis. To assess the functional relevance of MIA2, loss-of-function and gain-of-function studies were performed in pancreatic cancer cell lines.

Results: MIA2 staining in cancer cells was found in 71% (43 out of 61) of the PDAC tissues. Though MIA2 expression was found in ASPC-1, Capan-1 and Colo-357, MIA2 was secreted only by ASPC-1 and Capan-1. Sequencing results revealed a homozygous Met141/His547 allele in Colo-357 whereas a homozygous Ile141/Asp547 allele in ASPC-1 and Capan-1 cells. Moreover, PDAC patients (75/223) heterozygous or homozygous for Met141/His547 survived significantly shorter than patients homozygous for Ile141/Asp547(15 vs. 21 mths). Functionally, silence of Ile141/Asp547 MIA2 in Capan-1 and ASPC-1 conferred resistance to gemcitabine treatment, while silencing of Met141/His547 in Colo-357 had no such effect. Correspondingly, overexpression of MIA2 Ile141/Asp547 in Su86.86 cells increased sensitivity to gemcitabine which was specifi-cally rescued by MIA2 RNAi. However, overexpression of MIA2 Met141/Asp547, Ile141/His547 or Met141/His547 variants had no such effect. Furthermore, the different MIA2 polymorphisms were associated with specific activation patterns of AKT and ERK signal-ling pathways following gemcitabine treatment.

Conclusion: Haplotypes in MIA2 are associated with survival and chemoresistance in pancreatic cancer.

P33

Forced Hemidesmosome Assembly Blocks Pancreatic Cancer Cell InvasivenessS. Laval1, H. Laklai1, M. Fanjul1, M. Pucelle1, C. Susini1, S. Pyronnet1, C. Bousquet1

1INSERM U858, Toulouse, France

Introduction: Given the failure of conventional chemo- and bio-therapies, a major challenge in pancreatic cancer research is to identify critical events that initiate invasion.

Objectives: To investigate whether one priming step of pancre-atic carcinogenesis requires epithelial cell detachment from the base-ment membrane and disruption of hemidesmosome anchoring-structures, as described in carcinoma of stratified epithelia.

Materials and Methods: Human normal and cancer pancreatic tissues and cell lines were used in this study.

Results: We describe for the first time the presence of mature type-1 hemidesmosome-like structures, comprising the integrin alpha6beta4 and BP180, in human normal pancreatic ducts, a simple epithelium of digestive origin. Importantly, hemidesmosomes are here shown to disassemble during pancreatic carcinogenesis, an event triggering pancreatic cancer cell migration and invasion. Underlying mechanisms involve the cleavage of BP180, which is PI3Kand MMP-9-dependent, associated with the tyrosine-phosphorylation and delo-calisation of the integrin alpha6beta4 to the leading edges of migrating cells where it paradoxically promotes proinvasive signals through S100A4. Our precedent data demonstrated the oncosuppressive role of the somatostatin receptor sst2 when reexpressed in pancreatic can-cer cells, which lose sst2 expression during the process of carcino-genesis. Importantly, we here provide molecular evidences demonstrating that, by inactivating the PI3K-MMP-9 pathway, sst2 blocks BP180 cleavage, reassembles hemidesmosomes and inhibits

pancreatic cancer cell invasion. Conversely, abrogating sst2-depen-dent inactivation of this pathway rescues pancreatic cancer cell inva-sive behavior through hemidesmosome breakdown.

Conclusion: Sst2-expressing cells served here as unprecedented tools to identify molecular mechanisms required for restoring hemi-desmosome assembly in pancreatic cancer cells, and which could be targeted for early anti-invasive therapeutic strategies.

P34

Live Cell Capturing (LCC) and Pancreatic Cancer Cell Cultures: A New Methodological ApproachN. Funel1, M. Del Chiaro1, L.E. Pollina2, M. Baron3, U. Boggi1, C. Horlemann3, F. Mosca1, D. Campani4

1Division of General Surgery and Transplantation, University of Pisa and Pisa University Hospital, Italy, 2Department of Medicine Laboratory and Molecular Diagnoses, Hospital-University of Pisa, Italy, 3Leica Microsystems SPA, 4Departement of Surgery, University of Pisa, Italy

Introduction: Setting up of primary cultures from pancreatic adenocarcinoma is a delicate and complex procedure with very low chances of succeeding. One of the major issues is represented by the difficulty to separate epithelial cells from fibroblasts, which are very abundant due to the marked desmoplastic reaction associated to pan-creatic adenocarcinoma.

Objectives: of the present study was to expand the epithelial cell population by using laser microdissection on primary cultures derived from pancreatic adenocarcinoma.

Materials and Methods: Ninety samples from primary pan-creatic adenocarcinoma were selected to set up primary cultures. Cells were grown in RPMI 1640 medium at 37°C in 5% CO2 humid-ified atmosphere. Eight primary cultures were obtained. Primary cell cultures (PP244 and PP391) were sown a new support of poly-ethyl-ene tereftalate (IBIDI system, specifically designed for the laser microdissection instrument Leica LMD6000). Few cells, where microdessected from both cultures and directly transferred into the under IBIDI support by Live Cell Capturing (LCC).

Results: Microdissected primary cells from PP244 and PP391 cultures grow to form a single layer in the IBIDI support.

Conclusion: Cell growth and migration on the new IBIDI mem-branes, were comparable to those obtained using standard supports. Furthermore, LCC allowed successful isolation and expansion of cell cultures. This new method could offer several advantages: 1) reduced primary culture time setting, by isolating a target cell type from the original mixed cell population; 2) isolation of different cell popula-tions within a single primary culture; 3) the study of molecular inter-actions between tumor and stromal cells into a model very close to in vivo conditions.


P35

Knocking Down of the MUC4 Membrane-bound Mucin and Its Membrane Partner ErbB2 in Human Pancreatic Cancer Cells Alter their In Vitro and In Vivo Tumor PropertiesN. Jonckheere1, N. Skrypek1, N. Saint-Laurent2, P. Dumont3, C. Susini2, I. Van Seuningen1

1Inserm U837, JPARC, Team 5 “Mucins, epithelial differen-tiation and carcinogenesis”, Lille, France, 2Inserm U858, Institut de Médecine Moléculaire de Rangueil, Toulouse, France, 3UMR8161, Institut de Biologie de Lille, Lille, France

Introduction: Pancreas cancer is one of the most deadly cancers in the world with a very low (5%) survival rate at 5 years. The mucin MUC4 is not expressed in normal pancreas whereas it is neo-expressed in early preneoplastic stages PanIN1A and increases con-stantly till adenocarcinoma. As an ErbB2 ligand and target of TGF-beta pathway, MUC4 appears a potent therapeutic target.

Objectives: To define the role of MUC4-ErbB2 complex in pancreatic carcinogenesis

Materials and Methods: The human pancreatic cancer cell line CAPAN-2 was used to establish stable MUC4 and/or ErbB2 knocked-down (KD) cellular clones. Proliferation was studied by cell counting and flux cytometry. Migration and invasion were studied using Boyden chambers. CAPAN-2 KD properties were character-ized in vivo by subcutaneous xenograts in nude mice. Gene expres-sion was studied by RT-PCR and microarrays and protein expression by westernblotting.

Results: CAPAN-2 MUC4-KD, ErbB2-KD and double KD (DKD) clones have a proliferation defect correlated to a decrease in cyclin D1 alone (MUC4-KD) or combined to increase of cell cycle inhibitor p27kip1 (ErbB2-KD). MUC4-KD migration was reduced whereas invasive properties were increased. ErbB2-KD cells are less invasive. ERK1/2 and FAK phosphorylation were enhanced in MUC4-KD whereas JNK was reduced. In ErbB2-KD and DKD cells, phospho-JNK was unchanged whereas phospho-ERK1/2 was decreased. Sub-cutaneous xenografts of MUC4-KD and ErbB2-KD cells lead to a reduction of tumor formation.

Conclusion: These results show that MUC4 and ErbB2 play major roles in biological properties of CAPAN-2 pancreatic cancer cells suggesting an important function for this mucin in tumor pro-gression and confirm its potential as a therapeutic target.

P36

Mutations in the Mitochondrial Genome of Pancreatic Cancer Effect Resistance Against Anti Cancer DrugsS. Mizutani1, A. Hoshino1, K. Maejima1, O. Komine1, M. Yoshino1, M. Ogata1, M. Watanabe1, T. Aimoto2, H. Suzuki1, E. Uchida2

1Institute of Gastroenterology, Nipppon Medical School Musashikosugi Hospital, 2Department of Surgery, Nippon Medical School

Introduction: It has been established that the majority of cancer cells harbor homoplasmic somatic mutations in the mitochondrial genome(mtDNA).

Objectives: We show that somatic mutations in mtDNA are involved in anticancer drug-tolerance.

Materials and Methods: We used trans-mitochondrial hybrid cells (cybrids) to reveal the role of mutations in mtDNA in the pan-creatic cancer by excluding any effects of the nuclear background. Cybrids were constructed by repopulating HeLa devoid of mtDNA with mtDNA derived from enucleated the pancreatic cancer cells(CFPAC-1, CAPAN-2)harboring mtDNA mutations. We con-structed several cybrids with mutations derived from the cancer cells as well as those with wild mtDNA derived healthy individuals. We compared the mutant and wild cybrids in resistance against staurosporine(STS), 5FU, CDDP in vitro.

Results: The experiment revealed mutant cybrids were more resistant against the drugs than wild cybrids except hyperthermia. Next, Sub-G1 populations were examined to estimate nuclear DNA fragmentation during apoptosis. STS treatment increased Sub-G1 populations more greatly in wild cybrids than in mutant cybrids. Notably, an inhibitor of cytchrome c oxidase prevented the increase in Sub-G1 population of wild cybrids with STS, suggesting respira-tory chain activity is involved in STS-induced apoptosis. Furthermore, we investigated cyt. c release from mitochondriaby immunostaining. Most cells of wild cybrid lost m and were stained with anti-cyt. c antibody, indicating cyt. c release to the cytosol. In contrast, mutant cybrids maintained mitochondrial membrane potential and co-local-ization of cyt. c. These results indicate that mtDNA mutations of the pancreatic cancer inhibit cyt. c-dependent apoptosis.

Conclusion: Our results demonstrate that mtDNA mutationscan confer chemoresistance on cancer cells.


P37

Aberrant MUC13 Expression in Pancreatic Cancer and Detection of MUC13 mRNA in PBMC of Patients with Pancreatic DiseasesJ. Ringel1, R. Jesnowski2, K. Wunder2, M.M. Lerch1, J.M. Löhr2,3

1Dept. of Internal Medicine A, University of Greifswald, Germany, 2Dept. of Medicine II, Mannheim Medical Faculty, Univ. of Heidelberg and CCU Molecular Gastroenterology, German Cancer Center Heidelberg, 3Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden

Introduction: Pancreatic tumor cells show an altered mucin pattern with an aberrant MUC4 expression, and they interact, espe-cially, with immune cells. Recently, involvement of MUC13 in ovar-ian cancer was shown. Here, we examined the expression of MUC13 in pancreatic cancer. Furthermore, we investigated whether MUC13 mRNA is expressed in peripheral blood mononuclear cells (PBMCs) und whether it can be used as a marker for pancreatic cancer.

Objectives: Expression of MUC13 in pancreatic tissues and PBMC samples

Patients and Methods: Expression of MUC13 mRNA and protein in pancreatic cancer cell lines, normal pancreas, chronic pan-creatitis and pancreatic cancer (DPAC) was investigates by using RT-PCR and immunohistochemistry. Furthermore, we analyzed the expression of MUC13 mRNA in PBMC samples from 127 patients: 38 with pancreatic cancer, 30 with acute and 30 with chronic pancrea-titis, and 29 healthy volunteers using RT-PCR. The presence of circu-lating pancreatic cancer cells was investigated by using a specific nested PCR for cytokeratin-20 (CK-20) and chymotrypsinogen.

Results: MUC13 mRNA was amplified in pancreatic cancer cell lines, normal pancreas, chronic pancreatitis and DPAC. In contrast, immunohistochemistry revealed an aberrant expression of MUC13 protein in pancreatic cancer. Furthermore, in all PBMC samples MUC13 mRNA was amplified whereas neither CK-20 nor chy-motrypsinogen was detected.

Conclusion: Our findings demonstrate an aberrant expression of MUC13 protein in pancreatic cancer. First time, our experiments suggest an expression of MUC13 in PBMCs. This detection is inde-pendent of an associated pancreatic disease. The data support our recent results about the expression of mucins in PBMCs.

P38

In Situ Proteomic Analysis of Preneoplastic Lesions in Targeted Mouse Models of Pancreatic Cancer Using Maldi Imaging Mass SpectrometryB. Grüner1, H. Hahne2, M. Trajkovic-Arsic1, P. Mazur1, I. Esposito3, S. Rauser4, R.M. Schmid1, B. Küster2, A. Walch4, J. Siveke1

1II. Med. Dep., Technical University of Munich, Germany, 2Dep. of Bioanalytics, Technical University of Munich, Germany, 3Institute of Pathology, Technical University of Munich, Germany, 4Institute of Pathology, Helmholtz Center Munich, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is a fatal disease due to the late detection of locally advanced or meta-static tumors requiring advanced screening tools for earlier detection of preinvasive stages. Genetically engineered mouse models for PDAC develop preneoplastic pancreatic lesions and invasive carci-noma resembling the human disease. These models allow analysis of defined precursor lesions for novel diagnostic approaches.

Objectives: Here we used matrix assisted laser desorption/ion-ization (MALDI) imaging mass spectrometry (IMS) to analyze the peptide/protein-expression pattern of precursor lesions in comparison to normal pancreas, chronic pancreatitis and PDAC to identify poten-tial early biomarkers for detection of pancreatic cancer.

Materials and Methods: A molecular ex vivo analysis of resected mouse pancreata was performed by MALDI-IMS with spa-tial resolution. Statistical analysis revealed several discriminative m/z species between normal tissue, pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasia (IPMN), PDAC and chronic pancreatitis. Candidate proteins were identified through MALDI-TOF tandem mass spectrometry analysis and further vali-dated.

Results: PanINs and IPMNs could be distinguished from nor-mal pancreatic tissue, chronic pancreatitis and PDAC by 27 signifi-cant m/z species. PanIN-specific peptides/proteins of several m/z species were identified and expression in preneoplastic tissue was validated by quantitative RT-PCR, immunofluorescence and immu-nohistochemistry.

Conclusion: MALDI-IMS allows for in situ analysis of small precursor lesions and identification of potential preneoplastic bio-markers. Murine endogenous PDAC is a highly suitable model sys-tem for MALDI-IMS and subsequent MALDI-TOF tandem mass spectrometry analysis.


P39

Pigment Epithelium-Derived Factor Increases Neuropathy and Fibrosis in Pancreatic CancerT. Samkharadze1, M. Erkan1, C. Reiser-Erkan1, I.E. Demir1, K. Bo1, N.A. Giese2, G.O. Ceyhan1, I. Esposito3, C.W. Michalski1, H. Friess1, J. Kleeff1

1Chirurgische Klinik und Poliklinik Klinikum rechts der Isar Technische Universität München, München, Germany, 2Department of General Surgery, University of Heidelberg, Heidelberg, Germany, 3Institute of Pathology, Technische Universität München, München, Germany

Introduction: Pigment Epithelium-Derived Factor (PEDF) is a 50-kDa glycoprotein and a nonihibitory-member of serine protease inhibitor gene family with neuroprotective/neuroprolifeative and anti-angiogenic functions.

Objectives: The objective of this study was the role of PEDF in pancreatic fibrosis and neuropathy.

Materials and Methods: The expression of PEDF was assessed by quantitative-RT-PCR and its correlations with neural- and microve-ssel-density in the normal pancreas (n = 20) and pancreatic cancer (n = 55), was made by immunohistochemistry and quantitative image-analysis. Primary human pancreatic stellate- (PSC), mouse neuro-blastoma- and human Schwann-cells were used for functional experiments. The effect of hypoxia on PEDF production in cancer cell lines and immortalized pancreatic ductal epithelial cells was assessed by quantitative-RT-PCR and ELISA. The effect of recombi-nant PEDF on PSC was assessed by immunoblot analysis.

Results: PEDF expression was homogenous in the epithelial cells of the normal pancreas where some acinar cells consistently have stronger staining. Higher expression was found in tubular com-plexes, PanIN-lesions and inflammatory cells in pancreatic cancer. Cancer cells expressed various amounts of PEDF. In cancer cell lines and in human immortalized pancreatic ductal epithelial cells, hypoxia paradoxically increased PEDF-mRNA up to 132-fold. Higher expres-sion of PEDF in cancer cells was significantly correlated with better patient survival (21.5 mo vs. 17.5mo, p = 0.043), increased neuropa-thy (p = 0.0251), increased PSC activity and extracellular matrix pro-tein production.

Conclusion: PEDF increases PSC acitivity thereby contributing to the desmoplasia of pancreatic cancer. PSC overactivity likely leads to periacinar fibrosis and degeneration of the fine acinar innervation. Increased focal PEDF expression in cancer cells correlate with neuro-pathic changes and better patient survival.

P40

NT-S100A8 Effects on Cell SignallingA. Padoan1, D. Bozzato1, S. Moz1, E. Fadi1, P. Fogar2, E. Greco1, F. Navaglia2, C. Zambon3, S. Pedrazzoli3, M. Plebani1, D. Basso2

1Department of Diagnostic Sciences and Special Therapies, University of Padua, 2Department of Laboratory Medicine, University of Padua, 3Department of Medical and Surgical Sciences, University of Padua

Introduction: NT-S100A8 was isolated by us from pancreatic cancer (PC) tissue of diabetic patients.

Objectives: To verify whether NT-S100A8: 1) alters insulin, Akt and NF-kB signalling in PC cell lines and 2) interferes with insu-lin signalling in the insulin responsive hepatocellular cell line HepG2.

Materials and Methods: PC cell lines (BxPC3, Capan1, MiaPaCa2) and HepG2 remained unstimulated (negative control) or were stimulated with 50 mU insulin for 10 minutes (positive control) with/without 50 and 500 nM NT-S100A8 for 5, 10, 15 and 30 minutes. The immunoblot of the cell lysates was performed with anti-phospho IkB-alpha, anti-phospho-Akt (Ser473), anti-Akt, anti-phospho insulin receptor (Tyr1158, Tyr1162, Tyr1163) and anti beta-actin antibodies.

Results: In HepG2, insulin determined an increase in insulin receptor and Akt phosphorylation, which was not counteracted by NT-S100A8. Insulin and/or NT-S100A8 were able to independently induce Akt phosphorylation in BxPC3 and MiaPaCa2 whereas Capan1 were not affected. To study NF-kB signalling we assessed the phosphorylation of its cytoplasmic inhibitor IkB-alpha. In all cell lines IkB-alpha was constitutively phosphorylated. Insulin deter-mined a significant reduction of pIkB-alpha in HepG2, Capan1 and MiaPaCa2 and an enhancement in BxPC3, effects not counteracted by NT-S100A8. In HepG2 cells NT-S100A8 exerted an insulin like effect on pIkBalpha, causing its complete disappearance. In BxPC3 and Capan1, NT-S100A8 caused an increase in pIkB-alpha after 5 minutes, followed by its reduction after 10 and 15 minutes and recov-ery at 30 minutes. The IkB-alpha phosphorylation in MiaPaCa2 cells was not modified.

Conclusion: NT-S100A8 in PC cells activates Akt and NF-kB signalling, but does not counteract insulin signalling.

P41

Neurturin Mediates Pancreatic Neuroplasticity in Chronic Pancreatitis and Pancreatic CancerI.E. Demir1, K. Wang1, T. Kehl1, E. Tieftrunk1, H. Friess1, G.O. Ceyhan1


Introduction: Chronic pancreatitis (CP) and pancreatic cancer (PCa) are characterized by the multifold involvement of the glial-cell-derived-neurotrophic-factor (GDNF) family members artemin and GDNF in pancreatic neuropathy.


Objectives: Due to its crucial role in normal pancreatic innerva-tion, we aimed at identifying the role of the GDNF family member neurturin (NTN) in pancreatic neuropathy.

Materials and Methods: The expression of NTN and its recep-tor GFRalpha2 was investigated in human normal pancreas (NP), CP, PCa tissues and in 9 different pancreatic cancer cell (PCC) lines under normoxia and hypoxia via QRT-PCR, immunoblotting and immuno-histochemistry. MTT-proliferation-and Matrigel-invasion-assays were performed with PCCs in the presence of NTN-blocking antibod-ies or recombinant NTN. To verify whether NTN has an impact on pancreatic neuropathy, CP and PCa tissue extracts were supplied with NTN-blocking antibodies, and axonal sprouting from dorsal root gan-glia (DRG) neurons was measured.

Results: Pre-mature NTN was expressed at low levels in pancre-atic acini of NP. However, there was a prominent upregulation of dimeric NTN in degenerating acini in CP, PCa tissue, in PCCs and of GFRalpha2 in nerves. Hypoxic PCCs were marked by a downregula-tion of dimeric NTN. NTN significantly increased the invasiveness, but not the proliferation of PCCs. Depletion of NTN from CP and PCa tissue extracts remarkably abolished their neurotrophic effect on DRG neurons.

Conclusion: Concomitant upregulation of NTN in CP and PCCs and of GFRalpha2 in nerves leads to pancreatic neuroplastic altera-tions. As PCCs benefit from NTN for their invasive ability, the hypoxic tissue microenvironment may pose a threat to PCCs via NTN-downregulation.

P42

Expression of GLUT-2 in PanINs of Murine and Human Pancreatic CarcinomaV. Fendrich1, R. Schneider1, D. Bartsch1

1University of Marburg, Department of Surgery

Introduction: The identification of precursor lesions of pancre-atic cancer would be much better than diagnosing the carcinoma. These precursor lesions are called »pancreatic intraepithelial neopla-sia« (PanIN) and are graduated in grade 1â3, whereas grade 3 is clas-sified as »carcinoma in situ«.

Objectives: Currently no reliable, non-invasive imaging tech-nique (e. g. ultrasound, computed tomography, magnet resonance imaging) exists to verify these PanINs.

Materials and Methods: Recently a transgenic mouse model of pancreatic cancer was established in which the tumor progression of human pancreatic carcinoma is reproduced. These so called Pdx-1-Cre; LSLKrasG12D/+; LSL-Trp53R172H/+ mice develop PanINs, which transform to invasive growing pancreatic carcinoma. The pan-creata of mices in different ages were immunohistochemically stained using -GLUT- 2-antibodies.

Results: An expression of GLUT-2 in murine PanINs was found in PanINs of grade 1B and higher. This finding is associated with an elevated glucose metabolism. Additionally GLUT-2- expression could be demonstrated in human PanINs (n = 60). An immunohis-tochemical staining of GLUT-2 was detectable in 45/60 human PanINs (75%), whereas PanINs of grade 1B and higher showed a very extensive expression.

Conclusion: For the first time we could demonstrate an elevated glucose metabolism already in murine and human precursor lesions of pancreatic carcinoma. These findings could improve the detection of precursor lesions by PET-CT, in which the tumor detection is based on elevated glucose metabolism.

P43

Towards Targeting Alpha V Beta 6 in Pancreatic CancerS. Vallath1, I. Hart1, H.M. Kocher1, J. Marshall1

1Centre for Tumour Biology, Institute of Cancer, Queen Mary University of London, UK

Introduction: Novel therapeutic strategies are required for pan-creatic cancer. Our laboratory has identified alpha v beta 6, a unique integrin, as being implicated in invasion and metastasis for several epithelial cancers (Nystrom et al, 2005).

Objectives: To evaluate the role of integrin alpha v beta 6 expression in pancreatic cancer.

Materials and Methods: Expression of alpha v beta 6 was evaluated in human pancreatic cancer tissues, as well as in pancreatic cell lines with complementary methods such as immunohistochemis-try (IHC), Western Blotting (WB) and Flow Cytometry (FACS) and results were supplemented with functional studies.

Results: Alpha v beta 6 was found to be expressed on the sur-face of over 90% of tumour, but not any normal, pancreatic cells. 8 out of the 10 pancreatic cell lines expressed alpha v beta 6. Invasion assays (Matrigel coated 8 micron Transwell inserts) showed 5 out of 7 cell lines exhibited alpha v beta 6 dependent invasion as assessed using a blocking antibody (p < 0.01, student’s T test). An Organotypic pancreatic cancer model, (Froeling et al, 2009) demonstrated that cancer cells formed invasive and non-invasive multi-layered epithe-lium, cohesive invasion and complex lumen formation akin to PanIN and invasive cancer and such responses were affected markedly by interacting stromal, stellate cells.

Conclusion: The surface expression of alpha v beta 6 in pancre-atic cancers suggests its potential as an imaging and therapeutic target.

P44

The Blockade of Plasminogen-alpha-enolase Interaction Inhibits the Invasion of Pancreatic Cancer CellsP. Ceruti1, M.S. Chattaragada1, P. Cappello1, M. Principe1, J. Hamm1, S. Rolla1, F. Novelli1

1Center for Experimental Research and Medical Studies (CeRMS), San Giovanni Battista Hospital and Department of Medicine and Experimental Oncology, University of Turin, Turin, Italy

Introduction: Pancreatic Ductal Adenocarcinoma (PDAC) is a malignancy characterized by rapid progression, invasiveness and resis-


tance to treatment. It has been demonstrated that 70% of PDAC patients have circulating antibodies against the glycolitic enzyme alpha-enolase and this correlates with a longer time free of disease. Alpha-enolase is also expressed on the surface of some cell types where it acts as a plas-minogen receptor. By promoting plasminogen activation into plasmin, a serine-protease involved in the extracellular matrix degradation, alpha-enolase could play a crucial role in cell invasion and metastatization.

Objectives: The aim of this study was to investigate the alpha-enolase role in PDAC cell invasion.

Materials and Methods: We analyzed surface alpha-enolase expression on PDAC cell lines by flowcytometry. To asses its role in invasion we performed an in vitro matrigel assay with the PDAC cell line CF-PAC-1 in presence of plasminogen and anti-alpha-enolase monoclonal antibody. Cell proliferation was assessed in the same conditions by a MTT test. Moreover, SCID-beige mice were injected in the tail vein with luciferase expressing CF-PAC-1 cells and treated with anti-alphaenolase or control antibodies.

Results: We observed that alpha-enolase is expressed on cell surface of most of PDAC lines and the treatment with the specific antibody inhibited their plasminogen-dependent invasion, without influencing in vitro cell growth. Moreover, mice treated with the anti-alpha-enolase antibody displayed a reduced number of tumor mass compared to control mice.

Conclusion: These data indicate that alpha-enolase is involved in the PDAC invasion suggesting that interference with enolase-plas-minogen interaction could be of therapeutic value.

P45

S100A8 and S100A9 Activate Cellular Smad Signaling Pathway via Rage in Pancreatic Cancer CellsC.W. Ang1, A. Sheikh1, E. Tweedle1, T. Nedjadi1, S. Tonack1, S. Honap1, R. Jenkins2, K. Park2, I. Schwarte-Waldhoff3, I. Khattak1, B. Azadeh4, A. Dodson4, H. Kalirai4, J.P. Neoptolemos1, P.S. Rooney5, E. Costello1

1The Liverpool CR-UK Centre, Division of Surgery and Oncology, School of Cancer Studies University of Liverpool, UK, 2MRC Centre for Drug Safety Science, Department of Pharmacology, University of Liverpool, 3Department of Internal Medicine, University of Bochum, Germany, 4Division of Pathology, University of Liverpool, 5Department of Colorectal Surgery, Royal Liverpool University Hospital NHS Trust, Liverpool

Introduction: S100A8 and S100A9 have emerged as important carcinogenic mediators in various human cancers. We previously reported that Smad4-negative pancreatic tumors contain fewer stromal S100A8-positive immune cells than their Smad4-positive counter-parts. In vitro exeriments revealed that the exogenously added S100A8 and S100A9 proteins increased motility and proliferation of cancer cells, and that transient depletion of the tumor suppressor pro-tein, Smad4, in PANC-1 cells resulted in loss of motility and prolif-eration in response to exogenous S100A8, but not S100A9.

Objectives: Here, we examined the effect of S100A8 and S100A9 proteins on the cellular phospho-Smad expression in relation to the receptor of advanced glycation end products (RAGE).

Materials and Methods: PANC-1 cells were cultured in serum free medium and then treated with recombinant S100A8 and S100A9 proteins for 1 h, followed by cell collection for western blotting and immunofluorescence assay. For RAGE blocking, cells were treated with RAGE-blocking antibody for 1 h before the addition of recombi-nant proteins.

Results: S100A8 and S100A9 activated Smad4 signaling as evi-denced by phosphorylation of Smad2/3 but not phospho-Smad1/5/8 on western blotting. This is further confirmed by immunofluores-cence assay, where S100A8 and S100A9 increased the translocation of phospho-Smad2/3 to the nucleus. When PANC-1 cells were pre-treated with RAGE-blocking antibody, a reduction of phopho-Smad2 and phospho-Smad3 levels was observed in response to S100A8 or S100A9 stimulation.

Conclusion: Both S100A8 and S100A9 could signal via Smad4, through RAGE. Further research into S100A8 and S100A9 signaling will shed light on how these proteins may influence the processes of tumor development/spread and will provide opportunities for targeted intervention.

P46

Characterisation of the Mechanisms Underlying the Effects of S100A8/S100A9 in Pancreatic CancerT. Nedjadi1, S. Honap1, C. Ang1, A. Sheikh1, J.P. Neoptolemos1, E. Costello1

1Division of Surgery and Oncology, School of Cancer Studies, The University of Liverpool, Liverpool, United Kingdom

Introduction: Several studies have shown that tumor progres-sion is not determined by cancer cells alone but also influenced by tumour-associated stromal cells. Pancreatic cancer is characterized by the presence of dense desmoplastic stroma harbouring a variety of cells including macrophages/monocytes. The latter secrete potent chemokines called S100A8 and S100A9, which we have observed increase cancer cell proliferation and migration.

Objectives: The aim of the current study was to characterize further the influence of S100A8 and S100A9 on pancreatic cancer cells and determine underlying mechanisms.

Materials and Methods: Multiplex Luminex immunoassays (Bio-Rad) were used to simultaneously detect the expression of 27 cytokines in the conditioned media isolated from pancreatic cancer cells, in the presence or absence of recombinant S100A8/S100A9 and control proteins. To determine signaling mechanisms involved in S100A8/S100A9 mediated effects on pancreatic cancer cells, luciferase assays, using both Smad4 and NF-kB reporter constructs were undertaken, as was Western analysis of key proteins in these pathways.

Results: The secretion of a number of cytokines from pancreatic cancer cells was observed, and treatment with recombinant S100A8 and S100A9 proteins increased specific cytokine secretion further. S100A8 and S100A9 activated Smad4 signaling as evidenced by phosphorylation of Smad2/3 and activation of the Smad4 luciferase construct. S100A8 and S100A9 also activated phospho-p38 and phos-pho-p44/42 MAPK and enhanced NF-kB activity through RAGE.


Conclusion: These results demonstrate that S100A8 and S100A9 potentially play an important role in pancreatic cancer through the promotion of cytokine secretion. S100A8 and S100A9 activate a number of signaling pathways, the consequences of which merit further study.

P47

Expression of LAT1 and Analysis of Iodine-123-methyltyrosine Tumor Uptake in Pancreatic Carcinoma in MiceC. von Forstner1, M. Zuhayra1, O. Ammerpohl1, Y. Zhao1, S. Tiwari1, H. Kalthoff1, E. Henze1, J. Egberts1

1Oncology, Department of Surgery, University of Kiel, Germany

Introduction: Pancreatic cancer is frequently recognized at an advanced stage of disease. Imaging with 18F-FDG -PET has shown to be useful, however the specificity in discriminating pancreatitis is limited.

Objectives: The aim of the study was to examine tumor uptake of 123I-IMT in a fused highresolutionmicro-SPECT-(Hi-SPECT)-MRI in xenotransplantation models of pancreatic carcinoma in mice. To further elucidate the utility of (123I-IMT) in pancreatic tumor imaging gene expression level of L amino acid transport system 1 (LAT1) was analysed.

Materials and Methods: The pancreatic cancer cell line Colo357 was transplanted orthotopically (n = 4) and subcutaneously (n = 4) in SCID-beige-mice which received 15 MBq of [123I]IMT. Combined imaging was performed with Hi-SPECT and a 3T MR scanner using a dedicated mouse coil. Tumor uptake analysis was based on ROI interpretation using a Tumor/Background ratio with the close visceral region as background. We also compared the uptake to the gene expression of the LAT1.

Results: In all mice a significantly higher uptake into tumor tis-sue could be elicited. After subcutaneous xenotransplantation the tumor to background ratio (T/B) was 10.26 (2.88-17.95) and after orthotopic xenotransplantation it was 8.51 (2.57-16.61). Fusion with MRI enabled good correlation of the anatomical site of the tumor with 123I-IMT uptake. In Colo357 cells LAT1 expression was increased compared to other PDAC cell lines or non malignant controls.

Conclusion: A high 123I-IMT uptake in pancreatic tumor was shown in all mice. Accordingly, the cell line Colo357 showed an increased LAT1 expression. Since amino acids play a minor role in metabolism of inflammatory cells, the potential for application of 123I-IMT to distinguish pancreatic tumor from inflammatory pan-creatitis warrants further investigation.

P48

Combined Streptococcal-Antibody Therapy for Experimental Pancreatic CarcinomaC. Maletzki1, T. Ritz1, M. Linnebacher2, J. Emmrich1

1University of Rostock, Division of Gastroenterology, Department of Internal Medicine, 2University of Rostock, Section of Molecular Oncology and Immunotherapy, Department of General Surgery

Introduction: Our prior studies focussed on treatment of exper-imental pancreatic carcinomas using Streptococcus pyogenes as active immunotherapeutic compound.

Objectives: In order to make this approach more specific, we here combined EtOH-inactivated bacteria with the therapeutic anti-body (moAb) trastuzumab (HerceptinÂ®).

Materials and Methods: Established PaCa cell lines (MiaPaCa-2, BxPC-3, T3M4) were treated with bacteria (4.5 x 106 cfu/ml), moAb (4 μg/ml) or a combination of both for 24-72 hours. Metabolic activity of cells was assessed by WST-1 assay. Analysis of cell cycle was performed by flow cytometric DNA-staining. Additionally, contribution of immune cells on antitumoral responses was explored in co-culture experiments using peripheral blood leuko-cytes (PBL) from healthy volunteers.

Results: Bacteria reduced numbers of metabolic active cells at all times (60% vs. control). These effects were due to deceleration of cell cycle presented by increased S phase levels and lost of G2/M. However, addition of moAb did not further improve antitumoral effects and moAb without bacteria had no effect on cells. Antitumoral and immunostimulatory bacterial effects were boosted after coculture with PBLs. Numbers of viable cells were significantly reduced (72h: BxPC-3: 40% vs. control). Again, moAb alone did not influence cell proliferation (72h: BxPC-3: 100% vs. control) and combination of both did also not further enhance antitumoral effects (72h: BxPC-3: 40% vs. control).

Conclusion: Data presented here prove the direct antitumoral and immunostimulatory potential of inactivated streptococci without the need of a special targeted therapy. Current experiments focus on detailed characterization of the effector cell type by using in vitro T cell stimulation assays.

P49

Collagen V Affects Pancreatic Cancer Cell Motility and ChemoresistanceS. Berchtold1, I. Paron1, I. Esposito1

1Institute of Pathology, Helmholtz Zentrum München, Neuherberg, Germany

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is characterized by the presence of an abundant stromal reaction sur-rounding and sustaining tumor growth. This ‘desmoplastic’ tissue is rich in extracellular matrix (ECM) proteins secreted by cancer cells and, predominantly, by an activated myofibroblast-like cell type, the pancreatic stellate cell (PSC).


Objectives: The aim of this project is to investigate the role of collagen type V (Col V) in pancreatic cancer development and pro-gression.

Materials and Methods: Immunohistochemistry was per-formed on human pancreatic tissues to determine the expression of Col V in precursor lesions and invasive PDAC. To assess the effects of Col V on cancer cells, wound healing, growth, adhesion and inva-sion assays as well cytotoxicity assays after administration of gemcit-abine and 5-Fluorouracil were performed in vitro. In addition, immunoblotting and immunofluorescence for phosphorylated focal adhesion kinase (pFAK) and phosphorylated paxillin (pPax) were done to examine Col V-dependent activation of the integrin signalling pathway.

Results: Col V is mainly expressed by PSCs and its expression levels increase in the progression from low-grade pancreatic precur-sor lesions to PDAC. Col V significantly promotes pancreatic cancer cell adhesion, migration and chemoresistance in vitro. Pancreatic can-cer cells grown on a Col V-rich matrix display changes in morphol-ogy as well as an up-regulation of both pPax and pFAK at early time points.

Conclusion: Col V is up-regulated in pancreatic cancer progres-sion and affects important properties of pancreatic cancer cells, such as motility, and chemoresistance. These effects may be promoted by activation of the integrin signalling pathway.

P50

Destrin Is Associated with Basal and Perineural Invasion of Pancreatic CancerI. Abiatari1, T. Klose1, B. Kong1, H. Friess1, J. Kleeff1

1Department of Surgery, Klinikum Rechts der Isar, Technische Universität of Munich

Introduction: The small actin-binding protein destrin is one of the key regulators involved in remodelling of the actin cytoskeleton, a process crucial for cytokinesis, cell migration and polarized cell growth as well as for cancer cell migration and invasion. We have previously established a novel ex vivo nerve invasion model mirror-ing perineural cancer cell invasion as a key feature of pancreatic duc-tal adenocarcinoma. This model produced highly nerve invasive clones of human pancreatic cancer cell lines.

Objectives: Genome-wide transcriptional analyses of these cell clones revealed upregulation of destrin in highly versus less nerve-invasive pancreatic cancer cells.

Materials and Methods: Quantitative RT-PCR, immunoblot-ting and immunofluorescence methods were used to identify expres-sion of destrin in pancreatic cancer cell lines and nerve invasive clones. siRNA transfection method was used to downregulate expres-sion of destrin in cancer cells. Invasion migration and proliferation assays have been carried out for functional analysis.

Results: Increased expression of destrin in these nerve invasive cells was validated using quantitative RT-PCR and immunoblotting; concomitant changes in cell morphology were demonstratedusing immunofluorescence analysis. Silencing of destrin by specific siRNA oligonucleotidesin Panc-1 pancreatic cancer cells decreased invasive-ness and migration, and reduced proliferation of these cells.

Conclusion: In conclusion, destrin is upregulated in nerve inva-sive pancreatic cancer cells and its expression might be related to (perineural) invasiveness.

P51

Expression Profile of Gemcitabine and 5-FU Sensitive and Resistant Pancreatic Cancer Cell LinesK. Dajani1, A. Bauer2, S. Tonak1, W. Greenhalf1, E. Costello1, J. Hoheisel2, J.P. Neoptolemos1, P. Ghaneh1

1Division of Surgery and Oncology, School of Cancer Studies, Royal Liverpool University Hospital, 5th Floor UCD Building, Liverpool, UK, 2Division of Functional Genome Analysis, German Cancer Research centre, Heidelberg, Germany

Introduction: Pancreatic cancer cell-lines acquire resistance to gemcitabine and 5-FU when cultured with the drugs. The molecular changes responsible for this are unclear.

Objectives: To examine the expression profile of gemcitabine and 5-FU sensitive and resistant pancreatic cancer cell lines whole-genome expression arrays.

Materials and Methods: SUIT-2 pancreatic cancer cell-lines were cultured in increasing concentrations of gemcitabine and 5-FU to generate resistant cell lines. Total RNA was isolated, on which whole genome expression analysis was performed utilising the IlluminaWG-6 beadchip array. Data were analysed using CHIPSTER software to identify differentially regulated genes. Validation of the candidate genes was carried out by qRT-PCR.

Results: Of the 182 differentially regulated genes identified when comparing gemcitabine resistant to sensitive cell lines, 79 were down-regulated and 103 were up-regulated. Of the 664 differentially regulated genes identified when comparing 5-FU resistant cell to sen-sitive cell lines, 324 were up-regulated and 340 were down-regulated. Human Equillibrative nucleoside transporter 1 (hENT1) expression was significantly up-regulated in 5-FU resistant cells with a factor change of 1.668. Using qRT-PCR on a panel of six gemcitabine and 5 –FU sensitive and resistant cell lines, the overall relative mRNA expression of hENT1 showed a strong trend towards being increased in 5-FU resistant cell lines (p = 0.06).

Conclusion: Multiple mechanisms are likely to be responsible for resistance of pancreatic cancers to chemotherapy. Expression arrays provide valuable clues to these mechanisms. Ongoing work will concentrate on further validation of candidate targets with qRT-PCR and IHC in tissue microarrays.


P52

Chemotherapeutic Resistance in Capan-1 Pancreatic-Carcinoma Cell LinesM. Schober1, J. Sänger1, R. Faissner1, R. Jesnowski1, J.M. Löhr1,2

1Molecular Gastroenterology, DKFZ Heidelberg, Germany; 2Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden

Introduction: Pancreatic-adenocarcinoma has the worst long term survival rate (<5%) compared to other malignancies. At the time of diagnosis 80% of patients are already non-resectable and even the majority of resected patients suffer from recidives. Moreover, pancre-atic carcinoma is almost completely resistant against standard radio- and chemotherapy.

Objectives: Our study aimed to reveal relevant mechanisms underlying the resistance phenotype of pancreatic cancer cells.

Materials and Methods: Therefore we established 5-Fluoro-uracil resistant Capan-1 pancreatic carcinoma cell clones and analy-sed them using proteomics. Differentially expressed protein spots were identified by 2Dgelelectrophoresis combined with mass spec-trometry. Using a sandwich-ELISA-kit with predefined cell-signaling pathways and Western-Blotting we analysed mediators known to be of great importance for cell survival of resistant cell clones and native Capan-1 carcinoma cells.

Results: We were able to detect a marked downregulation of S100a4 protein using 2D-PAGE combined with mass spectrometry and western blot, also on the RNA this downregulation by 82% was detectable by RT-PCR. NfkB phosphorylation was comparable in both cell lines at basal levels. 5-FU treatment upregulated NfkB phos-phorylation in native Capan-1 cells but did not change phosphoryla-tion levels in resistant Capan-1. Phospho-s6-ribosomal-protein phosphorylation was induced in native Capan-1 but downregulated in resistant Capan-1 after 5-FU treatment. Additionally western blotting revealed differences in the expression of the pro-apoptotic mediators Bok and Bad.

Conclusion: We were able to identify several differentially expressed proteins or phosphorylation patterns, which may be impli-cated in 5-FU resistance of Capan-1 cells.

Clinical Science – Acute Pancreatitis

P53

Which Kind of Organ Failure Defines Better the Severity of Acute Pancreatitis?N. Moya1, E. de-Madaria1, J. Pérez-López1, G. Soler-Sala1, L. Sempere1, J. Martínez1, M. Pérez-Mateo1

1Pancreatic Unit, Hospital General Universitario de Alicante

Introduction: The development of organ failure (OF) is an important marker of mortality in patients with acute pancreatitis (AP). Different types of OF are associated with different outcome.

Objectives: To evaluate the association between different kinds of OF and mortality.

Patients and Methods: Prospective cohort study. OF was defined according to Atlanta Classification. We defined persistent OF (POF) as OF with >48 hour duration, transient OF (TOF) as <48 hour duration (those patients who died due to OF lasting less than 3 days were not consider as TOF), multiple OF (MOF) as the failure of >1 organ and single OF (SOF) as 1 organ failure.

Results: We included 265 consecutive patients with AP. Renal failure was developed in 7.2% patients, respiratory failure 7.2%, shock 4.5% and gastrointestinal bleeding in 1.1%. The incidence of TOF was 2.6%, POF 6.8%, SOF 6.4% and MOF 4.5%. Four of 7 patients died within the first 3 days after the onset of OF so criteria of POF were not accomplished. The mortality rate of TOF was 0, POF 22.2%, SOF 11.8% and MOF 50%. The sensitivity, specificity, posi-tive and negative predictive value for mortality was 50%, 94.6%, 22.2% and 98.4% for POF and 75%, 97.7%, 50% and 99.2% for MOF.

Conclusion: Multiple organ failure is a better marker of severity than persistent organ failure. The concept of transient and persistent organ failure is difficult to apply in the clinical practice due to patients who die within the first 3 days after the onset of organ failure.


P54

Early Veno-venous Hemofiltration and Mortality of Severe Acute Pancreatitis: Experience in Mainland ChinaK. Jiang1, X.Z. Chen2, W. Huang3, P. Fu4, L. Zhang4, Q. Xia1

1Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, China, 2Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, China, 3Departments of Surgery and Physiology, Royal Liverpool University Hospital, University of Liverpool, UK, 4Department of Nephrology, West China Hospital, Sichuan University, China

Introduction: Since 1991, early veno-venous hemofiltration (VVH) has been used in the initial management of severe acute pan-creatitis (SAP). However, its effects on overall mortality are still unclear.

Objectives: To compare the mortality rate of SAP patients receiving VVH to no VVH in studies reported in mainland China.

Materials and Methods: PubMed and Full-text Databases of peer-reviewed Chinese academic journals were included in a search ranging from 1990 to 2009. Only randomized controlled trials (RCTs) that reported mortality outcome and based on the mainland Chinese population were considered for meta-analysis. Subgroup analysis was performed between continuous VVH (CVVH) and short VVH (SVVH). Cochrane RevMan 5.0 software was used for pooled esti-mates. Pooled mortality rate, risk ratio (RR), and 95% confidence interval (CI) were calculated.

Results: In total, 19 small-sized, poor quality RCTs were included for meta-analysis. Subgroup analysis showed that both CVVH (10 RCTs, 378 patients, RR = 0.44, 95% CI 0.27-0.74, P = 0.002) and SVVH (9 RCTs, 498 patients, RR = 0.35, 95% CI 0.21-0.57, P < 0.0001) significantly reduced mortality compared to the group where hemofiltration was not used. The pooled mortality rate was 9.3% (19/204) versus 20.1% (35/174), 7.4% (18/242) versus control 21.9% (56/256) in CVVH group and SVVH group compared to their control groups, respectively. Funnel plot analysis indicated an apparent publication bias in both CVVH and SVVH subgroups.

Conclusion: Our findings indicate that early VVH might be an effective therapy to reduce the mortality of patients with SAP. However, further high-quality RCTs are needed to draw a confident conclusion.

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Assessing Mortality in Severe Acute Pancreatitis. Evaluation of the Bedside Index for Severity in Acute Pancreatitis (BISAP)J. Lariño-Noia1,2, R. Ferreiro1, A. Alvarez1, R. Souto1, J. Iglesias1,2, L. Nieto2, E. Domínguez-Muñoz1,2

1Dept. Gastroenterology. University Hospital of Santiago de Compostela, 2Foundation for Research in Digestive Diseases

Introduction: Severe acute pancreatitis (SAP) remains an important cause of in-hospital mortality. Early identification of patients with SAP may change therapeutic management and improve the outcome of the disease. BISAP score has been proposed as an accurate method for predicting mortality in SAP.

Objectives: Evaluate the accuracy of BISAP score for predict-ing mortality in SAP patients; other potential predictive factors of mortality were evaluated.

Materials and Methods: Patients admitted to our Intensive Care Unit because of SAP from January 2000 to December 2008 were included in the study. BISAP score was calculated using parameters of the first 24-hours (BUN > 25mg/dl, impaired mental status, SIRS, age>60years, pleural effusion). Each item gives one point (score ranges 0-5). Need of mechanical ventilation, organ failure, etiology and comorbidities were also evaluated. Data were analyzed by multi-variatestepwise-unconditional-logistic-regression, and shown as odds ratio(OR) and 95%(CI).

Results: 135 patients (72 male, mean age 64 years [24-88]) were included. 51 died because of SAP (mortality rate 37.7%). BISAP-score at admission was 0 in 19 (14.1%) patients, 1 in 23 (17%) patients, 2 in 44(32.5%) patients, 3 in 30(22.2%) patients, 4 in 16 (11.8%) patients, and 5 in 3 (2.2%) patients. BISAP>=2 wasnt associ-ated with an increased risk of mortality (OR 1.07, 95%CI: 0.168-6.72). However mortality was associated with the need of mechanical ventilation (OR 20.7, 95%CI: 4.62-92.33), development of organ fail-ure (OR14.9, 95%CI: 4.09-54.30) and age (OR = 7.8, 95%CI: 1.37-44.0).

Conclusion: In our study population, BISAP-score at admission didnt predict mortality in SAP patients. Need of mechanical ventila-tion, age and organ failure are the best predictors of fatal outcome of SAP.


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Collections in Acute Pancreatitis: Natural History According to the Association with Pancreatic NecrosisJ. Pérez-López1, E. de-Madaria1, G. Soler-Sala1, I. López-Font1, L. Sempere1, J.R. Aparicio2, J. Martínez1, S. Gil2, F. Lluís3, M. Pérez-Mateo1

1Unidad de Patología Pancreática, Hospital General Universitario de Alicante, 2Servicio de Radiología, Hospital General Universitario de Alicante, 3Servicio de Cirugía General, Hospital General Universitario de Alicante

Introduction: There is a lack of information regarding the inci-dence and natural history of collections associated with necrosis.

Objectives: To study the incidence and natural history of abdominal collections associated with AP according to the presence or not of pancreatic necrosis.

Patients and Methods: Retrospective cohort study: we revised every image technique performed to our patients with AP admitted in our unit between December 2007 and May 2009. We defined: 1. Acute peripancreatic collection (APC) as a collection not associated with pancreatic necrosis; 2. Acute post-necrotic collection (APNC) as a collection associated with pancreatic necrosis. 3. Pseudocyst (PSC) as a >4 –week APC and 4. Walled-off necrosis (WON) as a >4 - week APNC.

Results: We included 159 consecutive episodes of AP. Collections were present in 52 (32.7%) of them. Sixty (72.3%) out of 83 abdominal collections were APC (22 persisted as PSC and 9 were lost from follow-up) and 20 (24.1%) were APNC (14 persisted as WON and 4 were lost from follow-up). The diagnosis of pancreatic necrosis was not possible (contraindication of endovenous contrast) in 3 patients with collections. The maximum size of APNC-WON was 7.8 (4.3-11.4) cm vs 3 (2.3-6) cm in the case of APC-PSC (p < 0.01). According to Kaplan-Meier analysis, the median life for APNC-WON was 313 days vs 70 days for APC-PSC (p < 0.01). Invasive treatment was needed in 5 (26.3%) of APNC-WON vs 1 (1.8%) of APC-PSC (p < 0.01).

Conclusion: Collections associated with necrosis are bigger, stay longer and more often need invasive treatment.

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Exocrine Insufficiency of the Pancreas After Acute Necrotizing Pancreatitis: Risk FactorsT. Lubenets1, I. Kovalska1

1Department of general surgery 1, National Medical University, 2Department of general surgery 1, National Medical University

Introduction: Acute pancreatitis has a variable clinical presen-tation ranging from mild to severe. Pancreatic necrosis remains the most severe form. Necrotizing pancreatitis (NP) is usually accompa-nied by pancreatic parenchyma loss and septic complications as a result. The accepted surgical management of NP is the removal of necrotic pancreatic tissue.

Objectives: The aim of the study was to investigate whether there are risk factors to predict the development of exocrine pancre-atic insufficiency after NP depending on severity and methods of treatment.

Materials and Methods: We used measurement of fecal elastase-1 concentration for the detection of exocrine pancreatic insuf-ficiency. 40 patients were included in the study treated in our clinic in period of 2006-2008. In group 1 20 patients had sterile NP, they were treated with ultrasongraphy guided percutaneous manipulations and conservative. In group 2 20 patients with septic complications of NP were underwent open surgical procedures and necrosectomy.

Results: Two-year follow-up showed no patients with exocrine pancreatic insufficiency in group 1 (level of fecal elastase was 220-346 μg/g) and all patients having exocrine pancreatic insufficiency in group 2 (level of fecal elastase-1 was 13-80 μg/g).

Conclusion: The amount of remaining pancreatic parenchyma strongly influences the quality of long-term results concerning exo-crine pancreatic function. The improvement of long-term results of treatment NP may be achieved by early prevention of pancreatic necrobiosis.

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Comparison of Peroxiredoxin-4 with CRP as a Severity Marker for Acute PancreatitisA. Guenther1, A.A. Aghdassi1, C.J. Nitsche1, J. Schulte2, J. Struck2, M.M. Lerch1, F.U. Weiss1

1Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, Germany, 2Brahms AG, Hennigsdorf, Germany

Introduction: Acute pancreatitis (AP) is associated with a highly variable clinical course during which 10-20% of patients develop severe disease with single or multiple organ failure. Discriminating between mild and severe cases on hospital admission would allow for appropriate triage to an intensive care unit or early treatment.

Objectives: Here we tested whether Peroxiredoxin-4 (Prdx4), an oxidative-stress-marker elevated in sepsis and other types of inflammation, can predict severity in acute pancreatitis.

Patients and Methods: We measured levels of Peroxiredoin-4 in serum samples of patients suffering from mild (n = 106) or severe (n = 16) acute pancreatitis and in 138 healthy blood donors. Blood was drawn on admission and daily throughout the first 3 days of hos-pitalization and labeled with reference to the day of pain onset. Prdx4 was analysed by an immunoluminometric assay.

Results: At day 1 after disease onset Prdx4 was already signifi-cantly elevated in pancreatitis patients in comparison to controls (3,92 vs. 0,83 U./L). A significant difference in Prdx4 levels between mild and severe acute pancreatitis was not detectable until day 3 after onset of pain. CRP levels, in comparison, could discriminate between mild and severe pancreatitis as early as 48h after the onset of pain. At later time points (days 3 to 5) Prdx4 and CRP performed equally well in discriminating between mild and severe acute pancreatitis.

Conclusion: Peroxiredoxin-4 levels rise significantly during acute pancreatitis. Discrimination between mild and severe pancreati-tis using Peroxiredoxin-4 levels is possible - but 24h later than with CRP, an already established severity marker for acute pancreatitis.


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Timing of Cholecystectomy for Mild Biliary Pancreatitis: A Systematic ReviewM. van Baal1, M.G. Besselink1, O. Bakker1, H.C. van Santvoort1, A.F. Schaapherder2, V.B. Nieuwenhuijs3, H.G. Gooszen4, B. van Ramshorst5, D. Boerma6

1Dept. of Surgery, University Medical Center Utrecht, 2Dept. of Surgery, University Medical Center Leiden, 3Dept. of Surgery, University Medical Center Groningen, 4Dept. of Surgery, Radboud University Nijmegen Medical Centre, 5Dept. of Surgery, St Antonius Hospital Nieuwegein, 6Dept. of Surgery OLVG Hospital Amsterdam, the Netherlands

Introduction: Current guidelines recommend early cholecys-tectomy following mild biliary pancreatitis. There is, however, no consensus on the definition of ‘early’: during index admission, within 2 weeks or within 4 weeks after discharge.

Objectives: To perform the first systematic review on this topic.

Patients and Methods: We searched the MEDLINE library since 1992. Inclusion criteria were: 1) cohort of patients undergoing cholecystectomy after mild biliary pancreatitis; 2) essential outcomes reported: time between hospital discharge and cholecystectomy, num-ber of readmissions during waiting period, number or recurrent acute biliary pancreatitis during waiting period, surgical complications (bile duct injury, bleeding) and mortality. Exclusion criteria were: 1) cohort <5 patients; 2) cohort including severe pancreatitis without results for mild pancreatitis reported separately.

Results: 6 out of 811 studies were included, describing 11 dif-ferent “timing” cohorts in 791 patients. Cholecystectomy was per-formed during index admission in 385 patients (49%), without any readmissions for biliary complications. In 7 cohorts, including 406 patients, the median time between discharge and cholecystectomy was 44 days (range 14-68 days). Readmission rate was 76/406 (19% vs 0%, P < 0.0001); 40 patients (10%) with recurrent biliary pancrea-titis, 11 patients (3%) with acute cholecystitis and 25 patients (6%) with biliary colics. Complications occurred in 6 patients (2%) in the early group and in 11 patients (3%) in the delayed group. In both groups, no mortality after cholecystectomy was described.

Conclusion: This systematic review suggests that patients with mild biliary pancreatitis, should undergo cholecystectomy during index admission as delayed cholecystectomy increases the risk for readmissions, especially for recurrent biliary pancreatitis.

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Decompressive Laparotomy versus Percutaneus Puncture in Abdominal Compartment Syndrome in Acute Pancreatitis: Background and Design of Randomised StudyD. Radenkovic1, D. Bajec1, P. Gregoric2, V. Jeremic2, N. Ivancevic2, V. Bumbasirevic3, D. Mirkovic4, B. Kardzic2

1Clinic for Digestive Disease, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia, 2Clinic for Emergency Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia, 3Clinic for Anaestiology and reanimatol-ogy, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia, 4Surgical depart-ment, Military-Medical Academy, Belgrade Serbia

Introduction: Development of abdominal compartment syn-drome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease. Number of patients with this complication increases during the years due more aggressive fluid resuscitation, much bigger proportion of patients who is treated con-servatively or by minimal invasive approach, and efforts to delay open surgery. There have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the SAP.

Objectives: The aim of DECOMPRESS study is to compare decompresive laparotomy with temporary abdominal closure and per-cutaneus puncture with placement of abdominal catheter in these patients.

Patients and Methods: One hundred patients with ACS will be randomly allocated to two groups: I) decompresive laparotomy with temporary abdominal closure or II) percutaneus puncture with placement of abdominal catheter. Patients will be recruited from five university hospitals in Belgrade during two years period.

Results: The primary endpoint is the mortality rate within hos-pitalization. Secondary endpoints are time interval between interven-tion and resolving of organ failure and multi organ dysfunction syndrome, incidence of infectious complications and duration of hos-pital and ICU stay. A total sample size of 100 patients was calculated to demonstrate that decompresive laparotomy with temporary abdom-inal closure can reduce mortality rate from 60% to 40% with 80% power at 5% alfa.

Conclusion: DECOMPRESS study is designed to reveal a reduction in mortality and major morbidity by using decompresive laparotomy with temporary abdominal closure in comparison with percutaneus puncture in patients with ACS during SAP.


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Clinical Value of C-reactive Protein and Elastase in Assessment of Acute PancreatitisD. Stimac1, E. Fisic2, L. Bilic Zulle2, I. Krznaric Zrnic1, S. Milic1

1Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka, Rijeka, Croatia, 2Division of Laboratory Diagnostics, University Hospital Rijeka, Rijeka, Croatia

Introduction: The early prognostic evaluation of acute pancrea-titis (AP) is a key step in appropriate management of the disease.

Objectives: The aim of the study was to evaluate the serum lev-els of CRP and elastase (E) as early prognostic markers in a develop-ment of severe acute pancreatitis.

Patients and Methods: Elastase were analyzed by ELISA method and CRP by immunoturbidimetry in serum taken routinely from 150 patients with acute pancreatitis on the first and on the third day of admission. APACHE II score was calculated on admission. Systemic complications were classified according to the Atlanta crite-ria. Severe acute pancreatitis developed in 19% of patients.

Results: Serum levels of CRP and elastase on the first day of admission were not significantly different in patients without and those with complications of acute pancreatitis (14.4 vs 15mg/L; p = 0.954 and 5.7 vs 7.5ng/L; p = 0.249), but on the third day of admission, the serum levels of CRP and elastase were significantly higher in the group of patients with complications (85 vs 216 mg/L; p = 0.002 and 1.7 vs 2.5 ng/L; p = 0.001). The area under the curve (AUC) for CRP on the third day was 0.69, at a cut-off value of 214 mg/L and for elastase 0.70 at a cut-off value of 1.5 ng/L. CRP levels were higher, and elastase levels were lower on the third day compared to the first day after admission.

Conclusion: Quantification of CRP and elastase on the third day of admission seems to be an accurate method in the prognostic evaluation of acute pancreatitis.

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Serum Creatinine and eGFR in Early Assessment of Severity of Acute PancreatitisM. Lipinski1, A. Rydzewski2, G. Rydzewska3

1Department of Gastroenterology, Central Clinical Hospital of Ministry of Home Affairs and Administration, Warsaw, Poland, 2Department of Internal Medicine and Nephrology, Central Clinical Hospital of Ministry of Home Affairs and Administration, Warsaw, Poland, 3Department of Gastroenterology, Central Clinical Hospital of Ministry of Home Affairs and Administration, Warsaw, Poland

Introduction: Early prediction of severity of AP by a single laboratory test would be very helpful as it may improve outcome of the disease. High serum creatinine is already known unfavorable

prognostic parameter in AP. However, eGFR level was never assess as a predictor of the severity of AP.

Objectives: The aim of this study was to evaluate the correla-tion between serum creatinine level, eGFR and the severity of AP.

Patients and Methods: A cohort of 147 patients with AP were enrolled in the study. Serum creatinine level and eGFR on admission and 48 hours thereafter were compared with Ranson score as well as with Balthazar score in group of patient with CT scan performed within 96 h of admission.

Results: Both, high serum creatinine levels and low eGFR mea-sured on admission (P = 0.002, P < 0.001 respectively) and after 48 hours (P = 0.001, P = 0.016 respectively) were significantly correlated with Ranson score. Moreover the rise in the creatinine level (P < 0.001) and the decrease of eGFR (P < 0.001 on admission, P = 0.001 at 48 h) were directly related to Balthazar score. Pancreatic necrosis (PNec) was present in 41 (39,8%) of the patients. Both tests - creatinine and eGFR measured on admission (P < 0.001 and P < 0.001 respectively) and 48 hours after (P = 0.001, P < 0.001 respectively) were signifi-cantly associated with PNec confirmed in CT.

Conclusion: Serum creatinine levels and eGFR can be used for predicting of the severity of AP. The study revealed that low eGFR on admission and at 48 h and an increased level of creatinine indicates a high risk of PNec in patients with AP.

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Clinical Decision Support System for Prediction of Infected Pancreatic NecrosisA. Litvin1, O. Jarikov1, V. Kovalev2, V. Khokha3

1Gomel Regional Clinical Hospital, Gomel State Medical University, 2United Institute of Informatics Problems NAS, 3Mozyr City Hospital

Introduction: Infected pancreatic necrosis is associated with high morbidity and mortality and is mandatory for surgical or mini-mally invasive intervention.

Objectives: The aim of this study was to construct and validate the clinical decision support system (CDSS) to predict infected pan-creatic necrosis (IPN).

Patients and Methods: All patients who presented with severe acute pancreatitis from January 1996 to December 2009 were reviewed. Presentation data on admission and at 48 hours were col-lected. Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow severity (GS) score were calculated. CDSS (Artificial Neural Networks (ANN) and Support Vector Machine (SVM)) was created and trained to predict development of IPN and mortality from AP; 25% of the data set was withheld from training and was used to evaluate the accuracy of the CDSS. Accuracy of the CDSS in predict-ing infected pancreatic necrosis was compared with APACHE II and GS scores.

Results: A total of 1690 patients with acute pancreatitis were identified of whom 398 (23.6%) fulfilled the clinical and radiological criteria for severe acute pancreatitis and 98 patients died (5.8%). Median APACHE II score at 48 hours was 6 (range, 0 to 23). Our CDSS with 12 criteria (on basis of ANN and SVM) was more accu-rate than APACHE II or GS scoring systems at predicting infected pancreatic necrosis (P < 0.05 and P < 0.01, respectively).


Conclusion: Clinical decision support system (ANN and SVM) was able to predict development of infected necrotizing pancreatitis with considerable accuracy and outperformed other clinical risk scor-ing systems. Further studies are required to assess its utility in aiding management decisions in patients with severe acute pancreatitis.

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The Serum Lipid Profile in Acute PancreatitisJ. Khan1, R. Lappalainen-Lehto1, S. Järvinen1, S. Räty1, J. Sand1, I. Nordback1

1Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland

Introduction: The serum lipid profile is known to react during acute disease.

Objectives: The aim of this study was to measure changes in the serum lipid profile during acute pancreatitis and to ascertain possible associations with the aetiology, severity and prognosis of acute pan-creatitis.

Materials and Methods: The serum total cholesterol, LDL-cholesterol, HDL-cholesterol and triglyceride levels of 203 patients with acute pancreatitis was measured. 143 (70%) were male and the median age was 48 (range 17-90). The aetiology was alcohol in 117 (58%), gallstones in 44 (22%), other in 11 (5%) and unknown in 31 (15%) cases. The serum samples were obtained during the first two days after hospitalization. Pancreatitis was considered severe when it met with the Atlanta criteria.

Results: The aetiology of pancreatitis was not associated with differences in total cholesterol, HDL- or LDLcholesterol levels. The serum triglyceride levels were higher in patients with alcoholic pan-creatitis. In patients who developed severe pancreatitis, the serum total cholesterol concentration tended to be somewhat lower (3.50 vs. 3.90mmol/L, p = 0.096), and triglyceride levels somewhat higher (1.06 vs. 0.93mmol/L, p = 0.209). Serum HDL-cholesterol and LDL-cholesterol concentrations were significantly lower in patients who developed severe disease (0.88 vs. 1.07mmol/L, p = 0.025, and 1.64 vs. 2.22mmol/L, p = 0.014, respectively).

Conclusion: Serum concentrations of HDL- and LDL-cholesterol are significantly lower and total cholesterol levels tend to be lower in patients who develop severe pancreatitis during the first days after hospitalization. Further studies are needed to ascertain whether this might be useful in estimating the prognosis of acute pan-creatitis.

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Circulating Levels of Visfatin, Resistin and Proinflammatory Cytokines IL-8 and IL-18 in Acute PancreatitisP. Daniel1, B. Lesniowski1, A. Mokrowiecka1, A. Jasinska2, M. Pietruczuk2, E. Malecka-Panas1

1Department of Digestive Tract Diseases, Medical University of Lodz, Poland, 2Department of Laboratory Diagostics, Medical University of Lodz, Poland

Introduction: Resistin and visfatin, hormones produced by adi-pose tissue present the proinflammatory potential, however their role in acute pancreatitis (AP) was investigated only rarely.

Objectives: The aim of the study was to assess the serum con-centration of proinflommatory adipohormones: visfatin and resistin as well as cytokines IL-8 and IL-18 in the course of AP.

Patients and Methods: The study group comprised 32 patients with alcoholic AP and 30 controls. In all cases AP was classified as C according to Balthazar’s CT score and as severe according to Ranson’s criteria. The serum level of visfatin, resistin, IL-8 and IL-18 immuno-assays were measured on admission, on the third and fifth day of hos-pitalization with ELISA.

Results: On the admission day serum IL-8 concentration in AP patients were significantly higher than in controls and decreased on the third and fifth day of hospitalization. On the first day the mean serum visfatin and IL-18 concentrations in AP patients was signifi-cantly higher than in controls (p < 0.05), on third day its level increased and further decreased on fifth day. On the first day the mean serum resistin concentration in AP patients was significantly higher than in controls (p < 0.05) and increased on third and fifth day of hospitaliza-tion. The correlation between visfatin and resistin as well as between C-reactive protein and visfatin, resistin and IL-8 levels has been found.

Conclusion: In the course of AP, visfatin and resistin levels increase in parallel with C-reactive protein. We speculate that those parameters may provide an additional tool for the prognosis and mon-itoring of AP.


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Initial Concentration of IL-6 and SIRS Score on Admission as a Predictor of Outcome in Severe Acute PancreatitisP. Gregoric1, D. Bajec4, A. Sijacki1, D. Radenkovic4, N. Ivancevic1, V. Jeremic1, S. Stankovic2, B. Karadzic1, M. Pandurovic3

1Clinic for Emergency Surgery, Clinical Center of Serbia and School of Medecine, University of Belgrade, Serbia, 2Institute for Med.Biochemistry, Clinical Center of Serbia and School of Medecine, University of Belgade, Serbia, 3Institute for Anestesiology, Clinical Center of Serbia and School of Medecine, University of Belgade, Serbia, 4Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medecine, University of Belgrade, Serbia

Introduction: Early recognition of severe form of acute pan-creatitis is important because these patients need more agressive diagnostic and therapeutical approach an can develope systemic com-plications such as: sepsis, coagulopathy, Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS), Multiple Organ Failure (MOF).

Objectives: To determine role of the combination of Systemic Inflammatory Response Syndrome (SIRS) score and serum Interleukin-6 (IL-6) level on admission as predictor of illness severity and outcome of Severe Acute Pancreatitis (SAP).

Patients and Methods: We evaluated 234 patients with first onset of SAP appears in last twenty four hours. A total of 77Â (33%) patients died. SIRS score and serum IL-6 concentration were mea-sured in first hour after admission.

Results: In 105 patients with SIRS score 3 and higher, initial measured IL-6 levels were significantly higher than in the group of Â remaining 129 patients (72 +/- 67 pg/mL, Â vs 18 +/- 15 pg/mL). All nonsurvivals were in the first group, with SIRS score 3 and 4 and initial IL-6 concentration 113 +/- 27 pg/mL. The values of C-reactive Protein (CRP) measured after 48h, Acute Physiology and Chronic Health Evaluation (APACHEII) score on admission and Ranson score showed the similar correlation, butserum amylase level did not cor-relate significantly with Ranson score, IL-6 concentration and APACHE II score.

Conclusion: The combination of SIRSscore on admission and IL-6 serum concentration can be early, predictor of illnessseverity and outcome in SAP.

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Evaluation of Glasgow and Apache II Scores and CRP in Prediction of Severity of Acute PancreatitisD. Bajec1, D. Gunjic1, D. Radenkovic1, P. Gregoric2, B. Karadzic2, I. Pejovic1

11st Surgery Clinic, Belgrade, 2Center for Emergency Surgery Belgrade

Introduction: The early prediction of the severity of an acute attack of acute pancreatitis (AP) has important implications for man-agement and timely intervetnion.

Objectives: To compare the accuracy of Glasgow and Apache II scores and C-reactive protein (CRP) level in prediction of severity of acute pancreatitis.

Patients and Methods: Ninety one consecutive patients with acute pancreatitis primarily admitted were retrospectively studied. Apache II score was recorded on admission, while Glasgow score and CRP levels were the terminated 48h later. Severity of AP was defined according to Atlanta classification system. Two study groups com prising 33 patients with mild AP (MAP) and 58 patients with severe AP (SAP) were compared. The accuracy of Glasgow and APACHE II scores and CRP level, in prediction of severy of AP, using cat-off val-ues of 8 and 3 points 150mg/l, respectively (derived from ROC curves), were calculated.

Results: Mean values of Glasgow and Apache II scores and CRP were 4 and 10 points and 331mg/l, respectively in SAP groupe, while in MAP groupe it were 1 and 4 points and 62mg/l, respectively. The sensitivity and specificity of Glasgow and Apache II scores and CRP were 79% and 81%,72.7% and 100%,90.9% and 85.7% respectively.

Conclusion: The CRP offers little, if any, advatage over the Glasgow and Apache II score. CRP level and Glasgow score proved to be powerful a prognostic model as the more complicated Apache II scoring systems, but, with the disadvantage of a 24-hour delay.

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Miniaccess Laparotomy Experience at Patients with High Perioperational Risk with Biliary PancreatitisV. Boiko2, O. Pesotsky1, A. Kozachenko1, A. Vasko1, M. Suplichenko1, K. Gorbenko2

1Kharkov Prof. Meshchaninov City Clinical Hospital of First and Urgent Aid, 2Kharkov Institute of Urgent Surgery

Introduction: The biliary etiology of pancreatitis is found out in 42% of patients. The part of patients of elderly and senile age is 35%. This category requires special approaches to treatment that is connected with age changes of the organism, following diseases, non typical pancreatitis symptoms.

Objectives: To prove that using miniaccess laparotomy instead of traditional ‘open’ operation on biliary tract can improve outcomes.

Patients and Methods: During a 48-month period 44 patients (from 65 till 92 years old) were operated by laparotomies. From this


number 29 were operated by traditional laparotomy(5 died, lethality 17%),15 patients –by miniaccess laparotomy(1 died, lethality 6%). Groups are identical both on the condition and damage of the pan-creas. Cholecystectomy, choledocholithotomy, external drainage of the ductus choledochus have been carried out in all cases. The retro-spectiveanalysis has been spent at patients with biliary pancreatitis when biliary tract impassability did not manage to be liquidated by endoscopic papillotomy.

Results: The decrease of postoperative lethality using mini-access laparotomies is 11%. The reduction of hospital stay is 6 days. The minimal operational trauma has allowed to use miniaccess at 6 patients under local anaesthesia.

Conclusion: The miniaccess technology allows to reduce the operational trauma, depth and duration of anaesthesia; improves results of treatment; reduces hospital stay.

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Laparoscopic versus Open Cystgastrostomy for Retrogastric Pancreatic Pseudocysts: A Comparative Case-Matched StudyA. Kausar1, N. Hamza1, D. Sherlock1, D. O’Reilly1, A. Basil1

1North Manchester General Hospital

Introduction: Symptomatic large retro gastric pseudocysts require internal drainage. This is traditionally accomplished by lapa-rotomy but can be performed laparoscopically.

Objectives: To compare open and laparoscopic approaches to cystgastrostomy.

Patients and Methods: Patients who had surgery for retrogas-tric pseudocyst drainage between 2000-2009 were identified. Those who had laparoscopic cystgastrostomy were matched to those who had open surgery for age, sex and size of the pseudocyst. One surgeon adopted the laparoscopic approach for all comers while others per-formed open surgery. The two approaches were compared on an intention-to-treat basis. Data shown represent medians.

Results: 35 patients underwent 37 cystgastrostomies (27 laparo-scopic, 10 open). One laparoscopic procedure was converted to open surgery. The laparoscopic and open groups were comparable for age (52 vs. 59 years, p = 0.227), sex distribution, and size of pseudocyst (12 vs. 13.3 cm, p = 0.287). Although laparoscopic surgery was asso-ciated with significantly longer operating time (95 vs. 60 minutes, p = 0.02), it carried a significantly lower risk of morbidity (0% vs. 60%, p < 0.0001) and shorter postoperative hospital stay (2 vs. 8.5 days, p < 0.0001).

Conclusion: The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a smoother and more rapid recovery and a shorter hospital stay compared with open surgery

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Vascular Endothelial Growth Factor as Antiapoptotic Factor and Monocyte Chemoattractant Protein-1 in Acute PancreatitisI. Bihalskyy1, S. Chooklin1

1Medical University, Lviv, Ukraine

Introduction: Vascular endothelial growth factor (VEGF), also known as vascular permeability factor, is a glycoprotein with potent angiogenic, mitogenic, and vascular permeability-enhancing activi-ties. VEGF can also stimulate cell migration and inhibit apoptosis. Monocyte chemoattractant protein-1 (MCP-1) is the early and critical cytokine and chemokine, respectively in immune responses. The role of VEGF and MCP-1 in acute pancreatitis patients is not clear.

Objectives: We studied the role of VEGF and MCP-1 in organ dysfunction in acute pancreatitis patients.

Patients and Methods: Applying the ELISA technique, levels of VEGF, MCP-1 and CRP were studied in 36 patients with acute pancreatitis. According the Atlanta criteria the mild pancreatitis was established in 16 patients and severe in 20 patients.

Results: The mean value of serum VEGF levels in patientswith acute pancreatitis was significantly higher than that in healthy volun-teers. It was a clearcorrelation between levels of VEGF and severity of pancreatitis. MCP-1 inserum were all significantly higher in patients developing severe AP than inpatients with mild AP. Serum VEGF levels with hepatic dysfunction werehigher than those without hepatic dysfunction. Serum VEGF levels with renal insufficiency weresignificantly higher than those without renal insufficiency. MCP-1 serum concentrations showed a dramatic increase in patients whodeveloped local complications and/or remote organ dysfunction.

Conclusion: VEGF is closely related to organ dysfunction in acutepancreatitis. MCP-1 may play a pivotal role in thepathological mechanisms of complicated AP. VEGF may function asnot a vascular permeability factor, but a anti-apoptotic factor against theorgan inju-ries in severe acute pancreatitis.

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Epidemiologic Data of Acute Pancreatitis in AlbaniaF. Kurti1, J. Basho2, L. Cakerri3, A. Duni4, I. Akshia5

1Service of gastrohepatology, UHC “Mother Theresa”, Tirana, Albania, 2Service of gastrohepatology, UHC “Mother Theresa”, Tirana, Albania, 3Department of bio-physics Faculty of Medecine, UT, Tirana, Albania, 4Service of gastrohepatology, Central Policlinics, Tirana, Albania, 5Department of Statistics, UHC “Mother Theresa”, Tirana, Albania

Introduction: In the western countries, biliary stones and alco-hol abuse are the precipitation couses in over 80% of cases with acute pancreatitis (AP).


Objectives: Aim of this study was to evaluate the incidence and the ethiology of AP in Albania.

Patients and Methods: We retrospectively studied 116 cases admitted at the serivce of Gastro-hepatology UHC ‘Mother Theresa’ during one year, 93 males (80.17%), 23 females (19.82%), mean age 45.74±13.05 years old (range 20-76 years). All these patients were confirmed with AP with different degrees of severity with clinical, laboratory and imaging findings.

Results: We found alcoholic pancreatitis in 69 pts (62.08%), gallstone pancreatitis in 30 pts(25.86%), hiperlipidemia in 3 pts(2.6%), both alcoholic and gallstones in 4 pts (3.4%), and idiopathic in 7(6.03%). Daily intake of alcohol was 200-400 gr/d of ethanol; dura-tion of alcohol consumption from 5 to 25 years. The male female ratio was 4.04:1. Most of the cases were found in the third, fourth and fifth decade of life (74.13%). We found 20 pts with AP over 60 yrs. We found abdominal pain in 100% of cases, nausea in 91(78.44%), vomitting in 79 (68.1%), fever in 35(30.17%), abdominal distension in 78(67.24%), abdominal tenderness in 35(30.17%), diarrhea in 21(18.1%).

Conclusion: Alcohol abuse was the most frequent ethiological factor of AP. Most of the patients were under 60 years old. The num-ber of alcoholic AP is increassing due to alcohol consumption among young people. We found no mortality among of our patients.

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Soluble TNF Alpha Receptor (sTNF Alpha R) is an Important Marker of Severe Acute PancreatitisE. Fisic1, I. Krznaric Zrnic2, L. Bilic Zulle1, S. Milic2, D. Stimac2

1Division of Laboratory Diagnostics, University Hospital Rijeka, Rijeka, Croatia, 2Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka, Rijeka, Croatia

Introduction: Acute pancreatitis is inflammatory process, usu-ally limited to pancreas. Systemic involvement of distant organs defines severe form of the disease (severe acute pancreatitis – SAP) that leads to multiple organ failure and death ultimately. It is very important to predict the course in the early stage of the disease. Some cytokines (IL-6, IL-8) are good markers for prediction of SAP.

Objectives: To establish the prognostic value of sTNFαR as new potential marker for development of severe acute pancreatitis.

Patients and Methods: The study was carried out in a group of 150 patients with acute pancreatitis (71 males, 79 females) admit-ted to our Division of Gastroenterology. Concentration of sTNFR was determined by enzyme-linked immunosorbent assay (ELISA) from the blood samples taken on the admission day. Prognostic value of sTNFR was performed by ROC analysis.

Results: sTNFR showed high sensitivity (82%) for predicting development of SAP at cut off value of 1552 pg/mL. Specificity was 65% (AUC 0.69, CI 0.60-0.76). IL-6 and IL-8 showed also high prog-nostic values (AUC 0.71 95% CI 0.63-0.78 and AUC 0.66 95% CI 0.58-0.74).

Conclusion: Our results have shown that sTNFR could be a very useful early prognostic marker for development of severe acute pancreatitis.

P73

Red Distribution Width (RDW) and Ferritin as Prognostic Factors in Acute PancreatitisS. Milic1, I. Mikolasevic1, G. Poropat1, M. Radic1, N. Franjic1, D. Stimac1


Introduction: RDW is a standard parameter of complete blood count. The usefulness of determining the value of RDW examined in many pathological inflammatory and non-inflammatory conditions such as inflammatory bowel diseases, myocardial infarction, heart failure, renal failure, but not in acute pancreatitis (AP). Ferritin is an acute phase reactant and thus may be increased in patients with inflammation, like AP, and also in liver disease, chronic infection, autoimmune disorders, and some types of cancer. Ferritin is not typi-cally used to detect or monitor these conditions.

Objectives: To determine correlation of RDW and ferritin with the clinically used predictors of severity of acute pancreatitis such as complex scoring systems (Ranson and APACHE II).

Patients and Methods: One hundred and forty-one patients (52%male and 48% female) in a 2-year period (2007-2008) were enrolled in this study. RDW and ferritin values were obtained on an automated hematology analyzer (Olympus AU 640, Tokio, Japan). Statistical methods used Pearson’s correlation test.

Results: RDW showed moderate correlation to Ranson (r = 0.201, p = 0.017) and moderate correlation to APACHE II (r = 0.256, p = 0.002) as a marker for predicting severity of AP. There was neither significant correlation between ferritin and Ranson (r = 0.007, p = 0.932), as well as Appache II scores (r = 0.070, p = 0.414).

Conclusion: To our knowledge, our study demonstrates for the first time that RDW is inexpensive, easily obtained, and powerful prognostic marker for AP, but warrants further confirming studies in larger series of patients.

P74

Hematocrit, Serum Creatinine and Urea Nitrogen as Markers of Pancreatic NecrosisG. Poropat1, G. Hauser1, V. Licul1, D. Stimac1


Introduction: Pancreatic necrosis is a serious local complica-tion of acute pancreatitis associated with worse clinical outcome and higher mortality.


Objectives: To identify predictive value of serum creatinine, urea nitrogen and hematocrit in early detection of necrotizing pan-creatitis.

Patients and Methods: We analyzed 97 patients with moder-ate to severe acute pancreatitis defined by an APACHE II score of 6 and more. All subjects performed computerized tomography (CT) between days 4 and 7 of admission with the calculation of CTSI score. Values of serum creatinine, urea nitrogen and hematocrit were assessed on admission and on days 2 and 3. We calculated the intrave-nous fluid resuscitation volume for each patient on admission and within 72 h of admission.

Results: Of 97 included patients, 24 (25%) developed pancre-atic necrosis. Low serum hematocrit on admission showed a negative predictive value of 82%, while no significant results were obtained for serum creatinine and urea nitrogen. ROC curves for pancreatic necrosis revealed an area under the curve of 0.67 for admission hema-tocrit, 0.44 for peak creatinine, and 0.48 for peak urea nitrogen. Binary logistic regression retrieved no significant association between the three tests and pancreatic necrosis. We found that patients who developed pancreatic necrosis received a significantly higher volume of intravenous fluid resuscitation within the first 24 h (P < 0.005).

Conclusion: We confirmed that a low admission hematocrit is associated with a low incidence of pancreatic necrosis. Our results don’t suggest significant association of serum creatinine and urea nitrogen values with the development of pancreatic necrosis.

P75

PCD in Patients with Acute PancreatitisV. Lobankov1, A. Litvin2, S. Svistunov3, D. Khokha4, V. Khokha5

1State Medical University, City Clinical Hospital N 3 Gomel, 2State Medical University, Regional Clinical Hospital Gomel, 3Regional Clinical Hospital Gomel, 4State Medical University, City Hospital Mozyr, 5City Hospital Mozyr, Belarus

Introduction: Percutaneous drainage continue to gain popular-ity for treating fluid collections in acute pancreatitis.

Objectives: The aim of the study was to evaluate the results of this approach in patients with acute pancreatitis in Gomel Region of Belarus.

Materials and Methods: A retrospective audit of percutaneous drainage performed within 2004 and 2008 on surgical units of Gomel Clinical Regional Hospital and Mozyr City Hospital was carried out.

Results: The 75 patients, median age 52.5 (range 30 –77) years, were included in this study. PCD were used in patients with simple fluid collections as a final treatment (n –38) and in critically ill patients with infected necrosis to delay open necrosectomy (n- 37). Multiplanar CT images of pancreatic necrosis have greatly facilitated PCD. Pancreatic fluid collections were detected by CT in all 75 patients who all had Balthazar grade D or E, within 72 hours after admission. In the majority of cases collections were located in the tail (n –22) or body and tail (n-47) of the gland. Reasons for using an open technique included poor access route and failure to finish proce-dure, extensive retroperitoneal infected necrosis and multifocal necrotic foci. The time of drainage placement after hospital admis-

sion was with a median of 11,7 days. The median diameter was 1,5 cm. From 75 treated by PCD mortality was 10 (6%).

Conclusion: PCD is a therapy of choice for simple fluid collec-tions. In critically ill patients it allows to postpone open necrosectomy and improve the outcome.

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Stepped Approach in the Treatment of Severe Acute PancreatitisA. Litvin1, V. Khokha2

1Gomel Regional Clinical Hospital, Gomel State Medical University, 2Mozyr City Hospital

Introduction: Minimally invasive strategies are a possible first stage for the treatment in severe acute pancreatitis. In the Belarus, the standard intervention is necrosectomy by laparotomy and/or retro-peritoneotomy.

Objectives: To assess patient’s selection, techniques and results of stepped approach in the treatment of acute necrotizing pancreati-tis.

Patients and Methods: We treated 72 patients with acute necrotizing pancreatitis. Patients were recruited from 2 hospitals over a 5-year period (from January, 2004 to December, 2008). 72 patients with acute necrotizing pancreatitis were randomly allocated to 2 groups. Group A (37 patients) - minimally invasive approach (1st step) followed, if necessary, by open debridement (2nd step). Group B (35 patients) –initially maximal necrosectomy by laparotomy and/or retroperitoneotomy. Both tactics are followed by open packing method (Penrose drainage) with planned redebridement. The primary endpoint was the proportion of patients suffering from postoperative major morbidity and mortality. Secondary endpoints are complica-tions, new onset sepsis, length of hospital and intensive care stay.

Results: The most common cause of the pancreatitis was alco-hol abuse and gallstone disease (62.5% and 20.6%). The time from the onset of pancreatitis to minimally invasive drainage was 411 days (mean 5.3 days). The hospital stay time after laparotomy was 19.7 days (10-34) –Group A versus 27.7 days (18-62) –Group B. The over-all mortality was 27.0% (10/37) –A Group, 48.6% (17/35) –B Group. Signicant general complications (severe sepsis, severe MOF) occurred in 18 patients (48.6%) of A Group, 25 patients (71.4%) of B Group. The incidence of bleeding, extended phlegmon, and stula was 10.8% (4/37), 40.5% (15/37), and 8.1% (3/37) –Group A, 20.0% (7/35), 65.7% (23/35), 14.3% (5/35) –Group B, respectively.

Conclusion: We suggest the minimally invasive drainage as a first intervention in patients with severe acute pancreatitis. If septic symptoms or MOF developed in spite of drainage open debridement (2nd step) is mandatory. The stepped approach results in a reduction in postoperative major morbidity and mortality.


P77

Multi-discipline Management of Severe Acute Pancreatitis : 12 Years’ PracticeW. Li1, Z. Tong1, Z. Quan1, Y. Zhao1, W. Yu1, X. Ye1, Z. Wang1, X. Wang1, Z. Wang1, D. Ji1, N. Li1, J. Li1

1Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, 2Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, 3Research Institute of Nephrology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China

Introduction: The single-discipline management of severe acute pancreatitis is very difficult because of the complexity of the disease.

Objectives: To definite the role of muti-discipline management of severe acute pancreatitis on the therapic practice in last 12 years.

Patients and Methods: The traditional single-discipline man-agement of severe acute pancreatitis was changed to multidiscipline management from 1997 in a teaching hospital. The muti-discipline team includes intensivist, endoscopists, gastroenterologists, radiolo-gist, nephrologist and surgeons. All these members cooperate on the basis of Surgical Intensive Care Unite(SICU). From Jan 1997 to Mar 2009, a total of 1033 patients suffered SAP were admited with a mean APACHEII score 12.04±4.27. All patients were treated in SICU in the early phase. In these 1033 patients, 365 cases received mechanical ventilation, 218 with tracheotomy, 159 cases received high-volume continuous venovenous hemofiltration (CVVH), 179 received naso-biliary drainage, 513 were treated with ealy enteral nutrition. CT-guided percutaneous catheter drainge for peripancreatic fluid collection was pefromed for 316 times and 438 patients received surgical debride-ment for infected pancreatic necrosis.

Results: The survive of patiens was much improved in this group than before (1988-1996). In all these 1033 cases, 975 patients 94.4% survived, and 38 patients died (3.7%) at last. The total mortal-ity (3.7% vs 20.4%) and the mortality of patients who received surgi-cal debridement for infected pancreatic necrosis (7.1% vs 24.0% were both much lower than before (1988-1996).

Conclusion: The muti-discipline management of severe acute pancreatitis can remarkably improve the prognosis of patients.

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Necrotizing Pancreatitis: Early Drainage with Postponed NecrosectomyM. Rubtsov1, S. Galeev2, O. Klitsenko3

1General surgery, Saint-Lucas Clinical Hospital, Saint-Petersburg, 2Abdominal surgery, Saint-Petersburg State Med. Academy, 3Statistics department, Saint-Petersburg Postgraduate Med. Academy

Introduction: It’s generally accepted: necrosectomy in early phase of severe pancreatitis increases mortality. At the same time,

most of irreversible organ failures and deaths associated with infec-tion resistant to conservative measures.

Objectives: To perform comparative analysis of treatment results in two series of patients: managed conservatively (group 1), underwent early open drainage of extrapancreatic necrosis with delayed necrosectomy (group 2).

Materials and Methods: A retrospective study of 71 patient with severe pancreatitis (abscesses and cysts were excluded) in 9 year period (2000-2009) was done. 17 patients were treated without opera-tion, other (54) underwent early (mean time from the disease onset –6,1±7,1 days) drainage with further necrosectomy (mean time from primary operation –12,5±6,0 days).

Results: Above-mentioned groups were comparable in regard to local complications severity (Balthazar index turned out to be equal, p = 0,49; extended pancreatic necrosis (>50%) was diagnosed in 4 patients of group 1 (26,7%) and 8 of group 2 (19,5%), p = 0,83). Initial (on admission) systems dysfunction according to Atlanta consensus were present in 4 (23,5%) and in 33 (61,1%) patients of conservative and surgical groups, respectively, p < 0,05. Mean admission APACHE II score between two groups didn’t differ (8,9±5,4 vs. 14,5±7,8; p = 0,24). We haven’t observed early drainage negative effect on a course of the disease (mortality rates in groups were practically simi-lar: conservative therapy –4 patients died (23,5%); surgical treatment –19 patients died (35,2%), p = 0,37). Misfortune of surgery in most part of cases might be explained by late admission of patients with advanced septic complications.

Conclusion: Drainage and necrosectomy temporal separation seems to be beneficial sepsispreventive tactic, equalizing results of conservative and surgical treatment.

P79

Severe Acute Pancreatitis as Complication of Blunt Polytrauma which Increase MortalityA. Kozachenko1, K. Gorbenko1

1Kharkiv City Clinical Hospital of Emergency

Introduction: The urbanization and the raised technogeny dan-ger result in the increase of blunt polytrauma cases. Acute traumatic pancreatitis is severe complication of abdominal trauma. Contemporary methods of diagnostic make it possible to precisely determine character of pancreas injury.

Objectives: To determine the influence of severe acute pancreti-tis and its complications on outcomes of the blunt polytrauma accom-panied by pancreas injury.

Patients and Methods: We used the retrospective analysis of 346 blunt polytrauma patients which were treated in special “poly-trauma” department of the hospital from 2005 to 2009. They were divided for group (n = 24) with severe acute traumatic pancreatitis and (n = 322) without it. In the groups the patients were divided as to their severity according to ISS and polytrauma score scales. We assessed the role of the severe acute pancreatitis in outcomes of the trauma and necessity of additional treatment.

Results: Mortality was higher in the group with severe acute pancreatitis than the “nonpancreatitis” group (45,8% v. 13,4%; over-


all mortality 15.6%). The patients with AP needs more crystalloids and blood transfusion volumes, additional treatment (including the reserve antibiotics). The stages relaparotomy more often were per-fomed in group with severe traumatic AP. The diagnostic procedures in “pancreatitis” group more often include abdominal computed tomography (CT), MRI scans besides sonography for trauma (FAST) examination.

Conclusion: Among the polytrauma patients with abdominal trauma, 6.93% has severe acute traumatic pancreatitis, and mortality was higher among these patients than among those who did not have the AP. They need additional diagnostic and treatment.

P80

Is There Any Connection Between Bile Outflow Obstruction and Laparoscopic Signs of Necrotizing Pancreatitis in Patients with Acute Biliary PancreatitisA. Epshteyn1, S. Dynkov2, B. Duberman2, A. Sovershaev1

1First city hospital of emergency care, Arkhangelsk, 2Northern State Medical Univercity

Introduction: Problem of diagnosis and treatment of acute bil-iary pancreatitis (ABP) is still not solved. Some studies have showed that the presence of bile outflow obstruction impacts the course of pancreatitis.

Objectives: We tried to find connection between bile outflow obstruction and laparoscopic signs of necrotizing pancreatitis in patients with ABP.

Patients and Methods: Retrospective study. Diagnosis of ABP was based on standart criterions. We used urgent duodenoscopy to determine the presence of biliary obstruction in all patients with ABP. During 2002-2004 years were done 203 investigations. Based on the results of duodenoscopy we have picked out 2 groups of patients. Patients with signs of blocked bile outflow were in first group (112 patients). Second group consisted of 91 patients with normal bile out-flow and absence of papilla major inflammation. After urgent duo-denoscopy laparoscopy was done in 60 patients. It were 35 patients from first group, and 25 patients from second one.

Results: During laparoscopy signs of necrotizing pancreatitis in peritoneal cavity were revealed in 9(36%) patients from first group, and in 17 (48,6%) patients from second group. Normal picture was in 6 (24%) and 6 (17,1%), and signs of oedematous pancreatitis in 10 (40%) and 12 (34,3%) accordingly. We did not found any correlation ( = 0,256) between bile outflow obstruction and signs of necrotizing pancreatitis during laparoscopy.

Conclusion: Bile outflow obstruction does not definitely cause necrotizing pancreatitis. It is necessary to conduct further investiga-tions with emphasizing on time interval from the very beginning of pancreatitis.

P81

Role of the Pancreatic Antibodies in the Posttraumatic Pancreatitis DiagnosticsK. Gorbenko1, V. Boyko1, J. Volkova1, P. Zamyatin1, A. Kozachenko2, A. Vasko2

1Kharkiv National Medical University, 2Kharkiv Municipal Clinical Hospital of Emergency Medical Help

Introduction: Posttraumatic pancreatitis is the main complica-tion of the blunt pancreatic trauma, which may result in considerable morbidity and mortality. It is known, that serum level of pancreatic antibodies (PA), formed following pancreatic destruction, depends on the damage and inflammation grade in the organ.

Objectives: The aim of the study was to estimate the role of the pancreatic antibodies in the posttraumatic pancreatitis diagnostics.

Patients and Methods: 102 patients treated for pancreatic trauma were retrospectively studied. The diagnostic, operative infor-mation, hospital course and complication rates were abstracted from medical records. Only patients without chronic diseases of pancreas, liver or duodenum, blood diseases and cardiovascular diseases were selected. PA serum concentration was analysed using enzyme immu-noassay. Blood samples for analysis were collected in patients before intensive treatment and then in 1,3,5,7,9, 14 and 21 days during the postoperative period.

Results: PA level in patients without pancreatitis reached 0.22-0.23 ng/ml during the postoperative period. In patients with light pan-creatitis PA serum concentration increased in 1.5-2 fold (P < 0.05) on the 7 day comparing with the normal date, and raised to its maximal level (0.58ng/ml) on the 9 day, following further decrease. In patients with severe pancreatitis PA level lifted in 2.5-3.5 fold (P < 0.02) on the 5 day compared to the normal date, reaching 0,71 ng/ml on the 9-14 days and slowly decreasing to 21 day.

Conclusion: Thus, we can conclude that dynamical PA determi-nation in patients with pancreatic trauma may be used as the pathog-nomonic sign in pancreatitis diagnostics.

P82

Management of Severe Acute Pancreatitis with Integrated Chinese and Western Medicine: A 26-year Clinical Experience and Report of 1561 CasesT. Wenfu1, G. Hanlin1, L. Juan1, W. Meihua1, C. Guangyuan1, X. Qing1

1Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China

Introduction: There are no specific drugs or treatments for acute pancreatitis, Chinese herbal decoctions are accepted nation-wide. Here, we report the changes in management of SAP over the past three decades in China, during which an integrative approach involving Western medicine and Chinese herbal medicine has become


increasingly popular. The study focused on a university hospital that treated 1561 patients from 1980-2005.

Objectives: To report the changing trends of clinical manage-ment for severe acute pancreatitis with integrated Chinese and Western medicine.

Patients and Methods: Clinical data of 1561 patients with severe acute pancreatitis from 1980–2005 was retrospectively analyzed. The mortality and morbidity of complications were com-pared.

Results: Of the 1561 patients, were treated conservatively with integrated Chinese and Western medicine while 400 patients accepted surgical operation. There was a change towards conservative manage-ment together with Chinese purgative herbal medication use after 1990 (22.4% from 1980–1990 compared with 45.5% from 1991– 1993) because of high post-operative mortality. From 1994–2005, the treatment using a combination of Western medicine with Chinese herbal medications came to be preferred over the classic Western operation-based method. This shift was associated with decreased morbidity and lower mortality (40.52% in 1980–1990 compared with 17.17% in 1991– 1993 and 10.25% in 1994–2005).

Conclusion: The combination of conservative management with Chinese herbal medicines is favored over classic Western medi-cine treatment in the reduction of morbidity and mortality, with the use of surgery being a supplemental option.

P83

Acute Pancreatitis: Severity and Outcome Prediction. Is it a Sole Problem?S. Galeev1, M. Rubtsov2, O. Klitsenko3

1Abdominal surgery, Saint-Petersburg State Med. Academy, 2General surgery, Saint-Lucas Clinical Hospital, Saint-Petersburg, 3Statistics department, Saint-Petersburg Postgraduate Med. Academy

Introduction: There are few relevant methods for predicting of fatal outcome and prolonged ICU stay in acute pancreatitis. According to literature data, most scoring systems (Ranson, APACHE etc.) serve as predictors of severity and outcome simultaneously.

Objectives: To detect and compare precursors associated with severe pancreatitis and unfavorable disease outcome.

Materials and Methods: A retrospective study of 89 patients with acute pancreatitis in 9 year period (2000-2009) was done. 71 patients suffered from severe disease, 17 had mild pancreatitis con-firmed by CT with contrast-enhancement. There were different clini-cal, laboratory and instrumental data analyzed for detection severity and outcome markers.

Results: Univariate analysis showed that 5 signs are useful for severe pancreatitis prediction: APACHE >= 8, CRP >= 120 mg/l, serum amylase <250 U/l, procalcitonin >= 0,5 ng/ml, pleural effusion (on chest X-ray). Outcome prediction model also included 5 vari-ables, conjoined into 3 groups: 1. early pancreatitis-specific organ failure (PO2/FiO2 <250, creatinine >150 mcmol/l, pressure-adjusted heart rate >= 10); 2. CT data (extended pancreatic necrosis); 3. infected necrosis. Outcome prediction accuracy of this model amounted to 88,3% (sensitivity-93,3%; specificity-84,2%).

Conclusion: Our data suggest: severity predictors and precur-sors of outcome in acute pancreatitis are different. Early outcome pre-diction seems to be more important clinical problem than severity prognosis.

P84

Role of Hematocrit in the Early Prediction of Severity of Acute PancreatitisD. Bajec1, I. Pejovic1, D. Radenkovic1, P. Gregoric2, D. Gunjic1, B. Karadzic2

11st Surgical Clinic, Belgrade, 2Center of Emergency Surgery, Belgrade

Introduction: The early and accurate prediction of the severity of acute pancreatitis (AP) and the assessment of prognosis of the dis-ease are very important and can influence the course of disease and outcome.

Objectives: The aim of this study was to determine the relation between hematocrit level on admission and AP severity.

Patients and Methods: This retrospective study included 91 patientstreated in the Clinic for Emergency Surgery, Clinical Center of Serbia. Patients were divided into two groups: patients with severe (SAP) and patientswith mild AP (MAP). Severity of acute pancreati-tis (SAP) was defined accordingto Atlantaclassification system. Patients main characteristics curves (age, gender), etiology and result of the treatment were determined, as well as value ofhematocrit on admission. Receiver operation characteristics (ROC) analysisdeter-mined cut-off value, sensitivity and specificity of hematocrit level asparameters for prediction of severity of AP.

Results: Group with SAP consisted of 33 (36%) patientsand group with mild AP consisted of 58 (64%) patients. Average hemat-ocrit levelon admission was: 44% for SAP and 41% for mild AP patients. For hematocritcut-off level on admission (44%), sensitivity and specificity for prediction ofseverity of AP were 63,5% and 85,7% respectively.

Conclusion: The assessment of AP severity can be based on hematocrit level on admission that is higher than 44%. Among all the variables available, the value of hematocrit on admission can be a useful and cost-effective marker which provides significant predic-tive power for clinical decision making.

P85

Interleukin 2 in Complex Treatment of Severe Acute PancreatitisS. Chooklin1, O. Hranat1

1Medical University, Lviv, Ukraine

Introduction: In pathogenesis of acute pancreatitis the impor-tant role are play pro- and anti-inflammatory cytokines. Their disbal-ance leads to depletion of immunocompetent cells and defines the expressed secondary immunodeficiency, which after 7-14 days


becomes a leading pathogenetic link of acute necrotizing pancreatitis. Therefore adequate immunotherapy obvious a role in complex treat-ment of this severe pathology.

Objectives: Perspective use as preparations of immune support of cytokines in this respect is.

Patients and Methods: We examined 19 patients with severe acute pancreatitis. We studied quantity of theT-lymphocyte and level of cytokines (IL-2, IL-4, IL-8, TNF-). Ten patients received in com-plex therapy recombinant interleukin-2 in a dose of 3 million . Nine patients examined as control.

Results: The mean value of serum all cytokines levels in acutepancreatitis patients was significantly higher than in healthy volunteers. Reduction of total lymphocytes and active lymphocytes in peripheralblood is noted. Reduction of both helpers, and lymphocytes with cytotoxic and suppressorfunctions are noted. Changes of cytok-ines statusafter interleukin 2 therapy are noted too. Authentic levels depression of allcytokines in peripheral blood is established. The level of IL-2 tended to normalisationin comparison with a disease debut, but remains lower, than in healthy donors. After therapy nor-malization of lymphocytes level (CD3, CD4, CD8) is noticed. In the basic groupindicators of enzymatic activity were fast normalised, there was a smallercomplications and indications to operations.

Conclusion: Use of interleukin 2 in complex treatment of severepancreatitis expediently for correction immunoparalysis and preventive of purulent-septic complications.

Clinical Science – Chronic & Autoimmune Pancreatitis

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The Analisis Number of Aggravations on Patients with the Chronic Pancreatitis, Depending on Use Non-steroidal Antiinflammatory Drugs (NSAIDs)N. Shirinskaya1, L. Tcarkova2

1Omsk Medical Diagnostic Center, Omsk, Russian Federation, 2Omsk Emergency Hospital 2, Omsk, Russian Federation

Introduction: Estimates amount of disease attributable to Non-steroidal anti-iflammatory drugs have varied widely. But in the litera-ture there are few data of a course a chronic pancreatitis at patients use NSAIDs.

Objectives: –Patients and Methods: We retrospective analyzed of history

illines of patients with the chronic pancreatitis for the 7-years period. The study included 93 patient (39 female; 54 male; range 55,4±0,9 years). Patients have been section 3 subgroups according to use NSAID: 1 - not use NSAIDs –35 person, 2 - receiving therapy by COX-1 inhibitors –26 person, 3 - receiving therapy by COX-2 inhibi-

tors –32 person. The amount of aggravations of a chronic pancreatitis in a year was estimated.

Results: During supervision over patients has noted been the difference in amount of aggravations of a chronic pancreatitis depend-ing on use NSAIDs.

The patients not use NSAIDs, during supervision registered 5,4 ±0,25 aggravations in a year; at the patients use COX-1 inhibitors this parameter decreased up to 3,73 ±0,19 (1-2 < 0.001); and the patients use COX-2 inhibitors up to 2,45 ±0,13 (1-3 < 0.001; 2-3 < 0.001). The result of analysis it is shown, that the amount of aggravations at patients with a chronic pancreatitis use COX-2 inhibitors is authentic less than at patients use COX-1 inhibitors.

Conclusion: Our results support the hypothesis that COX-2 may be involved in inflammatory responses in chronic pancreatitis and in the progression of this chronic inflammatory disease. This research show, that inhibitions COX-1 and especially COX-2 can be the important factor in reduction of a inflammation in pancreas.

P87

Laparoscopic Internal Drainage of the Pancreatic PseudocystsA. Siatkouski1, A. Shchastny2, M. Kuhayeu2, S. Lyarski1

1Vitebsk Regional Clinical Hospital, Vitebsk, Belarus, 2Vitebsk State Medical University, Vitebsk, Belarus

Introduction: The usefulness of laparoscopic access in treat-ment of chronic pancreatitis has to be explored.

Objectives: The analysis of laparoscopic operations in treat-ment of pancreatic pseudocysts.

Patients and Methods: 180 patients with pseudocysts were treated (2002-2009). In 76(42.2%) cases minimally invasive proce-dures were used: fourteen patients were treated laparoscopically, and 62 –by the US-controlled draining.

Results: Traditional interventions were performed in 104(57.8%) and laparoscopic –in 14(7.8%) cases: cystogastrostomy 4, cystoduo-denostomy 1, cystojejunostomy 8 and cystectomy 1. In all the cases of laparoscopic procedures the communication of a cyst with the main pancreatic duct were confirmed by preoperative biochemical and cytologic analysis of cystic fluid taken under the US control puncture. There were two conversions because of bleeding (1), and the neces-sity of the inflammatory mass removal in the pancreatic head, which was impossible to perform laparoscopically. There were no complica-tions and deaths. Intraoperative blood loss was 80±40 ml. The hospi-tal stay was 8±2 days after the laparoscopic operations, against 16±5 days after traditional interventions.

Conclusion: The laparoscopic access is useful for the treatment of pancreatic pseudocysts including ones communicating with the pancreatic duct.


P88

Application of 13-mixed Triglyceride Breath Test for Diagnostics Pancreatic Insufficiency in Adult Payients with Coeliac DiseaseO. Kozhevnikov, Y. Chichula, L. Parunian

Department of internal medicine 1, National Medical University, Kyiv, Ukraine

Introduction: Coeliac disease (CD) is associated with exocrine pancreatic insufficiency which may lead to continued or recurrent gastrointestinal symptoms. We examined a group of patients with celiac disease (n = 48) and found that 12/48 patients with persistent diarrhea had exocrine insufficiency.

Objectives: The aim of investigation is to examine exocrine pancreatic insufficiency in adult patients with celiac disease with the help of 13C-mixed triglyceride breath test.

Materials and Methods: All 48 patients CD were diagnosed with coeliac antibody tTG and has also been confirmed byhistologi-cal examination of biopsy of the small intestine. All patients were investigated exocrine pancreatic function using noninvasive exo-crinepancreatic function diagnostic test –13C-mixed triglyceride (13C-MTG) breath test. The 13C-MTG breath test was performed by giving a solid test meal and 300 mg ofsubstrate. Breaths samples were collected before and in 30 min intervals for 6hours after the meal. The global cumulative 13CO2 recovery (%) measured by massspectrom-etry was considered as a result of the test. In the event must be assigned to enzyme replacement therapy.

Results: The result of 13C-MTG breath test showed that 25% of patients with persistent diarrhea and other signs of exocrine pancre-aticinsufficiency (12 out of 48) was found to decrease the activity of pancreaticlipase varying degrees of severity. Considering the data obtained, all patients diagnosed with exocrine pancreatic insuffi-ciency, was appointed byenzyme replacement therapy.

Conclusion: The 13C-mixed triglyceride breath test is a helpful in the diagnosis of exocrinepancreatic insufficiency in patients with celiac disease. This test has good sensitivityand specificity, but also suitable for use in clinical practice.

P89

Evaluation of Elimination Diet Efficacy in Patients with Pancreatic Exocrine Insufficiency Based on Individual Food Intolerance FED-testA. Martynchuk1, O. Shvets1, N. Mikhnyova1

1Ukrainian Research Institute of Nutrition

Introduction: Despite of existence of different dietetic approaches in patients with EPI, there is lack of evidence of clinical efficacy for most popular universal dietary restrictions.

Objectives: To study impact of dietary changes on exocrine pancreatic function in patients with exocrine pancreatic insufficiency (EPI) by mean of individual food intolerance detection.

Patients and Methods: The study included 37 patients (23 females and 14 males) with EPI. The mean age was 47±4,5 years with follow-up period of 6 month. All patients were divided onto two groups by level of stool pancreatic elastase 1: 1st group (21 patients) with mild EPI and second group (16 patients) with moderate EPI. The score from 1 to 5 had been used to evaluate clinical symptoms. The enzyme substitute therapy was used in all patients. The elimination diet was additionally introduced to 12 patients from first group and to 8 patients from second group based on results of FED-test.

Results: Independently from EPI rate there were intolerance of casein (38%); mushrooms (33%); legumes (32%); yeasts (32%); wheat (27%) and coffee (23%) among mostly intolerated foods. The symptoms’ score was significantly better after 6 months in both groups in patients on elimination diet. This improvement in symp-toms was more appreciable in 1st group in patients with mild EPI.

Conclusion: Adequate enzyme substitute therapy together with correction of individual food intolerance in patients with EPI could lead to significant clinical improvement in 6 months of follow-up.

P90

Functional State of Pancreas in Chronic Abdominal IschemiaN. Gubergrits1, K. Voronin1

1Donetsk National Medical University, Ukraine

Introduction: Blood flow in pancreas disturbs in atherosclero-sis of abdominal aorta and its branches that lead to decrease of pan-creas function.

Objectives: To study exocrine secretion of pancreas in patients with chronic abdominal ischemic syndrome (AIS).

Patients and Methods: 120 patients with AIS owing to athero-sclerosis were examined. Fecal elastase test, direct examination of exocrine function of pancreas (aminophylline-calcium test) were car-ried out. Presence of AIS was confirmed by dopplerography results.

Results: Normal indices of elastase test remained only in 9 (7,5%) patients. Severe pancreatic insufficiency was diagnosed in 16 (13,3%) patients, moderate - in 35 (29,2%) patients, mild - in 60 (50,0%) patients. According to results of aminophylline-calcium test hyposecretory type of pancreatic secretion was revealed in 81,5% of cases, low obturative type - in 12,3% of cases, upper obturative type of exocrine secretion of pancreas - in 6,2% of cases.

Conclusion: Overwhelming part of patients with AIS has exo-crine insufficiency of pancreas demanding replacement therapy by enzyme preparations.


P91

Exocrine Function of Pancreas in Patients with Chronic Posthemorrhagic AnemiasN. Gubergrits1


Introduction: It is known, that gastric secretion often decreases in chronic posthemorrhagic asiderotic anemias. Exocrine secretion of pancreas was not studied.

Objectives: To study results of fecal elastase test in chronic pos-themorrhagic anemias.

Patients and Methods: 122 patients with chronic posthemor-rhagic anemia were examined. All patients were women who were on treatment in gynecologic department. Exocrine secretion of pancreas was studied by means of fecal elastase test.

Results: Normal indices of fecal elastase-1 were revealed only in 43 (35,8%) patients. Indices of elastase were decreased in others 79 (64,2%) patients. 62 (50,8%) patients had mild pancreatic insuffi-ciency, 17 (13,9%) - moderate insufficiency. Severe decrease in exo-crine secretion of pancreas was not revealed in any case.

Conclusion: It is necessary to control exocrine secretion of pan-creas in patients with chronic posthemorrhagic anemia because its decrease can influence on results of anemia treatment.

P92

The Pecularities of the Cytokine Chain in Patients with Chronic Panreatitis Combined with Chronic Obstructive Pulmonary DiseaseJ. Teleki1

1Bukovynian State Medical University, Chernovtsy, Ukraine

Introduction: Exacerbation of chronic pancreatitis (CP) can be accompanied with systemic inflammatory response. Besides it was established that the exacerbation of the chronic obstructive pulmo-nary disease (COPD) is accompanied by the activation of the local inflammation in pulmonary tissue and rise of the cytokines in the peripheral blood. This is a sign that COPD exacerbation is associated with the systemic inflammatory response.

Objectives: To analyze the level of some circulating in blood pro- and anti-inflammatory cytokines, such as C-reactive protein (C-RP), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha), interleukin-10 (IL-10) in patients with CP combined with COPD.

Patients and Methods: 27 persons suffering from COPD formed group I, 25 COPD patients with concomitant CP formed the second group, and 7 healthy persons formed the comparison group.

Results: In patients of I and II groups high concentrations of IL-6 (p < 0.05), TNF-alpha (p < 0.05), CRP (p < 0.05) and IL-10 com-paring with a group of healthy persons were revealed. However, the level of IL-6 and IL-10 in the second group was lower than in patients of group I (in 1.3 times, p < 0.05), TNF-alpha (in 4.6 times, p < 0.05), CRP (in 2.4 times, p < 0.05).

Conclusion: Cytokine’s disintegration in patients with CP com-bined with COPD on the background of the increased level of the

inflammatory cytokines inadequate to the level of the anti-inflamma-tory IL-10 and almost no response to TNF-alpha was found. It can prove the exhaustion of the anti-inflammatory factors resistance and the spread of the inflammatory response beyond the pancreas and the bronchopulmonary system.

P93

State of Proteolysis and Fibrinolysis in Patients with Chronic Pancreatitis Concomitant with Ischemic Heart DiseaseD. Gontsariuk1, T. Kenzerska1, Z. Nechipay1

1Bukovynian State Medical University, Chernivtsi, Ukraine

Introduction: Proteolytic activity is the main reason of the inflammation in the pancreas. Diagnostic value has the correlation between antiproteolytic activity and the activity of the proteolytic enzymes. Imbalance can course not only proteolytic destruction of the pancreas, but grows progressively worse of ischemic heart dis-ease.

Objectives: To estimate the state of proteolysis and fibrinolysis in patients with chronic pancreatitis concomitant with ischemic heart disease.

Patients and Methods: We examined 23 patients with chronic pancreatitis concomitant with ischemic heart disease (13 male, 10 female). Total fibrinolytic activity, enzymatic fibrinolytic activity and nonenzymatic fibrinolytic activity was examined. Proteolytic activity was examined by the lysis of azocasein and azocol.

Results: Examined patients had decreased rate of fibrinolytic activity of serum, especially enzymatic fibrinolytic activity, because of disturbance in the regulation of angiotensin II, thromboxane A2 and deposit of fibrin in the pancreas. Activation of serum proteolysis with degradation of high-molecular enzymes (4,55 ±0,18 mg/h; the group of practically healthy persons –1,93 ±0,11 mg/h) was observed. Direct correlation between nonenzymatic fibrinolytic activity and collagenase activity (r = 0,784), total fibrinolytic activity collagenase activity (r = 0,614), indirect correlation between enzymatic fibrin-olytic activity and proteolytic activity with azoalbumin (r = 0,589) was determined.

Conclusion: The disorders of hemostasis was defined be increasing of proteolytic activity in patients with chronic pancreatitis concomitant with ischemic heart disease. Hypercoagulation intensify the flowing of fundamental illness both with ischemic heart disease.


P94

CFTR Mutations in Chronic Pancreatitis in MoscowI. Shulyatyev1, V. Drozdov1, L. Vinokurova1, J. Borunova1


Introduction: It is known that in the significant percent of cases in patients with chronic pancreatitis (CP) identify a mutation in gene Ð¡FTR. Detecting of this mutation in the different countries consider-ably differs from 2% to 37%.

Objectives: To define mutations CFTR in patients with CP, passing treatment in Central Research Institute of Gastroenterology Russia, Moscow.

Materials and Methods: Examine 56 persons with CP, 39 male - age of 42 ±5,2years and 17 female age 51,9 ±6,4. In all patients the diagnosis of a CP was been confirmed according to clinical, bio-chemical and radial methods of research. In 14 cases they have pan-creatonecrosis in anamneses, 17 have calcifications in pancreas, 11 pseudocystsin pancreas, 34 patients (60.7%) abused alcohol, in 8 patients have gallstones. Serious degree of elastase-1 test (result <100 mg/g) was detected in 32 persons. Also 7 women (mothers of patients with cystic fibrosis) was examend. To all patients examine by PCR mutations in gene CFTR: F508, del21kb, 2184insA, 394delTT, R553X, W1282X, R334W and N1303K.

Results: In patient in surveyed group (56 persons) have not been detect mutations in gene CFTR. In 7 patients (mothers of sick cystic fibrosispatients, middle age 35,2±3,6), heterozygote F508 - 6 persons, a heterozygote del21kb - 1, in 5 cases have been diagnosed precur-sory symptoms of a CP.

Conclusion: Mutation influence in gene CFTR on a case rate in Moscow on a chronic pancreatitis is low and need the further study-ing. Parents of patients with cystic fibrosis have a high risk of inci-dents CP.

P95

The Quality of Life in Patients with Chronic Pancreatitis Combined with Chronic Obstructive Pulmonary DiseaseT. Khrystych1, J. Teleki1, O. Olinyk1

1Bukovinskiy State Medical University, Ukraine

Introduction: Frequency of chronic pancreatitis increases all over the world. In the same time chronic obstructive pulmonary dis-ease (COPD) is a problem that is growing rapidly worldwide. According to the level of such indices as prevalence and mortality, this pathology still takes first place among chronic diseases.

Objectives: To examine the quality of life in patients with chronic pancreatitis with concomitant COPD.

Patients and Methods: 52 patients and 10 healthy persons were examined. Three groups were formed. Group I - healthy persons (n = 10), group II (n = 26) - patients with chronic pancreatitis com-bined with COPD II-III degrees, group III (n = 26) - patients with COPD without accompanied diseases. We made conclusions about

quality of life using ”Sent George Respiratory Questionnaire”. Changing the amount of points to 4 units was considered clinically significant.

Results: During the examination of patients a difference of the scales “symptoms” and “activity” (p < 0.05) between the patients of II and III clinical groups was revealed. On the scales “influence” and “sum” no clinical difference was observed (p > 0.05).

Conclusion: The presence of the concomitant chronic pancrea-titis to some extent reduces the physical activity of the patients and affects the severity of the clinical course of COPD.

P96

The Influence of Antihomotoxic Preparations on Dynamic of Sonographic and Ultrasound Histographic Indices of Pancreatic Structure Changes in the Process of Rehabilitation Treatment of Chronic Pancreatitis Combined with Chronic BronchitisV. Kolkina1


Introduction: Due to incomplete effect of traditional rehabilita-tion treatment of patients with chronic pancreatitis it is necessary to study efficacy of new preparations which promote the regeneration of pancreatic tissue, lead to renew of its structure and function.

Objectives: To assess the influence of rehabilitation therapy with including antihomotoxic preparation Momordica compositum on sonographic changes of pancreas, its echogeneity, and indices of ultrasound histographia.

Patients and Methods: 106 patients with chronic pancreatitis combined with chronic bronchitis were examined. Patients were divided into two groups depending on variant of treatment. Main group contained of 56 persons, comparison group –50 persons. Patients from the main group received traditional treatment, which include spasmolitics, analgetics, enzymes, antibiotics. Besides these preparations patients received antihomotoxic drug Momordica com-positum. Patients from comparison group received only traditional treatment. Enzymes for the main group of patients were prescribed only in case of pancreatic insufficiency. Structure changes were assessed with device “ALOKA SSD 630” (Japan).

Results: The positive dynamic on sonographic changes of pan-creas, its echogeneity, and indices of homogeneity demonstrated in main group. There was no reliable dynamic of ultrasound histographic indices under the treatment in patients of both groups. By sonographic data antihomotoxic preparation Momordica compositum mostly pro-moted the decreasing in frequency of enlargement of pancreas or its parts, heterogeneity of pancreatic structure, lowing-down its echoge-neity; rising the indices of homogeneity.

Conclusion: Inclusion of antihomotoxic preparation Momordica compositum to treatment of patients with chronic pancreatitis leads to improvement of sonography results of the pancreas.


P97

Growth Factor in Patients with Chronic Pancreatitis and Concomitant Chronic Obstructive Pulmonary DiseaseJ. Teleki1, D. Gontsariuk1, Z. Nechipay1, K. Chympoi1

1Bukovinskiy State Medical University, Chernovtsy, Ukraine

Introduction: In spite of interconnection between local and sys-tem inflammatory reaction in patients with COPD, it is not clear enough why serum inflammatory cytokines have high variability of concentrations.

Objectives: To estimate the rate of circulating vascular endothe-lial growth factor (VEGF) and granulocytic colony-stimulating growth factor (G-CSF) in patients with chronic obstructive pulmo-nary disease and concomitant chronic pancreatitis.

Patients and Methods: Three groups were formed. I group –practically healthy persons, II group (n = 26) - patients with chronic obstructive pulmonary disease and concomitant chronic pancreatitis, III group (n = 26) - patients with chronic obstructive pulmonary dis-ease without concomitant disease.

Results: The patients of II group has increasing rate of VEGF in comparison with practically healthy persons (p < 0,05). The patients without concomitant chronic pancreatitis has lower rate of VEGF. The concentration of G-CSF was lower in patients of both groups in comparison with practically healthy persons. Intergroup difference was not detected.

Conclusion: The increasing rate of circulating VEGF in the acute period of COPD with concomitant chronic pancreatitis associ-ated with the syndrome of systemic reply on inflammatory process. The presences of chronic pancreatitis complicate the course and prog-nosis of COPD.

Poster session II

Clinical Science – Pancreatic Cancer

P98

Cyst Fluid SPINK1 May Help in the Differentiation of Benign or Potentially Malignant Cystic Pancreatic LesionsS. Räty1, J. Sand1, J. Laukkarinen1, K. Vasama1, C. Bassi2, R. Salvia2, A. Scarpa2, I. Nordback1

1Tampere University Hospital, 2Verona University Hospital

Introduction: Although disease history and imaging techniques are usually sufficient in the differential diagnosis between benign and potentially malignant cystic pancreatic lesions, additional data for the decision making is sometimes needed. We have earlier suggested that cyst fluid Tumour associated trypsin inhibitor (TATI = SPINK1) might be a promising maker.

Objectives: The aim in the present study was to evaluate SPINK1 levels in benign and potentially malignant cystic pancreatic lesions in larger patient population.

Patients and Methods: Between 2003 and 2009, 61 patients operated on for cystic pancreatic lesions in Tampere University Hospital and in Verona University Hospital were included. Cyst fluid was aspirated at operation and stored at –70 °C. The final histopatho-logical diagnosis was acute pancreatitis with infected fluid collection in 4 patients, chronic pseudocyst (PS) in 17 patients, serous cystade-noma (SCA) in 7 patients, benign mucinous cystadenoma (MCA) in 21 patients and intraductal papillarymucinous neoplasm (IPMN) in 12 patients (9 main duct and 3 branch duct type).

Results: We found that SPINK1 levels were significantly higher in patients with pre-malignant cysts (IPMN and MCA) compared to benign cysts (PS and SCA), (median and range, [453 (13-3602) vs 18 (0.1-278) μg/L], p < 0.0001). The sensitivity and specificity of SPINK1 value for detecting benign lesions with cut-off value 118 μg/L were 85% and 84% (AUC 0.94). Patients with acute pancreatitis and infected fluid collection had high SPINK1 levels, but in those cases differential diagnosis is relatively easy to make by disease history.

Conclusion: SPINK1 is a potential marker for the differential diagnosis of potentially malignant and benign cystic pancreatic lesions.


P99

Radiofrequency Ablation of Stage III Pancreatic Cancer: Impact on SurvivalA. Giardino1, I. Frigerio1, R. Girelli1, S. Partelli2, C. Bassi2, R. Salvia2, P. Pederzoli2

1HPB Unit-Pederzoli Clinic, 2Gastroenterological and Surgical Department-University of Verona

Introduction: Locally advanced pancreatic cancer (LAPC) has a median survival of 12-15 months after standard treatment. Radiofrequency ablation (RFA) is a widely accepted treatment for different solid tumours.

Objectives: We evaluate the impact on survival of RFA fol-lowed by Chemo-Radiotherapy in patients (pts) with LAPC.

Patients and Methods: We enrolled, for a minimum 12 months follow-up, 50 patients with LAPC who underwent RFA between February 2007 and December 2008. Overall survival and disease spe-cific survival were analyzed.

Results: Males were 25 with median age of 61 years. Tumor was located in the head-uncinate process in 30/50 pts. Median tumor diameter was 37 mm. 37 pts (76%) received RFA as up front treat-ment while 13 pts (24%) received Chemo-Radiotherapy before RFA. Palliative surgery was associated to RFA in 30 pts (61%). Postoperative mortality occurred in 3 pts (4%). 24 pts are alive (49%) at a median follow-up of 15 months. 34 pts had recurrence of disease and 20 of them died of disease. The 1-2 year was 67% and 45% respectively with a median survival of 20 months; disease specific survival was 74% and 51% respectively with a median survival of 28 months. The 6-12 months progression free survival was 62% and 24% respectively with a median of 10 months.

Conclusion: Survival of LAPC after Chemo-Radiotherapy is dis-appointing. The apparent positive impact on survival of RFA associ-ated to chemo and/or radiotherapy is tempting. RFA could be considered as part of a new multimodal treatment but further studies are needed.

P100

Distal Bile Duct Cancer – Clinicopathological Features and Prognostic FactorsK. Kamposioras1, A. Anthoney1, G. Ferentinos2, A. Smith3, K. Menon3, A. Cairns4, C. Verbeke4

1Department of Oncology, St James’s University Hospital Leeds, UK, 2Hellenic Centre for Disease Control and Prevention, Greece, 3Department of Surgery, St James’s University Hospital Leeds, UK, 4Department of Histopathology, St James’s University Hospital Leeds, UK

Introduction: To date, clinicopathological data on distal bile duct (DBD) cancer are limited, and the factors that influence survival following curative resection remain unknown.

Objectives: To identify prognostic factors in a series of DBD cancers that underwent fully standardized pathological examination.

Patients and Methods: Patients undergoing curative pancre-atoduodenectomy for DBD adenocarcinoma between January 2001

and April 2009 were identified from the pathology database. Demographics, histopathology and survival data were analysed.

Results: 68 patients were identified (median age: 64 years, range: 37-86). 97% of cases were stage pT3 (TNM 7) with 76% showing nodal metastasis and 77% vascular invasion. Margin involve-ment was found in 71%, the R1 rate differing between tumours that involved the very distal part of the DBD and were entirely intrapan-creatic (40% of cases, R1:48%), and those located more proximally, towards the superior border of the pancreas, with or without encroach-ment on the extrapancreatic DBD stump (R1:85%; p = .001). Tumours <2 cm were more frequently found in the distal DBD (p = 0.02). Overall median survival was 26 months. Age >65 years and >2 posi-tive lymph nodes were independent adverse prognostic factors on multivariate analysis. Resection margin status, perineural invasion and involvement of the DBD close to the superior pancreatic border were significant on univariate analysis only.

Conclusion: DBD cancer is a locoregionally advanced cancer with a high R1 rate, particularly in tumours that involve the proximal end of the DBD close to the superior pancreatic border. Age >65 years and >2 positive lymph nodes are independent adverse prognostic fac-tors after curative resection.

P101

Prevalence of K-ras Mutations Do Not Differ Between Early and Late Onset Pancreatic CancerC. Weidenauer1, S.L. Haas2, M. Wannberg3, R. Jesnowski1, R. Faissner2, R. Heuchel3, J.M. Löhr3

1CCU Molecular Gastroenterology, German Cancer Research Center, Heidelberg, Germany; 2Klinikum Aschaffenburg, Department of Medicine II, Aschaffenburg, 3Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute, Stockholm, Sweden

Introduction: Pancreatic ductal adenocarcinoma (PC) is one of the most lethal human malignancies which predominantly affects patients at an older age (late onset PC, LOPC), whereas only 5-10% of all PC patients are aged 50 years and younger (early onset PC, EOPC). Activating point mutations in the K-ras oncogene are among the most common genetic alterations in pancreatic cancer, occurring early in the progression of the disease.

Objectives: To determine whether EOPC is genetically differ-ent from LOPC by determing K-ras mutation rates in both groups.

Patients and Methods: Seventy-four PC patients (EOPC: n = 29; LOPC: n = 45) underwent surgical resection at the University Hospital Mannheim (1999-2007). Following DNA extraction from tumor tissue and amplification by semi-nested PCR, RFLP was per-formed by the restriction enzyme MSP-1 for the detection of hot-spot codon 12 mutations.

Results: In the EOPC group the mutation rate was found to be 44.8% (13/29) whereas 48.9% (22/45) of LOPCs exhibited K-ras mutations (p = 0.4).

Conclusion: Similar K-ras mutation rates in EOPC and LOPC suggest that other still ill-defined genetic factors account for PC development at an early age in this subset of PC patients.


P102

Molecular Marker for the Prognosis of Pancreatic CarcinomaC. Pilarsky1, C. Winter2, G. Kristiansen3, D. Aust4, T. Knösel5, P. Rümmele6, M.W. Büchler7, H. Friess8, M. Bahra9, M. Niedergethmann10, H.D. Saeger1, R. Grützmann1

1Dept. of Surgery, University Hospital Dresden, 2Inst. for Bioinformatics, Technical University Dresden, 3Inst. for Pathology, University Hospital Zürich, 4Inst. for Pathology, University Hospital Dresden, 5Inst. for Pathology, University Hospital Jena, 6Inst. for Pathology, University Hospital Regensburg, 7Dept. of Surgery, University Hospital Heidelberg, 8Dept. of Surgery, Technical University Munich, 9Dept. of Surgery, Charite Berlin, 10Dept. of Surgery, University Hospital Mannheim

Introduction: Prognosis for patients with pancreatic carcinoma (PDAC) remains poor. Despite of increasing knowledge about the molecular basis of PDAC neither a specific marker for early diagno-sis nor target proteins for a new therapeutic approach have been iden-tified so far. However, reliable prediction of survival might help to improve the therapeutic outcome for patients with PDAC.

Objectives: To identify a molecular signature for pancreatic cancer survival.

Patients and Methods: We analyzed the gene expression pro-file of 29 PDAC samples using the Affymetrix GeneChip U133 2.0 array. We correlated gene expression values with postoperative sur-vival time using a novel computational approach that incorporates background knowledge based on the Transfac database and validation by multiple training and test sets. Candidate genes were further vali-dated using RT-PCR and immunohistochemistry of tissue microar-rays containing cores from 458 patients with PDAC.

Results: We identified a signature of 8 genes, which were able to predict the survival of the patients with 65% accuracy. RT-PCR and immunohistochemistry confirmed the findings of our gene expression experiments for most of the genes. Integrating clinical, pathological and molecular parameter we were able to identify a signature with 70% accuracy based on the immunohistochemical analysis.

Conclusion: The combination of gene expression analysis, novel bioinformatic approaches and large-scale immunohistochemis-try with tissue microarrays is suited to identify novel marker genes for prognosis of PDAC patients.

P103

Chronic Stress Profoundly Impairs Survival in Pancreatic Cancer But Prognosis Can Be Significantly Improved by Beta BlockersW. von Bernstorff1, A. Käding2, M. Sendler3, S. Speerforck2, U. Weiß3, M.M. Lerch3, C. Heidecke1, L.I. Partecke1

1Department of Surgery, Clinic of General Surgery, Visceral, Thoracic and Vascular Surgery, 2Research Unit Surgical Oncology, 3Department of Internal Medicine A

Introduction: Chronic stress induces massive immunosuppres-sion. This may lead to a further impaired prognosis in pancreatic cancer.

Objectives: To study underlying mechanisms and therapeutic strategies of chronic stress in a murine pancreatic cancer model.

Materials and Methods: In a murine orthotopic pancreatic cancer model mice were treated by chronic acoustic and restraint stress. The level of stress and/or immunosuppression was measured by stress parameters: behaviour of animals, levels of corticosterone, sizes of adrenal glands, levels of tyrosine hydroxylase, concentrations of different cytokines. The impact of catecholamines on proliferation and invasion of tumour cells was tested in vitro. During stress trials tumour growth and survival were monitored. These were also moni-tored when analyzing the effects of beta blockers.

Results: Chronic stress significantly elevated all stress parame-ters (p < 0.05) as well as leading to severe immunosuppression (p < 0.05). Catecholamine treatment significantly increased prolifera-tion and invasion of tumour cells (p < 0.05). This was significantly inhibited by beta blockers (p < 0.05). After 5 weeks of chronic stress mice had significantly larger tumours than untreated mice (798 mm3 versus 348 mm3; p < 0.05). This was significantly inhibited by oral beta blockers. Furthermore, chronic stress led to a significant reduc-tion of survival (52 versus 66 days, p < 0.0001). Again, oral beta block-ers significantly improved survival from 52 to 59 days (p < 0.005).

Conclusion: Chronic stress can significantly reduce survival. This is mediated via catecholamines. The targeted therapy of chronic stress in pancreatic cancers patients using beta blockers could signifi-cantly improve their prognosis. This is a new therapeutic strategy in pancreatic cancer therapy.

P104

Patterns of Recurrence After Resection for Pancreatic AdenocarcinomaG. Capretti1, G. Balzano1, A. Zerbi1, M. Reni2, S. Cereda2, N. Pecorelli1, V. Di Carlo1

1Pancreas Unit, Dept. of Surgery, San Raffaele Scientific Institute, Milan, Italy, 2Dept. Of Oncology, San Raffaele Scientific Institute, Milan, Italy

Introduction: The majority of patients undergoing resection for pancreatic cancer will die of the disease.

Objectives: To define patterns of recurrence in resected pancre-atic cancer, identifying prognostic factors for recurrence site.


Patients and Methods: From 1997 to 2007, 192 patients who underwent resection for ductal carcinoma were followed-up at our Institution with scheduled clinical evaluation, Ca 19-9 assessment and CT scan every 3 months. Log-Rank and Cox regression were used for statistical analysis.

Results: Median overall survival (OS) was 23.7 mo, 5yr OS was 18%. 158 pts (82.3%) developed recurrence (2-73 mo); local relapse occurred in 73 pts (46.1%), distant metastases in 114 pts (72.1%) (29 pts had both). Median disease-free (DF) survival was 12.7 mo. Three of 8 actual 5yr DF survivors recurred after 5 years. No difference was found in time of recurrence between local vs. distant recurrence, (12 and 11.5 mo), and in survival after detection of local and distant recur-rence (9.4 and 11.1 mo). At multivariate analysis, significant prognos-tic factors of recurrence were: nodal status (OR 4.54), nodal ratio (OR 4.41), diameter (OR 1.13) and adjuvant therapy (OR 0.47). Regarding the site of recurrence, no factor (including margin status) significantly predicted local relapse, whereas nodal ratio (OR 6.46) and adjuvant therapy (OR 0.43) were determinants for distant metastases.

Conclusion: Distant metastases is the most frequent recurrence site, suggesting chemotherapy as first strategy in adjuvant therapy. Local relapse was not related to R-factor, indicating that its role should be reconsidered. Recurrence may occur even after prolonged DF survival.

P105

Are Pancreatic Incidentalomas Worthy of Consideration?C. Ansorge1, A. Skarin1, R. Segersvärd1, G. Sandblom1, Å. Andrén-Sandberg1

1Dept. of Surgery, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden

Introduction: The incidence of âen-passantâ diagnosed asymp-tomatic pancreatic tumours, i.e. pancreatic incidentalomas (PI) increases as imaging-quality and -accessibility improves; the clinical relevance of that is unknown.

Objectives: To investigate whether resected PI and resected symptomatic pancreatic tumors (SPT) differ in histopathological tumor characteristics.

Patients and Methods: Single center prospective observa-tional study on pancreatic resections 2004-09. Tumordiagnosing investigation was identified. Symptoms/signs from the medical record retrospectively linked to the tumor manifestation were obtained including information whether a tumor was suspected or not. An independent investigator blinded for the surgical and histopathologi-cal outcome grouped the patients into SPT or PI. The groups were compared according to histopathological findings.

Results: Of 472 cases, 33 were assigned to the PI-group (7%), and 315 to SPT (66%), 124 were not assignable (26%). PI and SPT did not differ in age or sex distribution. Main SPT symptoms were jaundice (29%), abdominal pain (29%) and weight loss (18%). Premalignant lesions were more frequent in the PI-group (PI 15% vs. SPT 3%; p < 0.05), malignancies were more frequent in the SPT-group (SPT 70% vs. PI 55%; p < 0.05). Benign lesions were equally distrib-uted (PI 30% vs. SPT 27%).

Conclusion: Resected PI have a larger fraction of premalignan-cies and a lesser fraction of malignancies compared to resected SPT, making PI to a greater extent curable. “En-passant” detected pancre-atic incidentalomas should not be ignored. To complete diagnostics and finally the assessment by a multiprofessional team seems to be reasonable for pancreatic incidentalomas as it is for symptomatic pancreatic tumors.

P106

Preoperative Determinants of the Length of Hospital Stay in Patients Undergoing Surgery for Pancreatic CancerV.V. Chandrabalan1, D.C. McMillan2, R. Carter3, J. Kinsella4, T. Quasim4, C. Pow4, J. Edwards4, J. Al-Refaai4, A. McPhee1, C.J. McKay1, C.R. Carter1, E.J. Dickson1

1West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, 2University Department of Surgery, University of Glasgow, 3Department of Respiratory Medicine, Glasgow Royal Infirmary, 4Section of Anaesthesia, Glasgow Royal Infirmary

Introduction: Surgery for pancreatic cancer is associated with considerable morbidity. Both surgeon-related and patient-related fac-tors are important in determining postoperative outcome. As a conse-quence most pancreatic surgery is now carried out in specialist centres. However, patient optimisation is complex since the factors that determine postoperative morbidity are less well understood.

Objectives: To compare preoperative measures of patient comorbidity and length of hospital stay in patients undergoing pan-creatic surgery.

Patients and Methods: 103 patients who underwent surgery for pancreatic cancer (pancreaticoduodenectomy n = 87, and trial dis-section with bypass n = 16) had preoperative evaluation of their body habitus, systemic inflammatory response (Glasgow Prognostic Score, mGPS) and routine laboratory blood analysis . Cardiopulmonary function (cardiopulmonary exercise test, CPET) was measured in 54 patients.

Results: The median length of hospital stay was 17 days. 39 patients stayed 14 days and 64 stayed >14 days. Length of hospital stay was not associated with body habitus, the systemic inflammatory response or blood analysis. In contrast, in those patients who had CPET, more patients with a low anaerobic threshold (p = 0.030), a high base excess (0.056) and a high VE/VCO2 (p = 0.022) had a hos-pital stay greater than 14 days. Prolonged hospital stay was associated with pancreatico-duodenectomy (p = 0.027) and anastomotic failure (p < 0.001).

Conclusion: In this study CPET was the only pre-operative objective measure of patient physiology that correlated significantly with prolonged hospital stay. Length of stay is a useful surrogate marker of post-operative adverse events. Although CPET does not predict specific complications, it may determine the host response to major surgery and its immediate sequelae.


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Prognostic Relevance of Lymph Node Metastases and Adjuvant Treatment for Patients with Invasive Intraductal Papillary Mucinous Neoplasms (IPMNs) of the PancreasS. Caponi1, E. Vasile1, M. Del Chiaro2, N. Funel3, A. Sainato4, F. Pasqualetti4, M. Coppola4, L. Ginocchi1, C. Caparello1, M. Lucchesi1, C. Croce2, C. Greco4, D. Campani3, A. Falcone1, F. Mosca5, U. Boggi2

1U.O. Oncologia 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana; Polo Oncologico Area Vasta Nord-Ovest, Istituto Toscano Tumori; Pisa, Italy, 2U.O. Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, 3U.O. Anatomia Patologica 3, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy, 4U.O. Radioterapia, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, 5U.O. Chirurgia Generale 1 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy

Introduction: IPMNs are intraductal mucin-producing cystic neoplasms of the pancreas with malignant potential. Few data regard-ing prognostic factors and the role of adjuvant treatment are available.

Objectives: –Patients and Methods: The database of pancreatic surgery at

our institution was explored from 1/2005 to 12/2009 and matched with pathological data to identify patients resected for invasive IPMN. A retrospective review was conducted to evaluate clinical and patho-logical factors associated with prognosis in these patients.

Results: Fifty-four patients (M/F 27/27) radically resected for an invasive IPMN were identified. Median age was 68 years (range 37-87). Forty-three patients were evaluable for an adequate follow-up. Most patients (34, 79%) had T3 tumor; twenty-four (56%) had posi-tive nodes (median number 5; range 1-14). Twenty-two (51%) patients received gemcitabine as adjuvant therapy (17 of them were N1); nine were treated also with radiotherapy. After a median follow-up of 28 months, 21 patients progressed and 10 died. The median disease-free-survival (DFS) was 30 months. Lymph-node involvement (N1) was the main prognostic factor (DFS 44 versus 15.6 and OS not reached (NR) versus 25.3 months for N1 versus N0 patients; p = 0.01 and 0.05, respectively). Patients with N1-IPMN had similar DFS to N1-PDAC treated with adjuvant gemcitabine in the same period (11.9 versus 15.6 months, p = NS). Adjuvant chemotherapy seemed beneficial for N1 patients (DFS 16.7 versus 12.7 and OS NR versus 17.3 months for treated versus untreated patients; p = 0.39 and 0.009).

Conclusion: Our results confirm that node positive invasive IPMNs has a dismal prognosis. The role of adjuvant treatment seems promising and should be further investigated.

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The Relationship Between the Systemic Inflammatory Response, Patient Physiology and Anaerobic Threshold in Patients Undergoing Surgery for Pancreatic CancerV.V. Chandrabalan1, D.C. McMillan2, R. Carter3, J. Kinsella4, T. Quasim4, C. Pow4, J. Edwards4, J. Al-Refaai3, C.J. McKay1, C.R. Carter1, E.J. Dickson1

1West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, 2University Department of Surgery, University of Glasgow, 3Department of Respiratory Medicine, Glasgow Royal Infirmary, 4Section of Anaesthesia, Glasgow Royal Infirmary

Introduction: There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor long term outcome in patients undergoing surgery for pancreatic can-cer. However, the basis of this systemic inflammatory response is not clear. One hypothesis is that the presence of an ongoing systemic inflammatory response reflects comorbid disease [1].

Objectives: To examine the relationship between the systemic inflammatory response, patient physiology and anaerobic threshold in patients undergoing surgery for pancreatic cancer.

Patients and Methods: 56 patients who underwent pancrea-tico-duodenectomy for pancreatic cancer and had preoperative evalu-ation of their systemic inflammatory response (Glasgow Prognostic Score, mGPS), patient physiology (physiological POSSUM score, PPS) and cardiopulmonary function (anaerobic threshold - AT) were studied. Clinical information was obtained from a pancreatic database and analysis of the case notes.

Results: The mGPS was inversely associated with anaerobic threshold (AT < 11mls/kg/min, p = 0.028) and directly associated with bilirubin (>22mg/dl, p < 0.001) and prothrombin time (>12s, p = 0.008) but not associated with age (p = 0.699), sex (p = 0.278), BMI (p = 0.262), smoking status (p = 0.189) or PPS (p = 0.337). PPS was directly related to smoking (p = 0.010) but not associated with the other factors. A low anaerobic threshold was associated with females (p = 0.010), BMI (>25, p = 0.002), elevated bilirubin (p < 0.001) and prothrombin time (p = 0.017).

Conclusion: This study suggests that the systemic inflamma-tory response is more closely associated with a poor anaerobic thresh-old than with the physiological POSSUM score. This may indicate an underlying hypoxic basis for the presence of a systemic inflammatory response in patients prior to surgery for pancreatic cancer.

1. Roxburgh CSD and McMillan DC Ann Surg 2010;251:390-91.


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Safety and Feasibility of Pancreaticoduodenectomy in the Elderly: A Matched StudyV. de Franco1, E. Frampas2, M. Wong1, G. Meurette1, M. Charvin1, J. Le Borgne1, N. Regenet1

1CCDE, IMAD, University Hospital Centre, Hotel Dieu, Nantes, France, 2Radiologie, University Hospital Centre, Hotel Dieu, Nantes, France

Introduction: Surgery has proven to be the only effective means of cure for pancreatic cancer. The elderly are recognized as being of greater surgical risk. Recent advances in surgical techniques have reduced the operative risks. There is still no consensus about an age limit for performing pancreatic resections, including pancreaticoduo-denectomy.

Objectives: To compare the clinical outcomes after pancreati-coduodenectomy (PD) in patients above 70 years old, against a matched cohort of patients under 70.

Patients and Methods: A search of the Department database revealed that 285 consecutive patients underwent PD from 1996 to 2009. Forty-one patients (14%) were identified to be more than 70 years old (Group 1), and they were matched with 41 patients under 70 (Group 2) according to gender, Body Mass Index (BMI), American Society of Anaesthesiology (ASA) score and tumor stag-ing. Medical comorbidities, preoperative CA 19-9 and haemoglobin levels, operative and histopathology data, postoperative course and survival outcomes were compared between the 2 groups of patients.

Results: Statistical analyses revealed no significant difference between the 2 groups, except for preoperative CA19-9 and haemoglo-bin levels, operating time, duration of hospitalization and the number of lymph nodes removed. These parameters, however, did not have an impact on morbidity, mortality and overall survival.

Conclusion: Based on our study, peri-operative morbidity, mor-tality and overall survival are not poorer in patients older than 70. Thus, PD should not be contraindicated withheld solely on the basis of chronological age. Moreover PD can be rationally proposed to patients meeting the “fit elderly” definition.

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Extrapancreatic Malignancies in Pancreatic Cancer Patients – Epidemiological Observations and Possible Clinical ConsequencesC. Tjaden1, T. Hackert1, U. Hinz1, W. Hartwig1, O. Strobel1, M.W. Büchler1, J. Werner1

1Dept. of Surgery, University of Heidelberg, Heidelberg, Germany

Introduction: Tumor syndroms are known in hereditary col-orectal cancer and multiple endocrine neoplasia. Exocrine pancreatic cancer (PDAC) has not been associated with other malignancies.

Objectives: Aim of the study was the characterization of addi-tional extrapancreatic tumors in PDAC patients and long-term outcome.

Patients and Methods: 1316 patients who underwent surgery for PDAC in our institution were analyzed regarding former tumor manifestations with type of tumors, epidemiological data, risk fac-tors, PDAC tumor stage. and long-term survival.

Results: 175 PDAC patients (13.3%) had a history of 204 malig-nant tumors, 23 patients had 2 preceeding malignancies and 3 patients showed a history of 3 cancers. Leading tumors were breast cancer (45 patients) and prostate cancer (34 patients), followed by colorectal, urothelial and gynaecologic tumors (27, 26 and18 patients, respec-tively). No significant difference in overall survival was found between PDAC patients with and without preceeding malignancies.

Conclusions: PDAC seems to be related with other tumors in a large number of patients. Especially glandular organs show a disposi-tion for extrapancreatic tumor manifestations implying predisposing genetic disorders. Preceeding malignancies did not affect the overall survival in PDAC patients. Further epidemiological and genetic investigations are necessary to clarify possible tumor syndroms and identify risk populations for the development of PDAC.

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Preoperative Radiological Resectability Assessment of Pancreatic TumorsC. Ansorge1, Å. Andrén-Sandberg1, J. Permert1, R. Segersvärd1

1Dept. of Surgery, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden

Introduction: The group of pancreaticoduodenal tumors (PT) is heterogeneous regarding tumor characteristics and postoperative sur-vival. The crucial aim to achieve radical oncological resection (ROR) applies to all PT. The resectability assessment constitutes the surgical treatment strategy (STS) within a multimodal curative-intent treat-ment concept. For standardization purposes we developed an imag-ing-based PT-classification with four ROR-categories (A1: without vessel resection VR, A2: stand-by for VR, B: planned VR, C: explo-ration/resection after neoadjuvant downstaging treatment).

Objectives: To evaluate the precision of this preoperative clas-sification.

Patients and Methods: Single-Center prospective-observa-tional study including planned pancreatic resections 2005-9, PT-classification results compared to the intra-operative surgical assessment. Intra-operative changes of STS were defined understaged (US), overstaged (OS) or confirmed unresectable (UR).

Results: 470 patients underwent curative-intent surgery. Of 291 A1-classified cases 90% performed resection according to STS, 8% were UR and 2% US. Of 88 A2-cases 82% performed according to STS, 8% were UR. Of 33 B-cases 40% performed according to STS, 42% were UR and 18% OS. Of 27 C-cases 82% performed according to STS, and 18% were UR. The main UR-cause was dissemination in A1 (liver metastasis 3,4%, carcinosis 2,1%) otherwise locally advanced tumor growth (A2:10%, B:30%, C:11%).


Conclusion: The PT-classification outlines relevant tumor char-acteristics and separates standard resection cases from cases that demand highest surgical expertise. It can be used to stratify cases in clinical trials or to compare results between different centers. However, the surgical consequences need continuous re-evaluation. The high UR-ratio observed in the B-classified cases warrants a review and possibly changes of the surgical treatment strategy for this group of patients.

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The Role of Inflammation in Patients with Intraductal Mucinous Neoplasm of the Pancreas and in Those with Pancreatic AdenocarcinomaC. Ricci1, R. Pezzilli1, M.M. Corsi2, A. Barassi2, A.M. Morselli-Labate1, G. Dogliotti2, R. Casadei1, G. Melzi d’Eril2

1Alma Mater Studiorum, University of Bologna, Sant’Orsola-Malpighi Hospital, Bologna, Italy, 2University of Milan, Milan, Italy

Introduction: There are very few data regarding inflammation processes in patients with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas.

Objectives: To evaluate the circulating concentrations of pla-cental growth factor (PlGF), transforming growth factor-alpha (TGF-α), transforming growth factor-beta1 (TGF-β1), tumor necrosis factor receptor 1 (TNF-R1) and matrix metalloproteinases-2 (MMP-2) in patients with IPMNs and in those with pancreatic adenocarcinoma and to also evaluate the concentrations of these molecules in com-parison with CA 19-9.anemias.

Patients and Methods: Sixty-nine patients (39 males, 30 females, mean age 69.8±10.4 years) were enrolled: 23 (33.3%) had IPMNs and 46 (66.7%) had histologically confirmed pancreatic ade-nocarcinoma. Thirteen healthy subjects were also studied. PlGF, TGF-, TGF-1, TNF-R1, MMP-2 were determined using commer-cially available kits. CA 19-9 was also assayed.

Results: The only two substances showing significant differ-ences among the three groups were TNF-R1 (P = 0.003) and CA 19-9 (P = 0.007). In particular, TNF-R1 concentrations were significantly higher in both patient groups than in healthy subjects (IPMN, P = 0.004; pancreatic adenocarcinoma, P = 0.001). On the other hand, serum CA 19-9 concentrations were significantly higher in patients with pancreatic adenocarcinoma than in those with IPMNs (P = 0.044) and healthy subjects (P = 0.003).

Conclusion: Serum TNF-R1 is elevated in patients with IPMN and in those with pancreatic adenocarcinoma suggesting a high apop-totic activity in both groups of patients studied; it is also a potentially good marker for selecting patients with pancreatic ductal adenocarci-noma having distant metastases.

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Risk for Immediate Postoperative Complications After Pancreaticoduodenectomy Is Increased by High Frequency of Acinar Cells, and Decreased by Prevalent Fibrosis of Cut Edge of PancreasM. Laaninen1, M. Bläuer1, K. Vasama2, S. Räty1, J. Sand1, I. Nordback1, J. Laukkarinen1

1Dept. of Gastroenterology and Alimentary Tract Surgery, and Pancreas Laboratory, Tampere University Hospital, Tampere, Finland, 2Dept. of Pathology, Tampere University Hospital, Tampere, Finland

Introduction: Soft pancreas is one risk factor for postoperative pancreatitis after pancreaticoduodenectomy. Pancreatitis may increase the risk for anastomotic leakage.

Objectives: Our aim was to analyse the amount of different cell types of cut edge of pancreas (CEP), and to study the possible corre-lation to early postoperative complications after pancreatoduodenec-tomy.

Patients and Methods: In 40 Whipple-operated patients, HE stained section of CEP was electronically photographed and areas of different cell types were calculated. Positive urine trypsinogen (early detector of pancreas irritation), was measured on 1.-6. p.o. days and drain amylase on 3. p.o. day. Anastomotic leakages were graded according to ISGPF classification and delayed gastric emptying (DGE) according to ISGPS classification.

Results: High frequency of acinar cells in CEP was a risk for positive u-trypsinogen (p < 0.05), high drain amylase (p < 0.05), DGE (p < 0.05) and leakages (NS; total 5%). High amount of fibrosis, in turn, was protective for positive u-trypsinogen, drain amylase release and wound infections.

Conclusion: High amount of acinar cells of CEP may increase the risk for, whereas high amount of fibrosis of CEP seems to be protec-tive for postoperative complications after pancreaticoduodenectomy.


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Genetic Polymorphisms and Somatic Mutations in Pancreatic Ductal Adenocarcinoma: Possible Roles in Disease Risk and Patient SurvivalF. Canzian1, D. Campa1, C. Rizzato1, J. Hoheisel1, P.S. Rachakonda1, R. Kumar1, N.A. Giese2, J. Werner2, J. Lorenzo-Bermejo3, J.P. Neoptolemos4, M.W. Büchler2, A. Bauer1

1German Cancer Research Center (DKFZ), Heidelberg, Germany, 2Clinic for General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany, 3Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany, 4Division of Surgery and Oncology, University of Liverpool, UK

Introduction: Little is known about etiology of pancreatic can-cer, particularly regarding inherited risk. Tobacco smoking, obesity, diabetes, chronic pancreatitis and family history are established risk factors. Sequential accumulation of somatic mutations in K-Ras, CDKN2A, TP53 and SMAD4 leads to progression of pancreatic duc-tal adenocarcinoma (PDAC). The PanScan project, a genome-wide association study, identified several common polymorphisms affect-ing pancreatic cancer susceptibility.

Objectives: Our aims are: to re-evaluate the risk associations identified by PanScan, to investigate possible effects of inter-individ-ual genetic variation and overall patient survival, and to study somatic mutations in K-Ras, CDKN2A and other cancer-related genes and assess their correlation with survival.

Patients and Methods: Fifteen SNPs mapping to six regions identified by PanScan were genotyped in a collective of pancreatic cancer patients (including 314 patients with PDAC) and 2,200 healthy controls recruited from Heidelberg and Liverpool. We performed genotyping using KASPar assays, and mutation analysis (on 276 PDAC tumor samples) using SSCP and sequencing. Associations between SNPs and pancreatic cancer risk were evaluated by logistic regression; associations between SNPs or somatic mutations and patient survival were studied with Cox regression.

Results: Most of the SNPs identified by PanScan were associ-ated with PDAC risk in our study. In addition, we found one SNP in chromosome 15 that may influence overall survival of PDAC patients. Data from mutation screening showed that frequency of K-Ras muta-tion in tumors was 55%.

Conclusion: The majority of the associations found in PanScan were replicated in this population and one SNP was found to be asso-ciated with overall survival of PDAC patients.

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Serum Biomarkers of Pancreatic Cancer (PC) and Pancreatic Cancer Derived Diabetes Mellitus (DM)E. Fadi1, E. Greco1, A. Padoan1, P. Fogar2, D. Bozzato1, S. Moz1, F. Navaglia2, C. Zambon3, R. Seraglia4, S. Pedrazzoli3, M. Plebani1, D. Basso2

1Department of Diagnostic Sciences and Special Therapies, University of Padova, Italy, 2Department of Laboratory Medicine, University of Padova, Italy, 3Department of Medical and Surgical Sciences, University of Padova, Italy, 4CNR, ISTM, Padova, Italy

Introduction: NT-S100A8 peptide was isolated by us from PC tissue of diabetic patients.

Objectives: To verify whether discontinuous SDS-PAGE, per-fomed in the conditions which allowed the isolation of NT-S100A8 from PC tissues, can identify potential serum markers of PC and PC induced DM.

Patients and Methods: We collected sera from 42 PC patients (17 with, 25 without DM) and from 11 healthy controls (C).

Results: In the low MW range (15,000-1,000 Da), nine protein bands were identified and numbered 1 to 9 from heaviest to lightest. Only band number 2 (14,200 Da approximately), was correlated with PC diagnosis, being present in 10/11 C and absent in 37/42 cancer cases (Chisquare = 26.8, p < 0.001). Two bands, 4 and 9, MW 10,000 and 1,000 Da respectively, correlated with each other (Chi-quare = 4.8, p < 0.05). In PC, the absence of both bands correlated with the pres-ence of DM (Chi-square = 8.6, p < 0.01 for band 4 and Chi-square = 6.6, p < 0.05 for band 9). and was significantly associated with higher fast-ing plasma glucose levels (p < 0.05 for band 4 and p < 0.01 for band 9). The absence of band 9 was also significantly associated with HbA1c (p < 0.05) and with glucose/C-peptide ratio(p < 0.05). To char-acterize the protein inversely correlated with PC diagnosis, we per-formed a MALDI-TOF analysis of the tryptic in-gel digestion of band 2. The identified peaks were analysed by Mascot Peptide Mass Fingerprint and showed a high homology with human hemoglobin subunit beta (score 76, p < 0.05).

Conclusion: SDS-PAGE analysis of the low MW serum pro-teins allowed the detection of peptides correlated with PC derived DM and the identification of free beta-globin as a potential PC serum marker.

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Hereditary Pancreatic Cancer and BRCA2 Mutation AnalysisA. Staka1, A. Pukitis1

1Faculty of Medicine, University of Latvia, Riga, Latvia

Introduction: Inherited pancreatic cancer represents approxi-mately 5-10% of all pancreatic cancers. Pancreatic ductal adenocarci-noma (PDA) can be inherited as a part of hereditary cancer syndroms or associated with familial pancreatic cancer (FPC). The role of BRCA2 mutation in PDA heredity is still not proven.


Objectives: BRCA2 mutation analysis in FPC cases.Patients and Methods: For 114 patients with confirmed diag-

nosis of PDA a detailed family history was performed. Patients with a familial risk according to EUROPAC criteria, and those who have at least two firstdegree kinship relatives with pancreatic cancer - were considered as FPC patients. Blood analysis for BRCA2 gene and mutations was performed for all FPC patients, using all 28 exones (except the 1st exone, which is a nontranslating area) for DNA frag-ment amplification and analysis by 38 direct and reverse oligonucle-otide primer pairs (framework of EUROPAC).

Results: FPC was found in four patients with PDA. Three of them reported one PDA case in a family member, one of the patients reported two PDA cases in the family (3,5%out of 114 patients included in the study). BRCA2 gene sequencing for pathogenic muta-tions in one female patient was done to a full extent, in the rest three patients – partially (also in the 11th exone), no changes were found.

Conclusion: FPC is not common (3,5%) in our study popula-tion. BRCA2 gene sequencing for pathogenic mutations showed that this mutation is not the commonest in a case of PDA, but no definite conclusion can be drawn due to a small number of patients checked.

P117

Clinical Outcome and Angiogenic Plasma Factors/Circulating Mature/Progenitor Endothelial Cells in Pancreatic CarcinomaB. Vizio1, S. Silvestri2, A. Novarino2, G.P. Sapia4, A. Giacobino5, D. Campra6, G.R. Fronda7, L. Ciuffreda8, G. Bellone9

1Department of Clinical Physiopathology, University of Turin, Italy, 2Department of Surgery, University of Turin, Italy, 3Department of Medical Oncology, Azienda Ospedaliera Universitaria San Giovanni Battista, Molinette, Turin, Italy, 4Department of Surgery, University of Turin, Italy, 5Department of Medical Oncology, Azienda Ospedaliera Universitaria San Giovanni Battista, Molinette, Turin, Italy, 6Department of Surgery, Azienda Ospedaliera Universitaria San Giovanni Battista, Molinette, Turin, Italy, 7Department of Surgery, Azienda Ospedaliera Universitaria San Giovanni Battista, Molinette, Turin, Italy, 8Department of Medical Oncology, Azienda Ospedaliera Universitaria San Giovanni Battista, Molinette, Turin, Italy, 9Department of Clinical Physiopathology, University of Turin, Italy

Introduction: Circulating endothelial cells (CEC) and bone-marrow-derived endothelial progenitors (CEP) play important roles in tumor growth and are proposed to be non-invasive markers of angiogenesis. CEC and CEP levels in pancreatic carcinoma patients has not been investigated.

Objectives: The study aimed to analyze the presence of rCEC, aCEC and CEP and the levels of angiogenesis related proteins, i.e. VEGF-A, VEGF-D, Angiopoietin (Angio)-1, and CXCL12 in the blood of patients with locally-advanced or metastatic pancreatic car-cinoma, before and after different chemotherapy regimens.

Materials and Methods: Using four-color flow cytometry pro-cedures, we evaluated resting (rCEC), activated (aCEC), and CEP numbers in the peripheral blood of pancreatic carcinoma patients

before and after chemotherapy, consisting in gemcitabine (GEM) alone or in combination with oxaliplatin (OX) or 5-fluorouracil (FU). We also correlated CEC and CEP levels with plasma levels of rele-vant angiogenic factors VEGF-A, VEGF-D, Angio-1 and CXCL12 measured by ELISA, and with clinical features of pancreatic cancer.

Results: The aCEC, rCEC and CEP and VEGF-A plasma levels were significantly higher in locallyadvanced and metastatic patients than controls. CEC and VEGF-A levels were positively correlated with disease stage and inversely correlated with patient’s overall sur-vival. Measurements after the treatment course showed that VEGF-A plasma concentrations decreased significantly. In particular, rCEC were significantly down after GEM monochemotherapy, and rCEC and VEGF-A after GEMOX treatment. Responders had significantly lower basal aCEC, probably detached from tumour vessels, in versus nonreponders.

Conclusion: Our study provides novel insights for angiogenesis mechanisms in pancreatic carcinoma, for which antiangiogenic tar-geting of VEGF-A and CEC could be of interest.

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Risk Factors, Clinical Features and Outcome of Early Onset Pancreatic Cancer Patients Compared to Older PatientsM. Piciucchi1, G. Capurso1, R. Valente1, M. Cavallini2, V. Barrucca3, A. Romiti3, P. Marchetti3, V. Ziparo2, G. Delle Fave1

1Digestive and Liver Disease Department, S.Andrea Hospital II Faculy of Medicine and Surgery, Sapienza University, Rome Italy, 2General Surgery Department, S.Andrea Hospital II Faculy of Medicine and Surgery, Sapienza University, Rome Italy, 3Oncology Department, S.Andrea Hospital II Faculy of Medicine and Surgery, Sapienza University, Rome Italy

Introduction: 5-10% of pancreatic adenocarcinoma (PDAC) are diagnosed <50 and defined as early onset pancreatic cancer (EOPC). A role for smoking and genetics has been hypothesized, but risk factors and features of EOPC have not been investigated.

Objectives: To analyze the prevalence of EOPC and compare its risk factors, clinical and histological features, with PDAC patients aged > 50 (normal-onset, NOPC).

Patients and Methods: We recorded risk factors, neoplasm features and outcome of a prospective cohort of PDAC patients and we assessed the differences between EOPC and patients NOPC through appropriate statistics.

Results: 11/116 PDAC were EOPC (9,1%). No differences for sex, BMI, chronic pancreatitis, cancer family history (no PDAC-associated genetic syndromes in EOPC) were found, but 44,7% of NOPC and none EOPC were diabetics (p = 0,002). Higher, but not significantly different, rates of smokers (63,6% vs 55,2%) and alco-hol consumers (63,6% vs 46,7%) in EOPC. Tumour was located in the head in 84,8% of NOPC vs 54,5% of EOPC (p = 0,02), in which accordingly jaundice was more rare (9,1% vs 45,7% p = 0,02). EOPC had a less differentiated grading (G3 87,5% vs 58,1% p = 0,1) and distant metastases at diagnosis in 72,7% vs 35,2% of NOPC (p = 0,02), but survival probability was not different.


Conclusion: We confirmed a 10% rate of EOPC, and observed that most of them present with metastasis at diagnosis, and are located in the body/tail, possibly supporting the case for a different biology. Our data may be underpowered, and may have missed a possible sig-nificant role of smoking and alcohol, which need confirmation in a wider series.

P119

Basement Membrane Fragments as Markers for Pancreas Cancer – A Comparison to Conventional BiomarkersD. Öhlund1, B. Ardnor1, M. Öman1, P. Naredi1, M. Sund1

1Department of Surgical and Perioperative Sciences, Umeå University, UMEÅ, Sweden

Introduction: Pancreas cancer has a poor prognosis due to late symptoms. The only curative treatment is Whipple’s operation of a local tumor. A major problem is to find tumors at a local stage and to select patients suitable for operation. Due to this, there is a great need for new biomarkers. Type IV and type XVIII collagen are both expressed in basement membranes, and fragments of these are secreted to the circulation when a pancreatic tumor grows. Potentially these fragments can be used as biomarkers.

Objectives: We have compared type IV and type XVIII colla-gen with conventional biomarkers for pancreas cancer (TPS, CEA and CA 19-9).

Patients and Methods: The circulating plasma levels of the biomarkers were measured by ELISA- and Luminex-based methods. 13 patients with samples taken at the time of diagnosis (preoperative) and >1 month after surgery (postoperative) were included in the study. Patients operated for nonmalignant disorders were used as controls.

Results: For all markers except CEA the levels were elevated at the time of diagnosis. The levels decreased after surgery for all mark-ers except type IV collagen, where the mean levels remained elevated. Instead, the postoperative value for each individual patient correlated to survival. For type XVIII collagen the preoperative levels correlated to survival. Neither the pre- nor postoperative levels of TPS, CEA or CA 19-9 correlated to survival.

Conclusion: This study shows that type IV and type XVIII col-lagen fragments can function as biomarkers for pancreatic cancer with advantages compared to conventionally used markers.

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The Impact of Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) on the Palliative Care of Patients with Unresectable Pancreatic Cancer: Preliminary ResultsA. Seicean1, I. Gulei2, R. Stan-Iuga2, C. Cainap3, T. Mocan1, T. Pop1

1University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca, 2Third Medical Clinic Cluj-Napoca, 3”Ion Chiricuta” Cancer Institute Cluj-Napoca, Romania

Introduction: EUS-CPN represents an alternative approach of pain palliation in patients with advanced or metastatic pancreatic cancer.

Objectives: To evaluate the safety and initial efficacy of EUS-CPN in terms of pain relief and quality of life in patients with painful unresectable pancreatic cancer.

Patients and Methods: Patients with inoperable body-tail pancreatic cancer (without prior chemotherapy) and pain requiring narcotic analgesia were included in this prospective study. EUS-CPN was performed with a linear array echoendoscope by central injection of the celiac plexus with 10-15 ml of alcohol. The multidimensional pain inventory measurement was applied before and 2 weeks after the procedure.

Results: Sixteen patients (11 men, mean age 57) underwent the procedure during one single session. Follow up at 2 weeks revealed overall pain relief in 11 cases (68.75%) and significant relief of pain scores for “worst pain” (5.44 vs 8.5), “average pain” (3.31 vs 6), “least pain” (0.56 vs 1.5) and “current pain” (2.81 vs 3.06, p = 0.045). The significant improvement in ratings of pain interference with gen-eral activity (5 vs 7.75), walking (2.69 vs 4.56), work (6.25 vs 7.94), mood (4.5 vs 7.25), enjoyment of life (4.13 vs 7.69), relations with others (3.5 vs 5.31), and sleep (4.05 vs 8.19) was also seen. Four patients experienced pain during the procedure. No other complica-tions were noted.

Conclusion: EUS-CPN central technique is an efficient and safe method for pain management in patients with inoperable body-tail pancreatic cancer.

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The Local Inflammatory Response and Prognosis in Pancreatic Ductal AdenocarcinomaM. Mohamed3, N.B. Jamieson1, A.K. Foulis2, E.J. Dickson1, R. Carter1, D.C. McMillan1, C.J. McKay1

1West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, 2Glasgow University Department of Pathology, Glasgow Royal Infirmary, 3Glasgow University Department of Surgery, Glasgow Royal Infirmary

Introduction: There is increasing evidence that both the local and systemic inflammatory response influence tumour progression.


In colorectal and oesphageal cancer, a pronounced lymphocytic infil-trate around the tumour, on simple hematoxylin and eosin stained sec-tions, is associated with improved survival.

Objectives: To evaluate the prognostic significance of inflam-matory cell infltration patterns following resection of pancreatic duc-tal adenocarcinoma (PDAC).

Patients and Methods: In 157 patients who underwent pancrea-ticoduodenectomy for PDAC between 2000-2008 we evaluated the local inflammatory peritumoural infiltrate in addition to established prognostic clinicopathological factors. Tumours were scored according to a 4-point score, from (1) no evidence of tumour infiltration to (4) frequent destruction of adenocarcinoma regions by inflammatory cells.

Results: According to our scoring criteria 47.7% of cases showed evidence of low-grade infiltrate. An absent/low-grade infil-trate was associated with vascular invasion (p < 0.01) and larger tumours (p < 0.05). An inflammatory infiltrate positively influenced survival, with the median survival for patients with highly infiltrated tumours being 28.1 months (95%CI:25.2-31.1) vs 11.6 months (95%CI:8.7–14.7), p < 0.001) for those patients with low-grade inflammatory infiltrate. On multivariate analysis in addition to resec-tion margin involvement (HR = 2.04,95%CI:1.28–3.26, p = 0.003), and adjuvant chemotherapy (HR = 0.60,95%CI:0.41–0.89, p = 0.012), the presence of a high-grade peritumoural inflammatory infiltrate remained an independent predictor of prolonged survival following resection (HR = 0.31,95%CI:0.21–0.46, p = 0.021). Interestingly, there was an inverse relationship between the local and systemic inflamma-tory responses(p = 0.001) as measured by C-Reactive protein.

Conclusion: In addition to established clinicopathological prog-nostic factors, we identified a lowgrade local inflammatory response is an independent predictor of reduced overall survival following pancreaticoduodenectomy. This suggests a simple evaluation of the local immune response following PDAC resection provides impor-tant prognostic information.

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Loss of Heterozygosity (LOH) Status of D9S105 Marker Is Associated with Down-regulation of Kruppel-like Factor 4 (KLF4) Expression in Pancreatic Ductal Adenocarcinoma and PaninsN. Funel1, M. Morelli2, E. Giovannetti3, L.E. Pollina4, M. Del Chiaro1, G. Bevilacqua2, F. Mosca1, A. Cavazzana2, D. Campani5, U. Boggi1

1Division of General and Transplantation Surgery, University of Pisa and Pisa University Hospital, Italy, 2Department of Oncology, Division of Surgical, Molecular and Ultrastructural Patholoy University of Pisa and Pisa University Hospital, Italy, 3VU University Medical Center, Amsterdam, The Netherlands, 4Department of Medicine Laboratory and Molecular Diagnoses, Hospital-University of Pisa, Italy, 5Department of Surgery, University of Pisa, Italy

Introduction: Homozygosis suppression of Kruppel-Like Factor 4 (KLF4) placing this gene as putative tumor suppressor gene

in gastric, bladder and colorectal cancer. Experimental data suggest that KLF4 may be over-expressed or down-regulated in Pancreatic Ductal Adenocarcinoma (PDAC) and its role in this pathology is unclear.

Objectives: This study was aimed at evaluating the association between loss of 9q31-32 region and gene expression of KLF4 in PDAC.

Materials and Methods: We investigated the Loss of Heterozygosity (LOH) in the 9q region and the expression of KFL4 gene in 35 PDAC, 6 PanINs, 6 Normal Ducts and 4 Primary Cell Culture of PDAC (PCC). Epithelial cells were isolated by laser micro-dissection. We used 4 microsatellite markers (D9S127, D9S53, D9S105, D9S106) flanking KLF4 locus to evaluate LOH, while mRNA gene expression was performed by RT-PCR.

Results: In 46.9% of PDAC and 83.3% of PanIN lesions there was a loss of the D9S105 marker, which resulted to be the most deleted marker. The PCC wild-type for D9S105 marker had mutated in Kras gene at codon 12 and expressed KLF4 and. Lack of KLF4 expression was found to be significantly associated with: 1) Genomic deletion flanking KLF4 in PDAC (p = 0.018) and in PanINs (p < 0.01); 2) LOH of D9S105 marker (p = 0.014); 3) Presence of low–grade of PDAC-associated PanIN (p = 0.021).

Conclusion: We identified a relation between D9S105 deletion and loss of KLF4 expression in PDAC. Our results suggested that the KLF4 gene can switch its role between tumor suppressor gene and oncogene depending on the biological context of PDAC.

P123

Impact of Leucocyte-depleted Blood Transfusion on Long-term Survival After Resection of Pancreatic AdenocarcinomaA.E. Frampton1, J.J. Bong2, C. Kyriakides1, M. Pai1, L.R. Jiao1

1HPB Surgical Unit, Dept. of Surgery & Cancer, Hammersmith Hospital, Imperial College, London, 2Department of Surgery, National University of Malaysia, PPUKM, Malaysia

Introduction: Blood transfusion may adversely affect progno-sis in cancer patients.

Objectives: To investigate whether leucocyte-depleted blood transfusion (LDBT) affects survival in patients following pancreatic ductal adenocarcinoma (PDAC) resection.

Patients and Methods: A retrospective cohort study was per-formed from 2001 to 2008. Clinical and transfusion data was col-lected from our transfusion laboratory and anaesthetic charts. Patients who died within 30-days of operation were excluded. Survival was calculated using the Kaplan–Meier method. Univariate and multivari-ate analysis was performed.

Results: A total of 269 pancreatic resections were performed for benign and malignant lesions. Seventy-six patients who had resection for PDAC were included in the analysis. Median age was 64.4 years (range 29.9 to 79.5 years). R0 resection was achieved in 47.9%. Median tumour size was 2.5 (range 0.9 to 5) cm. Lymph node metas-tases were present in 69.4% and perineural invasion in 68.9%. Thirty-


nine (51.3%) patients received a blood transfusion (median 3 units; range 1 to 8 units) and 32 (82.1%) were transfused intra-operatively. Median survival was 13.9 months for those who had a blood transfu-sion compared to 18.3 months for those who did not (P = 0.07). Twenty-six patients (34.2%) had a post-operative complication and the median length of stay was 18 (range 8 –96) days. Univariate anal-ysis indicated that sex, resection status, timing of blood transfusion (intra-operative, post-operative or both) and tumour (T) stage influ-enced survival. On multivariate an alysis, gender and resection status were the only predictors of survival.

Conclusion: LDBT would seem to have an adverse impact on survival in patients with PDAC.

P124

Management of Cystic Pancreatic LesionsK.V. Ånonsen1, T. Buanes2, I. Franco-Lie1, K.J. Labori2, I.M.B. Lothe3, T. Ikdahl4, T. Heiberg5, B. Edwin6, T. Hauge1

1Department of Gastroenterology, Oslo University Hospital Ulleval, 2Department of Gastrosurgery, Oslo University Hospital Ulleval, 3Department of Pathology, Oslo University Hospital Ulleval, 4Department of Oncology, Oslo University Hospital Ulleval, 5Research Forum, Oslo University Hospital Ulleval, 6Interventional Centre, Oslo University Hospital Rikshospitalet

Introduction: management of cystic pancreatic lesions is con-troversial. Since the reported ratio of benign histology after surgery is high, it is necessary to improve diagnostic accuracy.

Objectives: Describe the prevalence and management of cystic pancreatic lesions in a prospective cohort in a tertiary referral centre.

Patients and Methods: Oslo University Hospital in Norway is a tertiary referral centre for pancreatic surgery. All patients referred for both cystic and solid lesions from October 2008 to December 2009 were included and evaluated in our multidisciplinary team. Pseudocysts were excluded. Endosonography (EUS) with fine needle aspiration (EUS-FNA) including cyst fluid analysis was performed.

Results: A total of 185 patients were included and 51 patients (28%) had cystic pancreatic lesions. Of these, EUS was performed in 35 patients (69%) and EUS-FNA in 29 patients (57%). The manage-ment strategies were observation (33 patients) and surgery (14). Four patients were inoperable at evaluation. Surgical procedures included distal pancreatectomy (6), pancreaticoduodenectomy (4), total pan-createctomy (1) and inoperability at surgery (3). EUS-FNA was per-formed in 21 patients in the observed group and in 8 in the surgical/inoperable group. In these two groups median cyst fluid CEA was 256 and 3712, respectively (p < 0.05, Mann-Whitney Test).

Conclusion: The majority of patients has been selected for observation. Cyst fluid CEA level seem to influence the management strategy. Further longitudinal observation of larger cohorts is war-ranted.

P125

PanIN3 Lesions in Pancreata with and without Ductal Adenocarcinoma: Should We Extend the Resection?S.T. Barbu1, I. Domsa2, A. Zolog2, M. Cazacu1

1IVth Surgical Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca, Romania, 2Pathology Department, University CF Hospital Cluj-Napoca, Romania

Introduction: Although PanIN3 (carcinoma ‘in situ’) is a well-documented precursor of pancreatic cancer, few data are available about its natural history.

Objectives: To assess the evolution of PanIN3 lesions in pan-creata of patients with and without ductal adenocarcinoma (PDAC), while looking for the best surgical attitude.

Materials and Methods: Pancreatectomy specimens from 170 patients – 80 PDAC, 78 sporadic chronic pancreatitis (CP), and 12 low-grade malignancy neuroendocrine tumors (PET) – were retro-spectively evaluated for PanIN3 presence, and its relation with the resection margins. Patients included were followed-up till December 2009, or last personal contact, or death (mean PDAC = 2.3years, CP = 9.51years, PET = 6.7years).

Results: PanIN3 was present in 35 PDAC (43.7%), 9 CP (11.5%) and 1 PET (8.3%). PanIN3 positive resection margins (+RM) were identified in 9 specimens (5 PDAC, 3 CP, and 1 PET). During follow-up, 2 patients (1 PDAC, 1 CP) with PanIN3 present but free resection margins developed an adenocarcinoma in the pancreatic remnant after 7.2, respectively 9.4 years. None of the PanIN3+RM patients evolved to overt carcinoma. Mean follow-up of the 5 PanIN3+RM PDAC patients was 2.81 years (two are alive at 4.5 and 5.6 years).

Conclusion: PanIN3 progression to adenocarcinoma in 2 patients with free resection margins demonstrates that PanIN3 is a real precursor of PDAC, and suggests its even distribution throughout the pancreas. The progression may take many years (as previously reported), pleading rather for a close follow-up than for immediate total pancreatectomy in PET, sporadic CP and sporadic PDAC, with no need for PanIN3 free resection margins.


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Adjuvant Gemcitabine-based Chemoradiation Compared to Gemcitabine Alone Following Radical Surgical Resection for Pancreatic Ductal Adenocarcinoma (PDAC): A Retrospective AnalysisE. Vasile1, F. Pasqualetti2, A. Sainato2, M. Del Chiaro3, C. Caparello1, M. Coppola2, S. Caponi1, N. Funel4, C. Croce3, L. Ginocchi1, M. Lucchesi1, D. Campani4, F. Mosca5, U. Boggi3, C. Greco2, A. Falcone1

1U.O. Oncologia 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana; Polo Oncologico Area Vasta Nord-Ovest, Istituto Toscano Tumori; Pisa, Italy, 2U.O. Radioterapia, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, 3U.O. Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, 4U.O. Anatomia Patologica 3, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, 5U.O. Chirurgia Generale 1 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy

Introduction: Adjuvant gemcitabine improved disease-free sur-vival (DFS) and overall survival (OS) after resection of pancreatic cancer compared to surgery alone. The role of adjuvant chemoradia-tion is still debated.

Objectives: The aim of our analysis was to compare the out-come of radically resected PDAC patients treated with adjuvant gem-citabine-based chemoradiation (CT-RT) or with gemcitabine alone.

Patients and Methods: We retrospectively reviewed medical records of patients who underwent pancreaticoduodenectomy for PDAC at our institution from 2004 to 2006 and who were treated with adjuvant gemcitabine-based CT-RT or gemcitabine alone. Thirty-seven patients who had received the complete adjuvant treatment at our institution were included in the analysis: 21 treated with gemcit-abine alone (1000 mg/sqm on days 1,8,15 every 28 for 6 cycles) and 16 with CT-RT (two cycles of gemcitabine alone followed by weekly gemcitabine 300 mg/sqm with concurrent radiation of 50.4 Gy given in 28 fractions).

Results: Treatment groups were well balanced according to tumor and patients characteristics; the majority of patients had a T3 and/or N1 tumor. Median DFS was 19.3 months for patients who received chemoradiation versus 12.1 months for those treated with gemcitabine alone (p = 0.16), with a 1- and 2-year DFS rate of 73% and 26% for CT-RT group and 44% and 28% for chemotherapy group. Median OS was similar among the two groups (27 versus 25 months).

Conclusion: Adjuvant gemcitabine-based chemoradiation seems to produce longer DFS compared to gemcitabine alone in our small series, although no advantage was observed for OS. Larger and ran-domized trials should evaluate the true benefit of radiotherapy added to gemcitabine.

P127

Increasing Diagnosis of Pancreatic Cystic Lesions in an Italian Middle-High Volume Surgery DepartmentL. Degrate1, G. Mauri1, A. Redaelli2, C. Nobili1, M. Garancini1, R. Caprotti1, F. Uggeri1

1Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy, 2Service of Digestive Endoscopy, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy

Introduction: Pancreatic cystic lesions are increasingly recog-nized due to expanding use of cross-sectional imaging. High-volume pancreatic centers reported an increase of endoscopic ultrasound pro-cedures and surgical operations for these lesions.

Objectives: The aim is to assess the incidence and the manage-ment of pancreatic cystic lesions in an Italian Department of General Surgery of middle-high volume for pancreatic resections.

Patients and Methods: From January 2004 to March 2010 all patients who underwent endoscopic ultrasound for pancreatic cystic lesions were identified and analized.

Results: In the study period 70 patients were evaluated. Patients’ mean age was 68 years and 61% were women. The identification of pancreatic lesions was incidental in most of the cases. The number of endoscopic ultrasound procedures were 1 in 2004 and, respectively, 2, 5, 12, 20, 18 and 12 in the following years until 2010. 16 patients underwent surgical resection (10 pancreaticoduodenectomies, 6 distal pancreatectomies). Histopathological analysis showed intraductal papillary mucinous neoplasm in 5 cases, mucinous cystic neoplasm in 3, serous cystic neoplasm in 3, cystic ductal adenocarcinoma in 3, solid pseudopapillary neoplasm in 1, emorrhagic pseudocyst in 1.

Conclusion: The increasing incidence of pancreatic cystic lesions has been reported in dedicated high-volume pancreatic cen-ters. This study demonstrates an increase in recognition, endoscopic ultrasound procedures and surgical resections for these lesions also in a General Surgery Department of middle-high volume for pancreatic resections like ours. The evaluation of cystic lesions of the pancreas is challenging and international consensus guidelines are needed.


P128

A CD44+/CD133+ Cell Population in Normal Pancreas and Pancreatic Ductal Adenocarcinomas: Non-overlapping Membrane ExpressionH. Immervoll1, D. Hoem2, O.J. Steffensen3, H. Miletic4, A. Molven1

1Section for Pathology, the Gade Institute, University of Bergen, Bergen, Norway, 2Department of Surgery, Haukeland University Hospital, Bergen, Norway, 3Department of Pathology, Ålesund Hospital, Ålesund, Norway, 4Department of Biomedicine, University of Bergen, Norway

Introduction: Potential cancer stem cells (CSCs) can be iso-lated from disintegrated tumor tissue, using flow cytometry and the presence of specific cell surface proteins as sorting criterion. For pan-creatic ductal adenocarcinoma (PDAC), antibodies to either CD133 or CD44 have been employed.

Objectives: To characterize the postulated CSC marker CD44 in the normal and neoplastic pancreas, and to compare its expression pattern with that of CD133.

Materials and Methods: We studied normal and diseased pan-creatic tissue, including a series of 51 PDAC cases, employing identi-cal antibody clones as in previous CSC studies. CD44/CD133 expression was determined by immunohistochemical double-staining on formalin-fixed material. Subcellular protein expression was evalu-ated by immunofluorescence/confocal microscopy.

Results: In the normal, inflamed and neoplastic pancreas, CD44 and CD133 were co-expressed in different subcellular domains of cer-tain cell populations. CD44 was found on the basolateral cell mem-brane and in the cytoplasm, whereas CD133 was present on the apical/endoluminal cell surface. The amount and distribution of CD44-positive cells varied considerably, both between and within the tumors. The protein was in all cases detectable in the tumor stroma. In some malignant ducts, it was found at the apical cell membrane adjacent to, but never overlapping with CD133 expression. CD44 level associated with the patient’s lymph node status, but not with survival.

Conclusion: Membrane distribution of the two investigated markers is non-overlapping as CD44 is located basolaterally and CD133 apically. The preferentially centroacinar localization of dou-bly positive cells in the normal pancreas suggests that this population should be of particular interest in attempts to identify tumor-initiating cells in PDAC.

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Mechanism for Adipose Tissue Loss in Cancer Cachexia and their Association with SurvivalT. Agustsson1, M. Rydén2, T. Brismer, J. Permert1, P. Arner5, B. Isaksson1

1Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet at Karolinska University Hospital, 2Division of Medicine, Huddinge, Sweden, 3Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet at Karolinska University Hospital, 4Division of Medicine, Huddinge, Sweden, 5Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet at Karolinska University Hospital

Introduction: Many cancer patients have cachexia. We have recently shown that patients with cancer cachexia have increased lipol-ysis, expression and activity of Hormone Sensitive Lipase (HSL) but not increased local inflammation, apoptosis or decreased lipogenesis.

Objectives: To study the volume of visceral and subcutaneous adipose tissue and the association with survival in newly diagnosed cancer patients.

Materials and Methods: All newly diagnosed cancer patients were evaluated. After clinical examinations they were divided into: a) weight stable, b) weight loss >5% in three months or >10% in six months without stricture (cancer cachexia) or c) with stricture. Volume measurements of subcutaneous and visceral adipose tissue were done with CT in all patients and correlated with survival data.

Results: CT showed reduced volumes of subcutaneous adipose tissue in both of the weight loosing groups. Only the cachexia group had diminished visceral adipose tissue. Mean survival was lower in the stricture group (median = 350) compared to weight stable (median = 807, p < 0.0001) and cachexia (median = 497, p < 0.05) groups.

Conclusion: Adipose tissue was decreased in weight loosing, recently diagnosed cancer patients compared with weight stable patients. Furthermore, patients with cancer cachexia displayed a selective decrease in visceral adipose tissue, supporting the hypothe-sis that visceral adipose tissue wasting is an early and driving phe-nomenon in the cancer cachexia syndrome. Patients with cancer and reduced food intake caused by stricture had a poorer prognosis.


P130

Second-line Combination Chemotherapy in Metastatic Pancreatic Cancer (MPC) Patients After Failure of a First-line Chemotherapeutic DoubletL. Ginocchi1, E. Vasile1, M. Lucchesi1, S. Caponi1, C. Caparello1, A. Falcone1

1U.O. Oncologia 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana; Polo Oncologico Area Vasta Nord-Ovest, Istituto Toscano Tumori; Pisa, Italy

Introduction: The combination of gemcitabine with capecit-abine (GEMCAP) or oxaliplatin (GEMOX) has shown good activity and efficacy in phase III trials and metanalyses and is used as first-line treatment for selected MPC patients. Second-line chemotherapy with 5-fluorouracil and oxaliplatin improves survival after gemcit-abine, but few data about treatment of patients pretreated with combi-nation chemotherapy are available.

Objectives: –Patients and Methods: To evaluate the outcome of second-

line therapy after failure of GEMCAP or GEMOX, we retrospectively review data about responses, progression-free (PFS) and overall sur-vival (OS) of MPC patients with PS 0-1 who received second-line combination chemotherapy at our institution in the last two years.

Results: Fifteen eligible patients with a median age of 65 years pretreated with GEMCAP or GEMOX were included in the analysis. Five patients received FOLFOX, 4 GEMCAP, 4 GEMOX, 1 FOLFIRI and 1 capecitabine plus mitomycin. Six patients (43%) obtained a disease stabilization while 8 progressed. Median PFS and OS to second-line chemotherapy were 2.2 and 6.7 months, respec-tively. Patients who obtained a stable disease had a median PFS and OS of 6.1 and 12.6 months, respectively. Clinical features (age, sex, PS), response and PFS to first-line therapy and the regimen used in second-line do not resulted useful to predict a benefit from second-line chemotherapy.

Conclusion: Second-line combination chemotherapy has lim-ited activity in MPC patients pretreated with GEMCAP or GEMOX, even if a small number of patients may obtain a prolonged disease stabilization. Clinical features do not allow to identify these patients; a pharmacogenomic approach should be evaluated.

P131

Long Term Survival of Pancreatic Cancer Patients with Liver MetastasisW. Lou1, Y. Fan2

1Department of General Surgery, Zhong Shan Hospital, Fudan Unversity, 2Department of Chinese Medicine, Zhong Shan Hospital, Fudan Unversity

Introduction: Until now there is no satisfactory treatment for pancreatic cancer with liver metastasis.

Objectives: To investigate the optimal treatment protocol of pancreatic cancer with liver metastasis.

Patients and Methods: Patients with liver metastasis of pan-creatic cancer which was pathologically confirmed were eligible for the study. Gemcitabine 1,000 mg/m2 over 30 min on days 1and 15, while Oxaliplatin 100 mg/m2 was intravenously given on days 1and 15 daily as one cycle. After 2 cycles of chemotherapy, the objective response was assessed according to RECIST criteria. The treatment was stopped on progression of the tumor. For SD or PD patients, if the number of hepatic lesion was <4 and the diameter of lesions less than 3 cm, radiofrequency is employed to ablate the hepatic lesion. The chemotherapy is continuous with other SD or PD patients until tumor progression or intolerable toxicity. The primary end point is overall survival.

Results: 18 patients were quit after 2 cycles because of tumor progression.5 patients accepted radiofrequency ablation and 2 patients among them accepted primary tumor resection after another two cycles chemotherapy when there no sign of liver metastasis. Another 3 patients accepted 2 and 3 times radiofrequency ablation when there was recurrence in liver. The overall survival of this group was 9.3 months, while 14.6 months for 5 patients who accepted radiofre-quency ablation.

Conclusion: Gemcitabine+Oxiplatin regimen plus radiofre-quency ablation could achieve long term survival in some pancreatic patients with liver metastasis; good performance and metachronous liver metastasis are factors related to long term survival.

P132

Evaluation of Margin Status of Pancreatoduodenectomy with Venous Resection Using a Standardised Pathology ProtocolM. Cunha2, C. Verbeke2, A. Aldouri1, K. Menon1, A. Smith1

1Dept of Surgery, St James’ University Hospital, Leeds, UK, 2Dept of Histopathology, St James’ University Hospital, Leeds, UK

Introduction: Pancreatoduodenectomy with venous resection (PD+VR) has been shown to be safe and achieves survival outcomes comparable to same stage tumours resected by a standard pancre-atoduodenectomy.

Objectives: The aim of this study is to assess the margin status of patients undergoing PD + VR using a fully standardized pancreatic pathology protocol.

Patients and Methods: 30 consecutive patients (between 2005 and 2010) with pancreatic adenocarcinoma and distal cholangiocarci-noma underwent PD+VR were assessed using a fully standardised pancreatic pathology protocol. Venous resection included wedge and complete vein resections with reconstruction.

Results: All 30 specimens were staged T3 N1. In 24 out of 30 cases histology confirmed direct tumour invasion of portal and/or superior mesenteric vein (PV/SMV). The transection margins of the venous segments were always clear. However all specimens were R1 due to involvement of other circumferential resection margins (CRM). 21/30 had a positive margin in the PV/SMV groove beyond the VR (complete vein resection and reconstruction did not prevent this). Other CRMs involved included: 6/30 posterior, 3/30 anterior, 6/30


direct extension from the common bile duct. Overall 18/30 had mul-tiple positive CRMs. The median overall survival was 13 months (95% CI, 8.6 –18.2).

Conclusion: Despite the technical success of venous resection our standardised pancreatic pathology protocol has demonstrated a 100% R1 resection rate, with positive margins distant from the PV/SMV groove.

Clinical Science – Endocrine & Rare Tumors

P133

Enucleation of Benign Tumors of the Pancreas, a Parenchyma Sparing Operation. A Single Center ExperienceC. Pasquali1, L. Polizzi1, A. Parenti2, S.A. Canton1, R. Alaggio2, C. Sperti1, S. Pedrazzoli1

1Clinica Chirurgica 4, University of Padua, Italy, 2Pathology, University of Padua, Italy

Introduction: Tumor enucleation is a parenchyma sparing oper-ation to treat small benign tumors of the pancreas. Complication rate, in small series of patients, is reported to be high (>45%).

Objectives: To evaluate complication of pancreatic tumor enu-cleation in a series of patients collected in 41 years in a single center.

Patients and Methods: From 11/1968 to 12/2009, 62 patients underwent enucleation for benign or uncertain behaviour tumors of the pancreas. Fifty-seven patients had a simple tumor enucleation; 5 patients were excluded for an associated pancreatic resection. We ret-rospectively evaluated: age, sex, variety of tumor, site, size, i.o. ultra-sound, morbidity, mortality and lenght of hospital stay.

Results: 57 patients (24 M/33F) averaging 53 years (range 0,2 –86 years) were studied. Six cases had a previous pancreatic opera-tion. In three cases an additional surgical procedure on the G.I. tract was performed. Finally the operative procedures were 60, with 61 lesions. Mean size of the tumor was 2,0 cm. (range 0,5-15 cm), 55% in the head of the pancreas. 54/61 were endocrine tumors and 38 (62%) insulinomas. I.O. ultrasound was performed in 62% of cases. Hospital stay (15,4 days mean; range 6 –54) fell to 8,5 days in the last ten years (2000-09). Main surgical complications were found in 33,3% of cases: 12 pancreatic fistulas (20%), 3 acute pancreatitis (1 lethal), 4 abdomi-nal fluid collections (6,7%) and 2 cases (3,3%) with other complica-tions (duodenal fistula and abdominal wall dehiscence).

Conclusion: Enucleation of benign or uncertain behaviour tumors of the pancreas is a simple pancreas sparing operation but a complicated course is still found in 1/3 patients.

P134

Incidence and Risk Factors for Secondary Cancers in Patients with Sporadic Pancreatic Endocrine TumorsM. Rinzivillo1, G. Capurso1, M. Falconi2, F. Panzuto1, E. Merola1, L. Boninsegna1, R. Bettini2, P. Pederzoli2, G. Delle Fave1

1Digestive and Liver Disease Unit, “S.Andrea” Hospital, II Faculty of Medicine, “Sapienza” University, Rome, Italy, 2Surgery Department, University of Verona, Verona, Italy

Introduction: Pancreatic endocrine tumors (PETs) have an increasing incidence with prevalence of 10% of all pancreatic can-cers. There are no specific data published regarding the incidence of other primary cancers (secondary cancers = SC) in PETs.

Objectives: To evaluate the incidence of SC in PETs, and pos-sible risk factors for their occurrence.

Patients and Methods: Cohort of consecutive patients with histological diagnosis of sporadic PETs (MEN-I excluded). SC defined as a different tumor, diagnosed either before, sincronously or after PET diagnosis, with histological confirmation. The rate of SC was compared with expected cases in National Registries. Data on sex, age at diagnosis of PET, medical therapy and potential risk fac-tors for cancer recorded.

Results: Of 188 PET patients enrolled (95M, median age at diagnosis 53) with a mean of follow-up of 51.6 months, 23 patients (12.2%;10M) had 26 SCs either before (17;9%), simultaneously with PET (3;1.59%) or during follow-up (6;3.19%). Of patients develop-ing SC after PET, only one had received potentially genotoxic agents. Most common sites of SC were thyroid (6;3.19%;5F), nervous sys-tem (4;2.12%), breast (4,2.12%;3F). The rate of thyroid cancer for women with PET exceeded the expected lifetime incidence (5.3 SIR). There were no differences between patients with or without SC in terms of PET features. Patients with a SC were more frequently smok-ers (47.8% vs 34.5%), and heavy smokers (>20 pack-year) (30.4% vs 20.6%) although this difference was not significant.

Conclusion: We identified a relatively higher incidence than that expected for their age, of SC amongst PET patients. Most SC were diagnosed before PET, and were localized in other “neuroendo-crine” organs, possibly suggesting a common susceptibility. Smoking may be associated with an increased risk of SC.


P135

Longterm Results of Surgery for Pancreatic Endocrine Tumors in Patients with Multiple Endocrine Neoplasia Type 1 (MEN1)C. Lopez1, J. Waldmann1, V. Fendrich1, P.H. Kann2, D.K. Bartsch1, P. Langer1

1Department for Surgery, Philipps University Marburg, 2Division of Endocrinology and Diabetology, Department of Internal Medicine, Philipps University Marburg

Introduction: Pancreatic endocrine tumors (PETs) are the most common cause of death in patients with multiple endocrine neoplasia type 1 (MEN1).

Objectives: To asses the results of an aggressive surgical man-agement of PETs in MEN1 patients.

Patients and Methods: Since 1997 MEN1 patients were pro-spectively followed annually by biochemical testing and imaging studies. They underwent pancreatic resection when either biochemi-cal evidence of functioning PETs was demonstrated or nonfunction-ing PETs were larger than 1 cm in size.

Results: Thirty-five genetically confirmed MEN1 patients underwent duodenopancreatic surgery for functioning (n = 22) or non-functioning (n = 13) PETs. Malignantdisease occurred in 12 (35%) patients defined by either lymph node (12patients) and/or dis-tant metastases (4 patients). Five Zollinger-Ellisonsyndrome (ZES) patients required pylorus preserving pancreaticoduodenectomy (PPPD) as initial or redo-procedure and 30 patients underwent other-duodenopancreatic resections. After a median follow-up of 91 months (range, 1-259), 32 patients were alive, 1 patient succumbed to disease and 2 patients died of unrelated cause. All patients (n = 8) with insuli-noma and 5/12 patients with ZES were biochemically cured. One patient with malignant ZES developed diffuse bone metastases, but-none of the patients developed liver metastases in further follow-up. However, 30/35 (85%) patients developed new PETs in the pancreatic remnant which led tototal pancreatectomy in 2 patients.

Conclusion: Early resection of PETs in MEN1 prevents the development of liver metastases. However, the majority of patients develop new PETs in the pancreatic remnant which may require addi-tional surgery.

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Anaplastic Pancreatic Cancer: Presentation, Management, and OutcomeO. Strobel1, W. Hartwig1, F. Bergmann2, U. Hinz1, T. Hackert1, L. Grenacher3, M.W. Büchler1, J. Werner1

1Department of General Surgery, University of Heidelberg, 2Institute of Pathology, University of Heidelberg, 3Department of Radiology, University of Heidelberg

Introduction: Anaplastic pancreatic cancers are rare tumors. Available data is focused on pathological and molecular features; lit-tle is known about clinical presentation and management. The out-come of surgery is unknown.

Objectives: To analyze the clinical presentation and the out-come of surgery for anaplastic pancreatic cancer compared to ductal adenocarcinoma.

Patients and Methods: From a prospective database all con-secutive operations for anaplastic pancreatic cancer performed at our institution were identified. Clinicopathological details were analyzed and the outcome was compared to a matched group of ordinary pan-creatic ductal adenocarcinomas (nested case control study).

Results: Eighteen cases of anaplastic pancreatic cancer were identified. Patients had a median age of 64.1 years. Tumors were large (median diameter of 4 cm), and showed a peripheral contrast enhance-ment in radiologic imaging. Fifteen (83%) patients underwent resec-tion, palliative procedures were performed in one (5.6%) patient; two (11%) patients underwent exploration with biopsy only. Morbidity was 39% and mortality 5.6%. Median survival in anaplastic pancre-atic cancer was 5.7 months and shorter than in the control group of pancreatic ductal adenocarcinoma (15.7 months). In anaplastic pan-creatic cancer, median survival was significantly longer after R0/R1 resection compared to palliative surgery (7.1 vs. 2.3 months). Survival was significantly longer in tumors with osteoclast-like giant cells. Long-term survival was observed in three (17%) patients.

Conclusion: Anaplastic pancreatic cancer is an aggressive type of pancreatic cancer with short median survival. However, with pro-longed survival after resection and the observation of long-term sur-vivors, resection should be performed whenever possible. The presence of osteoclast-like giant cells is associated with a favorable prognosis.

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The Role of Pancreatectomy in the Management of Secondary Malignancy of the PancreasJ. Hung1, S. Wang1, Y. Shyr1, C. Su1, T. Chen2, C. Wu1

1Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, 2National Yang Ming University, Taipei, Taiwan

Introduction: For the rare incidence, the benefit of pancreatec-tomy for secondary malignancy of the pancreas(ie. metastasis or direct invasion from non-pancreatic malignancy)and the outcome are undefined.

Objectives: To determine the efficacy and risk of pancreatec-tomy for secondary malignancy of the pancreas and the survival pre-dictors.

Materials and Methods: Nineteen patients identified from our prospectively-gathered pancreaticobiliary database from 1980 to 2009 with secondary pancreatic malignancy undergoing pancreatec-tomy were analyzed with the pooled data from literature review.

Results: Total 329 patients were analyzed (241 with metastases and 88 with local invasions). Renal-cell carcinoma (RCC) (73.9%) and colorectal cancer (8.3%) were the most commonly resected metas-tases to the pancreas. Colon cancer (52.3%), stomach cancer (40.9%), and RCC (5.7%) were the most common primary malignancies with local invasion to pancreas. The median interval between metastasis and resection of primary malignancy was 84 months, with the longest


(108 months) for RCC. The surgical mortality and morbidity of patients undergoing pancreaticoduodenectomy (n = 199, 68.45%) were 2.6% and 14.6%. The 5-year survival rates of metastasis and local invasion group were not significantly different (61.1% vs.58.9%, p = 0.559). The best outcome after pancreatectomy is of patients with isolated metastasis from RCC (P < 0.001). Timing (synchronousvs. metachronou) and number (single vs. multiple) of metastasis were not significant survival predictors for cases with pancreatic metastasis. Though not significant to the survivals of RCC, primary lymph node metastasis predicted poorer outcome for resected metastasis from tumors other than RCC (P = 0.023), for local invasion from colon can-cer (P = 0.007) and stomach cancer (P = 0.004).

Conclusion: Long-term survival and favorable outcome can be achieved with pancreatectomy in selected patients with resectable secondary malignancy of the pancreas.

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Acinar Cell Carcinoma of the Pancreas: Is Resection Justified Even in Metastatic Disease?W. Hartwig1, M. Denneberg1, F. Bergmann2, T. Hackert1, U. Hinz1, O. Strobel1, M.W. Büchler1, J. Werner1

1Department of General Surgery, University of Heidelberg, Germany, 2Department of Pathology, University of Heidelberg, Germany

Introduction: Acinar cell carcinoma (ACC) of the pancreas is characterized by a better long-term survival compared to the more common ductal adenocarcinoma, and prognosis is better in resected compared to non-resected patients.

Objectives: To investigate the role of surgery in ACC with lim-ited metastatic disease.

Patients and Methods: All patients with a histologically con-firmed ACC treated at our institution between October 2001 and September 2009 were identified from a prospective database. Clinicopathologic details, perioperative, and follow-up results were analyzed.

Results: Seventeen patients with non-metastatic and metastatic ACC were identified. The mean age was 56 ±12 years, and the female to male ratio was 4 to 13. Initially, localized (T1-3, N0), locoregional (T4, No or any T, N1), and metastatic disease (M1) was present in 5, 7, and 5 patients, respectively. Pancreaticoduodenectomy, distal pan-createctomy, and total pancreatectomy were performed in 6, 7, and 2 patients, respectively. In limited metastatic disease, additional liver resection was performed in 3 patients and omentectomy in one patient. Two patients with metachronous liver metastasis underwent liver resection 7 and 9 months after pancreatic resection. Two patients with advanced locoregional disease or diffuse peritoneal carcinomatosis did not undergo resection. With a median follow-up of 28 months, overall 1-, 2-, and 3-year survival rates were 85%, 62%, and 41%, respectively. Long-term survival of resected patients with metastatic and non-metastatic disease showed no significant difference.

Conclusion: Acinar cell carcinoma of the pancreas is a rela-tively rare tumor entity where resection may result in long-term sur-vival even in limited metastatic disease.

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Operative Management and Outcome in Patients with Sporadic GastrinomasV. Fendrich1, P. Langer1, J. Waldmann1, D. Bartsch1

1Department of Surgery Philipps-University Marburg

Introduction: After biochemical confirmation of a Zollinger-Ellison syndrom and exclusion of diffuse metastases, a meticulous surgical exploration including intraoperative ultrasound, and duode-nal exploration should be performed. Depending on the localization, excision of the tumor in the duodenal wall or enucleation from the pancreatic head should be performed. If the tumor is localized in the tail of the pancreas, distal pancreatectomy is the treatment of choice. Complete resection of the tumor is the only curative attempt for the patients.

Objectives: To evaluate the outcome of patients with sporadic gastrinomas in a tertiary referral centre.

Patients and Methods: 177 patients with pancreatic endocrine tumors that underwent surgery between 1989 and 2009 were retro-spectively evaluated. The diagnosis of gastrinoma was based on clini-cal symptoms, biochemical tests and histopathology with immunohistochemistry. All patients with at least one operation for Zollinger-Ellison-Syndrome (ZES) were analysed regarding clinical characteristics, type of operative procedures and longterm follow-up.

Results: 28 patients (12 men, 16 women) with a median age of 50.5 years (range 28-73 years) were identified. 11 patients had pan-creatic gastrinomas, whereas 13 patients had their gastrinoma in the duodenum. In four patients a primary tumor could not be identified. 78% (23/28) of patients had malignant tumors. A total of 33 opera-tions were performed. Most performed surgical procedures were duo-denectomy with resection of a duodenal gastrinoma and resection of metastases in liver or lymph nodes. After a median follow up of 72 months (range 5-197) 9 patients are alive without evidence of disease, 12 patients are alive with disease, five patients were deceased dis-ease-related and two patients were deceased of an unrelated cause. The median survival time of the seven deceased patients was 112 (range 36-339) months after the primary operation and 7 (range 1-34) months after the last reoperation.

Conclusion: Although long-term cure can only be achieved in a proportion of patients with ZES, significant long-term palliation can be achieved.


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Diagnostic Value of Plasma Insulin and Plasma Glucose Variability During a Supervised Fasting Test in the Diagnosis of InsulinomaA. Kaczka1, L. Czupryniak2, M. Pawlowski2, E. Szymanska-Garbacz2, M. Saryusz-Wolska2, L. Durko1, J. Loba2, E. Malecka-Panas1

1Department of Digestive Tract Diseases, Barlicki Hospital No 1, Medical University of Lodz, 2Diabetology and Metabolic Diseases Department, Barlicki Hospital No 1, Medical University of Lodz

Introduction: A supervised 48-72 hours fasting test is an acknowledged method of insulinoma diagnosis. In some insulinoma subjects plasma insulin remains normal during the test, which may lead to misinterpretation of the test results.

Objectives: Evaluation of diagnostic value of plasma insulin and glucose variablity during the fasting test.

Materials and Methods: The study group comprised 61 sub-jects (48 women,13 men;mean age 43±15,5years, from 19 to 76 years) with clinical symptoms of hypoglycemia. All individuals were subject to supervise fasting test with blood sampling for glucose and insulin measurment every 6 hours. The test was terminated after 72 hours or until hypoglycemia symptoms developed.

Results: 10(16%)subjects were diagnosed with insulinoma (8 women,2 men;mean age 51±14,5 years, from 28 to76years). Their mean plasma insulin was significantly higher than in healthy patients (21.5±15.7mU/l vs 5.17±5.24mU/l respectively, p < 0.001), with the reference range 5-23mU/l. In this group of patients plasma insulin was typically rising during 48hours of the test despite low plasma glucose:mean insulin was 19.4±18.1mU/l during the first day and 25.2±18.8mU/l during the second day (p < 0.001), while in healthy subjects plasma concentration decreased from 7.1±8.0mU/l to 3.4±2.7mU/l within 48hours. Plasma insulin variability was similar in both groups (coefficient of variability CV 60-100%). Plasma glucose variability was greater in insulinoma subjects than in healthy indi-viduals (CV46-65%vs10-20% respectively). Glucose level was more stable in healthy group and was decreasing gradually by 12-20% dur-ing each day of fasting test.

Conclusion: Normal plasma insulin during the fasting test doesn’t exclude possibilty of insulionoma. The probability of diag-nosing insulinoma increases if plasma insulin values during fasting test don’t decrease or even rise with concomitant low but variable plasma glucose.

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Pancreatic Secondary Lesions from Renal Cell CarcinomaC. Pasquali1, L. Moletta1, V. Vincenzi3, S.A. Canton1, A. Parenti2, C. Sperti1, S. Pedrazzoli1

1Clinica Chirurgica 4, University of Padua, Italy, 2Pathology, University of Padua, Italy, 3Dept. of Medicine, Belluno Hospital, Italy

Introduction: Metastatic lesions to the pancreas from renal cell carcinoma (RCC) are considered slow-growing.

Objectives: To evaluate survival of patients with pancreatic RCC metastases and disease free survival in surgically treated patients.

Patients and Methods: We reviewed the clinical data of patients with pancreatic metastases from RCC, observed in our Department from 2004 to 2009.

Results: We observed 13 patients (8M/5F) averaging 66 years. All patients but one, had a nephrectomy 6 years before (median; range 0,5-22 yrs.). In two cases the pancreatic secondary was detected within 1 year. Reviewing imaging, in 3 more cases the lesion was evident 2, 3 and 6 years before referral. The pancreas was the only site of RCC recurrence in 10/13 patients. Four patients presented with symptoms (2 with jaundice and 2 with abdominal pain). Nine patients were resected (2 Pancreatico-duodenectomy, 1 Duodenum-preserving pancreatic head resection, 1 Central pancreatectomy, 5 Left pancre-atectomy). In these patients we had five complications: 3 pancreatic fistulas (two grade A and one B), 1 had also a lethal pulmonary embo-lism and one had a splenic infarction. The mean follow-up was 23.4 months (range: 1-70). Four/13 patients died 0-20 months after diag-nosis or surgery (2 for disease progression). Among the other nine patients, 8 are alive without disease (range: 1-57 months; mean 19), and 1 alive with liver metastases 70 mo. after surgery.

Conclusion: Pancreatic metastases from RCC are surgically curable, with long-term survival and disease free survival. Most of them have a slow growth; we are not able to predict patients who will have an early relapse.

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Patterns and Predictors of Failure After Curative Resections of Pancreatic Endocrine CarcinomaS. Crippa1, L. Boninsegna1, R. Bettini2, F. Panzuto4, S. Partelli1, P. Capelli3, A. Scarpa3, G. Dalle Fave4, C. Bassi1, P. Pederzoli1, M. Falconi1

1Department of Surgery, University of Verona, Verona, Italy, 2Department of Surgery, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy, 3Department of Pathology, University of Verona, Italy, 4Department of Surgery, Ospedale Sant’Andrea, University of Rome, Italy

Introduction: Pancreatic endocrine carcinomas (PECs) are associated with a good prognosis after radical resection. Lymph node


ratio is a major prognostic factor in several gastrointestinal neo-plasms, but it has never been investigated in PECs.

Objectives: To evaluate the prognostic role of LNR as well as patterns of recurrence after surgery in PECs.

Patients and Methods: Clinical and pathological data of patients with resected, pathologically confirmed, PECs were reviewed.

Results: Fifty-six patients (28 females, median age 58 years) were identified. Postoperative mortality was nil and morbidity was 41%. Median follow-up was 43 months. Two- and 5-year disease-spe-cific survival (DSS) were 69.8% and 52.1%. Tumor-recurrence was identified in 25 patients (44.6%, median interval time: 19 months). There were 19 (44%) patients with N0 disease, whereas 37 (66%) had lymph node metastases (N1). Patients with lymph node metastases had a LNR <=0.15 in 25 cases whereas 12 (32.4) had a LNR >0.15. The frequency of microvascular (76.8% versus 23.2%, p = 0.002) and peri-pancreatic fat (54.3% versus 35.7%, p = 0.0007) invasion as well as the median value of Ki67 (8% versus 3%, p = 0.003) were significantly higher in patients who developed recurrence. On multivariate analysis, LNR >0.15 (HR = 4) and a value of Ki67 >5% (HR 3.71) were signifi-cant predictors of recurrence (P < 0.002).

Conclusion: After curative resection for PECs, LNR and a value of Ki67 >5% are the most powerful predictors of recurrence. The presence of these factors should be considered in order to stratify patients for adjuvant treatments in future clinical trials.

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Incidence and Surgical Treatments of Rare Pancreatic Tumors – Clinical Series of the 1st Department of Surgery, Semmelweis University Between 1993–2009B. Tihanyi1, L. Nehez1, B. Jaray2, E. Szekely2, T.F. Tihanyi1

11st Department of Surgery, Semmelweis University, Budapest, 22nd Department of Pathology, Semmelweis University, Budapest

Introduction: With the development of the imaging procedures, continuously increasing number of pancreatic neoplastic lesions are diagnosed yearly. In spite of this fact, the resecability rate still hardly reaches 20 percent. The 1st Department of Surgery, Semmelweis University is a referral centre for pancreatic diseases.

Objectives: Between 1993 and 2009, 632 successful pancreatic resections for pancreatic neoplastic lesions were performed at the 1st Department of Surgery, Semmelweis University, Budapest. During the last 17 years there were 249 not common resected pancreatic tumor cases.

Patients and Methods: We found 137 cystic tumors of the pancreas of all resected cases. The incidence of the IPMN out of the pancreatic cystic neoplasms was found 13%. With the exception of 1 benign case, all of them proved to be malignant. There were 19 rare types of ductal carcinoma, like anaplastic tumor, shigillocellular car-cinoma, clear-cell type carcinoma, gigantocellular carcinoma, ade-nosquamous carcinoma and sarcomatoid tumor. We found only 2 acinar-cell tumor, 61 endocrine and 16 pseudopapillary endocrine tumor cases.

Results: Pylorus preserving pancreato-duodenectomy was per-formed when the tumor found to be malignant and localized in the

head or the body of the pancreas. Distal resection (in most cases (more than 90% with preservation of the spleen) was chosen when the tumor localized in the tail of the pancreas. Total pancreatectomy was needed only in malignant branch-duct or combined type of IPMT, or when the tumor margin reached the mesenteric vein. Local excision was performed only in the rare benign tumors localized in the body or in the tail of the pancreas.

Conclusion: The incidence of rare pancreatic tumors is rela-tively high, like the rate of malignancy in our cases as compared to data of the world literature.

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Multidetector CT in Determination of Resectability of Locally Advanced Pancreatic Ductal AdenocarcinomaC. Cappelli1, V. Vallini1, L. Novaria1, A. Di Giambattista1, S. Mazzeo1, N. Funel2, D. Campani2, F. Costa3, V.G. Perrone3, M. Del Chiaro3, U. Boggi3, C. Bartolozzi1

1Radiologia Diagnostica ed Interventistica, 2Anatomia Patologica Sperimentale, 3Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico

Introduction: According to the Expert Consensus Statement published in 2009 on Annals Surgical Oncology, pancreaticoduo-denectomy (PD) with vein resection is the standard of practice for borderline resectable pancreatic adenocarcinoma, locally involving the PV/SMV. Then an accurate preoperative CT staging is founda-mental in order to plan an R0 resection.

Objectives: To evaluate the predictive value of MDCT in assess-ing resectability in patients affected by locally advanced ductal ade-nocarcinoma of the pancreas.

Patients and Methods: The study included 52 patients with locally advanced ductal adenocarcinoma of the head, uncinate pro-cess or body of pancreas, submitted to surgical treatment with vascu-lar resection. On the basis of CT findings we identified three groups of patients: resectable patients, borderline resectable patients (absence of metastases and carcinosis, retroperitoneal infiltration and venous infiltration liable to resection likely R0) and palliative resectable patients (arterial or venous infiltration associated to retroperitoneal infiltration likely R+). The results were compared with histopatho-logical examinations after resection.

Results: At CT, 6 patients resulted resectable, 23 borderline resectable, 23 palliative resectable and at pathology 6, 31 and 15 respectively, with concordance in 34/52 cases (65%). Particularly CT overestimated 13 cases (all suspected arterial infiltration not con-firmed at pathology) and underestimated 5 cases (3 venous infiltra-tion and 2 R1 SMA margin). Sensitivity and diagnostic accuracy in detecting vascular infiltration and retroperitoneal involvement were 91%/73% and 96%/90% respectively.

Conclusion: MDCT represents an accurate technique that can help in identifying borderline resectable patients that can benefit from therapeutic surgery or patients that need neo-adjuvant chemotherapy.


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Multidetector CT in Characterization of Neuroendocrine Pancreatic Neoplasms NatureC. Cappelli1, L. Novaria1, V. Vallini1, B. Pontillo-Contillo1, A. Di Giambattista1, S. Mazzeo1, N. Funel2, D. Campani2, M. Del Chiaro3, U. Boggi3, C. Bartolozzi1

1Radiologia Diagnostica ed Interventistica, 2Anatomia Patologica Sperimentale, 3Chirurgia Generale e Trapianti nell’Uremico e nel Diabetico

Introduction: Suspicion of pancreatic neuroendocrine neo-plasm nature arises both from clinical and imaging finding, including type of secreted hormone, nodular dimension and presence of local and distant spreading.

Objectives: Aim of our study was to determine the nature of neuroendocrine pancreatic neoplasms by analysing lesions enhance-ment pattern at multidetector CT.

Materials and Methods: We analysed 59 lesions in 38 patients, submitted to MDCT study including early arterial (15”), pancreatic (30”), venous (70”), delayed (180”) post-contrastographic phases. Three different patterns were identified: pattern A (early arterial/ pan-creatic enhancement and rapid wash-out); pattern B1 (early wash-in and no wash-out) and pattern B2 (enhancement only in venous or delayed phase). Greatest lesion dimension was measured. CT find-ings were compared with pathology.

Results: At CT 30/59 lesions showed pattern A (average dimen-sion 11mm). Histology classified 23/30 as benign (a.d. 8mm), 1 as malignant (10mm) and 6 as borderline (a.d.14mm). Pattern B included 29/59 lesions (a.d. at CT 39mm); at histopathology 21/29 resulted to be malignant (particularly all B2 lesions and 13 B1 lesions) (a.d 43mm), 6 borderline (a.d. 18mm) and 2 benign (a.d. 19mm). Two malignant lesions presenting pattern B had dimension <2cm (14mm and 12mm respectively). Pattern A showed a PPV of 77% in predict-ing benignancy, while pattern B showed a PPV of 72% in predicting malignancy. We obtained an excellent (R = 0.90) correlation between MDCT and histology in evaluating lesion dimension.

Conclusion: Post-contrastographic MDCT pattern may repre-sent a further criterium for suspecting lesion malignancy in associa-tion with lesion dimension. Particularly, the presence of enhancement in delayed phase is suspected for malignancy.

Clinical Science – Endoscopy, Techniques & Imaging

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Data from 11.074 ERCP Procedures from the Swedish Register for Gallstone Surgery and ERCP (GallRiks)L. Enochsson1, F. Swahn1, U. Arnelo1, M. Nilsson1, J.M. Löhr1, G. Persson2

1Department of Surgical Gastroenterology, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden, 2Department of Surgery, Ryhov Hospital, Jönköping, Sweden

Introduction: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) is the first nationwide databased register for gall-stone surgery and ERCP in the world. We report here data from 11.074 ERCPs done in 2007 and 2008.

Objectives: The aim of this study is to present safety and meth-odological success of ERCP done in Sweden.

Patients and Methods: In GallRiks both surgery of the gall-bladder and ERCPs are registered. The register is based on an internet platform with on-line registration of the procedures and a 30-day fol-low-up as well as electronic reports on demand. The present data includes 76% of the ERCP procedures performed in Sweden in 2007 and 95% of the procedures in 2008. The database has been validated indicating a complete match between the medical records and the database in 97.3% of the ERCP cases.

Results: A successful bile duct cannulation rate of 92% was achieved. Common bile duct stones (CBDS) was found in 36.8% of the examinations. The per- and postoperative complication rates were 2.5% and 9.8%, respectively. An ERCP-induced pancreatitis fre-quency of 2.7% was registered. The total 30-day mortality ratein the database was 5.9% but varied significantly between the different diagnostic groups. The indications for ERCP differed between high- and low volume centres whereas success rate and morbidity were similar thus indicating an adequate referral pattern of difficult cases in Sweden.

Conclusion: ERCP is widely used at Swedish hospitals with acceptable cannulation success and ERCPinduced pancreatitis rates in line with international standards. The GallRiks registry is a popula-tion-based nation-wide registry with good data validity and high inclusion rates regarding ERCP procedures.


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Endoscopic Diagnosis and Treatment of CholedochoceleÁ. Pap1, A. Tarpay1, E. Tóth2, M. Burai1

1Dept. of Gastroenterology, National Institute of Oncology, Budapest, Hungary, 2Dept. of Oncopathology, National Institute of Oncology, Budapest, Hungary

Introduction: Choledochocele is the rarest form (1.4%) of cho-ledochal cyst. It has been described in two variations:(1) both bile duct and pancreatic duct drain directly into the choledochocele, which then drains into the duodenum with or without a long common chan-nel, and (2) the choledochocele is a duplication cyst of the duodenum proximal to a normal ampulla. Gallstones are associated with this entity in 25% of cases. Pancreatitis is also a common initial presenta-tion occurring in 30% of patients. Carcinoma arising in the wall of choledochocele is a rarely recognized phenomenon.

Objectives: MRCP and EUS can replace the diagnostic role of ERCP with good accuracy but endotherapy is the method of choice to treat symptomatic choledochocele in due time.

Patients and Methods: We have collected 8 cases of choledo-chocele from our ERCP records. Mean age of the 6 females and 2 males was 69.6 (46-81) years.At ERCP we have performed extended papillotomy (after precut in 5 cases) and detailed histology of snare or multiple biopsy samples to exclude malignant changes.

Results: Histology demonstrated inflammation in 5 and ade-noma in 3 cases.During the 72,5(9-186) months follow-up period 6 patients are doing well, one 46 years old woman has lost of followup, a 79years old man died from unrelated cancer with pulmonary and brain metastases. No relapse of pain or jaundice occurred during the long follow-up time.

Conclusion: Endotherapy of choledochocele seems to be a definitive treatment for this Type III choledochal cyst in contrast to the other biliary cysts which should be resected in due time to prevent cancer development. Extended papillotomy with detailed histology and long term follow-up are mandatory to explore natural history of this rare entity.

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Does the Texture Matter? Evaluation of Postoperative Pancreatic Fistula in 473 Patients with Pancreatic Endocrine Tumors, Pancreatic Cancer and Chronic PancreatitisV. Fendrich1, J. Waldmann1, M. März1, D. Bartsch1

1University of Marburg, Department of Surgery

Introduction: Postoperative pancreatic fistula (PF) is still regarded as one major complication. The incidence of PF varies greatly in different reports. One factor seems to be the texture of the pancreatic gland. A soft pancreas is to be considered as a risk factor for PF.

Objectives: In the presented study, we have evaluated the risk of a PF in a large study population in patients with PETs, pancreatic

cancer, chronic pancreatitis and other reasons (e.g. pancreatic trauma).

Patients and Methods: 639 patients that underwent pancreatic surgery between 1989 and 2008 at our institution were retrospectively evaluated. The diagnosis of PETs, pancreatic cancer and chronic pan-creatitis was based on clinical symptoms and histopathology. All patients were analysed regarding age, gender, BMI, alcohol, smoking, preoperative diabetes, reason for operation, operative procedure and PF (definition from Bassi et al. Surgery 2005). Three different grades of PF (grades A, B, C) are defined according to the clinical impact on the patient’s hospital course. For analysing proportions a two-tailed Fisher’s exact test was used. P-values <0.05 were considered as sta-tistically significant.

Results: From 473/639 (74%) of all patients undergoing pancre-atic surgery, grading of PF was possible by study material. 133 patients with PETs, 180 patients with pancreatic cancer, 83 patients with chronic pancreatitis, and 77 patients with other reasons were identified and evaluated. 357 of all 473 (75.4%) patients did not develop a PF, whereas 78 (16.6%) developed a PF grade A, 32 (6.8%) grade B and only 6 (1.2%) grade C. Patients with a PET had a signifi-cant higher risk to develop a PF than patients with pancreatic cancer, chronic pancreatitis or other reasons (p = 0.0001). 36/133 (27.1%) patients with PETs had a PF grade A, 14 (7.5%) grade B and one patient (0.75%) grade C. In contrast, 180 (84.9%) of 212 patients with pancreatic cancer had no PF, only 21 (9.9%) had a PF grade A, 8 (3.8%) grade B, and three (1.4%) grade C. Patients who underwent pancreatic surgery for chronic pancreatitis or other reasons had PF rates comparable to patients with pancreatic cancer. Enucleation of the tumor was associated with the highest rate of PF (p = 0.001). In a multivariate analysis, a BMI >26 and preoperative diabetes were associated with a higher PF (p = 0.042) and (p = 0.02). Remarkably, age, gender, smoking, alcohol abuse, and arterial hypertension had no significant impact on PF.

Conclusion: For the first time we can demonstrate that after excluding factors like different definitions of PF, or different peri- or postoperative management, patients with PETs have a significant higher risk of postoperative pancreatic fistula than patients with pan-creatic cancer or chronic pancreatitis.

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The Usefulness of a Grading System for Complications Resulting from Pancreatic Resections. A Single Center ExperienceC. Ricci1, R. Casadei1, R. Pezzilli1, A.M. Morselli-Labate1, L. Calculli1, D. Rega1, M. D’Ambra1, F. Monari1, F. Minni1

1Alma Mater Studiorum, Università di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy

Introduction: Unified grading systems of the severity of com-plications after pancreatic resection are lacking.

Objectives: To test the usefulness of the Clavien-Dindo classifi-cation (CDC).

Patients and Methods: Complications of 151 pancreatic resected patients were classified according to CDC and each grade was evaluated regarding the length of the postoperative stay and was


compared to the most important complications after pancreatic resec-tion such as postoperative pancreatic fistula (POPF), post-pancreatec-tomy hemorrhage (PPH), delayed gastric emptying (DGE) defined according to ISGPF and ISGPS. Finally, the presence of factors capable of predicting the length of the postoperative stay were also evaluated.

Results: No complications were present in 32 (21.2%) patients; 119 (78.8%) patients had complications: grade I, in 11.9%, grade II in 49.0%, grade III in 6.6%; grade IV in 7.3% and grade V in 4.0%. POPF rate was 26.1%, PPH, 33.7% and DGE, 21.4%. There was a progressive increase in the length of hospitalization from patients with no complications to those having grade IV (P < 0.001). POPF and PPH rates and their severity significantly increased from Clavien-Dindo grade I to grade IV (both P < 0.001). The multivariate analysis shows that cardiovascular disease, extended or liver resection, POPF grade B, PPH grade C, DGE and total pancreatectomy resulted inde-pendent factors capable of predicting a long hospital stay.

Conclusion: The CDC is an objective, simple, reliable, and reproducible method to classify complications following pancreatic resection. Furthermore, because CDC is determined after the patients discharge, we also identified independent factors related to the length of postoperative stay.

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Controlled Release of Basic Fibroblast Growth Factor Causes Rapid Healing of PancreaticojejunostomyT. Aimoto1, Y. Nakamura1, S. Mizutani2, A. Hoshino2, H. Suzuki2, Y. Tabata3, M. Miyamoto4, E. Uchida1

1Department of Surgery, Nippon Medical School, 2Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, 3Department of Biomaterials, Institute for Frontier Medical Science, Kyoto University, 4Department of Internal Medicine, Nippon Medical School

Introduction: Since pancreatic fistula (PF) after pancreaticodu-odenectomy is an important morbidity, a novel approach capable of achieving zero PF is awaited. On the other hand, bFGFincorporated gelatin hydrogel microsphere (bFGF-GH) has been applied as a con-trolled release system on organ reconstruction.

Objectives: We examined the healing process of the pancreati-cojejunostomy (PJ) following the novel technique to investigate sig-nificance of administration of bFGF-GH.

Materials and Methods: 28 dogs received a jejunal subserosal injection of 10g bFGF-GH (n = 16) or GH alone (n = 12). Sequential analysis of the healing process was performed on day 4, 7, 21, 28. Breaking strength test, pathologic examination, calculations of colla-gen content, TUNEL index, and microvessel density (MVD) were assessed.

Results: Histologically, an abundant granulation tissue was observed at the border zone in the bFGF-GH group on day 7 and the GH alone group on day 21. Marked neovascularization and dense col-lagen deposition were detected in both groups on day 28. Collagen content and breaking strength showed no significant difference between both groups on day 28. A higher value of TUNEL index and a rapid decline in the number of vimentin-positive cells was detected

since day 21 in the bFGF-GH group. The MVD in the bFGF-GH group was a higher value since day 7.

Conclusion: Basic FGF-GH administration can cause a rapid healing of PJ and may contribute to improvement of quality of the heal-ing with potent angiogenesis and promotion of apoptosis induction.

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Implementation of No-touch Pancreaticoduodenectomy (PD). Single Center First ExperienceV. Kopchak1, K. Kopchak1, I. Khomyak1, A. Duvalko1, A. Zelinskyi1, B. Borisov1

1National institute of surgery and transplantology, Kiev, Ukraine

Introduction: The long-term results of pancreatic tumors resec-tions are still disappointing. In order to increase postoperative sur-vival after resections no-touch techniques of PD were proposed.

Objectives: To increase the nearest and long-term results of sur-gical treatment of patients malignant periampullary tumors.

Patients and Methods: We investigated the results of surgical resections of malignant periampullary tumors in 121 patients, treated in our clinic in the period of 2008- 2009 years. Standard Whipple procedure was performed in 102 patients. In patients with malignant tumors of duodenum, papilla of Vater and distal bile duct pyloruspreserving PD was preferable (19 patients). In 14 patients no-touch PD was performed, including 3 patients with Hirota no-touch PD and 11 patients with Jichi-technique. In 2 patients of no-touch PD group additional resection of the affected portal vein was performed. In all patients modified extended lymphadenectomy was performed.

Results: Duration of the operation was 502,3 +46,4 minutes in no-touch PD group and 512,3+12,3 minutes in the control group. Mean blood loss was 446 + 256,9 ml (range from 200 to 1200 ml) in no-touch PD group. Early postoperative morbidity was 23,4% (25 patients) in control group and 7,1% (1 patient) in no-touch PD group. Postoperative mortality was 0,8% (1 patient). Mortality in no-touch PD group was zero. Maximal follow-up in patients of no-touch PD group was 13 months. At the end of follow-up all patients are alive without local recurrence or distant metastatic disease.

Conclusion: No-touch PD is as safe procedure as standard and could be applied in clinical practice.


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Post Operative Outcome of 231 Pancreatectomies Associated to Vascular Resection (PAVR)M. Del Chiaro1, V.G. Perrone1, F. Costa1, C. Croce1, D. Mariniello1, S. Signori1, F. Mosca1, U. Boggi1

1Pisa University Hospital, Division of General and Transplant Surgery, Pisa, Italy

Introduction: PAVR are considered high risk surgical proce-dures.

Objectives: To analyze the post-operative outcome in a consec-utive series of PAVR performed at our Institution and the impact of complications in the long term outcome.

Patients and Methods: From 1987 to 2010, 231 PAVR were performed at our Institution. An isolated venous resection (IVR) was done in 167 cases, an isolated arterial resection (IAR) in 25 and a combined arterovenous (AVR) in 39.

Results: The overall morbidity and mortality rates were 42.8% and 7.3%, respectively. The IVR, IAR, AVR morbidity and mortality rates were 38.9% and 6.5%, 52% and 4%, 53.8% and 12.8% (p = NS). A significant difference was found comparing mortality in patients undergoing pancreaticoduodenectomy, total pancreatectomy and dis-tal pancreatectomy. (4.8% vs 13.5% vs 3.1%; p = 0.04). The age of the patients, number of resected vessels, T diameter, number of lymphnodes removed, pre-operative Ca 19.9 value, pre operative jaundice, were not found as risk factors for post-operative complica-tions. A diagnosis of ductal adenocarcinoma (DA) seems to be associ-ated to low risk of complications versus other tumor types (38.1% vs 56.9%; p = 0.01). No statistically significant differences in 1, 3 and 5 yrs survival rates were found comparing DA patients with or without post operative complications (29%, 4% and 9% vs 61%, 4% and 5%; p = NS).

Conclusion: Patients diagnosed with DA seem to have less post-operative complications compared to other tumor types. Total pancreatectomy is associated with an increased risk of mortality. The development of post-operative complications have not an impact on long term survival.

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From Pancreatic Intraepithelial Neoplasia (PanIN) to Intraductal Papillary Mucinous Neoplasms (IPMN): What Is the Significance of Endoscopic Ultrasound (EUS) Findings?F. Maire1, A. Couvelard1, L. Palazzo1, A. Aubert1, M.P. Vullierme1, P. Hammel1, A. Sauvanet1, V. Rebours1, P. Lévy1, P. Ruszniewski1

1Beaujon Hospital, Clichy, France

Introduction: Management of patients with IPMN depends on the extent of the disease and the malignancy. PanIN lesions are close to IPMN but are not responsible for duct dilatation (or <5 mm). The relationship between IPMN and PanIN is poorly understood.

Objectives: To look for correlations between EUS and patho-logical findings in IPMN patients.

Patients and Methods: Preoperative EUS findings (MPD or BD dilatation, mural nodule >3 mm, hypo/hyperechoic foci, mass) were compared with pathological data, lesion by lesion, in 40 pts with IPMN operated on in 2008-2009.

Results: 1/ MPD: MPD 5-10 mm was associated with IPMN lesions and malignancy in 57% and 33%, respectively. MPD >10 mm and mural nodule were specific of malignancy. 2/ BD: BD 10-30 mm and >30 mm were associated with malignancy in 32% and 60%, respectively. Mural nodule was associated with malignancy in 62%. 3/ PanINs were observed in 78% of pts (grade 2/3 in 28% and 53% of benign and malignant IPMN, respectively). Microcysts (<5 mm) and hyperechoic foci were noted at EUS in 48% and 15% of pts and cor-responded to PanINs in 80%. Conversely, PanINs were found on the operative specimens without EUS abnormalities in 31% of the pts.

Conclusion: 1) MPD >10 mm, BD >10 mm and mural nodule at EUS are specific of IPMN lesions. 2) MPD >10 mm and MPD mural nodules are specific of malignancy. 3) PanIN lesions are frequently associated with malignant IPMN and can be detected at EUS in 2/3 of cases.

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Laparoscopic Distal Pancreatectomy as the Treatment of Choice for Benign and Selected Invasive LesionsF. Di Fabio1, G. Eltaji Elfarouki1, G. Jain1, M. Habib1, C. Johnson1, M. Abu Hilal1

1Hepatobiliary-Pancreatic Unit, Southampton General Hospital, Southampton University Hospitals NHS Trust, Southampton, UK

Introduction: The advantages of laparoscopic distal pancreate-ctomy (LDP) are well recognized and its implementation has been promoted by the creation of high-volume pancreatic centres in the UK. The consensus on indications and techniques is still under debate.

Objectives: Critical analysis of perioperative outcomes after LDP with splenectomy and LDP with spleen preservation (on main splenic vessels, or short gastrics).

Patients and Methods: We reviewed a database of patients undergoing LDP for benign, endocrine and malignant diseases between June 2007 and March 2010.

Results: LDP was performed in 25 patients. Indications for sur-gery were: benign lesions (n = 21), insulinoma (n = 2), malignant lesions (n = 2). Splenectomy was carried out in 15 patients (60%). Two patients (8%) had the spleen preserved on short gastrics. Median operative time was 210min, and was significantly less for spleen-pre-serving LDP (median 180min) compared with LDP and splenectomy (median 240min; p = 0.028). Median blood loss was 200ml. Conversion was necessary in one patient (4%) with infiltrating carci-noma due to SMV bleeding. The other patient with a malignancy (lymphoma) had a successful laparoscopic multivisceral resection (distal pancreas, spleen, partial stomach, adrenal, diaphragm and abdominal wall). Pancreatic leak was observed in 8 patients (31%),


but healed in all cases. Median postoperative length of stay (LoS) was 7 days, with a median high-dependency unit stay of one day. Postoperative complications and LoS were not significantly influ-enced by splenectomy. Mortality was nil.

Conclusion: LDP is safe and efficient, although requires great expertise in pancreatic and laparoscopic surgery. LDP can be recom-mended as the treatment of choice for benign and selected invasive lesions.

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Liver Perfusion Failure After Pancreatic Resections: Clinical Significance and OutcomeT. Hackert1, U. Stampfl2, H. Schulz1, W. Hartwig1, M.W. Büchler1, J. Werner1

1Dept. of Surgery, University of Heidelberg, Heidelberg, Germany, 2Dept. of Radiology, University of Heidelberg, Heidelberg, Germany

Introduction: Background. Liver function is an important deter-minant of postoperative outcome, especially after major abdominal operations. Impairment of liver perfusion, which may be the conse-quence of technical or cardiocirculatory changes intra- or postopera-tively, may lead to severe complications. The clinical significance of these changes ranges from morphologic or laboratory changes alone to severe complications including infected liver necrosis, SIRS and sepsis.

Objectives: Aim of the study was to define incidence, diagno-sis, therapy, severity and and outcome of liver failure after pancreatic resections.

Methods: Patient records of 762 consecutive patients undergo-ing pancreatic resections were analyzed with focus on disturbances of hepatic perfusion. Laboratory findings, CT characteristics, clinical symptoms, therapy and outcome were analyzed. Severity of liver fail-ure was classified following a 3 grade (A-C) scoring system including diagnostic and clinical findings.

Results: In 17 patients (2,2%) liver perfusion failure was identi-fied. Depending on the underlying causes, differential therapy included symptomatic treatment with restoration of circulation, radio-logical or surgical revascularisation or resection of necrotic liver tis-sue. The clinical outcome showed asymptomatic complete restoration of liver perfusion and function without prolongation of hospital stay (grade A), symptomatic courses with moderate local or mild systemic complications and need for prolonged hospital stay (grade B) and severely complicated courses with need for reintervention (grade C). Overall associated mortality in our patient collective was 29% (5/17 patients).

Conclusion: Hepatic perfusion failure is a rare but severe com-plication following pancreatic surgery. Even partial liver perfusion failure may cause significant problems in the postoperative phase. Therapy needs to be individually tailored and should not follow any standard regimens. To achieve good clinical outcome, aggressive interventional or surgical approaches is necessary in some patients.

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Minimal Invasive Surgical Treatment for Distal Pancreatic TumorsL. Nehez1, B. Tihanyi1, T. Winternitz1, T.F. Tihanyi1

11st Department of Surgery, Semmelweis University, Budapest

Introduction: Management of the pancreatic diseases is still a challenge to the laparoscopic technique. Anatomically the accessibil-ity of the distal pancreas provides the laparoscopic approach techni-cally feasible.

Objectives: We present our experience with laparoscopic distal pancreatic surgery.

Patients and Methods: Between 1997 and 2010, 13 patients had distal pancreatic resection and 5 had local enucleation, which were performed laparoscopically with the preservation of the spleen. Preoperative CT scan identified the solid or cystic tumor in the tail of the pancreas. Complete mobilization of the distal pancreas was fol-lowed by detachment from the splenic hilum after dividing the splenic vessels or with complete preservation of the splenic blood supply. The pancreas is Transsected proximally by a laparoscopic linear stapler. Removal of the spleen is not a necessary step during this procedure.

Results: Postoperative course was uneventful in 13 patients who left the hospital on the 5th postoperative day average. 4 patients had minor complications but reoperation was not necessary. Insulinoma, mucinous cystadenoma, papillary cystic tumor, solid papillary epithe-lial neoplasm and endometriosis diagnosed histologically in 8, 5, 3, 1,1 cases respectively. No recurrent tumor was diagnosed during the follow up period; the patients are free of complaints.

Conclusion: Advantages of the procedure were the earlier mobilization and shorter recovery time, less postoperative pain. Local laparoscopic excision in some cases is technically also possible. The procedure can be safely performed with a good experience in both pancreatic and laparoscopic surgery.

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Contemporary Techniques in Surgical Treatment of Acute Necrotizing PancreatitisV. Kopchak1, I. Khomiak1

1National institute of surgery and transplantology

Introduction: Acute necrotizing pancreatitis (ANP) is a danger-ous disease that could cause serious complications and death.

Objectives: To increase the results of surgical treatment in patients with ANP by implementation of technique of percutaneous necrosectomy.

Patients and Methods: We have analyzed the results of treat-ment of 177 patients with ANP, treated in our clinic in the period of 2006-2008 years. Aseptic forms were diagnosed in 64 (36,16%) patients. Infected necrosis with septic complications were diagnosed in 113 (63,84%) patients. Ultrasound controlled interventions were performed in 119 (67,23%) patients. Open surgical procedures were done in 48 (27,11%) patients. In 8 (4,52%) patients, that made a main group, percutaneous retroperitoneal necrosectomy was used.


Results: There were 42 (23,73%) patients with aseptic forms of ANP were treated successfully without any intervention. Percutaneous ultrasound- guided interventions made it possible to stabilize general state of the patient in 85 (71,43%) and to delay laparothomy that was done in 40 patients. 79 (66,39%) patients were treated by ultrasound-guided interventions alone. In 48 patients (27,11%) open surgical necrosectomy was done. Relaparotomies were done in 23 patients (47,91%). Mortality was 6,78% (12 patients), postoperative mortality –8,15% (11 patients). All patients with percutaneous retroperitoneal necrosectomy were alive, no laparotomies were done in this subgroup of patients.

Conclusion: We conclude that percutaneous retroperitoneal necrosectomy could be applied safely and effectively in a selected group of patients with septic complications of ANP and could poten-tially improve nearest postoperative results.

P158

Short-Term Results of Extended Pancreaticoduodenectomies with Sub- or Total Pancreatic Body ResectionV. Egorov1, O. Melekhina1, I. Kozyrin1, V. Vishnevsky1, T. Shevchenko1

1The Vishnevsky Institute of Surgery, Moscow, RF

Introduction: The endocrine function preservation makes the study of sub- or total pancreatic body resection (STPBR) during extended pancreaticoduodenectomy (EPD) reasonable.

Objectives: To assess the early postoperative course after EPD with STPBR.

Patients and Methods: Twenty EPD with STPBR had been performed from 2006 to 2009. We have prospectively compared short-term results of this procedure with 30 standard pancreaticoduo-denectomies (SPD) and 25 EPD performed for pancreatic malig-nancy.

Results: The postoperative morbidity and mortality rate accounted for 60% and 6.6% in SPDs, 60% and 5% in EPD with STPBR, 56% and 4% in extended PDRs. Blood loss in SPDs was 985±818ml, 1112±960ml in EPDs and 1008±710ml in EPD with STPBRs. Vessel resection was performed in 3.3% of patients during SPDs, in 35% during EPD with STPBRs and in 24% in EPD. Pancreatic fistula has developed in 16.6% of SPDs, in 5% of EPDs with STPBR and was not noted in EPDs. Intra-abdominal bleeding was found in 3.3% of SPDs, in 12% of EPDs and was not recorded in EPD with STPBRs. Delayed gastric emptying was registered in 28% of patients after SPD, in 16% after EPD and in 5% after EPD with STPBRs (p > 0.05). The postoperative hospital stay following SPD was 11.8 and 12.3 following EPD with and without STPBR. Diabetes mellitus has developed in 20% of patients after SPD, in 24% after EPD and in 30% after EPD with STPBR (p > 0.05).

Conclusion: EPD with STPBR does not increase morbidity and mortality rate, as compared with SPD and EPD. The reasonable dia-betes development rate after EPD with STPBR can make it alterna-tive to total pancreatectomy in selected cases.

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Central Pancreatectomy with Inframesocolic Intraperitoneal PancreatojejunostomyU. Boggi1, M. Del Chiaro1, F. Costa1, C. Moretto1, N. De Lio1, V.G. Perrone1, S. D’Imporzano1, C. Croce1, F. Vistoli1, S. Signori1, C. Cappelli2, G. Amorese3

1Pisa University Hospital, Pisa, Italy, Division of General and Transplant Surgery, 2Pisa University Hospital, Pisa, Italy, First Division of Radiology, 3Pisa University Hospital, Intensive Care Unit

Introduction: The high rate of pancreatic fistula (PF) after cen-tral pancreatectomy (CP) is believed to be the compounded effect of handling two divided edges of the pancreas. Although in the setting of CP PF usually pursues a benign course, severe local complications can occur.

Objectives: To analyze the short term result of five CP with inframesocolic intraperitoneal pancreatojejunostomy performed at our Institution.

Patients and Methods: From October 2008 to October 2009, 112 patients underwent pancreatectomy at our Institution, including 5 (4.5%) CP. One patient was male and 4 females. The mean age was 42.2 years. In three of them the entire operation was carried out by robotic approach. In every patient the margin of the distal pancreatic stump was brought down in the inframesocolic intraperitoneal space through the defect in the transverse mesocolon that is usually employed for the upward passage of the Roux-en-Y jejunal loop. Pancreatojejunostomy was hence constructed using standard techniques.

Results: The mean operative time was 315.0 minutes for open procedures, and 426.7 minutes for robotassisted laparoscopic opera-tions. There was no post-operative mortality, but four patients (80%) developed post-operative PF. No patient required reoperation. The mean post-operative stay was 21.4 days.

Conclusion: Construction of pancreatojejunostomy in the infra-mescolic intraperitoneal space does not increase the complexity of CP and segregates the two pancreatic stumps into different body districts. Leaving in the retroperitoneum only the right-sided pancreatic stump, a possible source of pure PF with limited digestive power, might reduce the severity of local complications after CP.

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An Innovative Surgical Technique for Pancreatojejunostomy After PancreatoduodenectomyP. Lampe1, K. Kusnierz1, A. Alli Balogun1

1The Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland

Introduction: Recently, many methods of anastomosis between the pancreas and the alimentary canal after pancreatoduodenectomy have been determined. Each method having advantages and disad-vantages depending on intra-operative conditions. The knowlegde and experience with different methods enables the surgeon to select the most suitable procedure.


Objectives: The authors present a method of anastomosis of the pancreatic stump and jejunal loop. The basis of the method is to limit surgical trauma to the pancreas to a minimum through the use of a decreased number of sutures.

Materials and Methods: The authors invaginate the jejunal transsection at a length of 2-3cm and form a cuff with underlying serosa from the lumen. The formed cuff is drawn - over using bridle sutures onto the pancreatic transsection. The cuff is then fixed with 3-4 sutures.

Results: Our initial experience (Whipple procedures were per-formed in 6 cases) shows that the method is more than satisfactory in certain intraoperative conditions. We have no complications up today.

Conclusion: Our method of anastomosis of the pancreatic stump with the intestinal loop after pancreatoduodenectomy is a safe type of anastomosis. Due to a small number of patients operated this way further tests are required.

P161

Evolving Indications for Central PancreatectomyT. Dumitrascu1, C. Stroescu1, V. Tomulescu1, M. Ionescu1, I. Popescu1

1Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute of Digestive Diseases, Bucharest, Romania

Introduction: Central pancreatectomy is a pancreas-sparing resectional procedure indicated mainly for benign and low malignant tumors of the pancreatic body. The role of central pancreatectomy for metastatic lesions and special malignancies like neuroendocrine carcinoma, pancreatoblastoma and solid pseudopapillary tumors is controversial.

Objectives: To asses the oncologycal impact of central pancre-atectomy in special malignancies of the pancreas.

Patients and Methods: Between 2002 and 2009 at our centre 17 central pancreatectomies were performed. The indications were: serous and mucinous cystadenoma in 9 patients, benign insulinoma, postoperative laceration of the main pancreatic duct, IPMN, meta-static melanoma, neuroendocrine carcinoma, metastatic tumor, pan-creatoblastoma and solid pseudopapilary tumor (one patient each).

Results: Postoperative morbidity was high, the main complica-tion being represented by pancreatic fistula (42%). Reinterventions rate was 33%. No postoperative death occurred. The survival for patients with malignancies was: for pancreatoblastoma and solid pseudopapilary tumor –13 months (alive, no recurrence); for patient with neuroendocrine carcinoma –50 months (alive, no recurrence); for patient with metastatic melanoma - 38 month (alive, lung metasta-ses); for patient with metastatic tumor from colon cancer –25 month (death, peritoneal metastasis).

Conclusion: Central pancreatectomy is recommended in selected patients due to a better immunological status and for pancreatic func-tion preserving (especially endocrine). It is a feasible procedure mainly for benign pancreatic diseases but also for low malignant and special malignancies of the pancreas with good local control of the disease.

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Immediate and Long-Term Effects of Pancreatic Duct Occlusion Using Fibrin GlueM. Stojanovic1, L. Jeremic1, M. Radojkovic1, A. Zlatic1, A. Bogicevic1, B. Stosic1, R. Jankovic1, M. Stojanovic2

1Surgical clinic Clinical Center Nis, 2Pediatric clinic Clinical Center Nis

Introduction: Pancreatic duct occlusion using fibrin glue appears to be theoretically optimal method of leakage prevention of pancreatico-jejunal anastomoses (PJA). In spite of very good experi-mental and clinical results, this method has associated with the pos-sibility of acute pancreatitis, permanent pancreatic duct occlusion and fibrous atrophy of exocrine and endocrine pancreas.

Objectives: The aim of this study was to establish immediate consequences of pancreatic duct occlusion by fibrin glue on pancreas parenchyma and long-term negative effects on exocrine and endo-crine pancreas secretion.

Materials and Methods: The experiment was performed on dogs, divided in two groups, each of which had 20 dogs. Experimental group comprised of the animals, which underwent pancreas resection with PJA formation and anastomosis protection by pancreatic duct occlusion method using fibrin glue (Tissucol-Immuno AG). Control group underwent pancreas resection and PJA without anastomosis protection. Postoperatively, the animals were followed 5 months and during this period they underwent clinical biochemical, pathohisto-logical, histochemical, immunocytochemical and scanning electronic-microscopic examination.

Results: Fibrin glue dissolution was noticed from the fifth day, and was completely finished the thirteenth PO day. Statistics analysis of biochemical parameters, as well as pathohistological and scanning-electronic examinations has shown the signs of mild, subclinical forms of edematous pancreatitis, with the short-term increase of amylase levels. Examinations performed after 150 days showed the intact morphology and functional integrity of exocrine and endocrine pancreas.

Conclusion: Fibrin glue application in prevention of pancrea-tico-jejunal anastomosis leakage represents a simple and effective procedure without immediate and long-term negative effects on exo-crine and endocrine function and morphology of pancreas.

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Results of Beger, Frey and Bern Procedures for Treatment of Chronic PancreatitisR. Petrov1, A. Schastny2, T. Shevchenko1, O. Zhavoronkova1, A. Siatkovsky2, V. Egorov1, V. Vishnevsky1

1The Vishnevsky Institute of Surgery, Moscow, RF, 2The Vitebsky State Medical University, Vitebsk, Republic Belarus

Introduction: More than half of the patients with chronic pan-creatitis (CP) need surgery due to chronic pain, but the choice of the procedure remains a topic of discussion.


Objectives: To assess the results of duodenumâpreserving pan-creatic head resections (DPPHR) for CP.

Patients and Methods: Prospective analysis of 220 patients surgical treatment, on whom Beger (101), Frey (59) and Bern (60) procedures had been performed (2002-2008). Long–term results and quality of life (QL) were assessed for 174 (79%) patients in 1- 6 years with the help of the SF-36 questionnaire.

Results: Demographic and clinical parameters were compara-ble. The mean operating time for Beger, Frey and Bern procedures was 366±64 min, 202±39 min and 288±41 min (p<0,05), general morbidity –25%, 11% and 13% (p < 0,05), blood loss –830 ±120ml, 440±150ml and 650±170ml (p < 0,05), and the postoperative hospital stay –19, 10 and 12 (p < 0,05). A significant difference was found on these subjects between the Beger procedure and other DPPHR vari-ants. Lethality was zero. The QL differs insignificantly, however full pain control, social and labor rehabilitation were achieved after the Beger procedure in 94% and 93%, after Bern in 93% and 93% and after Frey in 80% and 77%. There were no new cases of diabetes mel-litus after one year follow-up.

Conclusion: The Beger procedure and its Bern modification more frequently provide full and long–lasting pain control as com-pared to the Frey procedure. The Bern operation is as effective as a classical Beger for pain management, giving lesser morbidity, blood loss, operating time and hospital stay.

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Pancreaticoduodenectomy in Patients with Celiac Artery Occlusion by Median Arcuate Ligament CompressionR. Whistance1, C. Shearman1, N. Pearce1, A. Odurny1, B. Steadman1, C. Johnson1

1Southampton Universtity Hospitals

Introduction: Pancreaticoduodenectomy is the standard treat-ment for localised neoplasms of the pancreatic head. It can be per-formed safely in specialist units, but good outcome is compromised if postoperative blood flow in the hepatic artery (HA) is inadequate. Replaced HA arising from the superior mesenteric artery can be iden-tified on preoperative imaging, and by the surgeon at operation. Celiac artery (CA) stenosis secondary to median arcuate ligament (MAL) compression with retrograde flow through the gastroduodenal artery (GDA) to the liver is more difficult to recognise, especially during operation. Recognition of absent HA pulsation after occlusion of the GDA opens a difficult dilemma: abandon resection as too risky, or add a vascular reconstruction to an already complex procedure?

Objectives: Describe management.Patients and Methods: We describe two cases with a resect-

able pancreatic endocrine tumour in whom CA occlusion caused by MAL compression was identified from cross-sectional imaging and vascular reconstructions. We describe a strategy to correct the vascu-lar problem and allow safe pancreatic resection.

Results: Case 1: Preoperative dilation and stenting restored antegrade HA flow. At operation the MAL was divided, releasing the CA. Pancreaticoduodenectomy was performed without incident and the patient recovered without any biliary complication. Case 2: At a preliminary laparoscopy the MAL was divided, relieving CA com-

pression, restoring normal HA flow and reducing GDA flow. Intravascular stenting was not necessary. Pancreaticoduodenectomy was performed later without complication.

Conclusion: If suspected, MAL compression can be confirmed using colour flow Duplex. Preoperative division of MAL (+/- stent-ing) allows restoration of normal HA flow and safe pancreatectomy with biliary anastomosis.

P165

What Collaterals We Can Rely on in Performing Spleen-Preserving Distal Pancreatectomy with Splenic Vessels Resection?V. Egorov1, R. Turusov2, N. Yashina1, T. Zhurenkova1, M. Petukhova1, K. Dmitrieva3

1The Vishnevsky Institute of Surgery, Moscow, Russia, 2The Institute of Chemical Physics of the Russian Academy of Science, Moscow, Russia, 3The Russian State Medical University, The Chair of Topographical Anatomy, Moscow, Russia

Introduction: The knowledge of collaterals is important for dis-tal spleen-preserving pancreatectomy with splenic vessels resection (DPSVR).

Objectives: To clarify the sources of spleen blood supply after DPSVR.

Patients and Methods: Computation of the blood transit dis-tance through vessels of <1 mm in diameter; Perfusion of the cadav-eric left gastric artery with a colouring agent after the occlusion of all arteries except for the short gastrics (n = 6); Intraoperative Doppler ultrasound (IDU) for the evaluation of the splenic blood flow during distal pancreatectomy (n = 15) after the splenic artery clamping, fol-lowing the clamping of the splenic and the left gastro-epiploic arteries and after the clamping of the splenic and the short gastric arteries; CT-angiography (C) of gastric and splenic vessels before and after DPSVS (n = 7).

Results: The blood transit through vessels of <1 mm in diameter at a distance of >2 cm is theoretically impossible and this makes the splenic blood supply through the short gastrics doubtful; the perfu-sion of cadaveric arteries after the occlusion of all the arteries except for the short gastrics never revealed a dyestuff in these vessels; IDU never detected any blood flow in the splenic hilus after the clamping of the splenic and the left gastro-epiploic arteries; C after DPSVS never delineated short gastric vessels supplying the spleen.

Conclusion: Computation, as well as experimental, intra- and postoperative instrumental investigations didn’t reveal any involve-ment of the short gastric arteries in the blood supply of the spleen after DPSVR. In all the cases under review the left gastro-epoploic artery was the main collateral vessel.


P166

New Method of Pancreaticojejunal Anastomosis After PancreaticoduodenectomyV. Kopchak1, I. Khomyak1, K. Kopchak1, O. Duvalko1, A. Zelinskyi1, B. Borisov1

1National institute of surgery and transplantology

Introduction: Pancreaticoenteric anastomosis remains an Achilles heel in pancreaticoduodenectomy (PD).

Objectives: To increase the nearest results of PD by implemen-tation of a new method of pancreaticojejunostomy (PJ).

Patients and Methods: We investigated the results of 142 PD, performed in our clinic in the period of 2008- 2009 years. Standard Whipple procedure was performed in 104 patients. In patients with benign pathology and malignant tumors of duodenum, papilla of Vater and distal bile duct pyloruspreserving PD was preferable (38 patients). In all patients pancreaticojejunal anastomosis was per-formed with the pancreas remnant. In 49 patients (main group) new technique of telescopic duct-to-mucosa PJ was applied. A duct-to-mucosa end-to-end anastomosis was additionally invaginated into jejunal loop by one layer or running suture and one layer of inter-rupted suture. In 93 patients of the control group standard duct-to-mucosa or telescopic PJ was performed.

Results: One patient (0,7%) died after operation. There was no postoperative mortality in the main group. Pancreatic fistula rate of grade B and C was diagnosed in 5 patients (10,2%) of the main group and 16 patients (17,2%) in the control group, not reaching statistical difference (chi2 = 0,94, p > 0,05).

Conclusion: New telescopic duct-to-mucosa PJ could be rou-tinely and safely applied in pancreatic surgery. A randomized trial should be additionally provided to study possible advantages of the technique.

P167

Role of US and MRI in Diagnosing Pancreatic PathologiesF. Kurti1, F. Bilaj2, J. Basho1, M. Cela2, I. Akshia3

1Service of Gsatrohepatology, UHC “Mother Theresa”, Tirana, Albania, 2Service of Radiology, UHC “Mother Theresa”, Tirana, Albania, 3Department of Statistics, UHC “Mother Theresa”, Tirana, Albania

Introduction: Ultrasonography (US) is very important in the diagnosis of the pancreatic pathologies. The Role of Magnetic Resonance Imaging (MRI) is well recognized, but it is a more expen-sive examination and asking for a MRI requires a justification.

Objectives: The aim of this study was to examine the compara-ble roles of US and MRI in a group of patients with suspected pancre-atic disease during a period of twelve months.

Patients and Methods: 86 patients were recruited in the study. All of them underwent abdominal US and MRI. The indication for US included abdominal pain in 83 pts (96.5%) Jaundice 22 pts (25.5%) and/or elevated pancreatic enzymes in 60 pts (69,7%).

Indications for MRI included clinical suspicion for pancreatic pathol-ogies for 42 pts (48.8%) and ultrasonographically for 20 pts (23,2%), suspicion of biliary pathology in 8 pts(9,3%) or inconclusive ultra-sound in 18 pts (18.6%).

Results: Ultrasound identified pancreatic pathologies (inflam-mation, cyst, and carcinoma) in 20 pts (23,2%). A normal pancreas was identified in 40 pts (46.5%). Choledocolithiasis with duct dilata-tion was identified in 8 pts (9.3%) . Inconclusive Ultrasound accounted for 18 pts (20.9%). MRI identified pancreatic pathologies in 30 pts (34.8% of cases and confirmed a normal pancreas in 40 pts (46.5% of cases. Coledocolithiasis with duct dilatation was identified in 16 pts 18.6%.

Conclusion: MRI confirmed all positive US findings. The prin-ciple benefit of MRI was in establishing findings in the 19% of incon-clusive US studies.

P168

Pancreatic Tumors: Low-kilovoltage Computed Tomography (CT) for Improved Detection – A Phantom StudyJ. Holm1, L. Loizou2, N. Albiin2, B. Leidner2, N. Kartalis2, A. Sundin3

1Department of Clinical Science, Intervention and Technology (CLINTEC) at Karolinska Institutet, Stockholm, Sweden and Division of Medical Physics, Karolinska University Hospital, Huddinge, Stockholm, Sweden, 2Department of Clinical Science, Intervention and Technology (CLINTEC) at Karolinska Institutet, Stockholm, Sweden and Department of Radiology, Karolinska University Hospital, Huddinge, Stockholm, Sweden, 3Department of Molecular Medicine and Surgery at Karolinska Institutet, Stockholm, Sweden and Department of Radiology, Karolinska University Hospital, Solna, Stockholm, Sweden

Introduction: Detection of small pancreatic tumors by CT has always been challenging.

Objectives: The aim of this study was to investigate the effect of decreasing the tube voltage from 120 to 80 kV on the detection of pancreatic tumors.

Materials and Methods: Three scanning protocols was used; one using the standard tube voltage (120 kV) and two using 80 kV but with different tube currents (500 and 675 mA) to achieve equivalent dose (15 mGy) and noise (15 HU) as that of the standard protocol. Tumors were simulated onto collected CT phantom images. The attenuation for the tumor and normal parenchyma at 120 kV was 110 and 130 HU, respectively, as previously measured in clinical exami-nations. By scanning and measuring of iodine solution with different concentrations the corresponding tumor and parenchyma attenuation at 80 kV was found to be 185 and 219 HU, respectively. To objec-tively evaluate the differences between the three protocols, a multi-reader multi-case free-response receiver operating characteristic study was conducted, using three readers and 100 cases, each contain-ing 0-3 lesions.

Results: The highest reader averaged figure-of-merit (FOM) was achieved for 80 kV and 675 mA (FOM = 0,7635), and the lowest


for 120 kV (FOM = 0,5467). There was a significant difference between the three protocols (p = 3,454·10-12). Post-hoc analysis shows that there was a significant difference between 120 and 80 kV, but not between the two levels of tube currents at 80 kV.

Conclusion: We conclude that the effect of decreasing the tube voltage is larger than the effect of increasing the tube current.

P169

The Value of Real-time Contrast-enhanced Ultrasonography (SonoVue) and Timeintensity Curves Analysis in the Characterization and Differential Diagnosis of Pancreatic Cystic LesionsR. Badea1, R. Stan-Iuga1, M. Socaciu1, A. Seicean1, Z. Sparchez1

1Third Medical Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca, Romania

Introduction: Transabdominal ultrasonography (US) has a good sensitivity in detecting and characterizing the pancreatic cystic lesions (PCL). Contrast-enhanced ultrasonography (CEUS) (SonoVue) is useful for microcirculation studies.

Objectives: The quantitative analysis of the pancreatic micro-circulation using CEUS for the differential diagnosis of PCL.

Patients and Methods: 28 patients, suffering from PCL have been examined prospectively between December 2008 and February 2010. The study inclusion criteria meant patients with pancreatic anechoic lesions seen during US. CEUS examination (2,4 ml SonoVue) was performed using Pulse Inversion and a low mechanic index (<0.15). The quantitative analysis consisted in time-intensity curves (TIC) processed from the cyst’s walls, cystic cavity and an arterial ves-sel. CEUS parameters were measured from the fitted curves: Peak Intensity (PI), Time to Peak (TTP), Maximum ascending GRADient (GRAD), Time to maximum GRADient (TTG) and Area Under the Curve (AUC). All patients were assessed by endoscopic ultrasonogra-phy and fine needle aspiration and/or contrastenhanced CT.

Results: The final diagnosis was reached in 25 cases: pancreatic pseudocyst (11), pancreatic cystic neoplasms (PCN) (14): serous cys-tadenomas (7), mucinous cystadenomas (1), cystadenocarcinomas (5), solid pseudopapillary tumor (1). The analysis of the TIC param-eters inside cystic walls revealed significant differences between pseudocysts and PCN: AUC was significantly higher (-3134 vs -3576, p = 0.02), TTP was shorter (30,3 vs 36,9, p = 0,06) and GRAD was higher (1,26 vs 0,90, p = 0,07) in pseudocysts, due to their enhancing, congestive walls.

Conclusion: TIC analysis of the contrast signal from the walls of the PCL allowed us to better assess the differences in enhancement between pseudocysts and PCN.

P170

Pancreatic Intraductal Papillary Mucinous Neoplasms of the Branch Ducts: Usefullness of MR Imaging and MR Cholangiopancreatography in the Follow-upR. Gigoni1, S. Salemi1, P. Boraschi1, F. Donati1, V.G. Perrone1, M. Del Chiaro1, U. Boggi1, C. Bartolozzi1, F. Falaschi1

1Pisa University Hospital

Introduction: Focal intraductal mucin-producing tumors of side branches are pancreatic neoplasms frequently non malignant; some authors suggest MR follow-up but others surgery resection.

Objectives: To evaluate the usefulness of MR imaging and MR Cholangiopancreatography (MRCP) in the follow-up of branch-duct-type pancreatic intraductal papillary mucinous neoplasms (BD-IPMNs).

Materials and Methods: Thirty-six patients with diagnosis of BD-IPMNs (cysts less than 30mm in diameter without mural nod-ules) underwent initial and follow-up MRI and MRCP at 1.5T-device. After acquisition of axial T1w/T2w sequences, MRCP was performed using respiratory-triggered thin-slab 3D FRFSE T2w and breath-hold thick-slab SSFSE T2w sequences. The follow-up period ranged from 12 to 76 months and the follow-up intervals between 6 and 14 months. Two radiologists in conference evaluated the maximum diameter of cystic lesion, the presence of associated main pancreatic duct (MPD) dilatation and/or filling defects within cystic lesion.

Results: Cysts were located in the pancreatic head (n = 9), in the body-tail (n = 11) and involved the entire gland (n = 16). In 25 patients (69.4%) no significant change of the pancreatic findings was identi-fied on follow-up MRI and MRCP, whereas in 3 cases the cyst size decreased. Seven patients (19.4%) show a slight tumor enlargement (mean diameter increase:16.4%; range:10-30%) without associated MPD dilatation or filling defects. A filling defect within cystic lesion, confirmed at surgery, was observed only in one patient.

Conclusion: MR imaging and MRCP are useful in the follow-up of BD-IPMNs; however, a larger series of patients and a longer follow-up is required to confirm the safety of this MR protocol.

P171

Helical Tomotherapy and Chemotherapy in Locally Advanced Pancreatic CancerG. Boz1, R. Innocente1, F. De Marchi2, A. Buonadonna4, S. Venturini3, C. Bassi5, A. De Paoli1

1Radiation Oncology, CRO Aviano, 2Surgical Oncology, CRO Aviano, 3Radiology, CRO Aviano, 4Medical Oncology, CRO Aviano, 5Surgery Department, University of Verona, Verona, Italy

Introduction: Recent advances in radiation oncology are based on improvements in dose distribution by IMRT as well as improve-ments in target definition using new diagnostic imaging techniques such as spectroscopic or functional MRI or PET. However, anatomic


variation may occur during the course of treatment, which decrease the benefit of such optimizations. Imageguided radiation therapy reduces geometric uncertainties that occur during treatment, thus reducing the dose delivered to healthy tissues and enabling dose esca-lation for a better tumorhif1 control. Radiation therapy (RT) for locally advanced pancreatic cancer (PC) is technically difficult and partially deleterious because of the proximity of adjacent vital organs.

Objectives: Helical tomotherapy (HT) is a new irradiation modality that combines intensitymodulated fan-beam RT with mega-voltage computed tomography imaging for patient positioning. The recent availability of HT has opened new fields of exploration for pancreatic RT as a result of its ability to tailor the planned dose to the target areas.

Patients and Methods: Since 2008, 11 patients with PC have been treated with induction chemotherapy, with Gemcitabine and Oxaliplatin, followed by RT and low-dose Gemcitabine. RT was delivered with HT.

Results: The treatment was well tolerated. All patients had mild gastrointestinal toxicity and hematological toxicity was lower than grade II. At re-staging, 4 patient had partial remission and they under-went radical resection. One patient received also Intraoperative Radiation Therapy. Two patients had local control but progression of disease in the liver. However, evaluation of survival needs a longer follow-up time and a larger group of patients.

Conclusion: The present study will be continued to evaluate the potential role of HT in delivering an increased radiation dose to the tumor while sparing surrounding healthy tissues.

P172

Celiaco – Mesenterial Aberrations in Patients Undergoing Extended Pancreaticodudenectomy: Correlation of CT-angiography with Findings at SurgeryV. Egorov1, N. Yashina1, A. Fedorov1, G. Karmazanovsky1, V. Vishnevsky1, T. Shevchenko1

1The Vishnevsky Institute of Surgery, Moscow, Russia

Introduction: It is important to recognize arterial variants in the preoperative planning of extended pancreatic resections. The absence of surgical confirmation of radiological data is a limitation of the majority of angiographic or CT-angiographic (CTA) studies of celiac and mesenteric arterial anatomy (CMAA).

Objectives: To study the accuracy of CTA in delineating the arterial architecture by comparing the resultant 3D images with find-ings at surgery and determining the frequency of different CMAA variants.

Patients and Methods: Abdominal CTA of 350 patients were performed on a 64- and 256-MDCT scanner prior to major pancreatic or hepatobiliary surgery. Variants of CMMA were documented as 3D reconstructions. In 59 cases radiological data were compared to oper-ative photographs during extended pancreaticoduodenectomies (EPD) and extended distal pancreatectomies (EDP).

Results: Only 56% of patients had the classic arterial anatomy identified at CTA. The most common variants were replaced or acces-sory right hepatic artery originating from the superior mesenteric artery (20%) and replaced or accessory (13%) left hepatic artery orig-

inating from the left gastric artery. According to a comparison with operative photographs, CTA demonstrated 100% accuracy in identi-fying CMMA variants, stenoses, obstructions and aneurisms of the celiac and mesenteric branches, including hemodynamically signifi-cant ones, which influence the choice and sequence of operative procedures.

Conclusion: The CMAA variants are fairly common and are of great significance in planning extended pancreatic resections. Radiological findings were fully corroborated by operative data, which means that CTA is a reliable tool for identifying CMAA aber-rations and arterial lesions.

P173

Diagnostic Informativity of Endoscopic Ultrasonography Guided Fine Needle Aspiration in the Management of High Risk Pancreatic LesionsA. Pukitis1, J. Pokrotnieks2

1Faculty of Medicine, University of Latvia, Riga, Latvia, 2Gastroenterology Center, Pauls Stradins Clinical University Hospital, Riga, Latvia

Introduction: Assessment of cystic lesions of the pancreas remains difficult despite improvement in imaging modalities. Symptomatic, multilocular cysts, increasing age are predictors of malignancy. Endoscopic ultrasonography (EUS) guided fine needle aspiration (EUS-FNA) informativity in the management of high risk pancreatic cystic lesions using cystic aspirate analysis (cytology, amylase content, CEA) can accurately distinguish premalignant and malignant cysts from benign ones.

Objectives: EUS-FNA for pancreatic cystic lesions differentia-tion from cystic neoplasms.

Patients and Methods: EUS for pancreatic diseases was per-formed in 390 patients treated in Gastroenterology Center Pauls Stradins Clinical University Hospital. Patients who were considered for EUS-FNA examination had one or more pancreatic cystic lesions detected by US, EUS, MRI, or CT. In total 182 patients in an age from 26 - 81 (mean age 53.5 years) were involved. All pancreatic cystic lesions were considered for at least onesingle time EUS-FNA.

Results: EUS structure changes (n = 133, 73%), of pancreas parenchyma (lobulation, calcifications), pancreatic duct changes (n = 91, 50%), cystic lesions with septae, calcifications, solid structures (n = 78; 43%). Lesions less than 20mm (n = 78), lesions bigger than 20mm (n = 104). EUS-FNA study of the cyst content; malignant cells (n = 31, 17%), adenocarcinoma (n = 24), carcinoid (n = 2), neuroendo-crine tumor(n = 4), atypical cells (n = 15) Non-Hodgkin lymphoma (n = 1), inflammatory content (n = 85), non-inflammatory content (n = 40). CEA level more than 500 ng/mL was used as significant.

Conclusion: EUS-FNAhelps in decision making for medical or surgical approach. EUS guided punctureof pancreatic cystic lesions is safe procedure (success rate up to 97,5%). Combined CEA and cytol-ogy studies enhanced diagnostic sensitivity up to 100%.


Clinical Science – Miscellaneous

P174

Gabexate Mesilate Infusion Prevents Pancreatic Graft Damage After Pancreas TransplantationF. Vistoli1, U. Boggi1, G. Karam2, M. Giral2, R. Pisano1, M. Del Chiaro1, C. Croce1, C. Moretto1, S. Signori1, G. Amorese1, P. Marchetti1, J. Soulillou2, D. Cantarovich2

1Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy, 2Institut de Transplantation et de Recherche en Transplantation, Centre Hospitalier Universitaire de Nantes, Nantes, France

Introduction: Graft thrombosis and pancreatitis are the main causes of early failures in pancreas transplantation (PTx).

Objectives: To evaluate whether gabexate mesilate (GM), a synthetic protease inhibitor with anticoagulant properties, prevents early pancreatic graft damage acting on ischemia reperfusion injury and inhibition of leukocyte activation.

Patients and Methods: Four-hundred-seventy-two PTx (94.5% primary) were consecutively performed in 2 European Institutions. Recipient’s age ranged from 20 to 61 years (mean, 40), all receiving similar immunosuppressive regimen. The majority of grafts (n = 453) were enteric diverted and more than half (n = 259) with portal insulin drainage. Prophylaxis with heparine, low-dose aspirin and/or sodium warfarin was systematically given. Graft function and vascular moni-toring (daily plasma C peptide and color echo-doppler) were routinely performed. In 268 PTx GM was infused (1 g/day) just before grafting and for the following 72 hours (GM-group), in the other 204 PTx any protease inhibitor was given (noGM-group). The two groups were comparable for donor, recipient, harvesting, transplantation and post-operative variables.

Results: One-year patient and pancreas survival rates were 94.5% and 85.8% in GM-group and 96.4% and 86.3% in noGM-group, respectively. Complete pancreas graft thrombosis occurred in 3.7% of GMgroup vs 8.3% in noGM-group (p = 0.03). Any of the GM-group PTx recipients presented severe graft pancreatitis com-pared to 3.9% graft failure due to pancreatitis in no-GM group (p = 0.001). Immunological event rate was similar in the two groups.

Conclusion: Infusion of GM seems to prevent risk of thrombo-sis and pancreatitis in PTx. Prospective randomized trials are needed before any definitive conclusion can be drawn.

P175

Thrombosis of the Portal Venous System After Resection for Pancreatic DiseaseD. Ansari1, C. Ansorge1, R. Segersvärd1, Å. Andrén-Sandberg1

1Dept. of Surgical Gastroenterology, CLINTEC, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden

Introduction: Although rare, portal vein thrombosis (PVT) is recognized as a cause of death after pancreatic surgery. However, the exact incidence of this complication remains poorly understood.

Objectives: The objective of the present study was to assess the incidence, treatment and outcome of PVT following major pancreatic surgery in a large cohort of patients.

Patients and Methods: Between 1997 and 2009, medical records of all patients who had undergone pancreatic resection at Karolinska University Hospital, Stockholm, were reviewed retrospec-tively. Preoperative and postoperative CT were obtained in all patients, and the presence or absence of venous thrombi were investi-gated. All patients received standard thromboprophylaxis using low molecular weight heparin.

Results: Of 519 pancreatic resections,18 (3.2 per cent) were complicated by portal thrombosis. The most common clinical presen-tation was abdominal pain (n = 6) and/or ascites (n = 5). Other symp-toms were nonspecific and diverse. The main indication for pancreatic resection was pancreatic ductal adenocarcinoma. The median interval between surgery and diagnosis of portal thrombosis was 60 days (range 1-1440 days).

Conclusion: Portal thrombosis remains a relatively frequent complication after pancreatic resection. It should be suspected in patients presenting with vague symptoms after pancreatic resection as patients may benefit from early detection and prompt treatment.

P176

Polyamines and Human Pancreatic Beta-CellsL. Marselli1, M. Bugliani1, A. Lena2, F. Vistoli3, M. Tancredi1, M. Del Chiaro3, U. Boggi3, V. Gremigni2, P. Marchetti1

1Department of Endocrinology and Metabolism, Metabolic Unit, University of Pisa, 2Department of Human Morphology, University of Pisa, 3Division of General and Transplant Surgery in Uremic and Diabetic Patients, Azienda Ospedaliera Universitaria Pisana

Introduction: Polyamines (PA, in particular putrescine, spermi-dine and spermine) are ubiquitous chemical entities that play an important role in cell function and turnover.

Objectives: To assessed whether PA may be of importance in affecting beta-cells in non-diabetic subjects (ND) and type 2 diabetic individuals (T2DM).

Materials and Methods: Pancreatic tissue obtained from 17 T2DM and 15 ND was studied. The presence of PA in beta-cells was assessed on electron microscopy by immunogold technique. Gene


expression studies were performed with isolated islets or beta-cell enriched samples prepared by laser capture microdissection. Islets insulin secretion was determined in response to acute glucose stimu-lation after 24h incubation with or without 2-difluoromethylornithine (DFMO, an inhibitor ofornithine decarboxylase I, 5mM), putrescine (50mM) and spermidine (50mM), alone or in combination.

Results: Putrescine and spermine were detected in beta-cells from ND and T2DM by electron microscopy. Localization was mainly in the cytoplasm for putrescine and in both the cytoplasm and the nucleus for spermine. Microarray analyses showed that ornithine decarboxylase I (key enzyme in PA synthesis) was lower in beta-cell (p < 0.001) and islet samples (p = 0.03) from T2DM. Data were con-firmed by qPCR studies, which detected also a lower expression of arginase II in diabetic samples. DFMO caused a decrease (p < 0.05) of glucose-stimulated insulin release (-32±9.5%); the same was observed in presence of spermidine (-48±32%, p = 0.05). Putrescine prevented the inhibitory effect of spermidine.

Conclusion: This study shows that 1) PA are present in human beta-cells; 2) PA biosynthesis pathway may be different in type 2 dia-betic beta-cells; and 3) PA have a role in insulin secretion.

P177

Referral Rates for Pancreatic Surgery Depend on Personal Interactions Between CliniciansT. Armstrong1, N. Pearce1, M. Abu-Hilal1, C. Johnson1

1Southampton University Hospitals

Introduction: Pancreatic surgery in England was centralised from 2007. Each case is considered at a local multidisciplinary team (MDT) meeting, and referred according to agreed criteria for surgical assessment. Local MDTs interact with specialist MDT in various ways; we reviewed 3 years’ experience.

Objectives: To determine whether MDT interactions influence referral decisions.

Patients and Methods: All pancreatic surgery from two Cancer Networks is performed in Southampton. Referring hospitals interact face to face (FF: clinicians present in MDT), by video link (VL: surgeon discusses selected patients with local MDT), or by independent MDT meeting and referral (IMR) of selected cases. Numbers shown are patients per 100K population/year.

Results: FF pancreatic and HPB referrals rose from 1.05 and 1.68 in 2007 to 1.5 and 3.5 in 2009; VL referrals rose from 1.89 and 2.70 in 2007 to 2.16 and 4.86 in 2009. IMR referrals declined from 1.31 and 1.87 in 2007 to 0.95 and 0.95 in 2009. In 2009, one hospital continued to refer in the IMR pathway (no change in referrals): two now attend the specialist MDT (pancreatic referrals rose from 1.97 to 3.62). At one hospital a surgeon now attends the local MDT: pancre-atic referrals rose from 0.14 to 0.86.

Conclusion: We conclude that regular case discussions between clinicians are essential to ensure appropriate referrals for surgery, either by FF contact in MDT meetings, or by VL discussion of selected cases, provided that all cases of non-metastatic pancreatic cancer are discussed. Lack of direct contact between clinicians is associated with low referral rates despite clear referral guidelines.

P178

Pancreatic Surgery at Karolinska University Hospital – A Comparison Between Reimbursement Based on Diagnosis Related Groups and Actual CostP. Elbe1, C. Ansorge1, T. Agustsson1, B. Törnqvist1, R. Segersvärd1, Å. Andrén-Sandberg1


Introduction: Diagnosis Related Groups (DRG) is a system for classification and grouping of patients with a similar diagnosis and the financial reimbursement for these groups. However, the actual cost (AC), may differ substantially from the DRG.

Objectives: The objective was to study the difference between the DRG system and AC and to evaluate the effectiveness of the DRG system.

Patients and Methods: All patients who underwent pancreatic surgery at the Karolinska University Hospital in 2008 were studied. DRG reimbursement and AC for these patients were reviewed. We examined in particular the difference between DRG and AC (DRG-AC).

Results: A total of 98 explorations with curative intent were per-formed. Whipple, n = 60: DRG 27 000 €, AC 45 000 €(8 500 –280 000 €). DRG-AC: -18 000 €(-30 000 –200 00 €). Tail resection, n = 15:. DRG 26 000 €(7 500 –74 500 €), AC 56 000 €(8 000 –337 000 €). DRG-AC 30 500 (-17 000 –226 500 €). Total pancreatectomy, n = 8: DRG 24 000 €(14 000 –29 000 €), AC 24 500 €(7 500 –45 500 €). DRG-AC 650 €(-21 000 –29 500 €). Palliative double bypass, n = 11: DRG 23 000 €(5 500 –29 000 €), AC 40 000 €(12 000 –199 500 €), DRG-AC -17 000 €(-10 000 –170 500 €). I all patients sum of DRG 386 500 €, AC 845 000 €, DRG-AC 450 000 €.

Conclusion: In a majority of pancreatic resection there is a neg-ative differcence between the reimbursement based on the DRG sys-tem and the actual cost, and if DRG were to be used as payment in full model, the department would lose economically in most patients. The major differences between DRG and AC were found in patients who had serious complications eg pancreatic leakage and sepsis, but also in uncomplicated cases differences were found. DRGs are not suitable a system for this type of highly specialized care.

P179

Thromboembolism After Pancreatic ResectionD. Ansari1, C. Ansorge1, R. Segersvärd1, Å. Andrén-Sandberg1


Introduction: Thromboembolism is a well-known complication of surgery.


Objectives: The purpose of this study was to estimate the inci-dence of pulmonary embolism and deep venous thrombosis after pan-creatic resection.

Patients and Methods: The clinical and radiographic charts of all patients (n = 151) who underwent pancreatic resection at Karolinska University Hospital, Stockholm, between 2007 and 2009 were exam-ined for the presence of deep venous thrombosis and pulmonary embolism.

Results: Pulmonary embolism was found in 11 patients (7.3%) and deep venous thrombosis in 2 patients (1.3%) postoperatively. One patient (0.7%) had pulmonary embolism and two patients (1.3%) had deep venous thrombosis preoperatively. One patient had pulmonary embolism both before and after the operation. No patient had deep venous thrombosis both before and after surgery. Only one patient had both pulmonary embolism and deep venous thrombosis post-operatively.

Conclusion: The discrepancy between pulmonary embolism and deep venous thrombosis incidence in our study shows that one should question the relationship between pulmonary embolism and deep venous thrombosis. Pulmonary embolism might occur de novo. In that case this has implications for thrombosis treatment and par-ticularly the usefulness of vena cava filters. Our study also shows that pulmonary embolism is a relatively common complication after pan-creatic resection.

P180

Microarray Analysis of Type 2 Diabetic Isolated Human IsletsM. Bugliani1, R. Liechti2, L. Marselli1, M. Del Chiaro3, F. Vistoli3, U. Boggi3, I. Xenarios2, P. Marchetti1

1Dept. Endocrinology and Metabolism, University of Pisa, Pisa, Italy, 2Swiss Institute of Bioinformatics, Vital-IT group, Lausanne, Switzerland, 3Dept. Oncology, Transplantation and Advanced Technologies in Medicine, University of Pisa, Pisa, Italy

Introduction: Type 2 diabetes (T2D) is a multifactorial syn-drome with beta-cell failure playing a major role. However, informa-tion on islet transcriptome in human T2D is scanty.

Objectives: To better understand the pattern of the alterations in the diabetic condition, we performed microarray analysis on T2D islet samples.

Materials and Methods: The analysis, followed by quantita-tive RT-PCR (qPCR) of selected genes, was performed on six T2D (age: 71±9yrs; gender: 3M/3F; BMI: 26.0±2.2Kg/m2) and 7 nondia-betic (ND, age:58±17yrs; gender: 4M/3F; BMI: 24.8±2.5Kg/m2) islet preparations. RNA was hybridized on Affymetrix chips (HG U133A). Gene expression intensities were normalized with RMA and differen-tial expression was assessed using the limma.

Results: When T2D islets were compared with ND samples, the expression of 1345 probe sets resulted significantly (p < 0.01 and a fold change of <0.5 and >2.0) different; of these, 59 were upregulated and 1286 downregulated. By Gene Ontology and KEGG analysis it was observed that the differently expressed genes influenced 21 pro-cesses and 13 pathways. Such findings were confirmed by the Gene Set Enrichment Analysis, performed to evaluate how the overall gene expression profile could influence intracellular processes. This analy-sis showed that out of 1419 gene sets studied, 195 were positively and 42 negatively enriched inT2D islets. The expression of genes involved in oxidative phosphorylation and citrate cycle resulted consistently changed in T2D samples; when qPCR analysis was performed, a sig-nificant reduction in the expression of pyruvate and succinate dehy-drogenase complexes was found.

Conclusion: In conclusion, T2D islets show many alterations of transcriptome, including changes of genes involved in mitochondrial ATP production.




Author Index

Abdulla, A. 263, 283, 306, 308Abiatari, I. 342Abu Hilal, M. 320, 383, 392Adrian, T. 272Aghdassi, A.A. 262, 345Agustsson, T. 373, 392Aimoto, T. 336, 382Akshia, I. 350, 388Al-Maamari, S. 272Al-Refaai, J. 363, 364Al Saati, T. 269Alaggio, R. 375Albazaz, R. 300Albiin, N. 288, 301, 313,

388Aldouri, A. 374Algül, H. 263, 269, 283Alhonen, L. 329Allavena, P. 267Alli Balogun, A. 385Almada, L.L. 310Alvarez, A. 344Ammerpohl, O. 341Ammori, B. 289Amorese, G. 385, 391Andersson, R. 279André, F. 267Andrén-Sandberg, Å. 295,

301, 329, 363, 365, 391, 392

Andriulli, A. 297Ang, C. 340Angelelli, B. 317Annet, L. 296Ånonsen, K.V. 371Ansari, D. 391, 392Ansorge, C. 295, 321, 363, 365,

391, 392Ansquer, C. 278Anthoney, A. 361Aparicio, J.R. 345Apte, M. 333, 334Ardnor, B. 369Armstrong, T. 392Arnelo, U. 288, 293, 330, 380Arner, P. 373Artal, A. 333Aspinall O-Dea, M. 278Astarci, P. 296Aubert, A. 383Aust, D. 362Awla, D. 263, 283, 306, 308

Azadeh, B. 340Azuma, S. 277

Baczewska-Mazurkiewicz, D. 265

Badea, R. 389Bahra, M. 362Bajec, D. 346, 349, 355Bakker, O. 265, 284, 346Balzano, G. 318, 362Banks, P. 284Bano, B. 324Banting, S. 316Barassi, A. 366Barbano, R. 271Barbieri, E. 317Barbu, S.T. 371Baron, M. 335Barreto, S. 323Barros, F. 294, 295Barrucca, V. 368Bartolozzi, C. 379, 380, 389Bartsch, D. 282, 339, 376, 377,

381Barugola, G. 290, 317Basho, J. 350, 388Basil, A. 350Bassi, C. 290, 317, 360, 361,

378, 389Basso, D. 338, 367Bateman, A. 272Bauer, A. 312, 342, 367Bauhuber, S. 271Bazargan, M. 323Becker, K. 319Beijer, E. 288Belle, S. 291Belli, C. 318Bellone, G. 368Beltrame, V. 303Benyon, C. 272Benyon, R. 272Berchtold, S. 267, 341Berczi, S. 329Bergmann, F. 312, 376, 377Bergquist, A. 313Bertelè, A. 287Bertolini, S. 287Besselink, M.G. 265, 284,

346Bettini, R. 375, 378Bevilacqua, G. 370

Bhatia, M. 263Bianchi, P. 267, 279Biankin, A. 320, 334Biczó, G. 329Bihalskyy, I. 350Bilaj, F. 388Bilic Zulle, L. 347, 351Billadeau, D. 333Bläuer, M. 302, 366Bo, K. 338Boerma, D. 346Boermeester, M.A. 265Boggi, U. 289, 298, 319, 324,

335, 364, 370, 372, 379, 380, 383, 385, 389, 391, 393

Boggio, V. 332Bogicevic, A. 386Boiko, V. 349Boldis, A. 310Bollen, T.L. 265Bong, J.J. 370Boninsegna, L. 375, 378Booth, D.M. 284, 306, 325Boraschi, P. 389Borbath, I. 296Borisov, B. 382, 388Borka, K. 302Borrebaeck, C. 279Borunova, J. 359Bouamra, O. 306Bousquet, C. 335Boyko, V. 354Boz, G. 389Bozzato, D. 338, 367Brandt-Nedelev, B. 328Brecht, A. 279Brismar, T.B. 313Brismer, T. 373Brock, C. 286Bröker, B.M. 305Bronisch, H. 266Buanes, T. 371Buchholz, M. 280, 299Büchler, M.W. 271, 276, 280,

311, 362, 365, 367, 376, 377, 384

Bugliani, M. 391, 393Bumbasirevic, V. 346Buonadonna, A. 389Burai, M. 381Buskens, E. 265

Butler, J. 279Buus, R. 310

Cade, R. 316Cainap, C. 369Cairns, A. 361Cakerri, L. 350Calculli, L. 317, 322, 381Calvo, E. 270Calzolari, C. 287Cammà, C. 286Campa, D. 367Campani, D. 298, 335, 364,

370, 372, 379, 380Campra, D. 368Camuzeaux, S. 278, 312Cane, M. 302, 325Cano, C. 270Cantarovich, D. 391Canton, S.A. 303, 375, 378Canzian, F. 367Caparello, C. 364, 372, 374Capelli, P. 378Caponi, S. 364, 372, 374Cappelli, C. 379, 380, 385Cappello, P. 339Capretti, G. 362Caprotti, R. 372Capurso, G. 286, 368, 375Caras, S. 290Carati, C. 323Carella, M. 271Carlsson, A. 279Carrier, A. 267, 269Carter, C. 297Carter, C.R. 363, 364Carter, R. 363, 364, 369Casadei, R. 281, 317, 366, 381Casswall, T. 288Castellano, L. 299Castiñeira-Alvariño, M. 274,

294, 295, 298, 314Cavallini, M. 368Cavazzana, A. 370Cavestro, G.M. 287Cazacu, M. 371Cela, M. 388Ceranowicz, P. 326, 327Cereda, S. 318, 362Ceruti, P. 339Ceyhan, G.O. 310, 319, 338Chaisaingmongkol, J. 312

Pancreatology 2010;10:259–400 395Author Index

Chandrabalan, V.V. 363, 364Chang, D. 320, 334Charnley, R. 281Charvin, M. 365Chattaragada, M.S. 339Chelala, C. 270Chen, T. 376Chen, X.Z. 305, 344Chichula, Y. 357Chicunova, B. 331Chooklin, S. 350, 355Chuntao, G. 321Chympoi, K. 360Cieszkowski, J. 326, 327Ciuffreda, L. 368Clerc, P. 269Closa, D. 326, 328Cocomello, L. 286Cola, B. 322Collins, J. 272Colvin, E. 320, 334Comba, A. 333Coppola, M. 364, 372Corinaldesi, R. 317Corrente, V. 287Corsi, M.M. 366Costa, F. 289, 379, 383, 385Costello, E. 278, 312, 321, 340,

342Couvelard, A. 277, 278, 383Cowley, M. 333Criddle, D.N. 284, 302, 306,

325Crippa, S. 290, 317, 378Croce, C. 289, 364, 372, 383,

385, 391Cui, N. 331Cui, Y. 273Cunha, M. 374Czakó, L. 292Czupryniak, L. 378

Daccò, R. 264Dadabaeva, N. 272Dajani, K. 342Dalle Fave, G. 378D’Ambra, M. 281, 317, 381Danesi, R. 298Daniel, P. 348de Bortoli, N. 324De Dios, I. 326de Franco, V. 365De Lio, N. 289, 385de-Madaria, E. 308, 326, 343,

345De Marchi, F. 389De Paoli, A. 389De Raffele, E. 322Debus, J. 280

Degrate, L. 372Dejong, C.H. 265Del Chiaro, M. 289, 298, 319,

324, 335, 364, 370, 372, 379, 380, 383, 385, 389, 391, 393

Delle Fave, G. 286, 368, 375Dembinski, A. 326, 327Demir, I.E. 310, 319, 338Denneberg, M. 377Denninger, M.H. 275Deprez, P. 296Destro, A. 267D’Haese, J.G. 319Di Carlo, V. 318, 362Di Fabio, F. 320, 383Di Giambattista, A. 379, 380Di Marco, M.C. 317Di Mario, F. 287di Mola, F.F. 271di Sebastiano, P. 271, 310Dickson, E.J. 297, 363, 364,

369Diergaarde, B. 265Dignass, A. 266D’Imporzano, S. 385Dlubatz, K. 269Dmitrieva, K. 387Dobson, R. 270Dodson, A. 340Dogliotti, G. 366Dolgich, T. 315Dominguez-Muñoz, J.E. 274,

294, 295, 298, 314, 332, 344

Domsa, I. 371Donati, F. 389Dósa, S. 329Drewes, A.M. 286Drozdov, V. 359Duberman, B. 354Dubravcsik, Z. 292Dufresne, M. 269Dumitrascu, T. 386Dummer, A. 305Dumont, P. 336Duni, A. 350Durko, L. 378Durlik, M. 316Dusetti, N. 267, 269Dutruel, C. 312Duvalko, A. 382Duvalko, O. 388Dynkov, S. 354

Edderkaoui, M. 311Edling, C. 310Edwards, J. 363, 364Edwin, B. 371

Egberts, J. 341Egorov, V. 291, 304, 314, 315,

385, 386, 387, 390Eibl, G. 311Einwächter, H. 268El Ghoul, W. 320El khoury, G. 296Elbe, P. 392Ell, C. 266Elliot, V. 278Elliott, V. 284, 312, 325Elsawa, S.F. 310Eltaji Elfarouki, G. 383Emmrich, J. 300, 341Enochsson, L. 293, 380Epshteyn, A. 354Erkan, M. 338Esni, F. 268Esposito, I. 267, 337, 338, 341Evans, J. 279

Fadi, E. 338, 367Faissner, R. 343, 361Fakelman, F. 276Falasca, M. 310Falaschi, F. 389Falcone, A. 298, 364, 372, 374Falconi, M. 290, 317, 319, 375,

378Fan, Y. 374Fang, L. 273Fanjul, M. 335Fazio, E.N. 262Fed’kiv, O. 324Fedorov, A. 390Felix, K. 272, 276Fendrich, V. 282, 339, 376, 377,

381Ferentinos, G. 361Fernandez-Zapico, M.E. 310,

333Ferreiro, R. 274, 298, 344Fine, D. 272Fisic, E. 347, 351Fitzner, B. 300Fogar, P. 338, 367Földesi, I. 292Foretova, L. 322Foulis, A.K. 369Frampas, E. 278, 365Frampton, A.E. 274, 299, 370Franco-Lie, I. 371Franjic, N. 351Franzè, A. 287Freitag, M. 266French, J. 281Friess, H. 271, 310, 319, 334,

338, 342, 362Frigerio, I. 361

Froeling, F.E.M. 270Frøkjær, J.B. 286Fronda, G.R. 368Frulloni, L. 287Fu, P. 344Funel, N. 298, 335, 364, 370,

372, 379, 380

Gajdar, J. 330Galeev, S. 353, 355Garancini, M. 372Garcia, S. 267, 270Gasiorowska, A. 273, 319Gea-Sorlí, S. 326, 328Gentile, M. 297Gentry-Maharaj, A. 278, 312Germenia, S. 290Ghaneh, P. 342Ghazi, S. 282, 301Ghidini, M. 318Giacobino, A. 368Giardino, A. 361Gibson, P. 316Giese, N.A. 272, 312, 338,

367Gigoni, R. 389Gigot, J.F. 296Gigoux, V. 269Gil, S. 345Ginocchi, L. 364, 372, 374Giovannetti, E. 298, 370Giral, M. 391Girelli, R. 361Glineur, D. 296Gómez-Escolar, L. 308Gontsariuk, D. 358, 360Gonzalez Leon, L. 298Gooszen, H.G. 265, 284,

346Gorbenko, K. 349, 353, 354Gorelick, F.S. 327Goto, H. 277Graf, R. 275Granlund, E. 288Gräntzdörffer, I. 279Gray, M.A. 288Greco, C. 364, 372Greco, E. 338, 367Greenhalf, B. 278, 321Greenhalf, W. 279, 312, 342Gregoric, P. 346, 349, 355Gremigni, V. 391Grenacher, L. 376Gress, T. 280, 282, 299Griesmann, H. 299Grigorieva, I. 315, 316Grippo, P. 311Grocock, C. 279Grundsten, M. 275


Grüner, B. 337Grunet, M. 288Grützmann, R. 362Guangyuan, C. 289, 354Gubergrits, N. 290, 357, 358Guenther, A. 345Guido, A. 317Gukovskaya, A.S. 311Gulei, I. 369Gunjic, D. 349, 355Gustavsson, L. 288Guthrie, A. 300Gutiérrez, L.M. 326Gyökeres, T. 292

Haas, S.L. 361Habbe, N. 282Habib, M. 383Habib, N.A. 299Hackert, T. 280, 365, 376, 377,

384Haglund, C. 296, 314Hagman, B. 325Hagmann, W. 309Hagström, J. 314Hahne, H. 337Halangk, W. 263, 283, 305,

327, 328Hamidi, T. 270Hamm, J. 339Hammel, P. 273, 275, 277, 278,

383Hamza, N. 350Hanlin, G. 289, 354Harcus, M. 279Harrison, S. 279Hart, I. 339Hart, I.R. 270Hartman, H. 263, 283, 306Hartman-Magnusson, H. 308Hartwig, W. 280, 365, 376, 377,

384Hassan, Z. 318Hassen, S. 316Hauck, O. 276Hauge, T. 371Haugk, B. 281Hauser, G. 351Havranek, O. 322He, R. 321Hegyi, P. 288, 302, 307, 329Heiberg, T. 371Heidecke, C. 331, 362Heidecke, K.D. 311Heikenwalder, M. 275Heller, A. 272Henniges, U.M. 266Henshall, S. 320Hentic, O. 275, 277

Henze, E. 341Hernandez-Alvarado, N. 310Heuchel, R. 313, 325, 330,

361Heverhagen, J. 282Heyries, L. 294Hinz, U. 365, 376, 377Hirota, M. 293Hlavata, I. 322Hoem, D. 373Hofker, H.S. 265Hoheisel, J. 312, 342, 367Holcatova, I. 322Holm, J. 388Honap, S. 340Hong, X. 334Hong, Z. 263, 283Honstein, T. 280Horlemann, C. 335Hoshino, A. 336, 382Hranat, O. 355Huang, H. 310Huang, W. 284, 302, 305, 306,

325, 344Hubert, C. 296Humblet, Y. 296Hung, J. 376Hussey, D. 323

Iglesias, J. 344Iglesias-Garcia, J. 274, 294,

295, 298, 314Ikdahl, T. 371Immervoll, H. 373Innocente, R. 389Innocenti, P. 310Ionescu, M. 386Iovanna, J.L. 267, 270Isaksson, B. 373Ishiguro, H. 277Ivancevic, N. 346, 349Iványi, B. 329

Jacob, J. 299Jain, G. 383Jamieson, N.B. 369Jankovic, R. 386Jaques, B. 281Jaray, B. 379Jarikov, O. 347Järvinen, S. 266, 348Jasinska, A. 348Jaster, R. 300Jeanniard-Malet, O. 294Jenkins, R. 278, 340Jenkinson, C. 312, 321Jeppsson, B. 306Jeremic, L. 386Jeremic, V. 346, 349

Jesnowski, R. 309, 313, 337, 343, 361

Ji, D. 353Jia, W. 289Jia, X. 332Jiang, K. 305, 344Jiao, L.R. 274, 299, 370Jihui, H. 321Johnson, C. 292, 320, 383, 387,

392Johnston, E. 320Jonckheere, N. 336Jonsson, F. 282, 301Juan, L. 289, 354Judák, L. 302Juuti, A. 296

Kaczka, A. 378Käding, A. 362Kahl, M. 266Kalirai, H. 340Kalthoff, H. 333, 341Kamposioras, K. 361Kann, P.H. 282, 376Kaplan, W. 333Karadzic, B. 349, 355Karakhanova, S. 309Karam, G. 391Kardzic, B. 346Karmazanovsky, G. 390Karrar, A. 313Kartalis, N. 301, 388Kasahara, N. 311Kausar, A. 289, 294, 306, 350Kavallaris, M. 334Keating, D. 323Kehl, T. 310, 338Keller, J. 266Kemény, L.V. 288Kempf, T. 276Kench, J. 320Kenzerska, T. 358Keßler, W. 331Khan, J. 348Khattak, I. 340Khokha, D. 307, 352Khokha, V. 307, 347, 352Khomyak, I. 382, 384, 388Khrystych, T. 359Kinsella, J. 363, 364Kiviluoto, T. 296, 314Kleeff, J. 334, 338, 342Kleibl, Z. 322Kleiter, I. 325Klitsenko, O. 353, 355Klöppel, G. 268Klose, T. 342Knösel, T. 362Ko, S. 277

Kocher, H.M. 270, 310, 339Kolb, G. 269Kolkina, V. 359Komine, O. 336Kong, B. 334, 342Koop, I. 266Kopchak, K. 382, 388Kopchak, V. 382, 384, 388Kovalev, V. 347Kovalska, I. 345Kozachenko, A. 349, 353,

354Kozhevnikov, O. 357Kozlov, I. 304Kozyrin, I. 385Krarup, A.L. 286Kreider, R. 280Kristiansen, G. 362Krüger, B. 327Kruyt, P.M. 265Krylova, O. 330Krznaric Zrnic, I. 347, 351Kuehnemuth, B. 299Kuhayeu, M. 291, 314, 315,

356Kulig, A. 273, 319Kull, K. 285Kumar, N. 271Kumar, R. 367Kurti, F. 350, 388Kusnierz-Cabala, B. 326Kusnierz, K. 385Küster, B. 337Kylänpää, L. 285Kyriakides, C. 274, 370

Laaninen, M. 366Labori, K.J. 371Laghi, L. 267, 279Lagrange, X. 294Laklai, H. 335Lampe, P. 319, 385Lane, C. 278Langer, P. 282, 376, 377Lappalainen-Lehto, R. 266,

348Lariño, J. 274, 295Lariño-Noia, J. 294, 298, 314,

344Larsson, J. 332Laukkarinen, J. 302, 360,

366Laval, S. 335Layer, P. 266Lazebnik, L. 292, 331Le Baleur, Y. 277Le Borgne, J. 365Lecky, F. 306Lee, M. 268


Lega, S. 317Lehman, G.A. 290Leidner, B. 388Leifler, A. 282, 301Lekstan, A. 319Lelic, D. 286Lemke, J. 333Lena, A. 391Leonardi, G. 319, 324Leong, M. 323Lerch, M.M. 262, 271, 297,

305, 311, 327, 328, 331, 337, 345, 362

Lesina, M. 269, 283Lesniowski, B. 348Lévy, P. 273, 275, 277, 278,

383Li, F. 273Li, J. 264, 353Li, N. 264, 353Li, W. 264, 353Licul, V. 351Liebe, S. 300Liebl, F. 319Liechti, R. 393Limongelli, P. 274Lindberg, B. 313Lindblad, M. 285Lindgren, F. 288Lindkvist, B. 308Linnebacher, M. 341Lipinski, M. 347Lippert, H. 328Litvin, A. 307, 347, 352Liu, J. 334Liu, X. 303Liu, Z. 332Ljung, R. 285Lluís, F. 345Loba, J. 378Lobankov, V. 352Löhr, J.M. 275, 277, 279, 285,

287, 288, 291, 293, 301, 309, 313, 318, 325, 330, 337, 343, 361, 380

Loizou, L. 388Lombard, M. 279Lomberk, G. 270Longati, P. 313Lopez, C. 376López-Font, I. 308, 326, 345Lorenz, E. 331Lorenzo-Bermejo, J. 367Lothe, I.M.B. 371Lou, W. 374Loundou, A. 296Lozano, A. 295Lozano-León, A. 265, 294,

332

Lu, Y. 285Lu, Y.M. 325, 330Luaces-Regueira, M. 274, 294,

295, 298, 314Lubenets, T. 345Lucchesi, M. 364, 372, 374Lyarski, S. 291, 314, 315,

356

Maak, M. 319McCarroll, J. 334Macchini, M. 317McKay, C.J. 297, 363, 364,

369Mackay, S. 316McLaughlin, E. 325McMillan, D.C. 363, 364,

369McPhee, A. 363Maejima, K. 336Maffucci, T. 310Maire, F. 275, 277, 383Malecka-Panas, E. 273, 290,

319, 348, 378Malesci, A. 267, 279Maléth, J. 307Maletzki, C. 341Malla, S. 327Manas, D. 281Manso, M.A. 326Mantovani, A. 267Manu, M. 294Manusama, E.R. 265Marchesi, F. 267Marchetti, P. 368, 391, 393Marchi, S. 319, 324Mariniello, D. 383Marotta, F. 264Marsakova, L. 322Marselli, L. 391, 393Marshall, J. 339Martínez, J. 308, 343, 345Martynchuk, A. 357März, M. 381Mascetta, G. 271Matejak-Gorska, M. 316Mattsson, F. 285Mattsson, J. 318Mauri, G. 372Mawson, A. 334Maximov, V. 315, 316Mayerle, J. 262, 271, 297, 305,

311, 327, 328Mazur, P. 268, 337Mazzeo, S. 379, 380Meihua, W. 289, 354Mein, C.E. 270Melchisedech, S. 280Melekhina, O. 385

Melzi d’Eril, G. 366Menon, K. 300, 361, 374Menon, U. 278, 312Merola, E. 375Meurette, G. 365Michalski, C.W. 301, 334,

338Michl, P. 299, 301Mikhnyova, N. 357Mikolasevic, I. 351Mildner, A. 275Miletic, H. 373Milic, S. 347, 351Minni, F. 281, 317, 381Mirarchi, M. 322Mirkovic, D. 346Miyamoto, M. 382Mizuno, N. 277Mizutani, S. 336, 382Mocan, T. 369Mohamed, M. 369Mohelnikova-Duchonova, B.

322Mokrowiecka, A. 348Molero, X. 301Moletta, L. 378Molven, A. 373Monari, F. 281, 381Montero, M.P. 267Montorsi, M. 267, 279Montravers, F. 278Morelli, M. 370Moretto, C. 289, 385, 391Moro, M. 303Morselli-Labate, A.M. 366,

381Mosca, F. 298, 335, 364, 370,

372, 383Mosevicius, P. 311Moya, N. 343Moz, S. 338, 367Muallem, S. 277Muddana, V. 265, 284Mukherjee, R. 284, 302, 306,

325Murray, S. 278Mustonen, H. 296Muzgrove, E. 320

Naito, Y. 264Nakamura, Y. 382Nakhai, H. 268Nardi, A. 288Naredi, P. 369Naruse, S. 277Navaglia, F. 338, 367Nechipay, Z. 358, 360Nedjadi, T. 340Nehez, L. 379, 384

Neoptolemos, J.P. 278, 279, 301, 312, 321, 340, 342, 367

Neuhaus, P. 279Neuhöfer, P. 263N’guessan, P. 267Nguyen Trung, D. 331Niedergethmann, M. 362Nieto, L. 294, 295, 344Nieuwenhuijs, V.B. 265, 346Nikitenko, T. 315, 316Nilsson, M. 282, 301, 380Nitsche, C.J. 311, 345Nizze, H. 300Nobili, C. 372Noel, R. 293Noirhomme, P. 296Nordback, I. 266, 302, 314,

348, 360, 366Nordling, S. 296, 314Novaria, L. 379, 380Novarino, A. 368Novelli, F. 339Novotny, A. 319Novotny, J. 322Nylén, C. 321

O’Connell, M. 265Odurny, A. 387Ogata, M. 336Öhlund, D. 369Ohmuraya, M. 293Olakowski, M. 319Olesen, S.S. 286Olinyk, O. 359Olszewski, W. 265Öman, M. 369Omazic, B. 318O’Reilly, D. 289, 294, 306,

350Ouaissi, M. 296Ózsvári, B. 302

Padoan, A. 338, 367Pai, M. 370Pajic, M. 320, 334Palazzo, L. 383Pallagi, P. 302Pandurovic, M. 349Panzuto, F. 375, 378Pap, Á. 292, 381Papachristou, G. 284Parenti, A. 375, 378Park, K. 340Paron, I. 267, 341Parrella, P. 271Partecke, L.I. 331, 362Partelli, S. 290, 317, 361,

378


Parunian, L. 357Pasqualetti, F. 364, 372Pasquali, C. 375, 378Passoni, P. 318Patel, M. 272Pawlowski, M. 378Pearce, N. 320, 387, 392Peat, J. 292Pecorelli, N. 362Pederzoli, P. 290, 317, 361,

375, 378Pedrazzoli, S. 303, 338, 367,

375, 378Peiris, H. 323Pejovic, I. 349, 355Pelli, H. 266, 285, 296Pena-Sanchez, L.J. 333Pereia, S. 278Pereira, S. 312Pérez-López, J. 343, 345Pérez-Mateo, M. 308, 326, 343,

345Permert, J. 275, 282, 293, 301,

313, 318, 332, 365, 373Perri, F. 297Perrone, V.G. 289, 324, 379,

383, 385, 389Persson, G. 380Pery, C. 278Pesotsky, O. 349Peters, G. 298Petersen, O. 325Petrov, R. 291, 314, 315, 386Petukhova, M. 387Peuget, S. 267Pezzilli, R. 281, 317, 366, 381Pfützer, R.H. 285Phillips, P. 333, 334Piciucchi, M. 368Piemonti, L. 267Pierzynowski, S. 324Pietruczuk, M. 348Pilarsky, C. 362Pin, C. 262, 292Pinese, M. 320Pirola, R. 333Pisano, R. 289, 391Plass, C. 312Plebani, M. 338, 367Pokrotnieks, J. 390Polevoj, V. 330Polizzi, L. 375Pollina, L.E. 298, 335, 370Pontillo-Contillo, B. 380Pop, T. 369Popanda, O. 312Popescu, I. 386Popowicz, A. 329Poropat, G. 308, 351

Pötschke, C. 305Pouyet, L. 267Pow, C. 363, 364Presciuttini, S. 319Principe, M. 339Priyadarshini, M. 324Prykhod’ko, O. 324Pucelle, M. 335Pukitis, A. 367, 390Pyronnet, S. 335

Qing, X. 289, 354Qiu, F. 264Quan, Z. 353Quasim, T. 363, 364

Rachakonda, P.S. 367Rad, R. 268Radenkovic, D. 346, 349,

355Radic, M. 351Radojkovic, M. 386Radtke, F. 268Ragino, Y. 315Rahal, D. 267Rahman, A. 281Rahman, M. 283, 306Rakonczay Jr, Z. 288, 302,

307, 329Ramnath, R. 263Ramudo, L. 326Raña, P. 294, 295Räty, S. 266, 314, 348, 360,

366Rauser, S. 337Rázga, Z. 307Real, F.X. 301Rebours, V. 273, 275, 277,

383Redaelli, A. 372Reding-Graf, T. 275Rega, D. 317, 381Regenass, S. 275Regenet, N. 278, 365Regnér, S. 263, 283, 285, 306,

308, 321Reiser-Erkan, C. 338Reni, M. 318, 362Repas, K. 284Rezzonico, S. 318Ricci, C. 281, 317, 366, 381Rieder, S. 334Rigot, V. 267Ringdén, O. 318Ringel, J. 337Rinzivillo, M. 375Ripka, S. 299Ritz, T. 341Rizzato, C. 367

Robinson, S. 281Röcken, C. 279Rognone, A. 318Rolla, S. 339Romanova, T. 315, 316Romanowicz-Makowska, H.

273, 319Romiti, A. 368Roncalli, M. 267, 279Rooney, P.S. 340Ropolo, A. 332Rose-John, S. 283Rosenberg, R. 319Rotar, D. 330Rotar, O. 328, 330Rotar, V. 328Rubtsov, M. 353, 355Rudenko, A. 330Rülicke, T. 275Rümmele, P. 362Ruszniewski, P. 273, 275, 277,

383Rutkowska, J. 265Rydén, M. 373Rydzewska, G. 265, 347Rydzewski, A. 265, 347Ryschich, E. 311Ryska, M. 322

Saccone, G. 323Saeger, H.D. 362Sagynbaeva, V. 276Sahel, J. 294Sahin-Tóth, M. 302Said, K. 313Sainato, A. 364, 372Saint-Laurent, N. 336Salemi, S. 389Salvia, R. 290, 360, 361Samkharadze, T. 338Sánchez-Fortún, C. 308Sánchez-Payá, J. 308Sand, J. 266, 302, 314, 348,

360, 366Sandblom, G. 329, 363Sander-Struckmeier, S. 290Sandi, M. 270Sandström, A. 279Sänger, J. 343Santini, D. 317, 322Sapia, G.P. 368Saryusz-Wolska, M. 378Sauvanet, A. 277, 278, 383Scaillet, P. 296Scarlett, C. 320, 334Scarpa, A. 360, 378Scarsbrook, A. 300Schaapherder, A.F. 265,

346

Schastny, A. 386Schloithe, A. 323Schmezer, P. 312Schmid, R.M. 263, 268, 269,

283, 337Schmidt, J. 311Schneider, A. 277, 287, 291Schneider, R. 339Schnölzer, M. 276Schober, M. 343Schulte, J. 345Schulz, H. 263, 384Schumacher, G. 279Schütze, S. 333Schwarte-Waldhoff, I. 340Schwerdtfeger, C. 263Scimeca, D. 297Secq, V. 270Segerdahl, M. 275Segersvärd, R. 275, 279, 282,

295, 301, 318, 321, 330, 363, 365, 391, 392

Seicean, A. 369, 389Seleznik, G.M. 275Selvaggi, F. 310Sempere, L. 308, 343, 345Sempoux, C. 296Sendler, M. 262, 305, 327, 331,

362Seraglia, R. 367Serra, C. 317Serrano-Mollar, A. 328Seux, M. 267Shamarla, M. 267Shaw, V. 312, 321Shchastny, A. 291, 314, 315,

356Shearman, C. 387Sheikh, A. 340Shek, F. 272Shen, Y. 290Sheridan, M. 300Sherlock, D. 289, 294, 350Shevchenko, T. 385, 386,

390Shirinskaya, N. 315, 356Shulyatyev, I. 359Shvets, O. 357Shyr, Y. 376Siatkouski, A. 291, 314, 315,

356Siatkovsky, A. 386Signori, S. 289, 383, 385,

391Sijacki, A. 349Silvestri, S. 368Sim, A. 325Simán, H. 285Simon, P. 297


Sinclair, J. 278, 312Sinervirta, R. 329Singer, M.V. 277, 287, 291Singh, S.K. 287Singh, V. 284Sipos, B. 268, 269Sirén, J. 296, 314Siret, C. 267Siska, A. 329Siveke, J. 268, 337Sjöberg Bexelius, T. 285Sjölund, M. 275Skarin, A. 363Skrypek, N. 336Slater, E.P. 282Smart, H. 279Smerhovsky, Z. 322Smith, A. 300, 361, 374Smith, C. 323Smolarz, B. 273, 319Socaciu, M. 389Soler-Sala, G. 308, 343, 345Sollerbrant, K. 293Soucek, P. 322Soulillou, J. 391Souto, R. 344Sovershaev, A. 354Sparchez, Z. 389Sparwasser, T. 305Speerforck, S. 362Speicher, J. 268Sperti, C. 303, 375, 378Spinelli, A. 279Staka, A. 367Stampfl, U. 384Stan-Iuga, R. 369, 389Stankovic, S. 349Steadman, B. 387Stebbing, J. 299Steffensen, O.J. 373Steils, L. 271Stimac, D. 308, 347, 351Stojanovic, M. 386Storck, C. 262Stosic, B. 386Stpien, B. 265Streit, S. 334Strobel, O. 272, 280, 365, 376,

377Strobl, L. 268Stroescu, C. 386Strömmer, L. 295, 321Struck, J. 345Su, C. 376Sultana, T. 293Sun, L.K. 275Sund, M. 369Sundin, A. 388Sundqvist, K. 332

Suplichenko, M. 349Susini, C. 335, 336Sutherland, R. 320Sutton, R. 279, 284, 302, 306,

325Suzuki, H. 336, 382Svistunov, S. 352Swahn, F. 293, 380Sydorchuck, I. 330Syed, S. 320Szekely, E. 379Szepes, A. 292Szymanska-Garbacz, E. 378

Tabata, Y. 382Takács, T. 292, 302, 329Takeichi, T. 311Talar-Wojnarowska, R. 273,

319Tamburrino, D. 290Tancredi, M. 391Tang, J.M.F. 312, 321Tarpay, A. 381Tavano, F. 271Tcarkova, L. 356Teleki, J. 358, 359, 360Tepikin, A.V. 284, 306, 325Terracciano, F. 297Thereska, D. 272Thorlacius, H. 263, 283, 306,

308Tianshuo, Z. 321Tieftrunk, E. 338Tihanyi, B. 379, 384Tihanyi, T.F. 379, 384Timmer, R. 265Timms, J.F. 278, 312Tiszlavicz, L. 288, 292, 307Tiwari, S. 341Tjaden, C. 365Tomaszewska, R. 326, 327Tomulescu, V. 386Tonack, S. 278, 312, 340, 342Tondulli, L. 318Tong, Z. 264, 353Toouli, J. 323Topa, L. 292Törnqvist, B. 392Tost, M. 267Tóth, E. 381Trajkovic-Arsic, M. 337Trauzold, A. 333Treiber, M. 263, 269, 283Trubicina, I. 292, 331Tsai, J.A. 275Tsim, N. 299Turrini, O. 270Turusov, R. 387Tweedle, E. 340

Uchida, E. 336, 382Uggeri, F. 372Urrutia, R. 270

Vaccari, S. 322Vaccaro, M.I. 332Valente, R. 368Valeriani, M. 286Valkovska, N. 334Vallath, S. 339Vallini, V. 379, 380Van Baal, M. 346Van Beer, B.E. 296van der Harst, E. 265van der Schelling, G.P. 265van Eijck, C.H. 265van Goor, H. 265van Laarhoven, C.J. 265van Ramshorst, B. 265, 346van Santvoort, H.C. 265, 284,

346Van Seuningen, I. 336Vankovich, A. 304Vasama, K. 314, 360, 366Vasile, E. 298, 364, 372, 374Vasileva, G. 290Vasko, A. 349, 354Venglovecz, V. 288, 302, 307,

329Venturini, S. 389Verbeke, C. 300, 361, 374Verhelst, R. 296Verheul, H. 298Villa, E. 318Vincenzi, V. 378Vinokurova, L. 276, 292, 331,

359Vishnevsky, V. 385, 386, 390Vistoli, F. 289, 385, 391, 393Vizio, B. 368Vlavianos, P. 274, 299Voevoda, M. 315, 316Volante, S. 292Völker, U. 271Volkova, J. 354von Bernstorff, W. 331, 362von Forstner, C. 341Vonlaufen, A. 333Voronin, K. 357Vrana, D. 322Vullierme, M.P. 273, 275, 277,

278, 383

Wajant, H. 333Walch, A. 337Waldmann, J. 376, 377, 381Wang, F. 332Wang, K. 338Wang, S. 376

Wang, X. 264, 353Wang, Z. 353Wannberg, M. 361Ward, S. 316Wartmann, T. 263, 327, 328Warzecha, Z. 326, 327Watanabe, M. 336Weber, A. 275Weidenauer, C. 361Weiss, F.U. 262, 271, 305, 327,

331, 345Weiß, U. 362Wenfu, T. 289, 354Werner, J. 272, 276, 280,

312, 365, 367, 376, 377, 384

Westaby, D. 274Weström, B. 324Whistance, R. 387Whitcomb, D.C. 265, 284,

290White, S. 281Wilson, J. 333Wingren, C. 279Winter, C. 362Winternitz, T. 384Wirén, E. 329Wisén, O. 275Witt, H. 263Wittmann, T. 292, 302, 329Wong, M. 365Wortmann, T. 283Wu, B. 284Wu, C. 376Wunder, K. 337

Xenarios, I. 393Xia, Q. 305, 344Xiuchao, W. 321

Yadav, H. 264Yamamoto, A. 277Yamamura, K. 293Yamao, K. 277Yan, L. 279Yang, L. 333Yang, X.N. 305Yashina, N. 304, 387, 390Yatabe, Y. 277Ye, X. 353Yoshikawa, T. 277Yoshino, M. 336Youkhana, J. 334Yu, W. 264, 353Yubero, S. 326

Zabala, W. 294, 295Zagozda, M. 265Zaini, M.A. 293


Zambon, C. 338, 367Zamyatin, P. 354Zapater, P. 308Zelinskyi, A. 382, 388Zenker, M. 271Zerbi, A. 267, 318, 319, 362

Zhang, L. 344Zhang, S. 263, 283, 331Zhang, X. 273Zhao, Y. 341, 353Zhavoronkova, O. 386Zheng, Z. 303

Zhivaeva, N. 276Zhuo, Y. 331Zhurenkova, T. 387Zimber-Strobl, U. 268Ziparo, V. 368Zlatic, A. 386

Zolog, A. 371Zuhayra, M. 341Zuppardo, R.A. 287

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42nd European Pancreatic Club (EPC) Meetingukb.lf1.cuni.cz/abstrakta/epc2010_abstr.pdf · 264 Pancreatology 2010;10:259–400 42nd European Pancreatic Club (EPC) Meeting Antitrypsin-Gene