covering may be useful to enhance side-branch drainage and perhaps decreasecomplications.

Su1399The Incidence of Symptomatic Pancreaticojejunal AnastomoticStrictures After PancreaticoduodenectomySamir Kapadia*1, Kamron Pourmand1, Brian J. Steiner1, Philip Bao2,Juan Carlos Bucobo1, Jonathan Buscaglia1, Kevin Watkins2,Satish Nagula1

1Department of Medicine, Stony Brook University Medical Center,Stony Brook, NY; 2Surgical Oncology, Stony Brook University MedicalCenter, Stony Brook, NYBackground: Pancreaticojejunal anastomotic stricture (PJAS) is a complicationfollowing pancreaticoduodenectomy (PD). Stricture formation may lead to thedevelopment of exocrine pancreatic insufficiency, acute pancreatitis and diabetesmellitus (DM), leading to significant morbidity. The incidence of PJAS and theirassociated symptoms has not been well defined. Methods: In this single centerretrospective analysis, Stony Brook University Medical Center’s billing databasewas queried to identify all patients who underwent pancreaticoduodenectomyfrom January of 2000 to March of 2011. Of the 106 patients identified andincluded in our study, outpatient charts from the Division of Surgical Oncology,inpatient electronic medical records, as well as the results of any radiographicimaging were systematically reviewed. PJAS was defined by pancreatic ductaldilation seen on cross-sectional imaging. Rates of stricture formation, pancreaticinsufficiency, pancreatitis, new-onset or worsening DM were assessed. Results:Of the 106 patients included in this study (median age 66 years, range 33-91years), 55 (52%) were female. Pathology revealed pancreatic adenocarcinoma(n�40, 38%), cholangiocarcinoma (n�22, 21%), intraductal papillary mucinousneoplasm (n�12, 11%), chronic pancreatitis (n�6, 6%), ampullaryadenocarcinoma (n�6, 6%), other (n�10, 9%; duodenal adenoma, serouscystadenoma, lymphoma).Radiographic evidence of PJAS was observed in 28patients (26%), a median of 445 days after surgery (range 85 - 1824 days). Ofthese, 17/28 (61%) had exocrine pancreatic insufficiency despite oral enzymesupplementation, while the incidence was 36% (28/78) in those without PJAS (p� 0.023). Five patients (18%) with PJAS had multiple hospitalizations for acutepancreatitis compared to 0% in those without stricture (p�0.001). Of the 28patients with PJAS, 7 (25%) had new or worsening DM compared to 21% (16/78)in those without PJAS (p�0.622). Conclusion: PJAS occurs frequently afterpancreaticoduodenectomy, identified in 26% of patients in this series. PJAS isassociated with significant symptomatology, including pancreatic insufficiencyand episodes of acute pancreatitis. Development of these symptoms warrantsprompt radiographic evaluation for PJAS. Secretin stimulated MRCP maydiagnose strictures prior to the development of ductal dilation, and thus may alsohelp identify a relationship between PJAS and DM. Further studies regardingtreatment of PJAS with ERCP and stent placement, as well as studies regardingprophylactic pancreaticojejunal stent placement for the prevention of PJAS, areneeded.

Su1400Practice Variability of Sphincter Manometry and ProphylacticPancreatic Duct (PD) Stent Usage in Varying Degrees ofSphincter of Oddi Dysfunction (SOD) Suspicion in theMultinational ERCP Quality NetworkChunyan Peng*, Joseph Romagnuolo, Peter B. CottonGastroenterology and Hepatology, Medical University of SouthCarolina, Charleston, SCBackground: Suspected SOD, esp type II/III, should have manometry (mano)-driven therapy (NIH consensus). PD stent use is also advised to reduce post-ERCP pancreatitis. However, SOD cases can hide as other indications: “abnormalenzymes”, or even “suspected stone”. It is not clear how often these guidelinesare followed in clear, and less clear, SOD cases. Methods: ERCP Quality Networkallows submission of anonymous data to a central repository. This analysis wasrestricted to physicians entering � 30 cases. SOD indications were grouped: a)highly suspected (intermittent or chronic pain), b) moderately suspected(recurrent idiopathic pancreatitis or abnormal liver enzymes), and c) mildlysuspected (suspected stone but none found). Comparisons in mano and PD stentuse were made by: country, academics, high-experience (HE) (� 1000 lifetime),high-volume (HV) (�100 ERCP/yr) using univariate/multivariate analyses.Results: 86 academic and community MDs from 8 countries, entered �20,000ERCPs. 6906 had suspicion of SOD (a, b, or c). In group a (n�2711), mano usewas higher with HE (79.5 vs 40.7%, p�0.001), HV (79.1 vs 47.2%, p�0.001), andUS (79.1 vs 39.4%, p�0.001). PD stent use was higher in US (41.5 vs 28.2%,p�0.002) and academics (50.5 vs 35.3%, p�0.001). In group b (n�2533), manouse was higher in HE (26.0 vs 6.5%, p�0.001), HV (25.3 vs 7.2%, p�0.001), andUS (23.6 vs 3.2%, p�0.001) practices. PD stent use was slightly higher with HE(15.8 vs 11.5%, p�0.04) and academics (17.5 vs 12.5%, p�0.001). In group c

(n�1662), mano use was slightly higher with HE (1.8 vs 0%, p�0.007), HV (1.8vs 0%, p�0.019), non-academics (1.8 vs 0%, p�0.006) and US (2.1 vs 0%,p�0.001), but overall, was infrequent. PD stent use was higher with HE (6.5 vs3.6%, p�0.031), HV (7.0 vs 2.0%, p�0.001), US (7.1 vs 3.2%, p�0.001) and non-academics (6.4 vs 3.6%, p�0.029), but all rates were low. In multivariateanalysis, in group a, mano use predictors were: HE (OR�4.0, p�0.001), US(OR�34, p�0.001), or UK (OR�13, p�0.001); and for PD stents: academic(OR�2.0, p�0.001) and US (OR�3.4, p�0.002). In group b, predictors of manowere: HE (OR�3.9, p�0.001), HV (OR�2.5, p�0.02), academics (OR�1.7,p�0.001) or US (OR�9.8, p�0.001); for PD stent use: academic (OR�1.9,p�0.001) or US (OR�2.0, p�0.03). In group c, mano predictors were: HE(OR�4.0, p�0.001), US (OR� 34, p�0.001), or UK (OR�13, p�0.001); and forPD stents: HV (OR� 3.2, p�0.007) (lower in academics (OR�0.45, p�0.013)),UK (OR�0.34, p�0.001). Notably, in group a, in US HE academics, HV predictedmano and PD stenting (82 vs 25%; 55 vs 0%). PD stent use was higher in USacademics, vs community, even in the HE-HV group (55 vs 36%). Conclusion:There is global practice variability of mano and PD stent use, with seeminglylower than expected use of both in various degrees of suspicion of SOD.

Su1401PCR-Based Analysis of Bile Duct Brushing Cytology: CombinedSlide Microdissection and Centrifugation Supernatant FluidMolecular Analysis for Optimal Mutation DetectionJason Lewis*1, Vaibhav Mehendiratta1, Marluce Bibbo2, Ali A. Siddiqui1,David E. Loren1, Thomas E. Kowalski11Internal Medicine, Thomas Jefferson University, Philadelphia,PA;2Pathology, Thomas Jefferson University, Philadelphia, PAIntroduction: Brush cytology specimens for the detection of cancer inindeterminate pancreaticobiliary strictures suffers from low sensitivity due to acombination of factors including sampling variability, low cellularity andsubjective morphologic interpretation. Molecular analysis is emerging as anadjunct to cytologic diagnosis, and requires that multiple brush samples betaken, or that microdissection of selected cells from stained cytology slides beperformed and then analyzed. To more readily attain diagnostic molecularmaterial, we performed a pilot study to determine if analyzable DNA was presentin the supernatant of cytocentrifugation fluid. Methods: Cytocentrifugation ofsupernatant fluid was collected from 14 patients with indeterminantpancreaticobiliary stricture brushings. Between 5 and 10ml of cytocentrifugationsupernatant fluid was collected. DNA quantity was determined by optical densityand DNA amplifiability, a measure of DNA integrity and degradation, wasassessed by quantitative PCR (qPCR). Mutational analysis followed targeting 17genomic sites associated with mutational damage in pancreaticobiliary cancerincluding DNA sequencing for oncogene KRAS point mutation and loss ofheterozygosity (LOH) fragment analysis using polymorphic microsatellites locatedat 1p, 3p, 5q, 9p, 10q, 17p, 17q, 21q and 22q. Additionally cells weremicrodissected from a single stained slide guided by morphologic features forcomparison. DNA analysis of confirmed malignant strictures was compared tosurgical pathology or positive cytological pathology. Molecular abberations werecorrelated with findings of malignancy. Results: A total of 17 samples from 14patients were analyzed for DNA mutations from the brush cytology supernatant.Analyzable DNA was present in all 17 samples. Eleven of 14 patients had eithersurgical or cytologically confirmed malignancy (9 adenocarcinoma, 1neuroendocrine, 1 hepatocellular carcinoma). Molecular mutations were presentin 7/11 patients with confirmed malignancy (LOH mutations (n�3), KRas (n�2),LOH and KRas (n�2). In patients without a diagnosis of malignancy, nomutations were detected (autoimmune cholangiopathy n�1, inflammatorystricture n�1, indeterminate n�1). Conclusion: Cellular DNA material is presentin the discarded supernatant of cytology brushings collected during ERCP. KRASand/or LOH mutations were identified in a majority of patients with confirmedmalignant strictures. Further study is necessary to determine the impact of thistechnique on the diagnostic yield in the evaluation of indeterminate biliarystrictures.

Su1402Post-ERCP Pancreatitis Following Orthotopic LiverTransplantation: The Mayo Clinic ExperienceRyan Law* , Todd H. BaronDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester,MNIntroduction: Post-ERCP pancreatitis (PEP) in the general population ranges from5%-7% based on two large studies1,2. PEP incidence in patients following livertransplantation (OLT) remains unddefined. One recent study demonstrated adecreased incidence of PEP in the OLT population when compared to a cohortof non-transplanted patients (4.7% vs. 9.6%)3. Aims: Evaluate the incidence ofPEP in OLT patients who underwent diagnostic or therapeutic ERCP in patientswith native papillae. Methods: We retrospectively analyzed all ERCPs in patientsreceiving OLT with duct-to-duct anastomosis and native papilla from July 2000 to

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December 2008. Patients with prior sphincterotomy and previous PEP wereexcluded. PEP was diagnosed by typical pancreatic-type abdominal pain andelevation of amylase/lipase 3X ULN following ERCP. Severity of PEP was definedby established criteria4. Results: 549 OLTs with duct-to-duct anastomosis wereperformed during the study period. Of the OLT recipients, 100 patients (63%male; 89% Caucasian; mean age 51� 13) underwent ERCP (122 total ERCPs).ERCP was performed at a median of 96 days (IQ range, 30-387) following OLT.Findings at ERCP included: anastomotic stricture in 29% (35/122), bile leak in16% (19/122), stones/sludge in 9% (11/122), and papillary stenosis in 6% (7/122).Difficult cannulation was noted in 22% (27/122) and biliary sphincterotomy wasperformed during 66% (81/122) of the ERCPs. Prophylactic pancreatic stentswere placed during 12 procedures (10%). PEP occurred following 5 cases (4male, 1 female). Of the PEP cases, ERCP finding of anastomotic stricture wasobserved in 4 of 5 cases. Four cases of PEP occurred after documented difficultcannulation and 2 cases occurred despite pancreatic stent placement. Twopatients developed PEP during a repeat ERCP after a post-transplant ERCP hadbeen performed previously without sphincterotomy. There were no episodes ofsevere acute pancreatitis; three were moderate in severity, and 2 were mild.Conclusions: The rate of PEP in patients following liver transplant is comparableto that previously documented in the general population1,2. However, ERCPevidence of an anastomotic stricture and difficult bile duct cannulation appear tobe risk factors for development of PEP in the OLT population. References: 1.Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCPpancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001 Oct;54(4):425-34.2. Freeman ML, Nelson DB, Sherman S, et al. Complications ofendoscopic biliary sphincterotomy. N Engl J Med. 1996 Sep 26;335(13):909-18.3.Sanna C, Saracco GM, Reggio D, et al. Endoscopic retrogradecholangiopancreatography in patients with biliary complications after orthotopicliver transplantation: outcomes and complications. Transplant Proc. 2009 May;41(4):1319-21.

Su1403The Quality of Bowel Preparation for Screening Colonoscopy inan Inner City Health Care CenterDavid Widjaja*, Manoj Bhadari, Vivian M. Loveday-Laghi, Bhavna BalarMedicine/Gastroenterology, Bronx Lebanon Hospital Center, Bronx, NYBackground: The quality of bowel preparation determines the quality ofscreening colonoscopy. The characteristics of patients with inadequate bowelpreparation during screening colonoscopy in an inner city endoscopy facilityhave not been studied. Objectives: The aims of this study were to characterizepatients with inadequate bowel preparation and to evaluate the impact ofinadequate bowel preparation to polyp detection rate. Methods: Retrospectivestudy of medical records of patients with average risk of colorectal cancer whounderwent screening colonoscopy between January 1, 2005 and July 31, 2011 atBronx Lebanon Hospital Center, Bronx, New York. Patients with medical historyof constipation and the colonoscopy performed during hospitalization wereexcluded. Inadequate bowel preparation was defined as the presence of fair orpoor quality of bowel preparation. Excellent or good quality of bowelpreparation was considered as adequate bowel preparation. Results: Of 8589patients who fulfilled the study criteria, 109 (1%) had excellent quality of bowelpreparation, 4053 (47%) had good quality, 2892 (34%) had fair quality, 1285(15%) had poor quality, 250 (3%) had no documented quality. A total of 53% ofmen and 46% of women had inadequate bowel preparation (p�0.001). The ratesof inadequate bowel preparation were 42% (57/135) among patients agedyounger than 50 years, 50% (3954/7909) among patients aged 50 to 75 years and56% (166/295) among patients aged 75-85 years (p�0.019). The proportion ofpatients who had inadequate bowel preparation was higher in those whounderwent colonoscopy after 12 noon than those with colonoscopy before 12noon [52% (2457/4695) versus 47% (1720/3644), p�0.001]. Completecolonoscopy up to the cecum was performed in 99% (2850/2892) of patientswith fair quality of bowel preparation and 89% (1142/1285) of patients with poorquality of bowel preparation. Of 8090 patients who had complete colonoscopyup to the cecum, the polyp detection rate of left side colon was 26% ininadequate bowel preparation and 24% in adequate bowel preparation(p�0.052); polyp detection rate of right side colon was 21% in inadequate bowelpreparation and 18% in adequate bowel preparation (p�0.002). Conclusions: Inthis inner city endoscopy facility, 49% patients who underwent screeningcolonoscopy had inadequate bowel preparation. Men, older age and afternoonprocedure were associated with higher rate of inadequate bowel preparation.Polyp detection rates of left side colon were not significantly different betweeninadequate and adequate bowel preparation. However, polyp detection rate ofright side colon was higher in inadequate bowel preparation than in theadequate one. In the setting of inadequate bowel preparation, completioncolonoscopy up to the cecum may be beneficial.

Su1404Fecal Hemoglobin Concentration Is Related to Severity ofColorectal NeoplasiaJayne Digby*1, Callum G. Fraser2, Francis a. Carey3, Margaret Balsitis4,Robert H. Diament5, Robert J. Steele6

1Scottish Bowel Screening Centre, Dundee, United Kingdom; 2Centrefor Research into Cancer Prevention & Screening, Ninewells Hospitaland Medical School, Dundee, United Kingdom; 3Department ofPathology, Ninewells Hospital and Medical School, Dundee, UnitedKingdom; 4Department of Pathology, Crosshouse Hospital, Kilmarnock,United Kingdom; 5Department of Surgery, Crosshouse Hospital,Kilmarnock, United Kingdom; 6Academic Department of Surgery,Ninewells Hospital and Medical School, Dundee, United KingdomBackground: Screening for colorectal neoplasia using guaiac fecal occult bloodtests (gFOBT) reduces disease specific mortality. However, gFOBT are beingreplaced by automated quantitative fecal immunochemical tests (FIT) due to theirmany advantages. Fecal hemoglobin (Hb) concentrations are affected by gender,age, and deprivation. There is growing evidence that concentration may berelated to stage of colorectal disease. We aimed to investigate this hypothesisfurther. Methods: We invited 66225 individuals aged 50-74 years resident in twoNHS Boards participating in the Scottish Bowel Screening Programme to provideone sample of feces. Hb was determined on OC Sensor Diana (Eiken, Japan) onsamples from 38720 responders. Colonoscopy findings and full pathology datawere collected on all excised/biopsy specimens including polyp type, presenceor absence of malignancy, cancer stage, and the severity of dysplasia inadenomas. Data were collected on the 943 with Hb concentration � 400 ng Hb/mL, the selected cut-off for colonoscopy. Findings: Of the 814 participants withoutcome data (median age: 63 years, (50-75), 56.4% male), 39 had cancer, 190higher risk adenoma (HRA, defined as � 3 or any � 1 cm), and 119 low riskadenoma (LRA) as the most serious diagnosis. 74.4% of those with cancer hadfecal Hb concentration �1000 ng Hb/mL compared with 58.4% in HRA, and44.1% in those with no pathology. Median fecal Hb concentration was higher inthose with cancer than those with no (p�0.002) or non-neoplastic (p�0.002)pathology, and those with LRA (p�0.0001). Polyp cancers had lowerconcentrations than more advanced stage cancers (p�0.04). Higher Hbconcentrations were also found in those with HRA than with LRA (p�0.006), inthose with a large (�1 cm) compared with small adenoma (p�0.0001), and alsoin those with an adenoma displaying high grade dysplasia (HGD) comparedwith low grade dysplasia (LGD) (p�0.009). The relationship between grade ofdysplasia and fecal Hb concentration was not found to be independent, butrather related to the size of the adenoma, with adenomas with HGD being larger(mean 17.0 mm, 95% CI 13.6-20.4) than those with LGD (mean 10.8 mm, 95% CI9.9-11.7) (p�0.0001), and a higher proportion (27.2%) of the large adenomasdisplaying HGD than the small adenomas (7.5%). Interpretation: Fecal Hbconcentration was related to severity of colorectal neoplastic disease, althoughwith considerable overlap between groups. Hb concentration was also related tothe size of adenomas; large adenomas were more likely to show HGD and thesehad a higher malignant potential. These findings have ramifications for theselection of the appropriate cut-off Hb concentration to be used in screeningprograms. Moreover, our findings support the concept that fecal Hbconcentration could, with advantage, be included in risk scoring systems.

Su1405Endoscopic Over-Sizing of Polyps Changes Colorectal CancerSurveillance RecommendationsPeter Eichenseer*, Joshua E. Melson, Shriram JakateRush University Medical Center, Chicago, ILBackground Polyps greater than 1 cm are defined as advanced adenomas.Inaccurate size estimation can lead to inappropriate repeat screening intervalrecommendations of colorectal adenomas. Previous studies have been small,included hyperplastic polyps, and have not directly addressed what the effect ofsizing error is on current surveillance recommendations. Methods Colorectalcancer screening and surveillance colonoscopies were reviewed from 2010-12.Endoscopic polyp size estimation was compared to post fixation polypmeasurement for 15 different gastroenterologists. Only adenomatous polypsremoved in entirety with a snare were included in the analysis. Polypsendoscopically defined as � 10mm and � 25mm were excluded. Mis-sizing wasdefined as size variation �33%. In effort to determine the degree of sizediscrepancy due to polyp fixation, a small subset of polyps was measuredimmediately post polypectomy and compared to post fixation size. Results 4990procedures from 15 gastroenterologist were reviewed. A total of 231 polyps from200 patients met inclusion criteria. The average patient age was 62.6 years (sd10.1), 52% males. The mean size variation (difference between endoscopicestimate and post fixation measurement) was 5.2mm (sd 3.6mm) with a range of0.3mm - 7.7mm. 63.2% of all polyps were mis-sized �33%. 51.6% were mis-sized� 50%. 35% of all polyps mis-sized �33% resulted in inaccurate screeningrecommendations (even after considering size, number, and histology ofsynchronous polyps) with a range of 0%-67%. Post polypectomy measurementsdid not vary (�% 15 variance) from post fixation measurements (n�10).

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