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Abstracts of Papers Submitted to the Joint 45th Meeting of the American Pancreatic Association and Japan Pancreas Society, November 5–8, 2014, Kohala Coast, Hawaii

doi: 10.1097/MPA.0000000000000231
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Metachronous Pancreatic Ductal Adenocarcinoma (PDAC) After Resection of Branch Duct Intraductal Papillary Mucinous Neoplasms 3-Month Interval of Surveillance CT/MR Still Insufficient for Early Detection

T. Abe,1 H. Nakashima,1 M. Nakamura,1 M. Tanaka.21Department of Digestive Surgery, Kawasaki Medical College, Kurashiki, Japan; 2Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Context: There are few studies reporting the appropriate interval of screening for metachronous PDAC after resection of branch duct intraductal papillary mucinous neoplasms (IPMNs). Despite a strict surveillance protocol, some patients are diagnosed as having unresectable PDAC after resection of IPMN.

Case report: A 60-year-old man with branch duct IPMN in the pancreatic body underwent a distal pancreatectomy. Pathological findings was minimally invasive papillary carcinoma, pT1N0M0 fStageI(TNM) and resection margin was negative. Postoperative screening with computed tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) every 3 months showed no evidence of recurrence for 18 months. However, after 3 months from last MRCP, enhanced CT revealed delayed enhanced mass in the pancreas head. Cytology of pancreatic duct showed invasive ductal adenocarcinoma in the pancreas head. A total pancreatectomy was performed 22 months after first operation. Pathological examination showed pancreatic cancer of pT3N1M0 fStageIIB(TNM) with negative surgical margin. By immunohistochemistry, first IPMC was revealed as MUC1(−),MUC2(−).MUC5AC(+) (gastric type), and metachronous ductal adenocarcinoma was revealed as MUC1(+), MUC2(+), MUC5AC(+). Take the findings of immunohistochemistry into consideration, the second ductal adenocarcinoma was diagnosed as a metachronous invasive ductal adenocarcinoma.

Conclusion: In some patients with branch duct IPMNs, 3-month surveillance interval seems to be insufficient for early detection of concomitant ductal adenocarcinoma. It is important to reconsider the method of surveillance and identify the biomarker of high-risk patients who require surveillance at shorter intervals.

Towards a Structure-Based Discovery of PKD Inhibitors for Acute Pancreatitis

R. Abrol,1 J. Yuan,2,3 H.-Y. Su,1 R. Waldron,1,2,3 A. Lugea,1,2,3 S.J. Pandol.1,2,3Pancreatic Research Group, 1Cedars-Sinai Medical Center; 2Veterans Affairs; 3UCLA, Los Angeles, CA.

Acute pancreatitis is a potentially lethal disease whose pathophysiology is characterized by inflammation, necrosis, and inappropriate intracellular activation of digestive enzymes. The signaling pathways underlying this disease are not fully understood, which is one reason for the lack of effective therapies targeting its molecular pathogenesis.

Protein kinase D (PKD) isoforms constitute a family of novel serine/threonine protein kinases whose signaling has been implicated in all of the above mentioned characteristics of acute pancreatitis. Our data indicates that PKD1 and PKD3 are the major isoforms in both human pancreatic normal and chronic pancreatitis tissues. Known PKD inhibitors have been shown to reduce pancreatitis in both in vitro and in vivo models of this disease. Other high-affinity PKD1 inhibitors have been identified recently but their use in experimental pancreatitis models have shown them to lack the potency and efficacy to be viable therapeutically.

To develop potent and selective PKD inhibitors for acute pancreatitis, we have developed in silico structural models of the PKD1 kinase domain ranging from the fully inactive conformation to the active conformation, based on cAMP-dependent protein kinase domain crystallized in different functional states. In the absence of specific pathophysiological roles for different PKD1 states (inactive to active), their structural models provide good targets for attacking the PKD mediated signaling cascades in acute pancreatitis. The resulting PKD1 conformations are tested against an experimental PKD1 inhibitor screen. Five of the top ten hit molecules from a virtual screen using one of the two inactive PKD1 conformations are known PKD1 inhibitors. The two inactive PKD1 conformations are currently being used in the virtual screening of a large ligand database, and the top hits are being tested in in vitro and in vivo models of acute pancreatitis.

The Evaluation of Circulating miR-483-3p and miR-21 in Plasma of Pancreatic Ductal Adenocarcinoma Patients

M. Abue,1 M. Yokoyama,1 R. Shibuya,1 K. Tamai,2 I. Sato,3 N. Tanaka,2 K. Yamaguch,4 S. Hamada,5 T. Shimosegawa,5 K. Sugamura,4 K. Satoh.11Division of Cancer Stem Cell; 2Division of Cancer Biology and Therapeutics; 3Tissue Bank Center and 4Division of Molecular and Cellular Biology, Miyagi Cancer Center Research Institute, Notori, Japan; 5Division of Gastroenterology, Tohoku University Graduate School of Medicine. Sendai, Japan.

Background: MicroRNAs (miRNAs) were shown to be involved in tumorigenesis and development of various carcinomas including pancreatic ductal adenocarcinoma (PDAC). Recent studies demonstrated that miRNAs were stably detectable in plasma/serum. It was reported that miR-21 was highly expressed in PDAC tissues and was correlated with shorter survival of the patients. Together with miR-21, we identified miR-483-3p as significantly up-regulated miRNAs in PDAC tissues by comparing the miRNA expression profiles in PDAC with intraductal papillary mucinous neoplasms (IPMN) using miRNA microarray. However, little is known about the plasma expression of miR-483-3p and miR-21 in PDAC patients.

Aim: The aim of this study was to investigate whether miR-483-3p and miR-21 would be a plasma biomarker for PDAC.

Methods: The plasma samples were obtained from three groups including 32 PDAC patients, 12 IPMN patients, and 30 healthy controls (HC). The miR-483-3p and miR-21 expression in the plasma was examined by quantitative real-time RT-PCR. We compared the differences in the expression of these miRNAs among the three groups, and investigated the relationship between miRNA expression and clinical factors in PDAC.

Results: The expression of miR-483-3p and miR-21 was detected in all plasma samples. The plasma expression levels of both miRNAs were significantly higher in PDAC compared to HC (p < 0.01). The plasma miR-483-3p expression was significantly higher in PDAC than IPMN patients (p < 0.05). The plasma miR-21 level was associated with advanced stage (P < 0.05), metastasis to lymph node and liver (P < 0.01), and shorter survival (P < 0.01) of the PDAC patients.

Conclusion: Together with these findings suggest that the measurement of plasma miR-483-3p level is useful for discriminating PDAC from IPMN, and that plasma miR-21 level predicts outcome of PDAC patients.

Hospital Admission Volume Does Not Impact the In-Hospital Mortality of Acute Pancreatitis

E. Afghani,1 S.M. Hutfless,1 A. Sinha,1 M.A. Khashab,1 A.M. Lennon,1 D. Yadav,3 M.A. Makary,2 D.K. Andersen,4 A. N. Kalloo,1 V.K. Singh.11Division of Gastroenterology, 2Dept of Surgery, Johns Hopkins Hospital, Baltimore, MD; 3Division of Gastroenterology, University of Pittsburgh SOM, Pittsburgh, PA; 4National Institutes of Digestive and Kidney Disease, NIH, Bethesda, MD.

Background: Recent studies of acute pancreatitis (AP) have reported an inverse relationship between admission volume & mortality. However, it is not known how this relationship is affected by other demographic & clinical risk factors for mortality in AP.

Aim: To evaluate the association of demographic, clinical, & hospital factors with in-hospital mortality in AP.

Methods: The Maryland HSCRC database was queried for all adult (≥18 yrs) admissions with primary diagnosis of AP between 1/94-12/10. Diagnoses & interventions were defined by ICD-9-CM. Organ failure (OF); interventions (hemodialysis, mechanical ventilation, & ICU); & hospital characteristics (teaching status; # of beds; high volume (HV) defined as ≥118 AP admissions/year; & referral status) were evaluated.

Results: There were 72,601 admissions for AP in Maryland with 885 (1.2%) deaths. There was an increasing rate of AP admissions but decreasing mortality (p < 0.0001 for trend). A total of 1,657 (2.3%) were transfer patients, of whom 101 (6.1%) died. Multisystem OF (≥2 systems) occurred in 1,078 (1.5%), of whom 306 (28.4%) died. On univariable analysis, age, males, transfer status, comorbidity, OF, all interventions, & all hospital characteristics were significant. On multivariable analysis, only age, transfer status, OF, interventions, & large hospital size were significant. Patients with commercial health insurance had significantly less mortality compared to those with other forms of insurance (OR 0.65, 95 CI: 0.52, 0.82).

Conclusions: OF is the strongest predictor of mortality in AP after adjusting for demographic, clinical, & hospital characteristics. Admission to HV or teaching hospital has no survival benefit in AP once adjusting for OF & transfer status.

Optimal Follow-Up and Long-Term Clinical Outcome of Pancreatic Cystic Lesions

D.W. Ahn,1,3 S.H. Lee,1,2 D.K. Jang,1,2 K.H. Chung,1,2 B.S. Lee,1,2 J.B. Jeong,1,3 J.K. Ryu,1,2 Y.T. Kim.1,21Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; 2Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea; 3Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.

Background: It is generally accepted that cystic lesions in the pancreas (CLPs) 3 cm or less in size and without features suggesting malignancy can be managed conservatively with follow-up. However, the optimal duration and interval of follow-up for CLPs is not yet well established.

Aim: To investigate the optimal duration and interval of follow-up for CLPs in clinical practice.

Methods: Patients with CLPs 3 cm or less in size and without features suggesting malignancy received follow-up with computed tomography at 6, 12, 18, and 24 months and then per 12 months. A retrospective analysis with prospectively collected data was performed.

Results: A total of 205 patients with CLPs detected from 2004 to 2009 (initial mean size, 1.8 ± 0.7 cm) received follow-up during the median period of 56.6 months. Within the first 12 months of follow-up, no patients experienced the growth of cyst and three patients (1.5%) underwent surgery for the presence of symptoms related to CLPs. 11 patients (5.4%) experienced the growth of cyst after 5 years of follow-up. A total of 18 patients underwent surgery during follow-up and four malignant cysts were detected. Overall rate of malignant progression during follow-up was 2.0%. The malignant progression occurred after 48 months and 60 months of follow-up in one and three patients, respectively.

Discussion: The results of this study provide the evidence of the optimal duration and interval of follow-up for CLPs in clinical practice.

Conclusion: Long-term follow-up more than 5 year should be performed because of the potential for malignant transformation of CLPs. The 12 months interval of follow-up for asymptomatic CLPs might be sufficient in clinical practice.

Effect of Annexin A1 Deficiency on Cerulein-Induced Acute Pancreatitis in Mice

R.T. Akasheh, J.M. York, G. Fantuzzi. Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL.

Annexin A1 (ANXA1) is a glucocorticoid-regulated protein that modulates inflammation by activating the formyl-peptide receptor 2 (FPR2). Pharmacological agonists of the ANXA1-FRP2 axis are currently being developed as potential anti-inflammatory agents. Since no studies have yet evaluated the role of ANXA1 in acute pancreatitis (AP), we compared the response to repeated injections of cerulein in WT and ANXA1 KO mice. Because ANXA1 is mostly involved in the resolution phase of inflammation, we hypothesized that ANXA1 KO mice would have prolonged pancreatic disease with delayed resolution compared to WT mice.

Female BALB/c WT and ANXA1 KO mice received 5 hourly ip injections of cerulein at 50 μg/kg and were euthanized either 7, 24 or 48 hours after the first injection. Control mice received vehicle and were euthanized at the 48 hours time point. The kinetics and absolute amount of body weight loss, total and wet/dry pancreatic weight, serum amylase and lipase were comparable between WT and ANXA1 KO mice. However, histological examination of pancreatic tissue revealed significantly lower acinar cell death and edema in ANXA1 KO versus WT mice at both 7 and 24 hours, with both groups showing signs of resolution at 48 hours. In contrast, no significant differences between the two strains were observed in terms of kinetics or absolute scores for pancreatic inflammatory infiltrate at any time point. Circulating levels of IL-6 peaked at 7 hours in both WT and ANXA1 KO mice but were significantly lower in the latter group. Levels of IL-6 returned to baseline with comparable kinetics in both strains.

Contrary to our initial hypothesis, these data indicate that ANXA1 deficiency is associated with improved outcome in selected parameters using the cerulein model of AP. The mechanisms of this association as well as its possible extension to other experimental models of AP are currently under investigation.

Grading of Significant Risk Factors for Post-ERCP Pancreatitis: A Systematic Review of 39,229 ERCP Procedures

V.S. Akshintala,1 S.M. Hutfless,2 V.K. Singh,2 D. Yadav.1Divisions of Gastroenterology, 1University of Pittsburgh Medical Center, Pittsburgh, PA; 2Johns Hopkins Medical Institutions, Baltimore, MD.

Background: Several independent patient and procedural risk factors for development of Post-ERCP pancreatitis (PEP) have been reported. However, the individual studies are limited by sample size and the weight of these risk factors is unknown.

Aim: To identify significant risk factors for PEP and grade them based on a weighted mean of PEP incidence.

Methods: We searched MEDLINE, EMBASE and Cochrane databases for randomized controlled trials (RCTs) and non-randomized studies that evaluated risk factors for PEP using univariate or multivariate analyses. A risk factor was considered significant if it showed significance in at least 1 multivariate analysis. Risk factors were graded based on a weighted mean of PEP incidence associated with each of them across studies as: low (PEP incidence <10%), intermediary (10-15%) and high (>15%) grades.

Results: In a total of 36,916 ERCP procedures (18 RCTs, n = 2,313; 14 non-randomized studies, n = 36,916), 14 risk factors were identified to have a significant effect on PEP incidence. Low grade risk factors included young age, absence of chronic pancreatitis, female sex, pancreatic duct injection; intermediary grade included acinarization, balloon sphincteroplasty, difficult cannulation, history of acute pancreatitis, pre-cut sphincterotomy, trainee involvement; and high grade included pancreatic sphincterotomy, history of PEP, minor papilla sphincterotomy and SOD. History of PEP (20.7 ± 5.7%) and minor papilla sphincterotomy (32.2 ± 4.3%) had the highest incidence of PEP.

Conclusion: This systematic review shows that although independent and statistically significant, individual risk factors impart differential risk of PEP. This data is currently being translated in a risk stratification score and will be evaluated through patient level data of 2 high quality RCTs. A weighted risk score can be beneficial for the prediction of PEP.

Suppressor Leukocytes are Protective in Acute Pancreatitis

E. Alabraba,1 F. Campbell,2 D. Lataweic,1 J. Neoptolemos,1 R. Sutton.11NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK; 2Dept of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.

Background: Acute pancreatitis (AP) triggers inflammatory immune responses. Suppressor leukocytes namely: regulatory T-cells (Tregs) and M2 macrophages (M2M) exhibit potent immunosuppressive actions.

Aim: We tested if adoptively transferred Tregs or M2M could reduce the pancreatic injury in experimental AP.

Materials & methods: Balb/c mice with caeruelin-induced AP were either pre-treated with syngeneic Tregs or M2M adoptively transferred (AT) by IV injection into the tail vein inducing AP with caerulein. Tregs and M2M were generated from syngeneic splenic lymphocytes and bone marrow-derived monocytes respectively. Pancreatic histology and plasma amylase were assessed at 6, 12 and 24 hours thereafter (n = 6 all groups), CD4 T cell polarization and chemokine receptor expression assessed, and serum cytokines measured.

Results: Mice with adoptively transferred Tregs showed significantly less injury up till 6 hours but similar to control mice thereafter, while those with adoptively transferred M2 macrophages showed less injury up till 24 hours. Amylase levels were reduced in correlation with histological injury. For Treg experiments cytokines significantly (p < 0.05) reduced up till 6 hrs namely MCP-1, IL-12, TNF-α, and IFN-γ. For M2 macrophage experiments most cytokines significantly (p < 0.05) reduced up till 24 hrs were KC, IL-12, IL6 and TNF-α. For both Treg and M2 macrophage experiments, IL10 was significantly elevated up till 24 hrs and the mice showed Th2 polarization of CD4+ T cells. CD4 T cells showed significantly (p < 0.05) reduced expression of CCR2 in the Treg experiments and of CCR and CCR5 in the M2 macrophage experiments.

Conclusion: Adoptively transferred suppressor leukocytes attenuate injury in experimental acute pancreatitis, elicit Th2 serum cytokine profile, elicit Th2 CD4 T cell response and reduce chemokine receptor expression on CD4 T cells.

Retrospective Examination of Prediagnostic CT Findings of Pancreatic Cancer

H. Aoki,1 Y. Tada,2 T. Iwao,2 K. Yoshida.11Div. Interventional Bilio-pancreatology, Kawasaki Medical School, Okayama, Japan; 2Advanced Research Institute of Gastroenterological Imaging, Fukushima, Japan.

We reported that even minute pancreatic cancer like PanIN3 induce pancreatic duct stenosis and branch duct dilatation. Brune et al. reported that some patients with a strong family history of pancreatic cancer develop numerous precursor lesions associated with lobular atrophy of the pancreatic parenchyma. Follow-up or endoscopic examinations for these lesion of the pancreatic duct and parenchyma makes it possible to detect pancreatic cancer in early stage. In this study we reviewed prediagnostic CTs from 44 patients of the advanced pancreatic cancer. Pancreatic abnormalities in prediagnostic CTs was found 6 to 92 months before definitive diagnosis of pancreatic cancer. These CTs was performed for lung screening (n = 13), follow-up of other cancers (n = 13), etc. 37 of 44 prediagnostic CTs have abnormal lesions of pancreas, like pancreatic ductal dilation, parenchymal atrophy, contour abnormality and focal hypoattenuation. These lesions in prediagnostic CTs exist on the same part to full diagnostic CTs of pancreatic cancer. Otherwise we treated minute (less than 10 mm) pancreatic cancer (n = 21) by performing EUS and ERCP for similar lesion such as focal hypoattenuation, pancreatic ductal dilation, and atrophy above described. Careful screening of the abdominal image during the follow-up of other diseases without pancreatic disease makes it possible to detect pancreatic cancer in earlier stage.

Gene Expression in Blood During Increasingly Severe Cerulein-Induced Acute Pancreatitis

J. Armstrong, L. Wen, L. Rainbow, D. Latawiec, B. Lane, D. Criddle, R. Sutton. NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK.

Background and Aims: There have been few studies of genetic expression in acute pancreatitis. We have undertaken whole transcriptome studies of cerulein-induced acute pancreatitis to explore disease mechanisms and determine the differential effects of severity.

Methods: Acute pancreatitis was induced in 12-week-old male C57BL/6 mice by four (4 M), seven (7 M) or twelve (12 M) cerulein injections (50 μg/kg IP/h, CER-AP) to induce increasingly severe disease. Matched sham saline IP injections were used for controls, with one no injection control group (6 per group). Animals were killed 1 h after the last injection. Whole blood was collected by cardiac puncture and immediately placed in RNAlater (Ambion). Total RNA was extracted and microarray expression profiling performed using a Cy3/Cy5 dye swap loop design on 44 k whole genome oligo microarrays (G4122A; Agilent).

Results: CER-AP severity markedly increased from 4 M through 7 M to 12 M compared to controls, assessed by biochemical and blinded pancreatic histopathologic scores (all p < 0.05). Expression analyses were performed in limma (Bioconductor, v3.2) with inference of differential expression (DE) based on hierarchical control of false discovery rates down genes and across groups, selecting probes where p < 0.05 after multiple comparison corrections. This revealed 528, 659 and 829 uniquely DE genes in 4 M, 7 M and 12 M respectively when DE genes in sham were removed, compared to controls. Pathway analysis revealed that many differentially down-regulated genes in the most severe 12 M were T cell-related.

Discussion: This work implicates dysregulation of adaptive immunity in the pathogenesis of acute pancreatitis. Further, these data provide a foundation to compare events in different disease models and for equivalent translational studies in human acute pancreatitis.

Toxic Modulation of Pancreatic Acinar Cell Mitochondrial Bioenergetics by Antioxidants

J. Armstrong,1 R. Sutton,1 D.N. Criddle.1,21NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital; 2Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.

Background and Aims: Oxidative stress has been implicated in the pathogenesis of acute pancreatitis but the role is unclear and antioxidant therapy ineffective. We have analyzed the effects of antioxidants on mitochondrial bioenergetics of murine pancreatic acinar cells.

Methods: The actions of N-acetylcysteine (NAC) and mitochondrial-targeted mitoquinone (MitoQ) antioxidants were evaluated on basal respiration (oxygen consumption rate: OCR), glycolysis (extracellular acidification rate: ECAR) and a respiratory function "stress" test in isolated murine pancreatic acinar cells using a Seahorse XF24 Extracellular Flux Analyser.

Results: NAC at 0.1-10 mM did not alter basal OCR or mitochondrial bioenergetics at <0.5 mM. NAC at 1 mM and 10 mM decreased respiratory spare capacity (46 and 52% of control, respectively), whilst at 10 mM also reduced ATP production (confirmed by ATP luciferase assay) with subsequent bioenergetic collapse (n = 3). In contrast, MitoQ at 10 μM but not DecylTPP, a non-antioxidant control, increased basal OCR (from 496.4 ± 27.6 pmoles/min to 743 ± 30.7 pmoles/min; p < 0.0001, n = 3). Both MitoQ and DecylTPP at 10 μM significantly inhibited ATP turnover, with MitoQ additionally reducing maximum respiratory spare capacity. Furthermore, MitoQ and DecylTPP elevated ECAR (from 9 ± 0.9 to 16 ± 1.2 mpH/min and 10 ± 1.0 to 14 ± 1.4 mpH/min, respectively; p < 0.0001), an action shared by NAC at 10 mM (from 17 ± 1.8 to 27 ± 2.4 mpH/min; p < 0.0069).

Conclusion: While MitoQ increased basal OCR and NAC did not, both antioxidants suppressed aerobic metabolism with a reduction in respiratory reserve and ATP production, accompanied by an increase in glycolysis. These results do not support the use of non-specific antioxidant therapy in acute pancreatitis.

Analysis of Gut Microbiome in KPC Pancreatic Tumor Mice

N. Arora, K. Majumder, S. Modi, K. Jensen, S. Banerjee, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: The human body harbors 1014 microbial cells, which is 10 times greater than all our somatic and germ cells combined. Microbiota changes have been observed in a variety of human diseases like inflammatory bowel disease, type 2 diabetes, allergies as well as certain carcinomas. There is extensive research on the role gut microbiota plays in colorectal carcinogenesis. However not much is known about the role of gut microbiota in pancreatic cancer. The aim of our study was to study the differences, if any, between the gut microbiota in KPC [Kras(G12D);Trp53(R172H);Pdx1-Cre] mice with pancreatic tumors versus age matched controls.

Methods: Four groups of mice were used in the study: 1 month old KPC mice (n = 7), 1 month old Cre mice (n = 9), 6 month old KPC mice (n = 8) and 6 month old Cre mice (n = 8). We isolated the gut from the duodenum to the anus along with the faeces within it and the microbiome was analyzed. Serum and pancreatic tissue was also isolated from each mouse. The microbiome analysis was performed in terms of bacterial genus richness between the groups and in terms of relative abundance of specific operational taxonomic units (OTUs) between the groups. For analysis of inflammatory cytokine profile, Raybiotech Mouse Inflammation array was used on the serum samples. Further analysis of individual cytokines was done by ELISA and PCR.

Results: A significant difference was observed in the microbiome of 1 month old Cre mice versus 1 month old KPC mice. A significant difference in abundance of 71, 14 and 275 OTUs was observed between 1 m Cre vs. 6 m Cre, 1 m KPC vs. 6 m KPC and KPC vs. Cre samples respectively. Out of 275 OTUs which were different between control and cancer groups, 119 belonged to the phylum Bacteroidetes and 141 belonged to the phylum Firmicutes. Bacteroides acidifaciens (OTU 304047) was found to be more abundant in Cancer samples. OTU 337727, Oscillospira was significantly greater in many Control samples. Changes in the cytokines IL-17 and IL-22 were observed in the KPC mice compared to the control mice in the ELISA.

Conclusion: Our study shows that the microbiome is significantly different in the cancer mice at both early (1 month) and late (6 month) stage compared to the control mice. Even though the 1 month old KPC mice had not yet developed overt tumors, their microbiota was significantly different from the control group. Further studies are required to evaluate if this difference has a role to play in tumour progression, or if the microbiota is also affected by the mutations that predispose the mice to pancreatic tumour development.

Preoperative Independent Prognostic Factors in Patients With Borderline Resectable Pancreatic Adenocarcinoma Following Curative Resection: Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio

S. Asari, I. Matsumoto, H. Toyama, M. Shinzeki, T. Goto, J. Ishida, T. Ajiki, T. Fukumoto, Y. Ku. Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.

Background: Borderline resectable pancreatic adenocarcinoma (BR-PAC) is defined as locally advanced tumor of the pancreas without metastasis that is, although potentially resectable (R), at high risk for positive resection margin following surgery. The therapeutic strategy has remained unestablished because BR-PAC is biologically a heterogeneous subset in which the preoperative prognostic factors are undetermined.

Method: Between January 2003 and June 2012 at Kobe University Hospital, 136 consecutive pancreatic adenocarcinoma (PAC) patients who underwent surgical curative resection were retrospectively studied. Prior to surgery, the PAC patients were stratified into R- and BR-PAC patients according to the National Comprehensive Cancer Network guidelines. To evaluate the independent prognostic significance of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), univariate and multivariate Cox proportional-hazard models were applied.

Results: The median survival in PAC patients with preoperative NLR > 3 (n = 45) and NLR ≤ 3 (n = 91) was 17.5 months and 31.1 months, respectively (P = 0.0037). The median survival in BR-PAC patients with preoperative NLR > 3 (n = 7) and NLR ≤ 3 (n = 21) was 14.8 months and 27.2 months, respectively (P = 0.0068). In addition, median survival in BR-PAC patients with preoperative PLR > 225 (n = 5) and PLR ≤ 225 (n = 23) was 14.8 months and 26.2 months, respectively (P = 0.0050). Preoperative NLR > 3 (HR = 21.437, 95% CI = 4.119 -142.980; P = 0.0002) and PLR > 225 (HR = 30.993, 95% CI = 3.844 -384.831; P = 0.0009) were the only independent prognostic factors in BR-PAC patients.

Conclusion: Preoperative NLR and PLR offer independent prognostic information regarding overall survival in BR-PAC patients following curative resection.

Minnelide Causes Stromal Lysis and Improves Drug Delivery in Pancreatic Cancer

S. Banerjee, S. Modi, K. Majumdar, V. Dudeja, S.M. Vickers, A. Saluja. Division of Basic and Translational Research, Dept. of Surgery, University of Minnesota, Minneapolis, MN.

Background: Pancreatic cancer stromal microenvironment is considered to be the major reason behind the failing of conventional and targeted therapy for this disease. The desmoplasmtic stroma comprising mainly of collagen and glycosaminoglycans like hyaluronan (HA) is responsible for compression of vasculature in the tumor resulting in impaired drug delivery in this disease, leading to poor prognosis. Our group has recently evaluated Minnelide, a water-soluble pro-drug of triptolide in pre-clinical studies on multiple animal models of pancreatic cancer with very promising results. However, the effect of Minnelide on stromal depletion not been studied. The current study shows that Minnelide is able to deplete the stromal architecture of the pancreatic tumor, thereby widening vasculature and improving drug delivery in the tumor.

Results: Tumors derived from patients xenografted in SCID mice (PDX) and KRASG12DTP53-PDX-Cre spontaneous pancreatic tumor mice (KPC) were used in this study. Treatment with 0.42mg/kg Minnelide resulted in decreased HA (48% of control) in patient tumor derived xenograft as well as in KPC model (52% of control). Similarly expression of HA synthesis genes (HAS1, HAS2 and HAS3) were decreased in both tumor models in response to Minnelide (22% of control in PDX and 35% of control in KPC tumors). Enzyme activity was also consistently decreased in both the models after treatment with Minnelide (28% of control in PDX and 31% of control in KPC). No significant decrease was observed in expression or activity of hyalouronidase genes (Hyal1, Hyal2 and PH20). Minnelide decreased Sirius Red (for collagen) and aSMA (activated cancer stellate cells) staining in the stroma of PDX and KPC tumors. Further, treatment with Minnelide improved functional vasculature in the tumors resulting in 4- times more open vessels in the treated animals compared to untreated animals. Consistent with this observation, Minnelide also resulted in increased doxorubicin delivery into the tumor compared to untreated animals.

Conclusion: In conclusion, our study showed that Minnelide depleted the stromal architecture leading to increased functional vasculature and enhanced drug delivery in the tumor. This is an extremely promising observation for Minnelide that is currently under clinical trial at the University of Minnesota.

Morphine as an Analgesic Increases Injury to the Pancreas in L-Arginine-Induced Model of Acute Pancreatitis

U. Barlass, A. Dixit, R. Yuan, S. Roy, R. Dawra, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Background: In absence of targeted therapy, analgesia, supportive care and treatment of systemic complications are the basis of management of pancreatitis. Opioids such as morphine or its derivatives are widely used for moderate to severe pain associated with the disease. We have previously shown an increase in local and systemic inflammation in presence of morphine using cerulein induced mouse model of acute pancreatitis. The aim of this study was to confirm these findings using a different experimental model of acute pancreatitis to rule out these being a model specific effect.

Methods: Pancreatitis was induced using two intraperitoneal injections of L-arginine (4 g/kg, one hour apart). After 72 h of initiation of pancreatitis, mice were implanted with either subcutaneous pellet of morphine or placebo. Animals were sacrificed 36 h of pellet implant. Changes in pancreas and lungs were compared in placebo and morphine treated groups.

Results: The histological changes in pancreas of morphine treated group were severe as compared to placebo treated pancreatitis group. There was also significant increase in myeloperoxidase activity, a marker of neutrophil infiltration in pancreas of morphine treated pancreatitis group suggested more inflammation. In lungs, myeloperoxidase activity was more in morphine treated group but the change was not significant.

Conclusion: Morphine increases pancreatic damage and inflammation in L-arginine induced model of experimental acute pancreatitis. These findings are comparable to those observed earlier in response to morphine treatment in caerulein induced pancreatitis. Exacerbation of pancreatitis in presence of morphine treatment in experimental models suggests its cautious use in patients with acute pancreatitis.

Surgical Outcomes of Solid Pseudopapillary Tumors of the Pancreas

L. Barreda, J. Targarona, E. Pando, L. López, A. Yábar, L. Aliaga. Department of Surgery, Edgardo Rebagkiati Martins Hospital, Lima, Peru.

Introduction: Solid pseudopapillary tumors are neoplasms of very low incidence that generally affect young females and have a slow growth pattern, reaching therefore a large size. The majority of them are tumors of low malignant potential.

Results: During the aforementioned period of time, twenty four patients were operated on at the HNERM. 96% of these patients were females, being the average age 33 years and the average size 7.5 cm. Of the resections performed in these patients, nine were duodenopancreatectomy four middle pancreatectomies, eight were distal pancreatectomies two was duodenum preserving head resection of the pancreas and one only diagnosis laparoscopy.

Local invasion occurred in 12.5% of the cases and 17% of the patients presented metastasis. The overall 5-10-year survival rate of patients with SPN is about 94%- 63%.

Discussion: The solid pseudopapillary tumors are uncommon tumors which are generally benign or premalignant neoplasias. Nevertheless, 29% of them can behave like carcinomas; therefore, these tumors should not be ignored.

Laparoscopic Versus Open Distal Pancreatectomy for the Treatment of Pre-malignant and Malignant Lesions

J. Barrie,1 R. Deshpande,1 D. O’Reilly,1 N. De Liguori Carino,1 B.J. Ammori.21Department of Hepatopancreatobiliary Surgery, North Manchester General Hospital, Manchester, UK; 2The University of Manchester, Manchester, UK.

Background: Benign, borderline, or low-grade malignant tumors are considered the most appropriate pathology for laparoscopic distal pancreatectomy (LDP). The aim of this study was to examine oncological outcomes of LDP for borderline tumors in comparison with a contemporary series of open distal pancreatectomy (ODP).

Methods: 19 patients who underwent LDP were compared to17 patients who underwent OPD between May 2009 and March 2014. Histology reports and outcomes were retrospectively reviewed to assess tumour characteristics, adequacy of resection and survival in patients who underwent resection with intent to cure.

Results: 10 patients in each group with malignant lesions underwent resection with intent to cure. The malignant lesions in the LDP and OPD group were neuroendocrine (7 vs. 10), adenocarcinoma (2 vs. 0) and metastatic renal cell carcinoma (1 vs. 0). Groups were comparable for tumour size (mean, 38 vs. 41mm, p=0.680), frequency of R1 resections (2 vs. 0, p=0.3) and lymph node yield (mean, 10 vs. 8, p=0.390). There was, however, a difference in clear tumour margins (mean, 1.5 vs. 17.5mm, p=0.035) to the detriment of the laparoscopic group. At a mean follow up of 29 months after LDP and 15 months after ODP, two recurrences were encountered in the LDP group (both high grade tumors, one had R1 resection) but none after OPD. The mean survival after LDP was comparable with that seen after ODP (mean, 34 vs. 16.9 months, p=0.01) as were the 1-year (90% vs. 100%, p=1.0) and 2-year (80% vs. 100%, p=0.47) survival rates.

Conclusion: LDP for malignant disease achieves oncological results that are comparable to those seen after ODP. However, further evidence is needed before LDP can be fully implemented for this pathology.

Minimally Invasive Distal Pancreatectomy: A Single Center Analysis of Outcome With Experience and Systematic Review of the Literature

J. Barrie,1 B.J. Ammori.21Department of Hepatopancreatobiliary Surgery, North Manchester General Hospital, Manchester, UK; 2The University of Manchester, Manchester, UK.

Background: It is generally estimated that the learning curve for minimally invasive pancreatic resection is steep. The aim of this study is to analyze the learning curve for laparoscopic distal pancreatectomy (LDP) in our series and review the relevant literature on learning curves for LDP and robotic distal pancreatectomy (RDP).

Methods: Patients undergoing LDP between October 2002 and December 2013 were identified. Demographics, pathology and perioperative outcomes were recorded. Learning curve analysis was performed by split group analysis (of the initial 13 and subsequent 12 resections) and by cumulative sum analysis (CUSUM) of blood loss, operative time and length of hospital stay. The systematic review used a defined search strategy to identify studies analyzing changes in outcome with operative experience.

Results: 25 resections were performed. CUSUM analysis of operative time found learning curves of 10 cases or less for LDP and splenectomy and 11 or less for LDP with splenic preservation. CUSUM analysis of blood loss showed a learning curve of approximately 6 cases. Length of stay did not improve with case sequence. There were no statistically significant differences in outcomes between the two groups on split group analysis. In the literature, specific learning curve values of 10 cases of LDP and approximately 7 RDP were required to reach proficiency.

Conclusion: Low numbers of LDP are required to reach technical proficiency in the hands of expert laparoscopic surgeons. Our results correspond with the numbers quoted in the literature.

IgG4 Level in Pancreatic Juice: Update of a Pilot Study

M.J. Bartel,1 K.K.B. Kyanam,1 J. Hoyne,2 L. McCrone,1 T.A. Woodward,1 M.B. Wallace,1 M. Raimondo.11Department of Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL.

Background: Serum IgG4, as a part of a diagnostic algorithm, is an essential but not optimal test in distinguishing between autoimmune pancreatitis (AIP) and pancreatic cancer (PC). IgG4 was recently shown to be also detectable in pancreatic juice (PJ).

Aim: To assess the correlation between serum IgG4 and PJ IgG4, and to assess the feasibility of PJ IgG4 to distinguish between PC and AIP.

Methods: Serum IgG4 is evaluated in all patients with concern of pancreatic mass at our institution. We then prospectively collected PJ following secretin stimulation from the duodenum during upper endoscopy. Utilizing an ELISA kit, PJ IgG4 was measured in all patients who participated between 2007 and 2010 in the PJ biospecimen bank, with elevated serum IgG4 and/or AIP. According to tissue diagnosis, the following patients were included: PC (n=22, mean 68 yrs, SD±10, 50% male), chronic pancreatitis (CP) (n=7, mean 60 yrs, SD±7, 43% male), AIP (n=3, mean 63 yrs, SD±16.2, 100% male), normal controls (n=6, mean 66 yrs, SD±6.4, 0% male) and others (IPMN, ampullary and cholangiocarcinoma) (n=5, mean 73 yrs, SD±5.3, 80% male).

Results: PJ IgG4 was measured in 43 patients, with the following mean levels [mg/dL]: PC 0.26 (SD±0.44), CP 0.34 (SD±0.46), AIP 0.73 (SD±1), normal 0 (SD±0), others 0.12 (SD±0.18), all p=NS. Serum IgG4 level correlated poorly with PJ IgG4 level [mg/dL]: PC 41.1 (SD±64.3), CP 53 (SD±18.8), AIP 135.2 (SD±111.2), normal 23.7 (SD±13.3), others 21.3 (SD±21.9); r=0.002. One patient with serum IgG4 negative AIP had elevated PJ IgG4 (1.9 mg/dL) whereas 2 patients with serum IgG4 positive AIP proved to have low PJ IgG4 level (0 and 0.3 mg/dL).

Conclusions: This feasibility study shows that serum and PJ IgG4 do not correlate. PJ IgG4 was highest in the AIP cohort, in comparison with PC, CP, and normal (NS); however the study was limited by the small number of AIP patients.

Race and Gender Differences in Chronic Pancreatitis (CP): Analysis of Nationwide Inpatient Sample (NIS) from 2003 to 2011

J. Behzadi,1 D.L. Conwell,2 A. Hinton,3 S.G. Krishna.21Department of Internal Medicine; 2Section of Pancreatic disorders, Department of Gastroenterology; 3Division of Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: CP is a debilitating disease accounting for significant morbidity.

Aim: To analyze influence of racial and gender differences in hospitalized patients with CP.

Methods: Using the NIS, discharge records for all inpatient adults (age ≥18 years) from 2003–2011 with a primary diagnosis of CP were analyzed. Race was broadly categorized into white and non-white groups. Demographics (age, insurance type, income, comorbidity), hospital factors (teaching status, location, bed size), and outcomes [mortality, length of stay (LOS, in days), total hospital charges (total$), pancreatic procedures] were analyzed.

Results: There was a decrease in CP-related admissions (0.1% of 12.7 million to 0.06% of 19.5 million population) and this trend was observed for both genders (male 0.10% to 0.06%, p<0.001; female 0.06% to 0.04%, p<0.001) and across all races (white 0.07% to 0.05%, p<0.001, non-white 0.09% to 0.06%, p<0.01). There was a significant decrease in CP-related mortality (mean 0.48%; trend 0.61% to 0.21%, p<0.001).

Gender comparison: There were no differences in mortality (0.37% and 0.46%), total$, and rate of pancreatic procedures (5.3% vs. 4.8%). However the LOS was significantly higher for females [mean ± 95% CI: 5.41 (5.22, 5.61) vs. 4.99 (4.81, 5.17), p<0.001].

Race comparison: There were no differences in mortality (0.38% vs. 0.47%), and total$. However, whites had a longer LOS [5.32 (5.11, 5.52) vs. 5.01 (4.84, 5.18), p <0.004] and higher rate of pancreatic procedures (5.64% vs. 3.38%, p <0.001).

Conclusion: There was an overall decrease in CP-related admissions and mortality. Female patients and whites have a higher LOS and more pancreatic procedures were performed among whites. However these differences were not reflected in CP-related mortality.

Mitochondrial ATP Synthase Dysfunction Mediates L-arginine-Induced Pancreatitis

G. Biczó,1,2 E.T. Vegh,1,2 N. Shalbueva,1 S.W. French,3 J. Elperin,1 E. Lotshaw,1 O.A. Mareninova,1 P. Hegyi,2 Z. Rakonczay, Jr,2 A.S. Gukovskaya.11VA Greater Los Angeles and University of California Los Angeles, CA; 2University of Szeged, Szeged, Hungary; 3Harbor-UCLA Medical Center, Torrance, CA.

Background & Aims: Administration of L-arginine (Arg) causes severe necrotizing pancreatitis in rodents with no damage to other organs. The underlying mechanisms are poorly understood. Here we show that defective mitochondrial ATP synthase mediates key pathologic responses of Arg-induced pancreatitis.

Methods: Pancreatitis in wild type and cyclophilin D knockout (CypD KO) mice was induced by 3 i.p. injections of 3 g/kg Arg. Pancreatic and liver mitochondrial membrane potential ([INCREMENT]Ψm), ATP levels, synthesis and hydrolysis, mitochondrial morphology, and pancreatitis responses were measured.

Results: Pancreatic mitochondria isolated from Arg-treated mice showed impaired [INCREMENT]Ψm recovery upon addition of ADP and decreased ATP synthase activity, both evident as early as 5 h after induction of pancreatitis. This was associated with decreased ATP level (40% by 24 h) and pathologic changes in mitochondria morphology manifest by electron microscopy appearance of mitochondria with loss of cristae and flocculent matrix. Importantly, Arg treatment had no effect on liver mitochondria indicating selective pancreas damage. Co-immunoprecipitation experiments showed that pancreatic ATP synthase physically interacts with CypD, a key mediator of permeability transition pore. CypD KO restored ATP synthase activity, prevented pathologic alterations in mitochondria morphology, and markedly attenuated the severity of Arg pancreatitis, resulting in decreased trypsin activity, autophagic vacuoles, and acinar cell death.

Conclusions: The results show that ATP synthase impairment is a key pathologic event in Arg pancreatitis, and that its activity in pancreatic mitochondria is regulated by CypD. Together with our data in other models of pancreatitis, they indicate that CypD inactivation is a promising approach for pancreatitis treatment.

TGF-β1 Enhances Invasiveness of CAPAN-2 Cells Through Rac1-Dependent Secretion of Urokinase-Type Plasminogen Activator

M.G. Binker,1,2 A.A. Binker-Cosen,2 L.I. Cosen-Binker.1,21 Department of Molecular and Cell Biology, School of Dental Medicine, Boston University, Boston, MA; 2 CBRHC Research Center, Buenos Aires, Argentina.

Aim: We investigated the signaling pathway involved in TGF-β1-promoted u-PA secretion and invasion by human pancreatic cancer cells CAPAN-2.

Background: Human pancreatic tumor tissues with urokinase-type plasminogen activator (u-PA)-positive expression have been associated with larger tumors, enhanced invasiveness, distant metastasis and an increased clinical stage. The multifunctional cytokine transforming growth factor beta 1 (TGF-β1) promotes both secretion of u-PA and invasion by several pancreatic cancer cell types.

Methods: We measured Rac1 and nuclear factor-kappa beta (NF-κB) activity, and reactive oxygen species (ROS) production in culture of CAPAN-2 cells, as well as u-PA secretion in the culture media. We performed invasion assays using transwell chambers coated with Matrigel. We used specific inhibitors against key molecules.

Results: We found that stimulation of these tumor cells with TGF-β1 induced secretion of the serine protease u-PA, which was required for TGF-β1-stimulated invasion. Our results also indicate that signaling events involved in TGF-β1-enhanced CAPAN-2 invasiveness comprehend a phosphatidylinositol 3-kinase-mediated activation of Rac1, followed by generation of ROS through nicotinamide adenine dinucleotide phosphate-oxidase, activation of NF-κB, and secretion of u-PA.

Conclusion: TGF-β1 enhances invasiveness of CAPAN-2 cells via a Rac1 signaling pathway

Humoral Communication Stimulates Pancreatic Acinar and Stellate Cells in a Novel Long-Term In Vitro Co-Culture Model

M. Bläuer,1 M. Laaninen,1,2 J. Sand,1,2 J. Laukkarinen.1,21Tampere Pancreas Laboratory; 2Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Background and Aim: We have recently developed culture techniques for long-term in vitro maintenance of mouse and human pancreatic acinar cells and demonstrated with the former the possibility of acinar cell cryopreservation for on-demand use. These methods have permitted us to set up a co-culture system in which humoral interactions between acinar cells and pancreatic stellate cells (PSCs) can be studied on a long-term basis in vitro.

Materials and Methods: Cell type-specific media were used to obtain acinar cells and PSCs from mouse pancreata by explant outgrowth. Co-culture was performed in acinar cell-specific medium in 24-well format. Acinar cells were seeded in the wells and PSCs in a separate compartment in tissue culture inserts. After 4-day culture, acinar cells were analyzed for basal and caerulein-stimulated amylase release and the PSC compartment for collagen I and fibronectin expression.

Results: The co-culture system excellently supported the viability of both cell types for a minimum of 4 days. Co-culturing caused stimulation of acinar cell basal amylase secretion 2-fold compared to acinar cell monoculture. Further stimulation with 0.1nM caerulein was prevented in co-culture, while in monoculture the normal 2.4-fold amylase release compared to basal secretion was seen. The low level of extracellular matrix protein expression in PSC monocultures was markedly increased in co-cultures.

Conclusions: Humoral communication between acinar and PSCs in co-culture was shown to lead to their reciprocal stimulation. With its two separable cell compartments our co-culture system provides a versatile in vitro setting that allows independent analysis of both cell types.

Vitamin D Reduces Proliferation and Collagen I Expression in Pancreatic Stellate Cells In Vitro

M. Bläuer,1 N.H. Ikonen,1 J. Sand,1,2 J. Laukkarinen.1,21Tampere Pancreas Laboratory; 2Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Background: Vitamin D is an antiproliferative and differentiation-promoting steroid with a wide range of homeostatic functions in bone and extraskeletal tissues. The relationships between vitamin D and health and its potential therapeutic implications in various proliferative disorders have raised considerable attention in recent years. Pancreatic stellate cells (PSCs) are the key fibrogenic cells in pancreatic stroma and their activation upon tissue injury is characterized by increased proliferation and expression of extracellular matrix (ECM) proteins. In addition to their involvement in the development of fibrosis, PSCs are known to act as central modulators of the pancreatic tumor microenvironment.

Aim: Our aim was to investigate the effects of 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], on the proliferation and ECM protein expression of PSCs in vitro.

Methods: Mouse PSCs were seeded into 96- and 6-well plates for growth and protein analyses, respectively. The cells were exposed to 1,25(OH)2D3 concentrations ranging from 0.1nM to 10nM for 7 days and subjected to colorimetric crystal violet assay for cell growth assessment and to Western blot analysis of collagen I.

Results: Dose-dependent suppression of PSC growth by 1,25(OH)2D3 was detected, the percentages of inhibition ranging from 9% at the physiologic 0.1nM concentration to 62% at 10nM. At the clinically achievable concentrations of 0.5nM and 1nM the percentages were 33 and 47%, respectively. The reduction in collagen I expression ranged from around 20% at 0.1nM to approximately 50% at 10nM.

Conclusion: The effectiveness of physiologically and clinically relevant con centrations of vitamin D in suppressing the activation state of PSCs suggests an important role for vitamin D in pancreatic tissue homeostasis and proposes the pancreatic stroma as a potential target of vitamin D-based therapeutic modalities.

Elevated CA 19–9 in Obstructive Jaundice: True or False?

L.A. Bliss,1 D.K. Pleskow,2 M.F. Eskander,1 C.J. Yang,1 R.A. Miksad,3 S.C. Ng,1 T.M. Berzin,2 M.S. Sawhney,2 R. Chuttani,2 J.F. Tseng.11Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Boston, MA; 2Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA; 3Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, MA.

Background: Serum carbohydrate antigen (CA) 19–9 is often elevated in pancreatic cancer. However, clinicians may be uncertain how to interpret CA 19–9 in obstructive jaundice. We examined the change in CA 19–9 associated with biliary obstruction relief via endoscopic stent placement in pancreatic cancer patients.

Methods: Retrospective review of pancreatic cancer patients with initial endoscopic stent for obstructive jaundice at a single, academic medical center 2001–2011 with validation cohort 2012–2013. Patients with elevated serum CA19-9 and total bilirubin (TB) levels within 10 days prior to and 30 days after stent and before initial cancer treatment were analyzed.

Results: Of 1,858 records reviewed, 801 patients underwent endoscopic retrograde cholangiopancreatography (ERCP). 617 patients did not have necessary CA 19–or TB levels and 12 did not achieve adequate biliary decompression. 16 and 7 patients included in final initial and validation cohorts, respectively.

In initial cohort, CA 19–9 decreased in 5 patients. Median decrease was 120 u/mL (IQR −14, −588), and median % decrease was 13% (IQR −7%, −15%). CA 19–9 increased in 9 patients. Median increase was 3,250 u/mL (IQR 164, 20,297), and median % increase was 95% (IQR 21%, 330%).

In validation cohort, CA 19–9 decreased in 2 patients, by 15 u/mL (22%) and 214 u/mL (44%). CA 19–9 increased in 5 patients. Median increase was 1,063 u/mL (IQR 128, 7,416), and median % increase was 46% (IQR 13%, 117%).

Conclusion: CA 19–9 is used for prognostication in pancreatic cancer. In our cohort, the majority of patients did not have a decrease in CA 19–9 following relief of biliary obstruction. An elevated CA 19–9 should remain a poor prognostic factor despite obstructive jaundice.

Epigenetic Silencing of GNMT Gene in Pancreatic Adenocarcinoma

A. Botezatu,1 C. Bleotu,1 A. Nastase,2 G. Anton,1 N. Bacalbasa,3 D. Duda,4 S. O. Dima,2 I. Popescu.21Viral Genetic Engineering Laboratory, Romanian Academy “Stefan S. Nicolau” Virology Institute, Bucharest, Romania; 2Center of General Surgery and Liver Transplantation “Dan Setlacec”, Fundeni Clinical Institute, Bucharest, Romania; 3“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; 4Edwin L. Steele Laboratory for Tumor Biology, Department of Radiation Oncology, Harvard Medical School, Boston, MA.

Aim: To test the hypothesis that GNMT is epigenetic regulated in pancreatic adenocarcinoma (PDAC), we evaluated the GNMT gene expression and promoter methylation status in 30 paired samples of PDAC and normal pancreatic tissue.

Background: PDAC remains a major challenge for therapy since early detection are lacking. Epigenetic silencing of tumor suppressor genes is a major contributor to neoplastic transformation. The aim of this study was to identify new factors involved in PDAC progression. The GNMT gene possesses CpG islands in the promoter region and is important in methyl group metabolism and in maintaining a normal methylation status of the genome.

Results: We found significantly higher methylation frequencies (p< 0.001) in PDACs (2.82-100%, median=36.05%) than in controls (0.28-14.02%, median=4.39%). The GNMT gene expression was decreased in PDACs compared to normal pancreatic tissue in 26/30 cases (86.67%). Furthermore, we show that the treatment with 5-aza-dC increased GNMT mRNA expression and decreased viability in PDAC cells.

Discussion: To our knowledge, this is the first study reporting the methylation status of GNMT in PDAC. The data reported on GNMT methylation in hepatocellular carcinoma support our results.

Conclusions: Collectively, these data indicate that GNMT is aberrantly methylated in PDAC, and may be a major mechanism for gene silencing. Methylation of GNMT gene is directly correlated with disease stage and with tumor grade, indicating that these epigenetic effects may be important regulators of PDAC progression.

Accelerating Liquefaction of Pancreatic Necrosis With Enzymatic Solutions

L. Brown,1,2 J. Hong,2 M. Petrov,1 R. Flint,3 N. Zyromski,4 J. Windsor,1 A. Phillips.21Department of Surgery, University of Auckland, Auckland, New Zealand; 2Applied Surgery and Metabolism Laboratory, University of Auckland, Auckland, New Zealand; 3Department of Surgery, University of Otago, Christchurch, New Zealand; 4Department of Surgery, University of Indianapolis, Indianapolis, IN.

Background: Percutaneous catheter drainage (PCD) of infected walled off pancreatic necrosis (WOPN) has been established as first line treatment, but is effective as sole intervention in only a third of patients. One of the reasons for PCD failure is blockage from solid necrosum. Enzymatic therapy has been used in the chest and abdomen to facilitate drainage of loculated collections. The aim of this study was to test the effectiveness of commercial and novel enzymes on the liquefaction of human necrosum.

Methods: Human pancreatic necrosum was sourced with ethical consent. Using a 96-well plate format, standardized punch biopsies (25-50mg) of frozen pancreatic necrosum were incubated in enzymatic solutions at 37°C over 24 hours. Fourteen enzymes were evaluated at 3 concentrations, and compared with water, Normal Saline and hydrogen peroxide. Assessment was undertaken at 2, 12 and 24 hours. The supernatant after incubation with necrosum was measured for protein concentration using the EZQ Protein assay and DNA measured with QUBIT DNA assay. Enzymes were compared to their own control which was not added to necrosum.

Results: Collagenase proved to be the most effective enzyme at the 12 hour time period, with an average supernatant protein concentration of 32.4 (ug/mg of original wet tissue). Several other enzymes were more effective than Normal Saline. Of note, Chymotrypsin and Trypsin did not liquefy necrosum.

Conclusion: Several enzymes promoted liquefaction of pancreatic necrosum. Further studies are now justified to test the safety and effectiveness as an adjunct to irrigation of PCD for the treatment of infected WOPN.

Dissecting the Role of Hedgehog Signalling in the Interaction Between Pancreatic Stellate Cells and Pancreatic Tumour Cells Using 2D and 3D Modelling

S. Brumskill,1,2,4 L. Barrera,1 F. Campbell,3 C. Halloran,1,2 W. Greenhalf,1,2 M.-A. Campbell,4 E. Costello.1,21Liverpool NWCR Centre, Molecular and Clinical Cancer Medicine; 2NIHR Pancreas Biomedical Research Unit; 3Department of Pathology, Royal Liverpool University Hospital, UK ; 4Redx Oncology, UK.

Abstract: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a tumour supporting microenvironment including a dense fibrotic stroma. It is believed that Hedgehog (Hh) signalling is responsible for the activation of Pancreatic Stellate Cells (PSCs) and the formation of the fibrotic stroma. 3D models provide a method for studying the interaction of different cell types while also forming a metabolite gradient which more closely mimics the tumour microenvironment.

Tissues were obtained from patients undergoing surgery for chronic pancreatitis and/or PDAC at the Royal Liverpool University Hospital. PSCs were isolated from patient samples using the outgrowth method and immortalized using lentiviral transduction with human telomerase (hTERT). Expression of Hh pathway components (Shh, Smo, Ptch, Gli) was detected by immunofluorescence using the Operetta (Perkin Elmer) imaging platform and confocal microscopy.

Isolated PSC cultures were assessed by morphology and by immunocytochemistry using the markers, GFAP, α-SMA, desmin and vimentin. The expression of Hh pathway components in PSC was found to depend upon culture conditions. In co-cultures of PSC with pancreatic tumour cell lines the expression of Gli in PSC was increased relative to the levels observed in PSC monocultures. Expression of Hh pathway components were further increased when PSC and tumour cells were co-cultured under conditions supporting 3D cell growth.

3D modelling of the interaction between PSCs and tumour cells allows investigation of the role of Hh signalling in modulating the formation of the fibrotic stroma within the tumour microenvironment. These findings may provide us with a therapeutic avenue to exploit in order to effectively treat this malignancy.

Randomized Trial of Moderate Versus Aggressive Fluid Therapy in Patients With Mild to Moderate Acute Pancreatitis

J. Buxbaum,1 D. Mwengela,1 N. Jani,1 T. Kelly,1 K. Dhanireddy,2 J. Nneji,1 P. Jhun.31Departments of Medicine; 2Surgery; 3Emergency Medicine, University of Southern California, Los Angeles, CA.

Background: Animal models of acute pancreatitis suggest that aggressive intravenous hydration may prevent pancreatic microcirculatory compromise and necrosis. However, there is equipoise whether an aggressive or moderate approach to fluid resuscitation is needed given contradictory findings in clinical studies.

Design: Patients presenting with mild to moderate acute pancreatitis are prospectively randomized (1:1) to aggressive versus moderate goal directed therapy with lactated ringer’s (LR) solution.

Those with severe pancreatitis (Atlanta Classification) and systemic inflammatory response syndrome (SIRS) (defined by 2 of 4; HR > 90, RR > 20, temperature > 100.4 F, and WBC > 12) are excluded

A 20 cc/kg LR bolus followed by LR at 3 mL kg−1 hr−1 is given to the aggressive hydration group. A 10 cc/kg LR bolus followed by LR at 1.5 mL kg−1 hr−1 is given to the moderate hydration group. Patients are assessed at 12(+4), 24(±4), and 36(±4) hours. Patients who develop SIRS or increased hematocrit, BUN, and creatinine are given a 20 cc/kg LR bolus followed by LR at 3 mL kg−1 hr-1. Those with decreased hematocrit, BUN, and creatinine are transitioned to LR at 1.5 mL kg−1 hr−1

Endpoints include the development of SIRS, severe pancreatitis, volume overload, and increased hematocrit, BUN, or creatinine.

Results: Twenty-five patients have been randomized and completed the trial. Early mortality underscored the necessity for checkpoints. Enrollment challenges highlighted the need for a cooperative effort of emergency medicine and inpatient services. Important trends linking local inflammation, systemic perfusion, and systemic responses are emerging.

Conclusion: This randomized trial of fluid resuscitation strategies underscores the need for serial checkpoints and a committed multidisciplinary team in randomized trials for acute pancreatitis.

Glucagon–like Peptide 1 Receptor in Pancreatic Cancer

A.I. Cases,1 T. Ohtsuka,1 B. Zheng,1 K. Horioka,1 Y. Oda,2 K. Mizumoto,1 M. Tanaka.11Departments of Surgery and Oncology and 2Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Aim: Glucagon-like peptide 1 (GLP-1) is a gastrointestinal hormone secreted by L cells in distal ileum and colon which interacts with its specific high-affinity receptor, glucagon-like peptide 1 receptor (GLP-1R), inducing pancreatic β-cells growth and inhibiting their apoptosis. Recently, there have been controversies against drug safety within the group called glucagon-like peptide-1-based therapies. We aimed to investigate the role of GLP-1R in pancreatic cancer.

Methods: GLP-1R expression was semi-quantitatively evaluated by immunohistochemical staining in 48 samples of surgically resected pancreatic cancer, and the correlation between GLP-1R expression and clinicopathological features was investigated. GLP-1R was reviewed in several pancreatic cancer cell lines by real-time qRT-PCR and Western blot, and consequently, CFPAC-1 cell line was selected for GLP-1R knockdown by siRNA to evaluate the effect of the receptor in cell proliferation, migration, and invasion.

Results: There were 23 tumors with positive and 25 with negative expression of GLP-1R. We found no significant correlation between positive expression of GLP-1R and the clinicopathological characteristics. Correlatively, expression status of GLP-1R did not affect the prognosis of the patients (P = 0.74). On the other hand, 15 samples from 42 cases with lymph node metastasis were immunohistochemically analyzed, and most of the samples (11/15, 73%) showed positive staining for GLP-1R. Immunoreactivity for GLP-1R was also found in sites of perineural, and lymphovascular invasion. GLP-1R knockdown significantly reduced proliferation, migration, and invasion of CFPAC-1 cells (P < 0.05).

Conclusion: GLP-1R would have some implication in the metastatic ability of pancreatic cancer, although GLP-1R is not an independent prognostic factor in pancreatic cancer as shown by the immunohistochemical analysis.

Combined MEK and STAT3 Inhibition Overcomes Chemoresistance and Alters the Immune Microenvironment in Pancreatic Cancer

J. Castellanos,1 N. Nagathihalli,1,2 Y. Xiong,1 N. Merchant.1,2Departments of 1Surgery and 2Cancer Biology, Vanderbilt University Medical Center, Nashville, TN.

Background: Mutated Kras is a hallmark of pancreas cancer (PDAC) and has remained an elusive target. We have shown that activated STAT3 is a biomarker of therapeutic resistance and is regulated by MEK signaling. STAT3 inhibition remodels the tumor microenvironment (TME) and improves drug delivery, but minimally increases survival in a genetic mouse model of PDAC. We hypothesized that combined inhibition of MEK and STAT3 signaling will result in enhanced therapeutic response.

Methods: The effects of STAT3 and MEK inhibition on downstream targets were assessed. Invasion and colony formation assays were performed with human PDAC cells. Tumor xenografts and PKT mice (Ptf1acre/+;LSL-KrasG12D;Tgfbr2fl/fl) were treated with vehicle, STAT3 inhibitor AZD1480, MEK inhibitor AZD6244, or both. Tumor size and overall survival (OS) were assessed. Flow cytometry for CD44 + CD133+ cancer stem cells and myeloid derived suppressor cells (MDSC) was performed.

Results: STAT3 inhibition leads to immediate activation of MEK, delayed activation of Src and EGFR, and subsequent reactivation of STAT3 signaling. Combined inhibition of STAT3 and MEK results in sustained inhibition of Src, EGFR, MEK and STAT3 signaling in both Kras wild type and mutant cells. Invasion, colony formation and flank xenograft growth in vivo were significantly decreased with the combined therapy. OS in PKT mice was extended to a median of 85 days compared with 52 days in controls (p < 0.001). The combined treatment also resulted in a significant decrease in MDSCs within the TME.

Conclusions: Combined inhibition of STAT3 and MEK downregulates a key component of immune tolerance within the TME and significantly improves OS in PKT mice. These results provide a rationale for dual targeted blockade as a strategy to overcome therapeutic resistance in PDAC.

The Impact of Minimally Invasive Retroperitoneal Necrosectomy on Organ Dysfunction in Patients With Infected Pancreatic Necrosis

V.V. Chandrabalan, C.L. Tam, Z. Sherazi, D. O’Reilly. Department of Hepato-pancreato-biliary Surgery, North Manchester General Hospital, Manchester, United Kingdom.

Aims: Infected necrotizing pancreatitis remains a major surgical challenge with significant morbidity and mortality. The aim of this study was to evaluate the impact of minimally invasive retroperitoneal necrosectomy (MIRN) on organ dysfunction in patients with infected pancreatic necrosis.

Methods: Data was collected on all patients who underwent MIRN for infected pancreatic necrosis at our hospital in this retrospective study. The modified Marshall Multiple Organ Dysfunction Score (MODS) and Sepsis-related organ failure assessment (SOFA) score were calculated at admission as well as 24 hours before and 48 hours after every MIRN. Pre and post-MIRN MODS/SOFA score pairs were compared using the Wilcoxon signed ranks test.

Results: Twenty-seven patients (14 female, median age 56 years, gallstones in 56%) underwent 76 MIRNs between 2009 and 2013. The median Balthazar CT severity index at diagnosis was 8. A median of 3 necrosectomies (range 1 – 7) were performed in each patient. The median duration between MIRNs was 9 days. In-hospital/90-day mortality was 7% (n = 2). Organ dysfunction scores calculated 24 hours before and 48 hours after each MIRN showed no deterioration in MODS or SOFA scores (no change = 63, improved = 10, worse = 3, p > 0.05 Wilcoxon signed ranks test)

Conclusions: Minimally invasive retroperitoneal necrosectomy does not cause deterioration in organ function as measured by the modified MODS and SOFA scores and is associated with low mortality. Wider adoption of this technique will improve outcomes in patients with infected pancreatic necrosis by avoiding the ‘second hit’ of an open necrosectomy.

Prostaglandin E2 Activates mTORC1 Pathway Through an EP Receptor/PKA-Mediated Mechanism

H. Chang, G. Eibl. Dept. of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Obesity, a risk factor for pancreatic cancer (PaCa), is associated with inflammation and insulin resistance. The pro-inflammatory prostaglandin E2 (PGE2) that signals via EP receptors and cAMP, and insulin-like growth factor 1 (IGF1) that is elevated in insulin resistance and activates the Akt/mammalian target of rapamycin complex 1 (mTORC1) signaling module, are both shown to play critical roles in PaCa progression. We aimed at exploring the signaling crosstalk between the PGE2/EP/cAMP and IGF1/Akt/mTORC1 pathways in PaCa, which may be a key to unraveling the obesity-cancer link. In multiple human PaCa cell lines, PGE2 exposure increased intracellular cAMP levels, indicating the activation of Gsα-coupled receptors EP2 and/or EP4. In PANC1 cells, which showed the greatest cAMP response mainly via EP4, PGE2 dose- and time-dependently increased the phosphorylation of S6 ribosomal protein (Ser235/236 and Ser240/244) downstream of mTORC1, suggesting a crosstalk between PGE2/cAMP and mTORC1. Accordingly, mTORC1 inhibitor rapamycin suppressed PGE2-induced p-S6. Also, the effect of PGE2 on p-S6 was mimicked by forskolin, a cAMP stimulator. Importantly, PGE2 enhanced the effect of IGF1 on S6 activation, suggesting a positive reinforcement by the interaction between the two pathways. Interestingly, PGE2 and forskolin had no effect on p-Akt, suggesting a link downstream of Akt. PGE2-induced mTORC1 activation paralleled an increase in the phosphorylation of cAMP response element-binding protein (CREB), a substrate of protein kinase A (PKA). With the PKA inhibitor H89, baseline and PGE2-activated p-S6 were reduced, indicating a role of PKA in the crosstalk. Together, our data reveal a PKA-mediated novel link between the PGE2/EP4/cAMP and IGF1/Akt/mTORC1 pathways, which may be of great importance in elucidating the promoting effects of obesity in PaCa. Ultimately, a precise understanding of these molecular links may provide novel targets for efficacious interventions devoid of adverse effects.

Simvastatin is Associated With Improved Survival in Patients Undergoing Resection for Pancreatic Cancer

J.I. Chang,1 C.Y. Jeon,2 S.J. Pandol,2 B.U. Wu.31Department of Internal Medicine, Kaiser Permanente Los Angeles, CA; 2Basic and Translational Pancreatic Research, Cedars Sinai Medical Center, Los Angeles, CA; 3Center for Pancreatic Care, Division of Gastroenterology, Kaiser Permanente Los Angeles, CA.

Objective: To characterize the relationship between simvastatin use and disease free survival (DFS) and overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing surgical resection.

Methods: We conducted a longitudinal retrospective cohort study (2005–2014) on data from an integrated healthcare system in southern California. We included only surgical patients with stage IA-IIB PDAC and excluded palliative surgeries. Patients were censored at death, time of last follow-up, PDAC recurrence, or death from PDAC. Kaplan-Meier method was used to compare effect of simvastatin use in DFS and OS. Cox proportional hazards regression was used to generate hazard ratio (HR) for simvastatin use with adjustment for margin status, nodal metastasis, and adjuvant gemcitabine chemotherapy. Analyses were repeated for DFS and OS.

Results: Among 226 patients, 77 (34%) were statin users. Median disease free survival was 10.6 months and median overall survival was 17.7 months. Simvastatin users had both improved DFS (median 17.2 months with simvastatin vs. 10.1 months non-simvastatin, log rank p = 0.0027) and OS (median 31.6 months simvastatin vs. 15.3 months non-simvastatin, log rank p = 0.0001). In multivariate analysis, patients who received simvastatin were independently more likely to have improved DFS with HR = 0.58 (95% CL 0.41, 0.82) and OS with HR = 0.55 (95% CL 0.40, 0.77) after adjusting for margin status, nodal involvement and chemotherapy.

Conclusion: Simvastatin use was associated with improved DFS and OS in patients with early stage PDAC that underwent surgical resection.

Surgical Management of Functional Pancreatic Endocrine Tumors: A Retrospective Analysis of 118 Cases

G. Chen, H. Wang, L. Zhang, J. Ding, T. Xu, Z. Chen, P. Bie. Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China.

Objective: To investigate efficacy and safety of the surgical treatment of functional pancreatic endocrine tumors (PETs).

Methods: The clinical data of 118 patients with functional PETs who were admitted to the Southwest Hospital from January 1998 to December 2012 were retrospectively analyzed. Etiologic and localization diagnosis were made preoperatively according to the manifestation and the results of color Doppler ultrasound and computed tomography, respectively. 19 patients received resection of the body and tail of the pancreas and spleen, 88 received tumor enucleation, 3 received resection of the pancreatieobiliary junction and 8 received pancreaticoduodenectomy. All patients received chemotherapy after the operation.

Results: 95 cases of the PETs were benign and the rest 23 cases were malignant, 25 cases of the PETs were in the head of the pancreas, 61 in the tail of the pancreas. 18 in the body of the pancreas and 14 cases were with multiple PETs. The diameters of the PETs were 0.4-4.8 cm, and the diameters of the PETs in 53 cases were above 2.0 cm. 17 patients were complicated with pancreatic leakage, 5 with incision infection and 2 with abdominal infection. Of the 81 patients with insulinoma, the blood glucose of 11 patients with multiple PETs was still abnormal after the operation, 6 patients underwent reoperation and the other 5 were treated by diazoxide to control the blood glucose in the normal range. The clinical symptoms of the 15 patients with gastrinoma disappeared after the operation, and the gastric ulcer was also healed, both of the 12-hour gastric juice volume and the level of the gastric acid were in the normal range after a continuous treatment with proton pump inhibition agents for 6 months. Necrotizing or migratory rash and diabetes of the 9 patients with glucagonoma were cured three weeks later, and the level of the amino acid was back to normal. Diarrhea and electronic disturbance of 2 patients with vasoactive intestinal peptide tumor were alleviated after the operation. 109 patients were followed up for 18–120 months. Of the 91 patients with benign PETs, 5 patients had tumor recurrence, and 7 patients died of other diseases. Of the 18 patients with malignant PETs, 7 patients survived, and 7 patients died of hepatic metastasis or tumor recurrence, 4 patients died of other diseases.

Conclusions: Surgical treatment is effective and safe for the management of functional PETs. In addition to radical resection, a successful palliative resection of the tumor is also expected to improve the life quality of patients with functional PETs.

The Diagnosis and Surgical Treatment for Pancreatic Cystic Lesions

J. Chen, J. Wu, Z. Lu, K. Jiang, W. Gao, F. Guo, J. Wei, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Objectives: Uncertainties still exist in diagnosis and treatment for pancreatic cystic lesions.

Aims: To clarify the characteristics of pancreatic cystic lesions in our center, and evaluate results after surgery.

Methods: Clinical data were retrospectively analyzed in patients who had undertaken surgery for pancreatic cystic lesion in our center during the year of 2012.

Results: A total of 62 patients were analyzed. The most common diagnoses were serous cystic neoplasms (SCNs), intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs) and pseudocysts. Gender and age were helpful in diagnosing IPMNs, MCNs and Solid Pseudopapillary Tumors (SPTs), while there was a significant relationship between pancreatitis history with the diagnosis of IPMNs (p = 0.003). Tumor diameter could give a help in differential diagnosis between the MCNs with SCNs and IPMNs (p = 0.009 and 0.005, respectively). A raised serum CEA was helpful in diagnosing malignant cysts. Mean operation time was 191 ± 74 min, with median blood loss of 200 mL and 14.5% of our patients transfused. The postoperative morbidity rate was 37.1%, with clinical pancreatic fistula the most common one (24.2%). One patient underwent reoperation for hemorrhage (1.6%), while mortality was null. The median postoperative hospital stay is 11 days. Compared with classical pancreatectomies, organ-preserving procedures did not show any significant differences in terms of operation duration, percentage of receiving blood transfusion, complication rate and postoperative hospital stay. However, there was a reduced intraoperative blood loss in patients with organ-preserving pancreatectomies (p = 0.043).

Conclusions: Clinical picture and imaging studies can provide valuable information to the diagnosis of pancreatic cystic lesions. Organ-preserving pancreatectomies seem as safe as the traditional ones. However, our results need to be further verified by more adequately powered studies.

Inferior Mesenteric Vein Serves as an Alternative Guide for Transection of the Pancreatic Body During Pancreaticoduodenectomy With Concomitant Vascular Resection: A Comparative Study Evaluating Perioperative Outcomes

Y. Chen, X. Wang, N. Ke, X. Liu, G. Mai. Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.

Aim: To assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using inferior mesenteric vein (IMV) serves as a guide for transection of the pancreatic body (Whipple at IMV). In addition, the short-term surgical outcomes of this approach were compared with a standard procedure.

Methods: One hundred thirty-seven patients had segmental venous resection during PD between January 2006 and June 2013. Depending on whether or not the standard approach of creating a tunnel anterior to the mesenterico-portal venous (MPV) axis was achieved for pancreatic transaction, patients were subjected to standard PD with venous resection procedure (s-PD + VR, n = 75) or modified procedure (m-PD + VR, n = 62). Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed.

Results: The volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency was significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified intraoperative blood transfusion (p = 0.004) and vascular invasion (p = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients underwent m-PD + VR showed, twenty-eight patients (20.4%) underwent “Whipple at IMV” (WATIMV) procedure, with a higher rate of negative resection margins (96.4%) and as compared with those underwent usual procedure of transection as in the “central pancreatectomy” (c-PD + VR) (76.5%) (P = 0.06). Volume of intraoperative blood loss (p = 0.013), and intraoperative blood transfusion requirement (p = 0.07) were significantly greater in the c-PD + VR group compared the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin.

Conclusions: “Whipple at the IMV (WATIMV)” has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR to avoid the potential for venous injury and uncontrollable bleeding.

Receptor for Hyaluronic Acid-Mediated Motility Expression in Human Pancreatic Cancer Cells and Tissues

X.B. Cheng, K. Yamaguchi, S. Kohi, A. Higure, N. Sato. Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.

Background: Receptor for hyaluronic acid-mediated motility (RHAMM) is a nonintegral cell surface hyaluronan (HA) receptor that is overexpressed in many human cancers. In this study, we investigated the expression of RHAMM in a panel of human pancreatic cancer cell lines and tissues.

Methods: The HA concentration was tested quantitatively using an enzyme-linked immunosorbent assay (ELISA). RHAMM mRNA expression was examined using real-time RT-PCR. Using immunohistochemistry, the expression patterns of RHAMM were investigated in tissue samples from 70 pancreatic cancer patients. The differences in the RHAMM mRNA levels between pancreatic tissue samples (normal versus cancer) were compared using the Wilcoxon signed rank test. Spearman’s rank correlation coefficient was performed to assess the association between RHAMM mRNA expression and HA concentration. The patients’ overall survival and its association with RHAMM were evaluated using the Kaplan-Meier method and log-rank test.

Results: The RHAMM mRNA expression level was higher in all human pancreatic cancer cells than in normal pancreatic fibroblasts (median, 8.1-fold; range, 3.8- to 15.9-fold). Real-time RT-PCR analysis revealed higher RHAMM mRNA expression in pancreatic cancer tissues than in normal pancreatic tissues (median, 4.7-fold; range, 0.8- to 16.9-fold; P < 0.0001). There was a significantly negative correlation between the RHAMM mRNA expression level and the HA concentration in human pancreatic cancer cell lines (r = 0.8, P = 0.01) and tissues (r = 0.67, P = 0.009). Additionally, strong expression of RHAMM was significantly associated with a shorter survival time (log rank = 4.284, P = 0.038).

Conclusion: For the first time, our study suggests that HA may regulate RHAMM mRNA expression through negative feedback. Strong expression of RHAMM may predict poor survival in pancreatic cancer patients.

Acinar Cells Cytoprotection by Cytochrome-C in Acute Necrotizing Pancreatitis

O. Chepliaka, E. Medvetskiy, H. Tomashkevych. General Surgery Department, National Pirogov Memorial Medical University, Vinnytsia, Ukraine.

Objective: The effect of Cytochrome-C on the ultrastructure and morphometric parameters of mitochondria of acinar cells in experimental necrotizing pancreatitis is studied.

A focus of pancreatic necrosis formed in 6 dogs by injection into the parenchyma of the pancreas 0.2 ml of 1% KMnO4. After 3 days in the celiac trunk of 3 animals was injected 1 ml of 0.25% Cytochrome-C, another 3 dogs – 1 ml of normal saline.

In applying the Cytochrome-C showed a significant decrease in the area of mitochondria (more than threefold) decrease in the perimeter of the outer membrane, the form factor. However, it significantly increased the length of the internal membrane (a measure that more adequately reflects the level of respiration and ATP synthesis in pancreatic cells), which led to the prevention of significant degenerative changes in mitochondria and acinar cells in general.

The introduction of Cytochrome-C is often determined by the structural features of apoptosis, but cell membrane remained intact. Outer and intracellular membrane is compacted without release of cell contents into the environment.

The presence of such changes in the cells is the result of the realization of its genetic program whose execution without the additional cost of energy and macromolecular synthesis de novo is not possible. In contrast to apoptosis, and necrosis was observed rupture of cytoplasmic membrane with subsequent release of organelles into the intercellular space, leading to the progression of inflammation and the spread of the necrotic process.

The introduction of Cytochrome-C was not observed complete normalization of the morphometric parameters of mitochondria. Portion of acinar cells of the demarcation zone was dying, but this phenomenon often occurs as a result of apoptosis, which also reduces the likelihood of progression of the necrotic process.

Conclusion: Cytochrome-C is an active apoptogenic factor that prevents subsequent necrotic changes in the pancreas during pancreatic necrosis.

Clinical Efficacy of Neoadjuvant Chemoradiation Therapy for Locally Advanced Pancreatic Cancer

N. Chiba, T. Wakabayashi, M. Okihara, K. Tomita, K. Takano, M. Shimazu, S. Kawachi. Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan.

Background: Complete macroscopic resection in combination with chemoradiation therapy is the only potential treatment for locally advanced pancreatic cancer (LAPC). However, the clinical efficacy of neoadjuvant therapy in terms of surgical and oncological outcomes continues to be controversial. We sought to assess the results of resection after neoadjuvant chemoradiation therapy for LAPC.

Methods: Consecutive patients underwent neoadjuvant chemoradiation therapy from June 2010 to January 2014 were identified from a prospectively collected database. “Locally advanced” was defined as infiltration of the celiac axis or superior mesenteric artery (>180°) and/or unreconstructable mesenteric/portal vein without distant metastases in accordance with the National Comprehensive Cancer Network guidelines. All patients received a median dose of 50.4 Gy plus gemcitabine (400 mg/m2)/TS1 (40 mg/m2), and restaging was performed 6–8 weeks after completion of chemoradiation therapy. Resection rates, perioperative results, and overall survival were analyzed.

Results: Total seventeen patients had received neoadjuvant chemoradiation therapy (11, unresectable and 6 borderline resectable). Of these 17 patients, 6 (35.5%) underwent successful resection, whereas 11 patients underwent exploration only or no surgical treatment. Of the 6 patients who underwent successful resection, R0 resection was achieved in 5 and R1 resection was achieved in 1. Patients who underwent resection after chemoradiation therapy tended to have a better overall survival rate than those who did not undergo resection (median survival, 22.4 M vs 11.3 M).

Conclusion: For LAPC, R0 or R1 resection can be achieved in 35% of patients who undergo surgery after neoadjuvant chemoradiation therapy. Survival rates in these patients tend to be higher than those in patients who are unable to undergo resection and similar to those in patients with initially resectable pancreatic cancer.

Endoscopic Management of Severe Necrotizing Pancreatitis Combined With Colonic Fistula

Y.D. Cho, S.W. Cha, H.J. Choi, J.H. Moon. Digestive Disease Center, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Seoul, Korea.

Introduction: Infected pancreatic necrosis develops nearly 5% of patients with acute pancreatitis. Colonic complications occur rarer generally, but in up to 15% of severe pancreatitis. The current gold standard remains surgical treatment both infected pancreatic necrosis and colonic complication accompanying pancreatitis. But, cause of its high mortality and morbidity rate, role of endoscopic management to treating patient is growing in recent years. We report the case of infected pancreatic necrosis and combined colonic complication which was successfully treated with endoscopically.

Case Report: A 56-year-old man was admitted to our hospital with a chief complaint of diffuse abdominal pain with upper abdominal distension about 4 weeks ago. He was alcoholics and diagnosed to have alcoholic liver cirrhosis. He was diagnosed to severe acute necrotizing pancreatitis 1 month ago in another hospital and treated conservatively. Follow up CT scan showed wall-off necrotizing pancreatitis. He was referred to our hospital for proper management of pancreatitis. Percutaneous drainage was performed. Discharge from this cystic lesion comprised purulent matter and fluid analysis is as followed: WBC 172,800/μL (neutrophil 95%), lipase 1,962 U/L, amylase 2,095 U/L. E. coli was cultured in drained fluid and we start antibiotics to cover E. coli. Percutaneous tract was dilated gradually up to 16 Fr. After that we performed percutaneous endoscopic necrosectomy under the direct endoscopic (using cholangioscope) visualization. FU CT showed decreased necrotic tissue, but newly developed filstulous tract between colon and necrosum was noted. We achieved successful closure of fistula tract using over the scope clips (OTSC, (14 mm, t type, Ovesco Endoscopy AG, Germany) under colonoscopy guidance. The patient was discharged without any clinical problem.

Endoscopic Resection of Minor Duodenal Papilla: Report of 10 Cases

Y.D. Cho,1 S.W. Cha,1 Y.S. Lee,1 E.T. Park,2 S.W. Jung,1 J.Y. Jang.11Institute for Digestive Research, Digestive Disease Center, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea; 2Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Kosin University Hospital, Busan, Korea.

Background and Aims: Endoscopic resection of duodenal papilla is an efficient treatment for benign tumors of the duodenal papilla. Recently, reports about endoscopic tumor resection of the major duodenal papilla were increasing. However, a few papers have described endoscopic resection of minor papilla, because tumors of minor duodenal papilla are rare. In the present report, we report ten endoscopic resection cases of duodenal minor papilla.

Patients and Methods: From March 2013 to May 2014, consecutive patients who underwent endoscopic resection of minor papilla at two tertiary-referral centers over a 14-month period. All patients underwent an endoscopic ultrasonography (EUS) before an endosopic resection for evaluation of form inside the tumor and for exclude anatomical anomaly or ductal involvement. The minor papilla was resected by snare electrocautery in all patients. In some patients, a pancreatic stent was placed in the pancreatic duct to prevent post-ERCP pancreatitis.

Observations: The 10 patients underwent endoscopic resection of minor duodenal papillary tumor over a 14-month period. Mean age and standard deviation of the patients was 54.7(±17.8) years old. Generalized appearance of tumor were looked like a submucosal tumor (SMT) with bulging shape at an endoscopy and an EUS. The overall incidences of post papillectomy pancreatitis and hyperamylasemia were 30% (3/10) and 10%(1/10). There were no serious complications such as severe pancreatitis or perforation. The pathologic findings of resected minor duodenal papilla were almost ectopic pancreas (60%, 6/10), and two cases were adenoma.

Conclusions: Our data suggest that endoscopic resection of duodenal minor papilla is safe, technically feasible in experienced hand. Tumor of minor papilla looks like SMT lesions on endoscopy and EUS were almost (6/10, 60%) ectopic pancreas. There are a few reports about resection of minor duodenal papilla, therefore, more large scaled data will be needed.

Doppler Ultrasonography, Proinflammatory Cytokines and Adhesion Molecules in Acute Pancreatitis

S. Chooklin, I. Osmilovska, O. Usach, M. Shavarova. Regional Clinical Hospital, Lviv, Ukraine.

Introduction: Disorders of microcirculation are a major step from mild (preserved microcirculation, edematous pancreatitis) to severe disease.

Materials and Methods: We examined 53 patients with acute pancreatitis. According to the criteria of Atlanta in 28 patients diagnosed severe acute pancreatitis, in 25 - mild. Flow in the visceral arteries we measured by Doppler sonography. We measured interleukin-6 and E-selectin in the blood plasma by ELISA.

Results: Mild acute pancreatitis often not accompanied by hemodynamic disorders according to Doppler ultrasound during the first week of illness. Poor prognostic indicators are a steady increase in peak systolic and end-diastolic blood flow velocities, resistance index in the first week of the disease. Pancreatic necrosis is noted a steady increase in peak systolic blood flow velocity and resistance index in the common hepatic, splenic and superior mesenteric arteries during the first week of illness. There was a significant direct correlation concentrations of IL-6 with peak systolic velocity in the superior mesenteric artery (R = 0,502941, p = 0,047063), with an index of resistance in common hepatic (R = 0,532845, p = 0,033574), splenic (R = 0,511125, p = 0,043028) and superior mesenteric (R = 0,563200, p = 0,023107) arteries. The level of soluble E-selectin may also affect splanchnic flow in patients with acute pancreatitis, defined as a significant direct correlation between the concentration dependence of E-selectin and peak systolic velocity of blood flow in the common hepatic (R = 0,838249, p = 0,000095) and splenic (R = 0,689902, p = 0,004424) arteries and resistance index in the common hepatic (R = 0,710321, p = 0,003002) and superior mesenteric (R = 0,759862, p = 0,001012) arteries.

Conclusion: Changes in the quantitative and qualitative detection of Doppler spectrum are ahead echographic signs of necrotizing forms of pancreatitis in B-mode ultrasound. The levels of IL-6 and E-selectin correlates with disturbances in splanchnic blood flow.

Alcohol-Induced Impaired Pancreatic Regeneration is Associated With Altered Notch Signaling

D.L. Clemens,1,2 M.A. Wells,2 K.J. Schneider,2 S. Singh.21NEWI VA Medical Center; 2Dept. of Medicine, University of Nebraska Medical Center, Omaha NE.

Alcohol abuse is one of the most common factors associated with pancreatitis, although alcohol abuse alone does not initiate this disease. How ethanol sensitizes the pancreas to more severe disease is not entirely understood. One understudied aspect of ethanol’s role in pancreatitis is its effect on repair of pancreatic damage. Recent studies indicate that regeneration of the exocrine pancreas normally occurs from preexisting mature cells of the exocrine pancreas. This regenerative process requires genetic reprograming of mature cells, characterized by the expression of a number of developmental factors. Disruption of this process results in inappropriate tissue repair that is likely involved in the initiation and progression of pancreatitis.

The Notch signaling pathway is required for the development and regeneration of the exocrine pancreas. Using a model of virally induced acute pancreatitis in mice chronically provided ethanol, we have shown that ethanol consumption impairs regeneration of the exocrine pancreas. This ethanol-induced inhibition of pancreatic repair is associated with reduced expression of a number of developmental pathways, including the Notch pathway. We have found that expression of Notch-1 and Hes-1 mRNA is reduced in the pancreata of mice chronically provided ethanol throughout the course of the viral infection. Additionally, Hes-1 protein is also reduced up to 5-fold in the pancreata of these animals. Treatment of the mouse pancreatic tumor cell line, 266–6, with by-products of ethanol metabolism also reduced expression of Notch signaling components. Treatment of these cells with acetaldehyde reduced expression of Hes-1 by 7-fold and Notch-1 by 2-fold. Conversely, H2O2 treatment reduced Notch-1 by 2-fold, but had little effect on Hes-1. Thus, the metabolites of ethanol oxidation may alter Notch signaling, inhibit pancreatic repair, and thereby prolong the duration and increase the severity of pancreatitis.

Derivation of a Non-invasive, Chronic Pancreatitis (CP) Risk Score

D.L. Conwell,1 L.S. Lee,2 V. Kadiyala,2 S. Suleiman,2 P. Banks.21Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Ohio State University College of Medicine, Columbus, OH; 1Center for Pancreatic Disease, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

Background: A better screening method for CP is needed to determine who should undergo more costly and invasive testing.

Aims: Develop a CP prediction score to risk stratify patients for treatment or further testing.

Methods: Retrospective review of at-risk patients [alcohol > 20 g /day, smoking, RAP, abdominal pain] referred for chronic pancreatic disease evaluation and treatment. Data collection form recorded demographics, symptoms, TIGAR-O risk factors, exocrine dysfunction [pancreatic elastase, PE-1, <200 ug/g], secretory dysfunction [peak HC03- <75 meq/L], endocrine dysfunction [abnormal fasting glucose or HA1C] and abdominal imaging findings (Cambridge score on CT, MRI/MRCP). Statistical analysis included univariate [t-test continuous; Fisher exact or Chi square categorical variables] and multivariate logistic regression analysis [SAS, Cary, NC].

Results: Eighty-eight (88) pts stratified by pancreas secretory function into 2 groups [normal, abnormal]. Groups compared to determine independent predictors of pancreas function.

Univariate analysis [variable (p-value)] - The following variables predicted abnormal secretory function: heavy alcohol (0.033), nausea (0.011), abnormal PE-1 (0.009), moderate/marked CT scan (0.010) or moderate/marked MRI/MRCP imaging (0.001).

Multivariate analysis [variable OR (95% CI)] – Abnormal secretory function observed more with nausea 11.47 (2.13,61.86), abnormal MRI 9.45 (1.25,71.19), and exocrine insufficiency 6.05 (1.18, 31.14). Model Formula = −2.206 + 2.246 [MRI] + 2.440 [Nausea] + 1.801 [Exocrine function]. CP Risk Score: assigning 2 point / variable (total score = 0, 2, 4 or 6); the probability of CP (total points; % predicted CP): Low (0 pts, 9.5% CP); Intermediate (2 pt, 50% CP); High (4 pts, 86% CP, or 6 pts, 100% CP). Overall CP Risk Score AUC = 0.854.

Conclusion: A non-invasive, prediction score incorporating symptoms, imaging and exocrine function has been derived to stratify at-risk patients for treatment or further diagnostic testing for chronic pancreatitis.

Clinical Implications: For a low probability score (0), no further pancreas testing. A high probability score (4–6) requires treatment of chronic pancreatitis and its associated complications. An intermediate probability score (2) requires referral for invasive pancreas imaging and physiologic testing. Multicenter validation is planned.

Evaluation of STEP-wise Diagnostic Test Algorithm Used in the Evaluation for Chronic Pancreatitis

D.L. Conwell,1 L. Lee,2 V. Kadiyala,2 S. Suleiman,2 A. Hinton,2 P. Banks.21Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University, Columbus, OH; 2The Center for Pancreatic Disease, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

Background: A diagnostic testing algorithm has been published for patients with high suspicion of chronic pancreatitis (abdominal pain, steatorrhea, weight loss). While this algorithm minimizes patient risk by proceeding from a non-invasive to more invasive strategy, accuracy of this proposed method of evaluation has yet to be established.

Aim: Determine the diagnostic accuracy of STEP-wise diagnostic tests in the evaluation of patients for chronic pancreatitis.

Methods: Pancreatic disorders database queried for subjects with suspected and established chronic pancreatitis who underwent an endoscopic pancreas function test (ePFT). Patient demographics, symptoms, etiologic risk factors, habits, laboratory data and imaging findings were reviewed. Imaging studies were scored based on commonly accepted practice guidelines: Fecal elastase >100 mg/g; CT/ MRI Cambridge criteria; EUS total EUS score > =5 abnormal.

Results: A total of 88 patients: 33 patients positive ePFT and 55 negative ePFT. Using ePFT as surrogate gold standard the following diagnostic characteristics of the commonly used tests (Sensitivity, Specificity, PPV, NPV) for assessment of chronic pancreatitis are as follows: Fecal elastase (75,43,69,50 %); CT scan ( 53,90,82,68 %); MRI scan (32,95,83,69%) and EGD/EUS (76,14,34,50 %). The OR [95% CI] for advanced imaging changes predicting abnormal ePFT was: Fecal elastase 2.2 [NS]; CT scan 9.6 [1.7,55]; MRI scan 11.2 [2.3,56] and EGD/EUS 1.88 [NS]. The AUC [95% CI] for each test was fecal elastase 0.58 [0.35, 0.83]; CT 0.71[0.57,0.85]; MRI scan 0.64[0.55,0.73] and EGD/EUS 0.55[0.46,0.64].

Conclusion: The overall diagnostic accuracy of current testing methods is moderate. MRI and CT have the best diagnostic characteristics for initial assessment of chronic pancreatitis. The search for better diagnostic markers continues.

Meta-Cancer Outlier Profile Analysis of Pancreatic Cancer Expression Data Identifies a Novel Intracellular Bone Morphogenetic Protein 2 (BMP-2) Splice Variant

E. Cruz, S.K. Batra. Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE.

Background: Pancreatic cancer (PC) heterogeneity confers complex transcription patterns that require a subset approach to finding new gene targets. We performed meta-analysis on 11 COPA (Cancer Outlier Profile Analysis) transformed datasets ( depicting the mRNA profiles of 416 PC tumors. This revealed BMP-2 to be increased in a subset of PC samples. BMPs are key regulators of proliferation, motility, & differentiation during embryonic development. Likewise, there is an increasing recognition of the role of BMPs in cancer progression and metastasis. Canonical BMP-2 signaling is mediated via type 1 & type 2 serine/threonine kinase receptors, which upon ligand binding, phosphorylate SMAD proteins leading to induction of altered gene expression programs. Validation of BMP-2 candidate has revealed a novel splice variant (BMP-2 SV), which owing to exclusion of its signal peptide containing exon, escapes the secretory pathway and is endowed with an intracellular pattern of expression and function. We hypothesize that BMP-2 splicing leads to an altered subcellular localization which imbues this ordinarily extracellular protein with novel intracellular functional properties.

Methods & Results: Overexpression in PC cell lines was used to evaluate the functional role of the BMP-2 SV. Trans-well migration assays showed enhanced migration relative to the vector control. The effects of extracellular recombinant BMP-2 ligand and intracellular BMP-2 SV on Smad 1/5 phosphorylation was measured following Hek293 treatment with rhBMP-2 and/or BMP-2 SV transfection. Smad 1/5 phosphorylation was shown to be synergistically increased in the rhBMP-2 treated BMP-2 SV transfected cells.

Conclusions: Our data advocate for a cell-autonomous intracellular mode of BMP-2 signaling in pancreatic cancer whereby Smad 1/5 phosphorylation is sustained and enhanced by intrinsic BMP-2 SV signaling.

A Novel Technology for Fluorescence Guided Surgery and Photodynamic Therapy of Pancreatic Tumors

Z. Cruz-Monserrate,1 H. Wang,2 W. R. Abd-Elgaliel,3 C. Tung,3 C. D. Logsdon.11Department of Cancer Biology, 2Pathology, University of Texas, M. D. Anderson Cancer Center, Houston TX; 3Department of Translational Imaging, The Methodist Hospital Research Institute, Houston, TX.

Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer deaths in the United States and has the worst outcome of all major cancers. Surgery has the greatest impact on survival and is the only curative treatment of PDAC. Tumor resection increases the survival duration from the non-resected average of 6 months to 2 years. This is a better outcome than that achieved with any other current treatments. However, the disease is deemed to be resectable in only about 20% of patients owing to metastasis at diagnosis or to local spread of the disease to arteries and nerves, where resection is considered too dangerous. Residual cancer cells present in unrecognized metastatic sites or tumor margins after surgery result in local recurrence with reduced survival. These facts clearly emphasize the need for a molecular probe that can precisely locate and efficiently treat residual tumor cells after surgery. For this reason, we have developed a novel technology for guided surgery and photodynamic therapy (PDT) that is superior to those currently available. We have modified the current widely-used and clinically useful photosensitizing agent 5-ALA to make it cancer specific. This was accomplished by adding a peptide sequence that blocks the ability of 5-ALA to form a protoporphyrin that can only be removed by the protease Cathepsin E (CTSE). We have shown that CTSE is specifically localized in cancer cells. We hypothesize that use of this technology will improve surgery by allowing the visualization of residual cancer and will allow elimination of residual cancer with PDT. This will increase the numbers of patients that can undergo tumor resection and will improve outcomes for all surgeries. It will also allow the surgeon to identify metastases on the peritoneum and surface of the liver before operating, thus sparing the patient a useless surgery. This novel technology will be directly translatable to patient care.

Screening for Pancreatic Cancer in New-Onset Diabetes Mellitus is Beneficial?

L. Czakó, D. Illés, G. Zsóri, V. Terzin, T. Wittmann. First Department of Medicine, University of Szeged, Szeged, Hungary.

Background: Screening of the average population for pancreatic cancer (PC) is not cost-effective because the lifetime prevalence of PC is only 1.39%. Diabetes mellitus seems to be an independent risk factor for PC.

Objective: To assess the role of noninvasive diagnostic means (serum CA 19–9 level, transabdominal ultrasonography /US/ and computer tomography /CT/) in screening for PC among patients with new-onset diagnosed (within 36 months) diabetes mellitus.

Methods: Patients with new-onset type-2 diabetes mellitus were enrolled in a prospective study. Symptoms suggestive of pancreatic disease were excluding factors. The serum CA 19–9 level was measured 6-monthly, and US was performed yearly. If the CA 19–9 level was elevated or US showed any abnormality, CT was performed.

Results: A total of 87 patients (48 men, 39 women, mean age: 58.01 ± 11.09 years) were enrolled. The serum CA 19–9 level was elevated in 8 patients (9.1%), but no abnormality was revealed by US or CT. Imaging examinations detected PC in 2 patients (2.29%), but the CA 19–9 was not elevated. The sensitivity, specificity, and positive and negative predictive values of CA 19–9, US and CT were 0%, 89.4%, 0% and 97.4%; 50%, 100%, 100% and 98.6%; and 100%, 100%, 100%, and 100%, respectively. The value of the Standardized Incidence Ratio was 166.7 (95% CI = 2.76-10.03).

Conclusions: The likelihood of PC in patients with new-onset type-2 diabetes is significantly higher than that in the general population. US, together with CT in uncertain cases, can be a reliable screening modality, whereas CA 19–9 is not effective for PC screening.

Distal Pancreatectomy With Resection of the Celiac Axis for Pancreatic Cancer

C. Dai, Z. Qian, K. Jiang, J.Wu,W. Gao,Q. Li, J. Chen, F. Guo, J.Wei, Z. Lu, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Objective: To investigate the feasibility and safety of distal pancreatectomy with en-bloc celiac axis resection (DP-CAR).

Method: We retrospectively analyzed four cases who underwent DP-CAR for borderline resectable primary pancreatic cancer with invasion to the celiac trunk and/or common hepatic artery in our center.

Results: In all cases, no revascularization was performed. One patient had tumor involvement to the left adrenal gland and had it removed during surgery. Time for surgeries ranged from three to six hours. Pathology examination revealed pancreatic ductal adenocarcinoma in three cases and mucinous cystadenocarcinoma in one case, with two cases of lymph node metastasis. All resection margin in four cases were free of tumor cells. Mild diarrhea and pancreatic fistula presented in all four cases with delayed gastric emptying in one case, all of which were successfully treated with conservative management. Transient elevated level in aminotransferase was noted postoperatively, but came back to normal after conservative treatment. Preoperative abdominal or lumbar-back pain presented in three cases significantly relieved or disappeared after surgery.

Conclusion: DP-CAR is a feasible and safe procedure for pancreatic cancer invading celiac trunk and/or common hepatic artery, and can improve the chance of R0 resection.

Comparison of the International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasm (IPMN) With Analysis of Pancreatic Cyst Fluid Aspirates for mAb Das-1 Reactivity in Identifying High-risk and Malignant IPMN

K.K. Das,1 G. Marchegiani,2 X. Geng,3 H. Xiao,4 T. Huynh,4 C. Fernandez-del Castillo,2 M.B. Pitman,4 K.M. Das,3 M. Mino-Kenudson.41Div of Gastroenterology, University of Pennsylvania, Philadelphia, PA; Dept of 2Surgery & 4Pathology, Massachusetts General Hospital, Boston, MA; 3Div of Gastroenterology, Rutgers-RWJMS, New Brunswick, NJ.

Background: While International Consensus Guidelines for IPMN were adopted (Sendai) and revised (Fukuoka), studies have questioned their accuracy in identifying high-risk lesions. mAb Das-1 reacts specifically to a colonic epithelial phenotype and we have previously shown it accurately detects both tissue and cyst fluid from IPMNs at high risk for malignant transformation.

Methods: Cyst fluid was aspirated perioperatively from IPMNs (n=43) and histology confirmed. Sandwich ELISA and Western Blot were performed with mAb Das-1.

Results: We examined 3 main-duct, 16 branch-duct, & 24 mixed-type IPMNs. The highest dysplastic grade was invasive carcinoma in 9 and high-(HGD), intermediate-(IGD), and low- grade in 9, 13, and 12 patients respectively. Considering high-risk lesions as those with invasive carcinoma, HGD of any epithelial type, or IGD of intestinal type, Das-1 was 93% sensitive, 94% specific, with an area under the curve (AUC) of 0.986. Sendai (93% Sensitive, 19% Specific; AUC 0.613) and Fukuoka (85% Sensitive, 38% Specific; AUC 0.557) Guidelines were less accurate. Multivariate regression found the addition of neither guidelines, nor their elements (cyst >3cm, main duct dilation, mural nodules, symptoms) improved performance over Das-1 alone. Among 19 patients with available cytology, Das-1 was both more sensitive (92% vs 50%) and specific (100% vs 86%), and their combination did not improve performance.

Conclusion: Das-1 reactivity in IPMN cyst fluid is highly sensitive & specific for high-risk lesions and may play a significant role in risk stratification of IPMN.

Endoscopic Transpapillary Drainage for Postoperative Pancreatic Fistula

K. Date, S. Takahata, K. Tamura, T. Fujimoto, H. Kimura, T. Matsunaga, Y. Watanabe, Y. Miyasaka, T. Ohtsuka, M. Tanaka. Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan.

Background: Endoscopic drainage of postoperative pancreatic fistula (POPF) using transpapillary approaches has been reported. We often employ endoscopic placement of pancreatic stent or nasopancreatic drainage (ENPD) for treatment of intractable POPF. In this study, the usefulness of these procedures was investigated.

Methods: Medical records of patients who underwent pancreatic stenting or ENPD for POPF were retrospectively reviewed. POPF was defined and classified according to the International Study Group of Pancreatic Fistula, and grade B/C POPF was defined as clinical POPF. Postoperative data in such patients were assessed.

Results: Twelve patients underwent transpapillary drainage between 2008 and 2014, ENPD was performed in 6 patients and stenting in 6. Five patients were diagnosed as grade B POPF and 1 grade C in both ENPD and stent cohorts. ENPD and stenting resulted in a remarkable decrease in drain output in 9 of the 12 patients. In 3 of the 4 ENPD patients, the ENPD tube was cut in the stomach to establish internal drainage after POPF was improved (two-step treatment). In one patient in stent cohort, POPF was managed by a combination of endoscopic ultrasound guided abscess drainage and transpapillary stenting. One patient with ineffective stenting alternatively underwent ENPD. Stenting tended to be better treatment than ENPD in terms of time to resumption of oral intake (stenting: 0.4 vs ENPD:16.5 days), hospital stay (12.0 vs 27.1). Finally, POPF was improved and in all the 12 patients are well without the recurrence of pancreatic fistula.

Conclusions: Endoscopic transpapillary stenting is an effective therapeutic choice for POPF. In terms of resumption of oral intake and hospitalization, stenting seems to be better than ENPD. Individual selection of therapeutic methods is important and further investigation would be necessary to clarify the adequate therapeutic protocol.

Downregulation of Sp1 Leads to ER Stress and Cell Death in Triptolide Treated Cells

P. Dauer, S. Banerjee, O. McGinn, A. Nomura, S. Modi, K. Majumder, R. Chugh,V. Dudeja, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Background: Disturbances in the normal functions of the ER lead to an evolutionarily conserved cell stress response, the unfolded protein response (UPR). The UPR initially compensates for damage but eventually triggers cell death if ER dysfunction is severe or prolonged. Triptolide, a diterpene triepoxide has been shown to be an effective compound against pancreatic cancer. Previous studies from our group show that triptolide downregulates activity of transcription factor Sp1, cascading a series of signaling pathways resulting in cell death. The current study evaluates the role of Sp1 in inducing ER stress, leading to lysosomal membrane permeabilization (LMP) mediated death in pancreatic cancer cells.

Results: Our studies show that inhibition of Sp1 results in upregulation of GRP78 and CHOP at the protein and mRNA levels in a time-dependent manner. Inhibition of Sp1 also increased activity of ER stress response elements and lead to mRNA splicing of transcription factor XBP-1. Our data further suggests that downregulation of Sp1 by mithramycin, Sp1 siRNA or by triptolide results in increased expression of Ire1α and PERK, indicating that these pathways work in coalition to activate chronic ER stress pathways in pancreatic cancer cells.

Additionally, confocal imaging was performed on pancreatic cancer cells after six hours of treatments, followed by staining with Lysotracker Red and cathepsin B antibody. Our data suggests that ER stress induces LMP and eventually cell death in triptolide treated pancreatic cancer cells.

Conclusions: This data suggests that in addition to downregulation of HSP70, triptolide decreases expression of Sp1 and activates ER stress and cell death via permeabilization of lysosomes in tumor cells. These findings help elucidate the full mechanism of action of triptolide.

Intra-pancreatic Trypsin Activation Is Not Essential for Development of Chronic Alcoholic Pancreatitis in Mice

R. Dawra, A. Bekolay, Y. Ryu, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Chronic alcohol abuse is known to result in increased propensity to pancreatitis. How alcohol abuse alter the susceptibility to disease is not clear. Experimentally, increased intra-pancreatic trypsin activation is observed in presence of pre-exposure to ethanol. It is believed that this might increase susceptibility to develop the disease. Aim of this study was to find out if intra-pancreatic trypsin activation essential for alcoholic chronic pancreatitis.

Methods: Wild type mice and mice with either trypsinogen T7 or cathepsin B deletion were pair fed either control Lieber-DeCarli liquid or ethanol diet for 8 weeks. After this acute pancreatitis was induced using caerulein i.p. injections every alternate day for three weeks, while mice continued on their respective diets. Mice were sacrificed after 11 and 14 weeks from the start of experiment. Pancreatitis was evaluated by measuring pancreatic atrophy, loss of acinar cells, increase in fibrosis and presence of tubular complexes.

Results: There was significant pancreatic atrophy in pancreatitis groups as compared to control and atrophy was comparable in wild type, T7 and cathepsin B knockout mice. There was significant acinar cells loss, fibrosis and inflammatory cells infiltrates in all the groups with pancreatitis.

Conclusions: Intra-pancreatic trypsin activation is not essential for development of alcoholic chronic pancreatitis in mice.

Mechanism of Bile Acids Mediated Injury in Human Pancreatic Acinar Cells

R. Dawra, S. Sunderasan, A. Dixit, U. Barlass, A. Bekolay, Y. Ryu, B. Appakalai, B. Hering, A. Saluja. Department of Surgery, University of Minnesota, Minneapolis, MN.

Biliary pancreatitis is a major form of pancreatitis but the mechanism of the disease is not clear. It is believed that impacted flow in the common duct resulting in exposure of pancreatic parenchyma to bile constituents, triggers injury in acinar cells. Most of our current understanding on bile acids mediated injury to pancreas is based upon bile acids induced experimental animal models of pancreatitis. The relevance of these findings to human disease is not clear. Aim of this study was to investigate bile acids mediated injury in human pancreatic acinar cells derived from healthy human pancreas.

Methods: Human pancreatic acinar cells were prepared by collagenase digestion of healthy human pancreases. Pancreatic acinar cells were either hyper-stimulated with carbachol or different concentrations of bile acids to initiate injury. Trypsin, chymotrypsin activation and cell viability were measured to assess damage to the cells in response to treatments. Bile acid receptor and transporters were blocked using specific antibodies. Bile acid receptor specific agonists other than bile acids were used to delineate receptor contribution to injury in human acinar cells.

Results: Incubation of human acinar cells in presence of taurolithocholic acid sulfate, chenodeoxycholic acid, taurocholic acid or carbachol (1mM) resulted in activation of trypsin, chymotrypsin and loss in cell viability. Pretreatment with a specific antibody for sodium dependent bile acid transporter or organic anion transporter significantly reduced trypsin and chymotrypsin activation and protected cells from bile acid mediated injury. Stimulation of the cells with either ciproflaxin (50uM) or oleanoic acid (20uM), which have been shown to specifically bind and activate bile acid receptor did not cause protease activation or loss in cell viability. However, this treatment enhanced carbachol induced trypsin and chymotrypsin activation.

Conclusions: Bile acid membrane transporters are present on human pancreatic acinar cells and contributes to bile acid induced injury. Direct stimulation of bile acid receptor alone is not sufficient for pathological activation of proteases or loss in cell viability.

Identifying Molecular Targets for Pancreatic Cancer: Paving the Way for Image-Guided Surgery

S.W.L. de Geus,1 R.J. Swijnenburg,1 H.A.J.M. Prevoo,1 C.F.M. Sier,1 B.A, Bonsing,1 H. Morreau,2 C.J.H. van de Velde,1 P.J.K. Kuppen,1 A.L. Vahrmeijer.11Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; 2Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.

Background: A diagnosis of pancreatic cancer still remains a devastating one. The only chance of cure for these patients is complete surgical resection with negative tumor margins. Unfortunately, irradical resections are very common. Intraoperative optical imaging using tumor targeting contrast agents holds promise for better tumor detection and surgical elimination of residual disease.

Aim: The purpose of this study was to evaluate the expression of promising targets for tumor-specific image-guided surgery in pancreatic ductal adenocarcinoma (PDAC).

Methods: Tissue microarrays of PDAC (n = 132) and adjacent normal pancreatic tissue (n = 14) were evaluated for expression of the following eight tumor markers by immunohistochemistry: carcinoembryonic antigen (CEA), epithelial cell adhesion molecule (EpCAM), hepatocyte growth factor receptor (HGFR, cMet), vascular endothelial growth factor receptor (VEGFR), epithelial growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2), urokinase plasminogen activator receptor (uPAR), and integrin alphavbeta 6 (αvβ6).

Results: The expression of αvβ6 was abundantly present in 92%, HGFR in 91%, CEA in 86%, HER2 in 84%, EGFR in 70%, uPAR in 69%, EpCAM in 38% and VEGFR in 31% of pancreatic ductal adenocarcinoma cases. CEA, uPAR and αvβ6 and was also significantly (p < 0.01) higher in PDAC than in normal pancreatic tissue and did almost not react with adjacent, nonneoplastic pancreatic parenchyma.

Conclusion: These results suggest that based on expression rate and potential tumor-to-background ratios CEA, αvβ6 and uPAR are the most promising biomarkers for tumor-specific contrast agent development for image-guided pancreatic cancer surgery.

Follow-up Strategy for IPMN of the Pancreas is Safe

M. Del Chiaro,1 R. Segersvärd,1 L. Nilsson,1 J. Blomberg,1 E. Rangelova,1 C. Ansorge,1 R. Pozzi-Mucelli,2 N. Kartalis,2 M. Lohr,1 U. Arnelo,1 C. Verbeke.31Department of Surgery, Karolinska Institute, Sweden; 2Department of Radiology, Karolinska Institute, Sweden; 3Department of Pathology, Karolinska Institute, Sweden.

Background: The strategy of following up IPMN, in the majority of patients is currently considered best clinical practice, even though consensus regarding an appropriate follow-up interval is lacking.

Aim: This study analyzes the results of a follow-up program for patients with IPMN.

Patients & Methods: From January 2008 to December 2013, 503 patients diagnosed with IPMN were observed at the Pancreas Unit of Karolinska Institute. 452 patients (89.8%) were followed-up, while 51 (10.2%) underwent surgery. The patients under follow-up were included in this study

Results: Overall, 452 patients were analyzed. The mean follow-up was 932 days. 395 patients (87.4%) were under surveillance according to the prevailing guidelines (group 1), whereas 57 (12.6%) patients (group 2) were followed-up because of contraindications for surgery. In group 1, 55 patients (13.9%) required surgery for progression of their IPMN after a median follow-up of 560 days. In 2 patients (0.5%), a synchronous pancreatic cancer developed during follow-up. In group 1, 33 patients (8.3%) died under follow-up: 4 (1%) due to IPMN progression, 5 (1.3%) because of extrapancreatic cancer and 24 (6%) for other causes. In group 2, 22 patients (38.6%) died due to IPMN progression 10 (17.5%), extrapancreatic cancer, 5 (8.8%), or for other reasons 7 (12.3%).

Conclusion: This study confirms the safety of a surveillance program for patients with non-surgical IPMN. Incidence of pancreatic cancer and IPMN-related mortality were low during follow-up. Even if patients with an indication for surgical treatment were for excluded from surgery for various reasons, survival was acceptable.

Neural Remodeling in Pancreatic Neuropathy is Characterized by Neurotrophin-3-Mediated Increase in the Pancreatic Nociceptive Innervation, Demyelination and Selective Glial Activation

I.E. Demir, D. Carty, K.Wang, C.Waldbaur, L. Krauss, E. Tieftrunk, H. Friess, G.O. Ceyhan. Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.

Background: Neural remodelling in pancreatic cancer (PDAC) and chronic pancreatitis (CP) is characterized by reduced sympathetic pancreas innervation among patients with severe pain. This observation raises the question whether sympathetic innervation in PDAC and CP is replaced by increased nociceptive innervation and glial activation.

Material & Methods: Normal human pancreas (NP, n=16), CP (n= 26) and PCa (n=25) tissues were quantitatively analyzed for the neuro-immunoreactivity of a) nociceptive fiber markers substance-P (SP) and calcitonin-gene-related-peptide (CGRP), b) myelination markers neurofilament-H (NFH) and peripheral-myelin-protein-22 (PMP22), c) glial activation markers p75NTR and glial-fibrillary-acidic-protein (GFAP) and correlated to pain, neural invasion (NI) and pancreatic neuritis. Nociceptive neurite density of dorsal-root-ganglia-(DRG)-neurons that were cultivated in human NP, CP or PDAC tissue extracts was analyzed in the presence of neutralizing antibodies against nerve-growth-factor (NGF), neurotrophin-3 (NT-3) or brain-derived-neurotrophic-factor (BDNF).

Results: SP- and CGRP-containing nerve fibers were prominently increased in CP independently of the pain status. Accordingly, the neuro-immunoreactivity of NFH and PMP22 was remarkably decreased in CP and PCa. NI and pancreatic neuritis were more pronounced around nerves with decreasing SP- and CGRP-content, increasing myelination and enhanced glial activation. Cultivation of DRG neurons in CP extracts induced the sprouting of SP- and CGRP-containing neurites, which was reversed upon blockade of NT-3 within CP extracts.

Conclusion: Neural remodeling in CP and PDAC involves pain-independent, NT-3-mediated upregulation of nociceptive innervation, loss of myelination, and glial activation around nerves with NI and pancreatic neuritis. These alterations in nociception, myelination and glial activity may be the determinants of the pathologic pain response in PDAC and CP.

A New Surgical Technique of PD-SAR for Pancreatic Head-Body Cancer with Splenic Artery Invasion to Avoid Total Pancreatectomy, Based On the Preservation of Remnant Pancreatic Functions

R. Desaki, M. Kishiwada, S. Mizuno, Y. Murata, A. Tanemura, Y. Azumi, N. Kuriyama, M. Usui, H. Sakurai, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan.

Introduction: When pancreatic ductal adenocarcinoma (PDAC) of head and/or body invades the splenic artery (SA), we usually cannot avoid total pancreatectomy (TP), because the blood supply of distal pancreas becomes scarce after dividing SA. And TP results in an extreme form of pancreatogenic diabetes: iatrogenic hypoglycemia affects patient’s QOL and prognosis. For such tumors, we developed a new surgical technique of proximal subtotal pancreatectomy with SA and vein resection, so-called pancreaticoduodenectomy with SA resection (PD-SAR), in consideration of the balance between the preservation of remnant pancreatic functions and operative radicality.

Method: We retrospectively reviewed a total of 98 patients with curative intent PD for PDAC of head and/or body. These 84 patients were classified into the two groups: conventional PD (n=79) and PD-SAR (n=19).

Result: Postoperative MDCT clearly demonstrated enhancement of the remnant pancreas at 1 and 6 months in all patients. Overall survival rates were very similar between PD and PD-SAR (3-year OS: 28.1% vs. 21.8%, p=0.538), despite the fact that the tumor size and the percentages of UICC-T4 were higher in PD-SAR. Total daily insulin dose was significantly higher in PD-SAR than in PD at 1 month, while showing no significant differences between two groups thereafter. The prediction studies of postoperative pancreatic functions using several markers revealed no significance differences between PD and PD-SAR. Glucagon stimulating test confirmed enough insulin secretion ability from the remnant pancreas after PD-SAR.

Conclusion: PD-SAR seems to be promising surgical strategy for PDAC of the head and/or body with invasion of the SA, based on the preservation of remnant pancreatic functions and operative radicality.

Disruption of the Fractalkine/CX3CR1 Signaling Axis Attenuates Acute Pancreatitis and Pancreatic Pain

J. G.D’Haese,1 T. D. D’Haese,1 H. Sezgin,1 T. Kehl,1 IE. Demir,1 F. Bergmann,2 H. Friess,1 G. O. Ceyhan.11Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany; 2Institute of Pathology, University of Heidelberg, Heidelberg, Germany.

Background: Acute pancreatitis (AP) is characterized by vast inflammatory cell infiltration and severe abdominal pain. Fractalkine is a chemokine that chemoattracts inflammatory cells through its highly selective receptor CX3CR1 and has been suggested to aggravate pancreatic inflammation and pain. Spinal cord microglia express the receptor CX3CR1 and have been shown to modulate pain in chronic neuropathic pain states. Therefore, we aimed to investigate the course of acute cerulein pancreatitis in CX3CR1−/− mice and the potential therapeutic implications of CX3CR1 neutralization.

Material and Methods: AP was induced in CX3CR1-knockout and CX3CR1-blocking treated wild-type mice by repetitive intraperitoneal cerulein injections. Hyperalgesia was assessed by systematic behavioral observation and measurement of abdominal mechanical sensitivity. Pancreatic and spinal cord tissue was harvested after sacrifice for further analyses.

Results: Pathomorphological severity of AP in CX3CR1-knockout mice vs. wild-type controls was comparable. CX3CR1-blocking treated mice however showed a much more attenuated AP with significantly less pancreatic inflammatory cell infiltration. Both knockout and treated mice showed significantly less pain related behavior (p < 0.0001) with a clear dose–response correlation. Intrapancreatic IL6 and MCP-1 levels were lower in treated mice when compared to their controls. On the spinal cord level, CX3CR1-blocking treated mice showed a dose dependent decrease of microglial activation measured by p-p38 Immunohistochemistry.

Conclusions: Fractalkine signaling seems to be crucial in initiating and maintaining of pancreatic hyperalgesia in acute pancreatitis. This phenomenon is most likely triggered by the local inflammatory reactions and spinal cord microglia activation via the highly selective receptor CX3CR1. Therefore, these novel findings reveal CX3CR1 as a promising new target for the treatment of acute pancreatitis.

Pancreatic Metastases Originating From Uterine Leiomyosarcoma: A Case Report

S.O. Dima,2 N. Bacalbasa,2 M. Eftimie,1 L. David,1 M. Boros,3 D. Tomescu,4 I. Popescu.11 Center of General Surgery and Liver Transplantation “Dan Setlacec”, Fundeni Clinical Institute, Bucharest, Romania; 2“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; 3Dept Radiol, Fundeni Clinical Institute, Bucharest, Romania; 4Dept Anaesthesia & Intensive Care, Fundeni Clinical Institute, Bucharest, Romania.

Background: Uterine metastatic leiomyosarcoma of the pancreas is an extremely rare situation.

Case report: In 2009, a 67 years old woman underwent total hysterectomy and bilateral adnexectomy. The surgically resected uterine specimen was characterized as leiomyosarcoma. No postoperative adjuvant radio-chemotherapy was performed. The patient was free of disease, until November 2010, when follow-up chest computed tomography (CT) detected three pulmonary tumoral lesions. Wedge resections and enucleoresection of the lung tumoral nodules was performed in November 2011. She received adjuvant systemic chemotherapy (Gemcitabine and Vinorelbine). During regular follow-up, CT- scan on July 2011, 10 months after lung resection showed two tumoral masses in the pancreas. Since September 2011 the patient was switched to a combination of Gemcitabine and Dacarbazine. PET- CT performed in December 2013 showed slightly increased of the pancreatic lesions, and no signs of extrapancreatic recurrence. Due to suspected acquired chemoresistance and the apparent disease confined to the pancreas decision was made to perform pancreatic resection. In April 2014 pylorus-preserving pancreaticoduodenectomy was performed. Pathology and immunohistochemical staining of the surgically resected lung and pancreatic specimen showed features similar to those of the uterine leiomyosarcoma.

Discussion: Other case reports showed a good long term survival following aggressive surgical approach, indicating a possible benefit of surgery in the metastatic setting for selected cases.

Conclusion: We report a rare case of resected pancreatic and lung metastasis of uterine leiomyosarcoma.

The Role of MAP4K4 and S100A4 in Pancreatic Ductal Adenocarcinoma

S.O. Dima,1 V. Tica,1 M. Eftimie,1 A. Nastase,1 N. Bacalbasa,1 V. Herlea,3 C. Diaconu,2 C. Bleotu,2 M. Chivu-Economescu,2 V. Herlea,4 D. Duda,4 I. Popescu.11Center of Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania; 2Stefan S Nicolau Institute of Virology, Bucharest, Romania; 3Department of Pathology, Fundeni Clinical Institute, Bucharest, Romania; 4 Department of Radiation Oncology, Harvard Medical School, Boston, MA.

Aim: The objective of this study was to analyze biological and clinical significance of mitogen-activated protein kinase kinase kinase kinase 4 (MAP4K4) and S100A4 in pancreatic ductal adenocarcinoma (PDA).

Background: Expression of MAP4K4 and S100A4 has been reported to correlate with poor prognosis in PDA. However, little is known about specific functions.

Methods: we measured MAP4K4 and S100A4 gene and protein expression in 73 surgical PDA specimens using RT-PCR and immunohistochemistry, and determined their association with clinical outcomes. The role of MAP4K4 was investigated by knocking down its expression in 3 human PDA cell lines (MiaPaCa2, BxPC3, PCL35) and by measuring cell proliferative and migratory capacity.

Results: MAP4K4 mRNA expression was correlated with TNM stage (Kruskal-Wallis test, p<0.05), and MAP4K4 protein expression was significantly correlated with tumor grade (Spearman’s Rho, p<0.05). S100A4 mRNA expression was correlated with TNM stage (Kruskal-Wallis test, p=0. 013) and with lymph node status (Mann–Whitney test, p=0. 015).

MAP4K4 and S100A4 protein expression tends to associate with survival in PDA patients (p<0.05, and p =0. 043, respectively, log-rank test). In vitro functional tests showed that siRNA knockdown of MAP4K4 decreased the migratory capacity of PDA cells by 29–37% depending on the cell line.

Discussion: The biological role of the MAP4K4 and S100A4 in pancreatic carcinogenesis is largely unknown. In our study, MAP4K4 appears to primarily mediate cell invasion.

Conclusions: S100A4 could be a marker for progression, poor outcome and potentially target for therapy in patients with pancreatic cancer.

Organoid Formation by Human Pancreatic Progenitors From Normal and Carcinoma Tissue

C. Dorrell,1 B. Sheppard,2 M. Grompe,1 P.R. Streeter.11Department of Pediatrics, Oregon Health & Science University, Portland, OR; 2Department of Surgery, Oregon Health & Science University, Portland, OR.

Abstract: In order to selectively study the subpopulation of pancreatic cells responsible for the survival and proliferation of pancreatic ductal adenocarcinoma tumors, we have used a collection of novel monoclonal antibodies - including DHIC5-4D9/HPd3 and DHIC2-4A10/HPd1 - which have been previously shown to label live duct cell subpopulations in normal human pancreas. In both normal and PDAC tissue from multiple donors, the capacity to initiate highly proliferative self-renewing “organoid” structures in a 3D culture assay (developed by the Clevers group for intestinal stem cell culture) was restricted to the DHIC5-4D9++ subpopulation of ductal epithelium when sorted and recovered by FACS. Although the overall live duct cell frequency is dramatically elevated in PDAC (15-96%) relative to normal tissue (1-4%), less than 1% of these are clonogenic cells. Transplantation of passage 6 organoids from multiple patient-derived donor lines to immune-deficient mice has revealed that PDAC-derived organoids can produce tumor masses, but that normal organoid lines do not survive in this environment. Comparisons of post-transplant outcomes with clinical parameters and parent tumor morphology are in progress.

The identification of functional heterogeneity of duct subpopulations in PDAC may allow selective targeting of the key cells in these tumors. The ability to grow both normal and tumor-derived pancreatic organoid cultures will also permit parallel screens of anti-neoplastic agents to identify molecules that selectively inhibit self-renewal in PDAC while sparing normal pancreatic progenitors.

Novel Function of NRP-2 Axis in Pancreatic Cancer

S. Dutta, S. Batra, K. Datta. Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha; NE; Buffett Cancer Center, Eppley Cancer Institute, University of Nebraska Medical Center, Omaha, NE.

Abstract: Ductal adenocarcinoma of the pancreas is a lethal disease and resistant to most established therapies. Novel therapeutic strategies are therefore required to treat pancreatic cancer (PC). We have recently observed the activation of VEGF-C/Neuropilin-2 (NRP-2) axis in PC. Our preliminary results indicated a novel function of this axis in PC cells. Inhibition of this axis in PC cells significantly reduced the endocytic process. We hypothesize that the activation of NRP-2 axis in PC is required for the enhanced and aberrant endocytic process, which is important to maintain the oncogenic function of growth factor receptors, such as EGFR. Our preliminary studies have suggested that inhibition of NRP-2 axis facilitates increased accumulation of EGFR in the intracellular vesicles and promote EGF-induced pancreatic cancer cell death. Understanding the mechanism of this signaling axis in pancreatic cancer will help us develop approaches to efficiently target this axis and rationally combine them with established therapies to enhance their efficacy.

Combination of HDAC1 and GSK-3β Inhibition as a Treatment Strategy for Pancreatic Cancer

M. Edderkaoui,1,2 C. Chheda,1 S. Xu,2 D. Principe,3 P. Grippo,3 H. Benhaddou,1,4 M. Bourhim,4 A. Habtezion,5 Y. Dale,6 K. Pinkerton,6 S. Pandol.1,21Cedars-Sinai Medical Center, 2UCLA, and Department of VA, Los Angeles, CA; 3University of Chicago Illinois, Chicago, IL; 4University of Fez, Morocco; 5Stanford University, Stanford, CA; 6UC-Davis, Davis, CA.

Background: Strong correlation exists between high expression level of glycogen synthase kinase 3 beta (GSK-3β) and pancreatic cancer (PaCa) progression in humans. GSK-3β inhibition in a mouse orthotopic model of PaCa induced tumor shrinkage and inhibition of NF-κB activity. However, GSK-3β inhibition stimulates pro-metastasis epithelial to mesenchymal transition (EMT). We hypothesize that combination of GSK-3β and HDAC1 inhibition will prevent both cancer cell survival and EMT in vitro and in vivo.

Methods: Pdx-Cre;LSL-Kras mice were exposed to cigarette smoke for 6 weeks and ip injected with GSK-3β inhibitor TDZD-8 and/or HDAC1 inhibitor Saha. Pancreatic intraepithelial neoplasia (PanIN) lesions, fibrosis, and inflammation were measured by IHC. Pancreatic EMT and histone acetylation were measured by IHC and Western. Cell survival and apoptosis in cells were measured by MTT assay and DNA fragmentation, respectively.

Results: Treatment of mice with Saha prevented the increase in PanINs, fibrosis, inflammation, and EMT. TDZD-8 potentiated the effect of Saha on PanIN inhibition. Pharmacological and molecular inhibitions of GSK-3β significantly and dose dependently decreased proliferation and at a lesser extent stimulated apoptosis in PaCa cells. GSK-3β inhibition stimulated EMT in PaCa cells; whereas, saha reversed this effect. PaCa cell conditioned media stimulated pro-cancer macrophage M2 phenotype. Saha prevented IL-6 production by the cancer cells and macrophage M2 phenotype.

Conclusion: Combination of HDAC1 and GSK-3β inhibitions induced a triple beneficial effect by decreasing proliferation, stimulating apoptosis and inhibiting EMT. The approach we applied is a very promising strategy for treatment of the disease.

Efficacy of Recombinant Human Soluble Thrombomodulin During the Clinical Course in Severe Acute Pancreatitis With Disseminated Intravascular Coagulation

T. Eguchi, T. Hasegawa, M. Kurosawa, H. Yamashita, T. Fukuchi, D. Itou, K. Ashida. Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan.

Background: Severe acute pancreatitis (SAP) is a poor prognostic disease that results in disseminated intravascular coagulation (DIC). DIC is a life-threatening disease characterized by blood coagulation and damage with inflammatory mediators such as IL-6, and high mobility group box 1(HMGB1). A recombinant human soluble thrombomodulin (rTM) has anti-coagulation and anti-inflammation effects, and which have been shown to improve patients with DIC in Japan.

Aim: To investigate the efficacy of rTM on hemostatic disturbance, and inflammation in SAP patients with DIC.

Method: We retrospectively analyzed 49 patients with SAP who diagnosed with the Japanese severity scoring system for acute pancreatitis. The patients was divided into two groups, one group without DIC (Control group, 24 patients) treated with the Japanese guidelines, and the other group with DIC (rTM group, 25 patients) treated with rTM. Diagnosis of DIC was based on the Japanese Association for Acute Medicine DIC diagnostic criteria (JAAM criteria).

Results: The more severities of the rTM group were as follows; 1) Average age (71.8:60.6), and SOFA score (3.47:2.33) were significantly higher in rTM group than Control group (p<0.05). 2) The FDP level (42.5:21.5 μg/mL), and IL-6 level (583.9:134.9 pg/mL) were significantly higher at day 0 (just before initiation therapy) in rTM group than Control group (P<0.05). After the treatment of rTM, JAAM criteria, SOFA score, FDP levels, IL-6 level in rTM group were significantly decreased from day 0 to day 7 (P<0.05). Furthermore, there were no differences in clinical outcome, which was hospitalization period, and mortality between the groups. In addition, HMGB1 in rTM group were a tendency to decrease from day 0 to day 7, although HMGB1 in Control group were not decreased.

Conclusion: rTM may be beneficial in improving SAP with DIC.

Oncolytic Adenovirus for Iodine Radiotherapy and Imaging of Pancreatic Cancer

B. Eidenschink,1 M. Trujillo,2 J. Morris,2 M. Sato,1 M. Yamamoto,1 J. Davydova.11Department of Surgery, University of Minnesota, Minneapolis, MN; 2Division of Endocrinology, Mayo Clinic, Rochester, MN.

Abstract: The employment of oncolytic adenoviruses (Ad) constitutes a promising alternative for cancer therapy. In this study, we combine the advantages of the infectivity-enhanced Ad, radioiodine therapy, and radionuclide imaging to develop a novel approach for pancreatic cancer treatment and detection.

We apply oncolytic Ad expressing the human sodium-iodide symporter (NIS) gene. The natural expression of NIS in the thyroid has been successfully exploited to achieve non-invasive imaging and radiotherapy of thyroid cancer. We hypothesized, that NIS expression in pancreatic cancer will allow noninvasive staging of the disease, and more importantly, will allow therapy with radioiodine 131I.

The structure of our Ad is designed to overcome low efficacy of current Ads and make them practical for systemic administration. Ad replication occurs exclusively in tumors through the inclusion of a tumor specific promoter. The new NIS-expressing Ad exhibited selective and greatly improved oncolytic potency in S2O13, S2VP10, AsPC1 and MiaPaca2 pancreatic cancer cells. Radioiodine uptake was shown to be time- and dose-dependent and was significantly greater than that with a replication-deficient counterpart. The therapeutic and imaging abilities of novel Ad were further evaluated in a prostate cancer model in mice. A single i.v. injection of Ad efficiently suppressed tumor growth and resulted in sufficient noninvasive SPECT/CT tumor imaging. Importantly, survival rate was greatly improved when it was combined with 131I. This indicates the feasibility of our system to treat and visualize cancer upon systemic Ad delivery and efficacy of combination therapy with 131I.

The imaging of NIS-expressing tissues requires only minimal diagnostic doses of radionuclide and can easily be performed in humans. Radioiodine safety has been well established during our ongoing Phase 1 clinical trial employing a replication deficient NIS-expressing adenovirus for men with prostate cancer (Directed by Dr. Morris). SPECT/CT imaging has shown substantial 123I uptake in a prostate of a patient who received the maximum viral dose (10^12 vp).

This proves that NIS can be over-expressed specifically in tumor cell and concentrate radioactive iodine. SPECT/CT imaging of selective NIS expression mediated by Ad will give more sensitivity and specificity than other existing imaging modalities. The combination of virotherapy with the strong bystander effect of 131I will offer a new approach for inoperable patients.

Valproic Acid Causes Pancreatitis by Inhibiting Histone Deacetylases and Provoking an Imbalance in Pancreatic Recovery

J.F. Eisses,1 Z.R. Dionise,1 S. Sah,1 S. Sarwar,1 A. Criscimana,2 A.I. Orabi,1 F. Esni,2 S.Z. Husain.11Pediatrics and 2Surgery, University of Pittsburgh, Pittsburgh, PA.

Abstract: A black box surrounds the mechanisms by which drugs induce pancreatitis. A definite cause of acute pancreatitis is due to the ingestion of the anti-epileptic drug valproic acid (VPA). Based on three crucial observations—(1) that VPA inhibits a class of epigenetic factors the histone deacetylases (HDACs); (2) that HDACs mediate pancreas development; (3) and that aspects of pancreas development are recapitulated during recovery of the pancreas after injury—we hypothesized that VPA predisposes patients to pancreatitis by inhibiting HDACs and provoking an imbalance in pancreatic recovery. In two complementary mouse models of pancreatic ablation and subsequent recovery—(1) caerulein hyperstimulation and in a (2) selective pancreatic (Pdx1-Cre) diphtheria toxin receptor (DTR)-expression transgenic—we found that by qPCR, Western, and nuclear acetylation, that pancreatic expression of class I HDACs (which are the primary VPA targets) rose at least 4-fold above adult baseline levels in the mid-phase of pancreatic recovery (p<0.05 for each assay). VPA given to mice, at doses and serum levels approximating human intake, inhibited pancreatic HDACs by 15-fold (p<0.05). Importantly, VPA also delayed recovery of the pancreas (up to 21 days post-caerulein) and, in the late phase of recovery, led to the persistence of acinar-to-ductal metaplastic complexes and Sox9 expression, as well as reduced cell proliferation; the findings characterize an arrest in embryonic reprogramming. None of these effects were observed with valpromide, an analog of VPA that lacks HDAC inhibition. This is the first demonstration of a key mechanism, through HDAC inhibition of pancreatic recovery, by which VPA shifts the balance towards pancreatic injury and pancreatitis. The work also unravels a new paradigm for therapies that could exploit epigenetics to enhance pancreatic recovery and thereby treat pancreatitis.

The ABO Gene in Pancreatic Cancer: Non-O Phenotypes Increase the Risk for PDAC

K. El Jellas,1,2 H. Immervoll,1,3 K.G. Hagen,4 S. Aziz,2 M.B. Kalvenes,1 S. Steine,1 D. Hoem,5 S. Johansson,6,7 A. Molven.1,2,61Gade Laboratory for Pathology, University of Bergen; 2Department of Pathology, Haukeland University Hospital, Bergen; 3Department of Pathology, Ålesund Hospital; 4Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen; 5Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen; 6KG Jebsen Center for Diabetes Research, University of Bergen; 7Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway.

Background: Several studies have observed a link between the ABO gene and the risk for pancreatic cancer. The mechanism for such an association is not known, although suggested explanations are an involvement of infections or an immunologically protective effect of blood group-like antigens produced by the pancreatic cancer cells.

Aim: To evaluate the association between ABO status and pancreatic cancer in a Norwegian cohort of pancreatic ductal adenocarcinomas (PDAC). To examine the A1/A2 subtypes and the patients’ resection status.

Methods: TaqMan genotyping assays were used to determine the ABO status for both cases (n=198) and healthy blood donor controls (n=379). Additionally, a larger group of hospital patients (n=6149) was used for comparison.

Results: A1 frequency was significantly higher in PDAC patients than blood donor controls (29.3% vs. 41.9 %, p=0.002, OR=1.74 (1.21-2.49)) but no association was seen with the A2 phenotype. The B frequency was higher in PDAC patients than hospital controls (7.7% vs. 12.6 %, p=0.012, OR=1.73 (1.12-2.66)). The O frequency was significantly lower in the group who presented non-resected tumors (both control groups).

Conclusions: Blood group A1 and B individuals are at a higher risk for PDAC. Blood type O individuals seem less susceptible for developing PDAC and when they do so, their tumors are more likely to be resectable, but this needs to be followed up in larger studies. Our results call for studies of the role of ABO glycosyl-transferases activity in the development of PDAC.

3 Cases of Main Duct Type Intraductal Papillary-Mucinous Neoplasm Which Recurred in the Remnant Pancreas After the First Pancreatectomy

A. Endo, H. Shimamura, K. Kanehara, K. Takeda. Department of Surgery, National Hospital Organization, Sendai Medical Center, Sendai, Japan.

Aim: Main duct type intraductal papillary-mucinous neoplasm (MDIPMN) is considered to have malignant potential and high risk of recurrence. Here we report 3 cases of MDIPMN who underwent the second op for recurrence in the remnant pancreases a few years after the first op, and discuss how to follow up.

Case 1: A 54-y-o man was diagnosed as MDIPMN, and underwent middle pancreatectomy. Pathology: intraductal papillary-mucinous carcinoma (IPMC) without parenchymal invasion. Resection margins: mild dysplasia. At the age of 65, he frequently suffered from pancreatitis, and fine exams disclosed recurrence of IPMN in pancreatic head. We performed pancreaticoduodenectomy (PD). Pathology: invasive carcinoma derived from IPMN.

Case 2: A 79-y-o woman was diagnosed as IPMN with nodular lesions in pancreatic tail, and underwent distal pancreatectomy (DP). Pathology: IPMC without invasion. Severe atypia was found in the resection stump, at which recurrence was found at the age of 82. We again performed DP. Pathology: IPMC without invasion.

Case 3: A 68-y-o woman was hospitalized due to acute pancreatitis, and we found IPMN in pancreatic head. We performed PD. Pathology: IPMC without invasion. Resection margin: no atypia. After 3 years, recurrence was found. Since IPMN lesions were spread all over the remnant pancreas, we performed total pancreatomy.

Discussion: It was common to the 3 cases that pathology was IPMC without parenchymal invasion. In two female cases, recurrence was found around 39 months after the first op, and pathology of recurrent lesion was IPMC. On the other hand, in the male case recurrence was found 125 months after the first op and pathology of recurrent lesion was invasive carcinoma derived from IPMN.

Conclusion: MDIPMN should be carefully followed up, considering possibility of recurrence. Around 3 years after the first op, recurrent lesion should be resected.

Diagnostic Yield of EUS-FNA Without On-Site Cytopathology Is Improved With Increased Number of Needle Passes

D. Eshtiaghpour, S. Reicher, V. Eysselein,A.Datta. Department of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA.

Background: On-site cytopathology may not be readily available during Endoscopic Ultrasound Fine-Needle Aspiration (EUS-FNA). Aim: To compare the cytological and diagnostic yield of EUS-FNA with three or less versus four or more needle passes in the absence of on-site cytopathology.

Methods: 150 consecutive EUS-FNA performed at our institution from July 2011 to January 2014 without on-site cytopathology were reviewed; 70/150 were three or less passes and 80/150 were four or more. Data were collected with regards to procedure indication, needle size, and number of needle passes. Indications included pancreatic mass, pancreatic cyst aspiration, gastric mass and lymphadenopathy. 19, 22, and 25 gauge Boston Scientific, Inc. needles were used during procedures. All procedures were performed by 3 experienced endosonographers. FNA needles of various sizes were often used during the same procedure.

Results: The cytological yield for procedures performed with three or less passes was 38/70 (54%), while the cytological yield for procedures performed with four or more passes was 56/80 (70%). The diagnostic yield for procedures performed with three or less passes was 12/70(17%), while the diagnostic yield for procedures performed with four or more passes was 42/80(53%). A 19, 22, and 25 g needle was used in 9/150(6%), 116/150(77%), and 49/150(33%), respectively.

Conclusion: When on-site cytopathology is not readily available, the cytological and diagnostic yield of EUS-FNA is improved if four or more rather than three or less needle passes are made.

COPII Dependent ER Export: A Critical Component of ZG Biogenesis and Acinar ER Homeostasis

J. Fang, X. Chen. Department of Physiology, Wayne State University, Detroit, MI.

Introduction: Zymogen granule (ZG) proteins are produced in the endoplasmic reticulum (ER), exported to the Golgi and then packaged into ZGs. Our goal is to understand the molecular mechanisms by which ZG proteins exit ER.

Methods: A recombinant adenovirus was created expressing human chymotrypsin C (CTRC)-mCherry fusion protein as a reporter to monitor ZG processing and trafficking. Adenoviruses expressing wild type Sar1 and its mutants, T39N and H79G, were also created to study COPII dependent ER exit. An in vitro COPII vesicle formation assay was developed using permeabilized AR42J cells.

Results: Using laser scanning confocal microscope, it was shown that CTRC-mCherry had punctate red fluorescence in the ZG region of acinar cells consistent with its targeting to ZGs. Furthermore, CTRC-mCherry was secreted upon CCK stimulation with a similar dose response as amylase. These results indicated that CTRC-mCherry was normally processed and targeted to ZGs behaving as an endogenous soluble ZG protein. Next, we treated the AR42J cells with wild type and mutant Sar1 viruses. Whereas wild type Sar1 showed no effect, mutant Sar1 caused profound defect in CTRC-mCherry processing and secretion including: 1) elevated cellular protein level; 2) abolished CCK stimulated secretion; 3) altered glycosylation with Endoglycosidase H resistance; 4) altered subcellular distribution and colocalized with ER marker. These results indicated that ER exit of ZG proteins is COPII dependent. Furthermore, it was found, using in vitro COPII budding assay, that digestive enzymes, amylase as well as CTRC-mCherry, were packaged into COPII vesicles same as known COPII vesicle markers. Finally, it was found that blockage of COPII dependent ER export in acinar cells induced strong ER stress.

Conclusions: Adenovirus mediated CTRC-mCherry expression can be used to monitor soluble ZG protein processing, trafficking and secretion. COPII dependent ER export is required for ZG biogenesis and is a critical component of acinar ER homeostasis.

Categorizing the Resection Plane in Neck of the Pancreas

N. Fard,1* A. Strauss,2* M. Birdsey,2 C. Weis,2 G. Emami,1 A. Mehrabi,1 L. Grenacher.21Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; 2Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany.

*Authors contributed equally.

Objectives: Morphology of the pancreas is believed to be related to incidence of pancreatic fistula which is the most common complication after distal pancreatectomy. However the studies about pancreas morphology in terms of surgical resection plane are few. This study focused on a novel method of classifying the pancreatic resection plane, and thus morphology in order to investigate the variety in normal population.

Materials and Methods: Retrospectively, 100 healthy patients (m = 70, f = 30) between 24–86 years, with abdominal CT images were selected. Two radiologists separately reconstructed the images with “Aquarius Workstation” with cross sections of the neck of the pancreas. Three slices were obtained for every patient in coronal view with a thickness of 1 mm. The pancreatic circularity of each image was calculated with a customized program in MATLAB. The results were characterized into three distinct groups. A value of 1 was used to describe a perfect circle.

Results: There was a strong correlation between two separate operators calculating pancreatic circularity for each slice (R = 0.871, 0.878, 0.865; P < 0.001). There was also strong correlation between slices 1 and 2, 1 and 3, 2 and 3 (R = 0.756, 0.609, 0.794; P < 0.001). The mean circularity for slices 1, 2 and 3 were 1.67, 1.62 and 1.56 respectively. The average combined circularity was 1.62. There was a significant difference between genders with respect to pancreatic circularity with Females having a less-circular pancreas (P < 0.01). The mean circularity for females and males were 1.71 and 1.57 respectively. There was no significant difference between pancreatic circularity with age (P > 0.05). 17% of the cases were classified as having a circular pancreas (M = 17, F = 3), 26% patients were classified as having a borderline shape pancreas (M = 21, F = 5) and 57% patients were classified as having an oval pancreas (M = 35, F = 22).

Conclusion: This study adds to existing knowledge of pancreas head/neck anatomy and its variation within the population. We could show that more than the half of the Patients has shown an oval pancreas and 26% borderline shape and 17% circular. Knowing these differences may be of help to choose an optimal closure method for the resection plane in pancreas left resection, which lead to better surgical outcomes.

Correlation of Serum High-Mobility Group Box 1 (HMGB1), Heat Shock Protein 70 (Hsp70) and Cytokines With Mortality and Severity in Acute Pancreatitis (AP)

E. Ferat-Osorio,1,2 I. Boscó-Gárate,1 J.L. Martínez-Ordaz,2 I. Wong-Baeza,3 L. Arriaga-Pizano,1 M. Gutiérrez-Mendoza,1 P. Sánchez-Fernandez,2 C. López-Macías,1 M. Pelaez-Luna,4 R. Torres-González,5 A. Isibasi.11Medical Research Unit on Immunochemistry; 2Gastrointestinal Surgery Department Specialties Hospital, National Medical Centre "SXXI", IMSS; 3Immunology Department, National School of Biological Sciences, IPN; 4Pancreas Clinic, INCMNSZ and Research Division, School of Medicine, UNAM; 5Health Research Division, Trauma and Orthopedic Hospital, IMSS, Mexico City, Mexico.

Introduction: Several pro and anti-inflammatory cytokines play important roles in AP. HMGB1 is a key mediator of inflammation and organ failure in severe AP; Hsp70 has cytoprotective roles. We measured serum concentrations of HMGB1, Hsp70 and cytokines in patients with AP and correlated them with the severity and prognosis of AP.

Methods: We included all consecutive patients admitted with diagnosis of AP. Severity was defined according to the revised Atlanta Criteria. Blood samples were obtained within the first 24 h, 3 and 7 days after the onset of AP. Serum concentrations of HMGB1 and Hsp70, TNF-α, IL-1β, IL-6, IL-8, IL-10 and IL-12 p70 were measured.

Results: Fifteen patients with AP (6 mild AP, 4 moderately severe AP and 5 severe AP) were included. Eight patients had an APACHE II score >8. Two patients died due to complications related to AP. Increased HMGB1 and decreased Hsp70 serum concentrations were associated with severe AP and death. TNF-α, IL-6 and IL-8 serum concentrations were higher in non-survivors, and in patients with an APACHE II score >8 and severe AP. Compared to survivors, deceased patients, had significantly higher serum concentrations of TNF-α, IL-6, IL-8 and HMGB1 on admission.

Conclusions: High serum levels of HMGB1 and low levels of Hsp70 are associated to a poor prognosis in AP. Hsp70 may have a protective role in AP. TNF-α, IL-6, IL-8, HMGB1 and Hsp70 serum levels on admission could assess the risk of death in AP.

Inhibitive Effect of Adenylyl Cyclases 1 and 3 on Pancreatic Cancer Cell Proliferation

E. R. Floyd, K. Bathala, L. Chavez, S. Quinn, M. E. Sabbatini. Department of Biological Sciences, Georgia Regents University, Augusta, GA.

Cyclic AMP (cAMP) is a secondary messenger that has controversial effects on cell proliferation in cancer cells. Adenylyl Cyclases (ACs) are enzymes which increase the levels of cAMP when activated. Nine transmembrane AC isoforms are known, and each one has its own pattern of expression and regulation. First, we establish which transmembrane AC isoforms are expressed in the pancreatic carcinoma epithelial cell line HPAC. Using RT-PCR we found five different isoforms: AC1, AC3, AC6, AC7 and AC9. The expression profile is similar to that in pancreatic duct cells, but AC1, which is only expressed in pancreatic cancer cells. Using Q-PCR, AC3 was found to be highly expressed in HPAC cells. Finally, we determine the role that overexpression of AC1 and AC3 plays in cell proliferation. Both human ADCY1 cDNA and human ADCY3 cDNA plasmids were used to overexpress AC1 and AC3, respectively. To confirm the increase in protein levels of the corresponding AC, both Western-blotting were used and cAMP levels were measured. Forskolin, which activates AC, decreased cell proliferation. The overexpression of AC1 and AC3 inhibits much more the cell proliferation stimulated with forskolin. In conclusion, AC1 and AC3 are responsible for the antiproliferative effect of cAMP in pancreatic cancer.

KRAS Mutations Occur as an Early Event in Neoplastic Transformation of Intraductal Papillary Mucinous Neoplasms of the Pancreas

S. Fritz,1 A. Tampakis,1 J.H. Youm,1 F. Bergmann,2 M. Klauss,3 L. Schneider,1 J. Kaiser,1 T. Hackert,1 O. Strobel,1 J. Werner,1 M.W. Büchler.11Department of General, Visceral and Transplantation Surgery; 2Institute of Pathology; 3Department of Diagnostic and Interventional Radiology; University of Heidelberg, Heidelberg, Germany.

Background: Progression from benign IPMN with low-grade dysplasia to invasive carcinoma is estimated to occur within 5–6 years. In pancreatic cancer, mutations in KRAS and p53 are known to play a crucial role in tumor progression. However, to date little is known about their significance in IPMNs. The present study aimed to investigate molecular pathomechanisms of neoplastic progression in IPMNs.

Methods: The grade of epithelial dysplasia (low, moderate, high-grade, and invasive carcinoma) and the subtype of IPMN (main-, branch-duct and mixed type) were classified in surgically resected IPMNs. Subsequently, these characteristics were correlated with the mutation status of KRAS and p53.

Results: At total of 92 IPMN specimens were genetically evaluated. KRAS mutations were observed in 7/28 IPMNs with low-grade dysplasia (25%) and in 22/46 patients with invasive carcinoma (48%). In contrast, p53 mutations were not found in IPMNs with low-grade and moderate dysplasia (0/34), whereas 16/56 patients (29%) with high-grade dysplasia and invasive carcinoma revealed this mutation. Overall, the incidence of KRAS mutations in main-duct and mixed type IPMNs (30/65) was significantly higher when compared to branch-duct IPMNs 5/26 (p = 0.019).

Conclusions: Activation of KRAS oncogene is an early event during neoplastic transformation in IPMNs. In contrast, mutations in the p53 tumor suppression gene occur later, most likely during the progression from moderate to high-grade dysplasia. From a molecular point of view, the risk of malignant transformation in branch-duct IPMNs seems to be lower compared to IPMNs with main-duct involvement.

Surgical Enucleation for Branch-Duct Type IPMNs: A Meaningful Alternative to Formal Pancreatic Resection

S. Fritz,1 J. Kaiser,1 M. Klauss,2 F. Bergmann,3 O. Strobel,1 L. Schneider,1 T. Hackert,1 M.W. Büchler.11Department of General, Visceral and Transplantation Surgery; 2Department of Diagnostic and Interventional Radiology; 3Institute of Pathology; University of Heidelberg, Heidelberg, Germany.

Background: Due to modern abdominal imaging, asymptomatic pancreatic cysts are clinically recognized with increasing frequency. Particularly small branch-duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMNs) are treated conservatively, partly due to the risk of surgical complications and the risk of developing diabetes following formal oncologic pancreatic resection. The present study aimed to evaluate the characteristics and clinical outcome of patients who underwent pancreatic enucleation for BD-IPMN.

Methods: From a prospective maintained database, all consecutive patients who underwent pancreatic enucleation for BD-IPMN at the University Clinic of Heidelberg between January 2004 and December 2013 were included. Clinical and pathological characteristics as well as surgical outcome were analyzed.

Results: A total of 68 enucleations for BD-IPMN were performed in 58 patients. The median age of all patients was 63 years (range: 39–79 years). The majority of BD-IPMNs were located in the head of the pancreas (59%). The mean operating time was 145 minutes (range: 75–255 minutes) and the mean blood loss 100 ml (range: 20–500 ml). No postoperative mortality was observed. The overall rate of pancreatic fistula was 24%. 9/14 (64%) of patients with fistula had type A or type B fistula, 5 patients suffered from type C fistula according to the International Study Group of Pancreatic Surgery. The median hospital stay was 10 days (range: 3–111 days).

Conclusions: Pancreatic enucleation for BD-IPMN can be performed with low morbidity and no mortality. The majority of postoperative pancreatic fistulas were of type A and B. Thus, pancreatic enucleation is a meaningful alternative to formal pancreatic resection in BD-IPMNs when indicated.

Early Stage Pancreatic Cancer in the Remnant Pancreas Diagnosed During Strict Surveillance After Resection of Main Duct Intraductal Papillary Mucinous Neoplasm: A Case Report

T. Fujimoto,1 T. Ohtsuka,1 K. Date,1 H. Kimura,1 T. Matsunaga,1 Y.Watanabe,1 K. Tamura,1 S. Takahata,1 Y. Oda,2 M. Tanaka.1Department of 1Surgery and Oncology, 2Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Background: We sometimes experienced the recurrent lesion in the remnant pancreas after partial pancreatectomy for main duct intraductal papillary mucinous neoplasms (MD-IPMN), even if the surgical margin is negative. The prevalence has been reported to be 3% to 15%. However, there are few studies regarding whether the recurrent lesion after resection of MD-IPMN might be the multifocal occurrence or residual lesion.

Case report: We report herein a 76-year-old Japanese male patient with early stage pancreatic cancer that developed in the remnant pancreas after resection of the pancreatic tail for MD-IPMN with high grade dysplasia (HGD). Surgical margins were negative for neoplastic cell at the time of initial operation. The patient was surveyed postoperatively every 6 months using alternate CT and MRCP, and thereafter a solid component in the pancreatic body was detected by CT 42 months after the initial operation. He subsequently underwent resection of the pancreatic body under the diagnosis of pancreatic cancer in the remnant pancreas. The pathological diagnosis was stage I (according to the classification of Japan Pancreas Society) of pancreatic carcinoma with mucin production. In addition, there was also another distinct MD-IPMN with HGD in the resected specimen. Those 2 lesions in the resected specimen of the remnant pancreas had positive MUC2 expression and mutant KRAS/GNAS, just as did the initial MD-IPMN.

Conclusion: MD-IPMNs might have a feature of skip progression. Strict surveillance is necessary after resection of MD-IPMN for the early detection of such skip lesions.

Surgical Resection for Initially Unresectable Pancreatic Cancer After Preoperative Therapy

K. Fukase,1 F. Motoi,1 Y. Katayose,2 M. Unno.11Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Integrated Surgery and Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Surgical resection is the only potentially curative therapy for pancreatic cancer. However, resection rate remains low because of advanced stage at initial diagnosis. Current standard therapy of these patients is limited to chemotherapy (CT) or chemoradiotherapy (CRT). The following therapeutic strategies for patients with favorable response to CT or CRT have been unclear.

Methods: Between 2007 and 2013, 23 patients with initially unresectable pancreatic cancer (IURPC) underwent surgical resection after being treated with CT or CRT. Retrospective analysis was performed to evaluate efficacy, prognostic factors and safety.

Results: 18 patients had locally advanced unresectable tumors and 5 patients had distant metastases. 16 patients were treated with CRT, 7 patients were treated with CT alone. After preoperative therapy for a median of 3.4 months (1.2-11.3), all patients underwent radical pancreatectomy (PD: 14, DP: 6, TP: 3), including resection of the distant metastases, 15 (65%) patients required vascular resection. The mortality and morbidity rates were 0% and 39%, respectively. A partial pathologic response to preoperative therapy (<50% viable tumor) was seen in 8 (35%) patients. The rate of successful R0 resection was 91%. 21 (91%) patients received adjuvant post-operative CT. The 1-year, 2-year and 5-year survival rates from initial therapy were 91%, 63% and 54%, respectively. The recurrence was documented in 11 (48%) patients. A multivariate analysis revealed that pathologic response (<50% viable tumor) (P = 0.08) and lymph node-negative (P = 0.005) were favorable factors for survival.

Conclusion: Surgical resection for IURPC with a favorable response to CT or CRT is efficacy and safety. Moreover, the overall survival and R0 resection rate were satisfactory.

Whole Exome Sequencing Uncovered Unexpected Recurrent Mutations in BRCA2 and FAT in Pancreatic Acinar Cell Carcinoma

T. Furukawa,1 M. Ameri,1 H. Sakamoto,1,5 Y. Kuboki,1,3 T. Hatori,2 M. Yamamoto,2 M. Sugiyama,5 N. Ohike,6 H. Yamaguchi,7 M. Shimizu,7 N.Shibata,4 K. Shimizu,3 K. Shiratori.31Institute for Integrated Medical Sciences and 2Depts of Gastroenterological Surgery, 3Gastroenterology, and 4Pathology, Tokyo Women’s Medical University, Tokyo, Japan; 5Dept of Surgery, Kyorin University School of Medicine, Mitaka, Japan; 6Dept of Pathology, Showa University School of Medicine, Tokyo, Japan; 7Dept of Pathology, Saitama Medical University International Medical Center, Hidaka, Japan.

Whole exome sequencing of cancer tissues potentially benefits patients cure by uncovering druggable targets. We performed whole exome sequencing of 3 acinar cell carcinomas of the pancreas, a rare and molecularly poorly understood tumor with a poor prognosis. On average, an acinar cell carcinoma harbored 65 nonsynonymous mutations and 22 indels with a rate of 3.4 mutations/Mb. By accounting for not only somatic mutations but also germline variations with loss of the wild-type allele, we found recurrent mutations in BRCA2 and FAT family genes. BRCA2 showed a somatic frameshift deletion as well as a germline nonsense variation in tumors with loss of the wild-type allele. FAT1, FAT3, and FAT4 showed somatic missense mutations as well as germline missense variations with loss of the wild-type allele. Immunohistochemical examination of the expression BRAC2 protein in 11 acinar cell carcinomas using formalin-fixed and paraffin-embedded tissues showed loss of BRCA2 expression in 5 of the 11 tumors. A patient with a tumor with the BRCA2 mutation experienced complete remission of liver metastasis by cisplatin. These results indicate that acinar cell carcinoma may harbor mutations in BRCA2 and FAT family genes, revealing BRCA2 a potentially crucial biomarker for sensitivity to chemotherapy in acinar cell carcinoma.

Enucleation is a Feasible and Safe Procedure for Selected Patients With Pancreatic Tumors

W. Gao, X. Liu, Z. Qian, C. Dai, K. Jiang, J.Wu, Q. Li, F. Guo, J. Chen, J.Wei, Z. Lu, Y.Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Surgery is the mainstay treatment for patients with pancreatic benign or low-grade malignant tumors. Traditionally, most of these patients underwent pancreaticoduodenectomy (PD), middle pancreatectomy (MP) or distal pancreatectomy (DP), while enucleation would only be considered in selected patients, mostly for tumor diameter ≤2 cm.

Aim: To compare the feasibility and outcomes of enucleation versus standard resection in patients with benign or low-grade malignant pancreatic tumors.

Methods: All patients with benign or low-grade malignant pancreatic tumors who underwent surgery in our center were retrospectively analyzed. Cases underwent enucleations were compared with those after standard resections (PD, MP or DP), in terms of pathology, tumor size, operation time, intraopertaive blood loss, overall morbidity, mortality, reoperation and postoperative hospital stay.

Results: Forty-four patients received enucleation between March 2006 to May 2014, with 7 patients had an additional anastomosis with jejunum. Indications included solid pseudopapillary tumors, serous/mucinous cystadenomas, intraductal papillary mucinous neoplasms, and neuroendocrine tumors. The mean diameter is 2.27 cm, including 22 cases >2 cm. Enucleations were associated with shorter operation time, less blood loss and shorter postoperative hospital stay compared with standard resections. Overall morbidity rate after enucleations was 40.9%, with pancreatic fistula (36.4%) the leading complication requiring prolonged drainage. Two patients required reoperation, while no death occurred.

Conclusions: Enucleations can be safely performed in selected patients with benign or low-grade malignant pancreatic tumors. For tumor >2 cm, it is still feasible when the Wirsung’s duct can be safely protected. However, oncological effects after enucleation is not assured and require support from long-term follow-up data.

Predictors of Parenchymal and Ductal EUS Abnormalities in Patients Without Pancreatic Disease

T.B. Gardner, S.R. Gordon. Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Purpose: The EUS diagnosis of chronic pancreatitis relies on nine parenchymal and ductal (Minimal Standard Terminology (MST)) criteria. However, there are concerns about the ability of EUS to distinguish between pathophysiologic and normal pancreatic changes. We performed prospective EUS examinations on patients without pancreatic disease to determine which factors contribute to the development of MST criteria.

Methods: Patients were prospectively enrolled at the time of their EUS for a non-pancreatic indication and completed a detailed questionnaire evaluating demographic, medical history, gastrointestinal symptoms alcohol and tobacco use information. EUS exams were performed by one of two expert endosonographers. A multivariable regression model was then created to determine which features were predictive of developing MST criteria.

Results: 68 patients were enrolled in the study and underwent EUS for 20 different indications. 74% of patients had either a ductal or parenchymal abnormality; 65% had a parenchymal finding and 49% had a ductal finding. Factors which were predictive of parenchymal abnormalities included age >50 (OR 2.2 95% CI 0.7-6.4), female gender (OR 2.0 95% CI 0.9-4.5), and BMI >30 (OR 1.3 95% CI 0.5-3.2). Diabetes mellitus (OR 1.0 95% CI 0.3-3.3), smoking >10 pack years (OR 1.1 95% CI 0.5-2.4), and current alcohol use (OR 1.0 95% CI 0.3-2.7) were not predictive of parenchymal abnormalities. Factors which were predictive of ductal abnormalities included male gender (OR 3.8 95% CI 1.4-10.4), age > 50 (OR 1.4 95% CI 0.4-4.4), and BMI >30 (OR 1.5 95% CI 0.3-3.5).

Conclusion: Minimum standard terminology parenchymal and ductal abnormalities are frequent in patients without pancreatic disease undergoing EUS. Advanced age is the most prominent predictor of having an abnormality.

Imaging Characteristics and Role of EUS-FNA in the Management of Solid Pseudopapillary Neoplasm (SPN) of the Pancreas

H. Gavini, D.L. Salvador, C. Chan, W. Ross, M. Bhutani, B. Weston, J.H. Lee. Department of Gastroenterology, Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX.

Background: Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas with an excellent prognosis (5 year survival ~ 95%) when resected.

Aim: To identify the imaging characteristics and evaluate the role of EUS-FNA in the preoperative diagnosis of SPN.

Methods: The study was approved by the institutional review board. A retrospective review identified all patients with a histopathological diagnosis of SPN in 2002-14.

Results: A total of 32 patients [median age 35 (13-59); 25 females (78%)] were identified. Most patients were symptomatic (75%) with a majority presenting with abdominal pain. A total of 32 lesions were identified [head (13), body (11), tail (8)]. CT scan was done in 30/32 patients and was diagnostic in 10 (33%), suspicious in 12(40%) and non-diagnostic in 8 (27%).

On CT (n = 30), the mass was mostly well defined [median size: 4.4 cm(1.1 cm-11.2 cm)] with 10 showing calcifications, 10 vascular enhancement, 11 cystic degeneration, and only 1 pancreatic ductal dilation.

A total of 13 patients underwent EUS-FNA confirming CT findings with correct diagnosis in 10/13 (77%). In 3/13, FNA showed 1 non-diagnostic sample, 1 neuroendocrine tumor, and 1 adenocarcinoma with no complications. 30/32 patients underwent surgery [central pancreatectomy (2), pancreatoduodenectomy (12), distal pancreatectomy (16). 2/32 patients did not undergo surgery; one declined surgery and the other had multiple comorbidities. There were no recurrences during a median follow-up of 48 months (range 1-131 months). A total of 2/30 patients who underwent surgery died (at 20 months and 34 months)

Conclusion: When compared with pancreatic ductal adenocarcinoma, SPN occurs in younger females; is often larger, well circumscribed with vascular enhancement, calcifications, rare pancreatic ductal dilation, and a better prognosis. EUS-FNA is safe and effective in providing a tissue diagnosis in SPN.

Early Organ Failure is Associated With a High Mortality in Acute Pancreatitis: A Systematic Review and Meta-analysis

J. George, S.Agarwal, R. Padhan, T.G. Jacob, P.K. Garg. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

Background: Mortality in acute pancreatitis (AP) is largely governed by organ failure (OF). There are 2 peaks of severity in AP – early and late. Although early OF has been shown to result in high mortality, the timing of the organ failure has not been given much attention. Late severity of AP is mainly due to sepsis. The revised Atlanta classification has dichotomized the severity of AP into mild and severe. Most studies have not distinguished between early and late severe AP with regard to the outcome.

Objective: Our objective was to find out the difference in the outcome between patients with early OF diagnosed as having early severe acute pancreatitis (ESAP) and those with late severe acute pancreatitis (LSAP).

Methods: A systematic review was conducted of all the relevant studies that have defined ESAP and a meta-analytic approach was adopted to compare the outcome i.e. mortality between ESAP and LSAP. The literature search was performed through MEDLINE/Pubmed, Embase, and Scopus databases to find out the studies highlighting relevance of the timing of organ failure and severity of AP. Severe acute pancreatitis (SAP) was defined according to the original Atlanta classification. ESAP was defined as early persistent OF within the first 7 days of the onset of AP. Patients with SAP but without early OF were diagnosed as having LSAP. The relevant studies were reviewed and the data obtained from them were analyzed to estimate the proportion of ESAP and LSAP among severe AP, the mortality in ESAP and LSAP, and the Odds Ratio (OR) of mortality in ESAP compared to LSAP.

Results: A total of 378 studies were identified and 11 of these were finally selected for review and meta-analysis. There were 1783 patients who had severe AP. Of these 1783 patients, 599 (29.99% [27.46 - 32.51]) had ESAP. The overall mortality in severe AP was 16.08% [95% CI 14.22 - 17.94]. However, the mortality in ESAP group was significantly higher at 34.06% [95% CI 29.39 - 38.72] compared with the mortality in LSAP (8.08%, [95% CI 4.71 - 11.45]; p < 0.01). The OR of fatal outcome in ESAP compared with LSAP was 9.43 [95% CI 5.47 - 16.28].

Conclusions: The ESAP subgroup had an extremely high mortality. The recognition of the concept of ESAP is important not only for prognostication and early referral but also for designing therapeutic trials for targeted therapy.

Bedside Electromagnetic Guided Placement of Nasojejunal Feeding Tubes in Patients After Pancreatoduodenectomy: Prospective Single-Center Pilot Study

A. Gerritsen,1 A. Duflou,2 M. Ramali,2 O. Busch,1 D. Gouma,1 E. Mathus- Vliegen,2 M. Besselink.1Dept of 1Surgery and 2Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.

Background: Bedside electromagnetic (EM) guided nasojejunal feeding tube placement by nurses has been found to be a simple, safe and cost-effective strategy in several patient categories. To date, however, an altered anatomy of the upper gastrointestinal tract is seen as a relative contraindication.

Aim: To determine the success rate of bedside EM-guided placement of nasojejunal feeding tubes in patients after pancreatoduodenectomy (PD).

Methods: We performed a prospective single-center pilot study in all patients requiring a nasojejunal feeding tube after PD (July 2012 - March 2014). EM-guided nasojejunal tubes were placed by two specialized nurses with extensive experience with the technique. Primary endpoint was the success rate of primary tube placement confirmed on plain abdominal x-ray (AXR). Success was defined as the tip of the tube positioned in the efferent jejunal limb.

Results: In our study period, 55 of 126 (44%) patients who underwent PD required a nasojejunal feeding tube. In 36 patients the tube was placed under EM-guidance at a median of 8 (6–11) days after pancreatoduodenectomy. Initial tube placement was successful according to the nurse in 25 (69%) patients and on AXR in 21 (58%) patients. Median procedure time was 25 (15–35) minutes. 22 (61%) patients underwent 50 replacement procedures after previously failed placement attempts (n = 27) or after luxation or blockage of the tube (n = 23). 36 replacements were performed endoscopically and 14 under EM-guidance. No tube (re)placement related complications occurred.

Conclusions: Bedside EM-guided placement of nasojejunal feeding tubes after PD was successful in 58% of patients, which seems acceptable given the potential benefits for the patient. Based on these findings we have included patients after PD in an ongoing randomized multicenter trial comparing EM-guided to endoscopic placement.

Diagnostic Value of a Pancreatic Mass on Computed Tomography in Patients Undergoing Pancreatoduodenectomy for Presumed Pancreatic Cancer

A. Gerritsen,1,2 T. Bollen,3 C. Nio,4 Q. Molenaar,1 M. Dijkgraaf,5 H. van Santvoort,1 J. Offerhaus,6 L. Brosens,7 K. Biermann,8 E. Sieders,9 K. de Jong,9 R. van Dam,10 E. van der Harst,11 H. van Goor,12 B. van Ramshorst,13 B. Bonsing,14 I. de Hingh,15 M. Gerhards,16 C. van Eijck,17 D. Gouma,2 I. Borel Rinkes,1 O. Busch,2 M. Besselink2 for the Dutch Pancreatic Cancer Group. 1Dept of Surgery, University Medical Center Utrecht, 2Academic Medical Center Amsterdam, 9University Medical Center Groningen, 10Maastricht University Medical Center, 11Maasstad Ziekenhuis Rotterdam, 12Radboud University Medical Centre Nijmegen, 13St.Antonius Hospital Nieuwegein, 14Leiden University Medical Center, 15Catharina Hospital Eindhoven, 16OLVG Amsterdam, 17Erasmus Medical Center Rotterdam, Dept of Radiology, 3St. Antonius hospital Nieuwegein, 4Academic Medical Center Amsterdam, 5Clinical Research Unit, Academic Medical Center Amsterdam, Dept of Pathology, 6University Medical Center Utrecht, 7Academic Medical Center Amsterdam, 8Erasmus Medical Center Rotterdam, The Netherlands.

Background: Some 5-14% of patients undergoing pancreatoduodenectomy for suspected malignancy are ultimately diagnosed with benign disease.

Aims: To determine the diagnostic value of a pancreatic mass on computed tomography (CT) in patients with presumed pancreatic cancer and the additional value of reassessment by expert-radiologists.

Methods: We performed a multicenter retrospective cohort study in 1629 consecutive patients undergoing pancreatoduodenectomy for suspected malignancy (2003–2010). All patients with an unexpected benign diagnosis postoperatively were included in a 1:3 ratio with random patients with (pre)malignant disease. The preoperative CT-scan was reassessed by two blinded expert-radiologists separately and subsequently in consensus.

Results: 86 patients with benign and 258 patients with (pre)malignant disease were included. In 66% of patients a mass was reported in the original CT-report versus 48% and 50% on reassessment by the two expert-radiologists separately and 44% in consensus (P < 0.001 vs. original report). Interobserver agreement among expert-radiologists was moderate (kappa = 0.47, 95%CI 0.38-0.56). 167/212 (79%) masses identified in the original report proved to be malignant after pancreatoduodenectomy versus 139/150 (93%) masses identified in expert-consensus (P < 0.001). The sensitivity, specificity, positive predictive value and negative predictive value of masses identified in the original CT-report were 68%, 42%, 79%, and 7%, respectively. For masses identified in expert-consensus these were 54%, 87%, 98%, and 12%, respectively.

Conclusion: In patients with presumed pancreatic cancer, the diagnostic value of a pancreatic mass on CT is high, whereas the absence of a mass cannot rule out malignancy. Expert-radiologists less frequently identified a pancreatic mass as compared to the original CT-report, with doubled specificity for malignancy.

Feeding Patients With Gastric Outlet Obstruction Undergoing Pancreatoduodenectomy: Routine Tube Feeding Versus Early Oral Feeding

A. Gerritsen,1,2 R. Wennink,2 G. Kazemier,3 I. Borel Rinkes,2 D. Gouma,1 O. Busch,1 Q. Molenaar,2 M. Besselink.11Dept of Surgery, Academic Medical Center, Amsterdam; 2University Medical Center, Utrecht; 3VU Medical Center, Amsterdam, The Netherlands.

Introduction: Early oral feeding is now considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). However, patients with preoperative symptoms of gastric outlet obstruction (GOO) may have such a high risk of delayed gastric emptying (DGE) that preoperative GOO remains an indication for routine postoperative tube feeding.

Aim: To compare the clinical outcomes after PD with routine tube feeding versus early oral feeding in patients with preoperative GOO.

Methods: A multicenter retrospective cohort study was performed in all consecutive patients undergoing PD in three tertiary referral centers between 2010 and 2013. GOO was defined as two or more of the following preoperative symptoms: nausea, vomiting, loss of appetite, dysphagia, or postprandial complaints. Patients with GOO were categorized into two groups based on the applied feeding strategy postoperatively: routine tube feeding or early oral feeding per protocol (with on-demand tube feeding). Primary outcome was time to resumption of adequate oral intake.

Results: Of 484 patients undergoing PD, 79 (16%) had preoperative symptoms of GOO. Of these 79 patients 30 (28%) received routine tube feeding and 49 (62%) early oral feeding. Time to resumption of adequate oral intake (13 (7–65) vs. 14 (4–69) days, P = 0.61), incidence of DGE (40% vs. 41%, P = 0.94) and length of hospital stay (13 (7–67) vs. 13 (4–46) days, P = 0.11) did not differ between the two feeding strategies. Of the patients receiving early oral feeding, 24 of 49 (49%) patients ultimately received a postoperative feeding tube on-demand.

Conclusion: In patients with preoperative GOO undergoing PD, clinical outcomes were comparable between routine tube feeding and early oral feeding. Since half of patients with GOO tolerate early oral feeding after PD, there may be no added value of routine tube feeding in these patients.

Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis

I. Gomatos,1 C. Halloran,1 M. Raraty,1 J. Evans,2 P. Ghaneh,1 H. Smart,3 R. Yagati-Satchidanand,1 J. Garry,1 P. Whelan,1 F. Hughes,1 F. Polydoros,4 H Wei,1 R. Sutton,1 J. Neoptolemos.11Departments of Surgery, 2Radiology and 3Gastroenterology, NIHR Pancreas Biomedical Research Unit and Liverpool Clinical Trials Unit4, Royal Liverpool University Hospital, Liverpool, UK.

Background: This study examines the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) from severe necrotizing pancreatitis in a single center.

Methods: Between 1997 and 2013 all patients with necrotizing pancreatitis at the NIHR Liverpool Pancreas BRU were reviewed. Outcome measures were analyzed by intention to treat.

Results: There were 399 patients that initially had either MARPN (276, 69.2%) or OPN (118, 29.6%); missing data in 5 (1.3%). 32 MARPNs also had OPN and 3 OPNs also had MARPN. Endoscopic necrosectomy was used additionally in 15 MARPNs and in 5 OPNs. Complications occurred in 153 (55.4%) patients who had MARPN and 82 (69.5%) in OPN (p = 0.013); operation-related complications were less frequent in MARPNs (70 (25.4%) vs 45 (38.1%), p = 0.016); the median (IQR) postoperative ITU stay was less for MARPN (0 (0, 7) vs 3.5 (1, 12) days, p <0.001); but median (IQR) overall hospital stay was increased for MARPN (97.5 ( 75–132) vs 71.5 (40–103) days, p < 0.001). The mortality rate was 42 (15.2%) in MARPNs and 28 (23.7%) in OPNs (p = 0.061). Both the mortality and the overall complication rate were significantly decreased between 1997–2008 and 2008–2013 (45 (24.1%) vs 25 (12.1%) p = 0.002 respectively; 124 (66.3%) vs 111 (53.6%), p = 0.018 respectively). Age (p < 0.001), preoperative ITU stay (p = 0.011), preoperative multiple organ failure (p = 0.001), date of operation before 2008 (p = 0.011) and MARPN (Odds Ratio = 0.31; 95% CI = 0.15, 0.64; p = 0.002) were independent predictors of mortality.

Conclusions: These results confirm the role of MARPN in reducing death and complications within a multimodality approach.

Pigment Epithelium-Derived Factor (PEDF) Inhibits Wnt-Mediated Epithelial-Mesenchymal Transition in Primary PanIN Cells

J. Gong,1 G.S. Belinsky,1 B.N. Sreekumar,2 A. Rhim,3 C. Chung.1,21Sections of Digestive Diseases, Dept of Medicine, Yale University School of Medicine, New Haven, CT; 2Veterans Affairs Connecticut Healthcare System; 3University of Michigan Medical School, Ann Arbor, MI.

Background: Epithelial-mesenchymal transition (EMT) and dissemination into distant organs by pancreatic intraepithelial neoplasia (PanIN) cells can occur prior to the formation of a primary tumor. Wnt/β-catenin signaling is necessary for EMT, however, its role in pancreatic carcinogenesis remains unclear. Our group previously showed that the secreted tumor suppressive protein pigment epithelium-derived factor (PEDF) modulates Wnt/β-catenin signaling, and its absence promotes invasive cystic pancreatic neoplasms. In this study, we tested PEDF-mediated effects on Wnt/β-catenin signaling and its effect on EMT in PanIN cells.

Methods: Two primary murine PanIN cell lines, PI5505 (PanIN-2) and PI34 (PanIN-3) were generated from Pdx-Cre; LSL-KrasG12D; p16fl/fl; YFP mice at 6 wks of age. Primary PanIN cells were treated with PEDF protein for 0.5, 2 and 21 h. The Wnt/β-catenin pathway and EMT markers were determined by qPCR and immunoblotting. Functional effects on EMT in PanIN cells were quantified by wound scratch assay and transwell migration assays.

Results: Wnt ligands 3a and 5a (100 ng/ml) induced EMT in PanIN (PI5505) cells and was blocked by PEDF. PEDF-mediated inhibition of EMT decreased the mesenchymal markers (vimentin and Zeb1) and increased E-cadherin. PEDF treatment of P15505 but not PI34 cells led to a 40% decrease in thrombospondin 1 (ThbS1) expression (p < 0.001). In contrast, addition of Wnt ligands with PEDF led to a more than five-fold increase in ThbS1, a mediator of senescence in oncogenic Kras cells. Interrogation of Wnt signaling revealed that the active Wnt receptor, p-LPR6, and active β-catenin, were down-regulated by PEDF. Following 21 h PEDF treatment, wound closure in the PEDF-treated group was ~50% less compared to controls in PI5505 cells (p < 0.001), but not in PI34 cells (p = ns). Similarly, a 70% reduction in transwell migration in P15505 cells occurred with PEDF. No inhibition was observed in response to PEDF in PI34 cells.

Conclusion: The endogenous tumor suppressor PEDF can inhibit Wnt-mediated EMT changes in PanIN-2 but not PanIN-3 cells. These effects may be mediated by the induction of ThbS1 in response to Wnt ligands.

Pulmonary Embolism After Laparoscopic Distal Pancreatectomy: Report of a Case

T. Goto,1 I. Matsumoto,2 M. Shinzeki,3 H. Toyama,1 S. Asari,1 H. Kinoshita,1 T. Matsumoto,1 K.Kuramitsu,1 M. Tanaka,1 M. Kido,1 T. Ajiki,1 T. Fukumoto,1 Y. Ku.11Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan; 2 Department of Surgery, Kinki University Hospital, Osaka, Japan; 3Department of Surgery, Saiseikai Nakatsu Hospital, Osaka, Japan.

We report a case of pulmonary embolism after laparoscopic distal pancreatectomy. A 63-year old woman (BMI: 22.7) was admitted to our hospital for evaluation of an abdominal tumor that had been detected by PET-CT for postoperative examination of parotid gland tumor. A 3 cm cystic lesion was identified in the pancreas body, and a huge hepatic cyst in the right lobe. The pancreas tumor was diagnosed as an MCN. We performed laparoscopic distal pancreatectomy and splenectomy. No intraoperative complications were seen. We performed routine thromboprophylaxis. On the 10th post-operative day, the patient presented acute respiratory distress, drowsy consciousness, and circulatory collapse. CT scan showed a massive pulmonary embolism (PE) and deep vein thrombosis (DVT). Anticoagulation therapy with heparin was immediately started and inferior vena cava filter was placed to prevent PE. Pulmonary function was progressively restored in subsequent weeks. The patient was discharged from the hospital on the 29th post-operative day.

Usually laparoscopic surgery is considered to be less invasive compared to laparotomy and is regarded as a relatively minimal risk procedure for postoperative complications because of the reduced surgical stress and earlier mobilization. Venous thromboembolism (VTE) in association with laparoscopic surgery may be caused by detrimental effects of pneumoperitoneum on venous flow and activation of the hemostatic system. In this case, huge hepatic cyst may also contribute to the risk in developing venous thrombosis. For prevention of VTE, it is important to take into consideration the patient’s individual risk factors and comorbidities.

Sox9 Regulates Erbb Signalling In Pancreatic Cancer Development

A. Grimont,1 A.V. Pinho,2,3 M.J. Cowley,2,3 C. Augereau,1 A. Mawson,2,3 M. Giry-Laterrière,2,3 G. Van den Steen,1 N. Waddell,3,4 M. Pajic,2,3,6 C. Sempoux,5 J. Wu,2,3,6 S.M. Grimmond,3,4,7 A.V. Biankin,2,3,6,7 F. P. Lemaigre,1 P. Jacquemin,1 I. Rooman.2,3,61Université catholique de Louvain, de Duve Institute, Brussels, Belgium ; 2The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Sydney, Australia; 3Australian Pancreatic Cancer Genome Initiative; 4Queensland Centre for Medical Genomics, Institute for Molecular Bioscience, University of Queensland, Queensland, Australia; 5Department of Pathology, Université catholique de Louvain, Cliniques Universitaires St Luc, Belgium ; 6St Vincent’s Clinical School, University New South Wales, Australia; 7Wolfson Wohl Cancer Centre, University of Glasgow, Scotland, United Kingdom.

*equally contributing authors.

Rationale: The transcription factor SOX9 was recently shown to stimulate ductal gene expression in pancreatic acinar-to-ductal metaplasia (ADM) and to accelerate development of premalignant lesions preceding pancreatic ductal adenocarcinoma (PDAC).

Objective: Here we investigate how SOX9 operates in pancreatic tumorigenesis.

Methods and Results: We analyzed genomic and transcriptomic data from surgically resected PDAC, and extended the expression analysis to xenografts from PDAC samples and to PDAC cell lines. SOX9 expression was manipulated in human cell lines and mouse models developing PDAC. We found genetic aberrations in the SOX9 gene in about 15% of patient tumors. Most PDAC samples strongly express SOX9 protein, and SOX9 levels are higher in classical PDAC. This tumour subtype is associated with better patient outcome and responds to therapy targeting epidermal growth factor receptor (EGFR/ERBB1) signalling, a pathway essential for pancreatic tumorigenesis. In human PDAC, high expression of SOX9 correlates with expression of genes belonging to the ERBB pathway. In particular, ERBB2 expression in PDAC cell lines is stimulated by SOX9. Inactivating Sox9 expression in mice confirmed its role in PDAC initiation; it demonstrated that Sox9 stimulates expression of several members of the ERBB pathway and is required for ERBB signalling activity.

Conclusions: By integrating data from patient samples and mouse models, we found that SOX9 regulates the ERBB pathway throughout pancreatic tumorigenesis. Our work opens perspectives for therapy targeting tumorigenic mechanisms.

Pancreaticojejunostomy Stenosis After Pancreatic Surgery: An Emerging Problem

F. Guo, Z. Qian, C. Dai, K. Jiang, J.Wu, W. Gao, Q. Li, J. Chen, J. Wei, Z. Lu, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Stenosis of pancreaticojejunostomy (PJ) is one of the long-term complications after surgery with pancreaticojejunal anastomosis. As patients with long-term survival increase, this complication increasingly draws people’s interest.

Aims: To introduce a simple and effective surgical intervention for PJ stenosis.

Methods: Six patients with past history of pancreatic resection were identified with PJ stricture. Laparotomy was carried out and PJ was partially re-done to restore patency of the anastomosis.

Results: Repeated onset of abdominal pain was the chief complaint of all patients, who had previous pancreatic resections with PJ for benign tumors. CTexaminations showed a dilated Wirsung’s duct in pancreatic remnant without identifiable mass or stones. The PJ was partially cut open at anterior aspect of the anastomosis, leaving posterior side intact. Stricture at the side of pancreatic stump was incised open to the dilated duct, and a compatible opening was made at the jejunal side. After ruling out recurrence by frozen section, a partially new-made PJ was accomplished by placing absorbable stitches between pancreatic parenchyma and full thickness of jejunal wall. The pancreatic duct and jejunal mucosa should be diligently approximated together. Follow-up studies showed no recurrent symptoms after reoperation.

Conclusions: PJ stenosis is not a rare complication after pancreatectomies, especially in patients with benign disease. Surgery remains a safe and reliable method in relieving the anastomotic stricture. Our choice of partial reconstruction of the PJ effectively diminish the stenosis while simplify the surgery to the maximum extent.

Role of Endothelin Axis in Recruitment of Tumor Associated Macrophages in Pancreatic Cancer

S. Gupta,1 S. Rachagani,1 S.L. Johansson,2 S. Kumar,1 S.K. Batra,1,3,4 K. Datta, M. Jain.1,3,41Departments of Biochemistry & Molecular Biology; 2Pathology & Microbiology; 3Eppley Institute for Research in Cancer & Allied Diseases; 4The Fred and Pamela Buffet Cancer Center; University of Nebraska Medical Center, Omaha, NE.

Background: While pancreatic cancer (PC) is characterized by active infiltration of tumor-associated macrophages (TAM), the mechanism of TAM recruitment is poorly understood. We studied the role of endothelin (ET) axis in TAM recruitment in pancreatic tumor microenvironment.

Methods: Expression of ET receptors A (ETAR) and B (ETBR) in TAM in human and KPC mice tumors was determined by co-staining for macrophage markers and the expression in murine and human macrophage cell lines was determined by immunoblotting. The effect of ET-axis antagonism on TAM recruitment was investigated in KPC mice using dual ET receptor inhibitor Bosentan. The impact of ET-axis antagonism on tumor cell-induced migration of murine (RAW 264.7) and human (U937) macrophage-like cell lines was studied using Boyden chamber assay in the presence of ETAR (BQ123), ETBR (BQ788) and dual (Bosentan) ET receptor antagonists.

Results: The incidence of ETAR and ETBR expression in infiltrating immune cells in human PC tumors was 29.5 % and 43% respectively. Dual staining indicated that both human and murine TAM predominantly express ETBR. In macrophage-like cell lines, high levels of ETBR were detected independent of their differentiation status. Treatment of 20 wk KPC with dual ET receptor antagonist for 10 days resulted in >50% reduction (p < 0.008) in TAM infiltration in autochthonous tumors. ET-axis antagonism with specific and dual ET receptor antagonists reduced tumor cell-induced macrophage migration in vitro. While the effect of BQ123 was marginal (13% inhibition), BQ788 and Bosentan resulted in 73% and 68% inhibition of macrophage migration respectively.

Conclusions: ET-axis contributes to TAM recruitment in PC by promoting macrophage chemotaxis via ETBR receptors expressed on macrophages.

Targeting Endothelin Axis in Pancreatic Tumor Microenvironment

S. Gupta,1 M.A. Macha,1 S. Rachagani,1 S.L. Johansson,2 S.M. Lele,2 L.M. Smith,3 S.K. Batra,1,4,5 M. Jain.1,4,51Departments of Biochemistry & Molecular Biology; 2Pathology & Microbiology; 3Biostatistics 4Eppley Institute for Research in Cancer & Allied Diseases; 5The Fred and Pamela Buffet Cancer Center; University of Nebraska Medical Center, Omaha, NE.

Background: Components of tumor microenvironment (TME) are critical determinants of tumor progression in pancreatic cancer (PC). Our recent studies suggest that Endothelin-1 (ET-1), and ET receptors A (ETAR) and B (ETBR) are overexpressed in tumor and stromal cells. Here we characterized the expression pattern of ET receptors in PC TME and studied the impact of targeting ET axis.

Methods: The expression pattern of ETAR and ETBR was studied in human and KPC mice tumor tissues with CK19, α-SMA, F4/80 (or CD68), CD31 as markers for epithelial cells, stellate cells, macrophages and blood vessel, respectively. The effect dual ET receptor antagonist Bosentan was studied in KPC mice and histopathological changes were studied for apoptosis, macrophage infiltration, and desmoplasia. The effect of ET-axis antagonists on the proliferation of tumor and stellate cells in vitro was studied using MTT assay.

Results: In both human and murine tumor tissues, CK19 positive tumors cells expressed both ETAR and ETBR while α-SMA positive PSCs predominantly expressed ETBR. Blood vessels predominantly expressed ETAR and macrophages expressed ETBR. The incidence of ETAR and ETBR expression on blood vessels was 61% and 32%, respectively while that on infiltrating immune cells was 29.5 % and 43%, respectively in human PC tumors. Bosentan treatment resulted in a significant increase in the apoptotic cells and decrease in the number of infiltrating macrophages along with marked reduction in the desmoplasia in autochthonous murine tumors. ET-axis antagonists resulted in a significant reduction in the proliferation of tumor and stellate cells in a dose dependent manner.

Conclusions: ET-axis exhibits pleiotropic effects and its antagonism results in significant modulation of PC TME.

A Novel Human Specific lncRNA SZP1 Regulates Components of Polycomb Repressor Complex in Pancreatic Cancer

P.B. Hajeri,1 W.-O. Lui,2 S. Subramanian.11Department of Surgery, University of Minnesota, Minneapolis, MN; 2Department of Molecular Genetics, Karolinska Institute, Sweden.

Non-coding RNAs (ncRNA) are implicated in the pathogenesis of many cancer types. NcRNAs affect key cellular processes like chromatic remodeling, transcriptional activation/repression, protein inhibition and posttranscriptional modifications. Most of the ncRNA candidates discovered are limited to only a subset of cancers and based out of screening in animal models and cell lines. Although multiple factors have been established in contributing to cancer, some are factors master regulators as they act higher in the hierarchy and regulate key signaling pathways and genes. Polycomb Repressor Complex (PRC2) component EZH2 is one such candidate and inhibitors of EZH2 are projected as novel therapeutic agents. Here, we have identified a novel human specific lncRNA SZP1 which can regulate the expression of PRC2 components like EZH2 and SUZ12. We have observed this novel lncRNA SZP1 is overexpressed in pancreatic and colon cancer tissue samples and cell lines compared to their normal and benign counterparts, suggesting its role in cancer pathobiology. By overexpressing this lncRNA in HEK293T cells we have identified that this lncRNA induces expression of PRC2 components and various other genes/miRNAs that are implicated in cancer. We also found significant increase in the level of H3K27me3 levels indicating this lncRNA functions through PRC2 complex and by altering chromatin modifications. We also observed significant overexpression in specific Alu elements indicating increased genomic instability in these cells. Together, our data suggest that SZP1 functions a master control of gene expression and can be investigated as a novel therapeutic target in pancreatic cancer.

The MiR-365 Increases Gemcitabine Resistance by Regulating Cell Cycle and Apoptosis-related Molecules

S. Hamada, A. Masamune, T. Shimosegawa. Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.

Background: We have been identified that the microRNA expression profiles in invasive ductal adenocarcinoma of the pancreas (IDA) and intraductal papillary mucinous neoplasm differ, which affected the invasion-related cellular functions. In addition to these microRNAs, a microRNA miR-365 was found to be highly expressed in IDA, whose function in pancreatic cancer cells has not yet been described. We examined the biological function of miR-365 using human pancreatic cancer cell lines in the current study.

Methods: Introduction of miR-365 or siRNA was performed by lipofection. Down-regulated genes by miR-365 were screened by microarray. MiR-365 target genes were estimated by TargetScan database. Direct interaction between target genes’ 3’UTR and miR-365 was assessed by 3’UTR assay.

Results: Introduction of miR-365 increased cell viability after gemcitabine treatment in Panc-1 and AsPC-1. MiR-365 also attenuated BrdU incorporation and cell cycle progression. Microarray analysis identified the decreased expression of cell cycle-promoting genes E2F2 and CCNE1. On the other hand, promoters of apoptosis, SHC1 and BAX were also attenuated. Knockdown of SHC1 and BAX expression by siRNA resulted in the increased cell viability after gemcitabine treatment. SHC1 and BAX mRNAs contained specific sequences that could interact with miR-365. The luciferase reporter activity containing these 3’UTR sequences was repressed by miR-365, suggesting direct targeting of these genes by miR-365.

Conclusion: Current study identified the miR-365/SHC1/BAX axis that contributes to the cell survival against gemcitabine. Inhibitory effects on cell proliferation also might be beneficial for cell survival in a context-dependent manner.

High-Risk Pancreatic Cancer Patients and Quality of Life

S. Han, J. Kheder, D. Kaufman, L. Bocelli, A. Wachholtz, W. Wassef. Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA.

Background: Pancreatic Cancer is the 4th leading cause of cancer-related deaths in the US, stressing the importance of early identification of high-risk patients. Patients are identified as being high-risk based on risk factors including family history, history of chronic pancreatitis, genetic mutations, and smoking. High-risk patients often receive genetic testing and surveillance EUS to assess their risk. No study has assessed the quality of life in these patients.

Methods: 10 patients in our high-risk Pancreatic Cancer (CA) clinic were divided into 2 groups, consisting of asymptomatic and symptomatic patients. The control group consisted of 52 “healthy” medical students. Demographic data was collected and all groups received a PANQOLI (PANcreatitis Quality Of Life) questionnaire to address quality of life. Genetic testing and EUS results were collected in the high-risk group.

Results: There were no demographic differences between the 2 high-risk groups, but the asymptomatic group had a significantly better quality of life (p <0.04). 100% of the asymptomatic group had a 1st degree family history of Pancreatic CA, while only 40% of the symptomatic group had a family history (p <0.04). In addition, the symptomatic group had a 40% incidence of SPINK1 mutation, while the asymptomatic group had no SPINK1 mutations. The symptomatic group also had a higher incidence of moderate to severe chronic pancreatitis on EUS (p <0.04). The control group had a significantly better quality of life than either of the high-risk groups (p <0.001).

Conclusions: The symptomatic group had a poorer quality of life, highlighting the inequality between these subgroups within this high-risk population. The asymptomatic group had a worse quality of life as well compared to the control group, suggesting that asymptomatic patients do not have entirely “healthy” lives. High-risk patients and their risk factors should be identified early to better address their needs

Quality of Life in Smokers With Chronic Pancreatitis

S. Han, J. Kheder, L. Bocelli, A. Wachholtz, W. Wassef. Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA.

Background: The link between smoking and Chronic Pancreatitis (CP) is well-established, and smoking has been known to accelerate the course of CP. What is unknown however is how smoking affects quality of life in CP. This study aims to compare smokers and non-smokers with CP in terms of quality of life measures.

Methods: 53 patients followed in our Chronic Pancreatitis clinic (previously diagnosed by EUS) were given a series of questionnaires including the Short-Form 12, Michigan Alcohol Screening Test (MAST), Drug Alcohol Screening Test (DAST), Hospital Anxiety and Depression Scale (HADS), Pancreatitis Quality of Life Instrument (PANQOLI), Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R), Brief Cope 24, MUST nutrition screen, and Visual Analog Scale for pain (VAS) to address quality of life measures. Demographic data was also collected and smokers were compared with non-smokers in terms of questionnaire scoring.

Results: The non-smoking group had a significantly better quality of life in terms of PANQOLI scoring (p <0.01). There was also higher rates of opiate abuse in the smoking group based on SOAPP-R scores (p < 0.04) as well as higher rates of depression in terms of the HADS scoring (p < 0.005). Smokers also had poorer coping skills in terms of the Brief Cope 24 (p < 0.03). There were no significant demographic differences between the 2 groups.

Conclusions: In this comparison between smokers with CP and non-smokers with CP, several screening instruments found significant differences, most notably in quality of life, depression, coping skills, and opiate abuse. This highlights the various issues that plague this subset of CP patients, while illustrating potential areas for future interventions. Lastly, this study speaks to the importance of emphasizing smoking cessation in patients with CP.

Risk of Other Cancers in Familial Pancreatic Cancer

T. Hanna,1 J. Nicholson,1 S. Harrison,1 M. Johnstone,1 P. Ghaneh,1 R. Sutton,1 T. Brown,2 D. Bartsch,2 G.Webster,2 M. Lerch,2 P. Hammal,2 J. Neoptolomos,1 W. Greenhalf1 on behalf of the EUROPAC research group. 1NIHR, Pancreatic Biomedical Research Unit, Liverpool University, Liverpool, UK; 2EUROPAC Research Group.

Introduction: EUROPAC specifically registers families with apparent autosomal dominant predisposition for pancreatic cancer (FPC). There is a risk that the appearance of autosomal dominance results from selection bias.

Aim: To determine if pancreatic cancer (PDAC) risk in FPC is associated with risk of other cancers.

Methods: Families registered with EUROPAC were divided according to the number of cases of pancreatic and other cancers. Kaplan-Meier analysis was used to compare cancer risk.

Results: We assessed 424 families with 6,055 individuals, 976 deaths from PDAC and 508 from other cancers. Lifetime risk of all forms of cancer were lower than in the general population with the exception of PDAC 51.9% (95%CI: 50.0,53.9) and gastric cancer; 4.4% (3.1,5.7) cf 1.57% from National Statistics.

Including censored data, PDAC occurs later in families with gastric cancer (median age 67 vs 72 years, P = 0.001). The age of death of PDAC (excluding censored data) was equivalent in gastric and non-gastric families. In families where PDAC was restricted to one generation there was no significant difference (71 years, P = 0.729). Families with 2 cases of PDAC had equivalent PDAC risk in gastric/Non-gastric families. Of 130 FPC families with 3 or more affected individuals, 33 had gastric cancers (Median age of PDAC 67 years vs 73 years in gastric families, P = 0.005).

Conclusion: Gastric cancer is a competing risk with PDAC, but not in those families that are most likely to originate by chance cluster. Evidence that FPC individuals without PDAC are divided into high and low risk strongly supports genetic predisposition without selection bias.

Incidence of Thromboembolism and Significance of Plasma D-Dimer Levels in Pancreatic Cancer Patients

T. Harada,1 H. Inoue,1 R.Yamada,1 Y. Takei.11Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Japan.

Background: Pancreatic cancer is known to be associated with venous thromboembolism (VTE), but contemporary rates of incidental and symptomatic VTE events and their association with prognosis are incompletely understood. Elevated levels of D-dimer are frequently observed in patients with venous thromboembolism (VTE) and malignancy.

Methods: We investigated the incidence of VTE before treatment in 66 consecutive patients with pancreatic cancer. D-dimer levels prior to initial treatment were examined in all patients. Venous ultrasonography of the lower extremities was performed in patients with D-dimer ≥1.0 μg/ml. Deep vein thrombosis (DVT) in the pelvis or abdomen and pulmonary thromboembolism (PTE) was diagnosed by enhanced computed tomography.

Results: Eleven patients (16.7% 10 DVT, 4 PTE, 1 cerebral infarction) were diagnosed with thromboembolism. All DVT and PTE cases are diagnosed asymptomatic. Patients with VTE had a significantly poorer survival than patients without VTE (The median survival times were 154 days vs 483 days, p = 0.007). Plasma D-dimer level of patients with VTE was significantly higher than patients without VTE (p = 0.007). Plasma D-dimer level was significantly higher in metastatic disease (P =0.02).

Conclusion: Our data suggest that the occurrence of VTE may be associated with poor prognosis in pancreatic cancer patients.

Plasma D-dimer level of pre-treatment may be useful in the prediction of survival and screening VTE.

Bcl-2 Family Inhibitors Effectively Sensitize Human Pancreatic Cancer Cells to TRAIL

Y. Hari,1 N. Harashima,2 A. Kidani,1 H. Hayashi,1 Y. Kawabata,1 M. Harada,2 S. Yano,1 Y. Tajima.11Department of Digestive & General Surgery, Shimane University Faculty of Medicine, Shimane, Japan; 2Department of Immunology, Shimane University Faculty of Medicine, Shimane, Japan.

Background: Pancreatic cancer cells are relatively resistant to cytotoxic chemotherapeutic drugs, and patients with pancreatic cancer generally show poor prognosis. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) can induce apoptosis in various types of cancer cells without damaging normal cells, whereas some pancreatic cancer cells are resistant to TRAIL. Alternatively, Bcl2-family molecules play an important role in apoptosis in cancer cells, and several types of inhibitors clinically applicable have been developed.

Purpose: In this study, we determined whether combination with Bcl-2 family inhibitors could sensitize TRAIL-resistant human pancreatic cancer cells to TRAIL.

Methods and Results: As Bcl-2 family inhibitors, ABT-263 and ABT-199 were used: ABT-263 inhibits Bcl-2, Bcl-xl and Bcl-w, but ABT-199 inhibits Bcl-2 and Bcl-w. Among 9 human pancreatic cancer cell lines, 6 lines were TRAIL-resistant. Among these 6 cell lines, 2 lines were highly sensitive to ABT-263 alone, whereas the other TRAIL-resistant 4 cell lines showed the increased sensitivity to TRAIL when treated with ABT-263, but not with ABT-199. Immunoblot assay revealed that the combination of TRAIL and ABT-263 induced activation of both caspase-8 and caspase-9. Regarding AsPC-1, which showed the highest synergistic effect, selective knockdown of Bcl-xL with RNA interference enhanced TRAIL-induced apoptosis.

Conclusions: These results indicate that Bcl-2 family proteins, especially Bcl-xL, play a crucial role in TRAIL-resistance of human pancreatic cancer cells, and that TRAIL and ABT-263 could be a promising combination for the treatment of pancreatic cancer.

Clinical Profiles and Outcomes in Type 2 Autoimmune Pancreatitis (AIP): the Mayo Clinic Experience

P. Hart, M. Levy, T. Smyrk, N. Takahashi, B.A. Dayyeh, J. Clain, F. Gleeson, R. Pearson, B. Petersen, M. Topazian, S. Vege, L. Zhang, S. Chari. Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN.

Introduction: Type 2 AIP requires pancreatic histology for definitive diagnosis; recently clinical criteria for probable type 2 AIP have been proposed. It remains uncommonly diagnosed and has limited disease characterization. We report our experience with type 2 AIP.

Methods: From our AIP database through May 2014 we identified adult subjects with definitive (n = 31, (core biopsy n = 15, resection n = 16)) or probable (n = 12) type 2 AIP according to the International Consensus Diagnostic Criteria. We obtained clinical data from medical records and patient interviews and using the Kaplan–Meier method determined relapse free survival after diagnosis.

Results: Subjects with definitive and probable type 2 AIP had similar demographic profiles (median age at diagnosis 36.5 years vs 27.0, respectively; 54.8% vs 50.0 male). The most common presentations were acute pancreatitis (AP) (n = 25, 58.1% (including 12 (27.9%) with recurrent acute pancreatitis)) and pancreatic mass/obstructive jaundice (n = 15, 34.9%). IBD was diagnosed in 19 (44.2%); 14 (32.6%) had ulcerative colitis. Management included steroids (n = 20), surgery (n = 15) or observation (n = 8). The cumulative relapse rate was 10.6% at median follow-up of 2.9 years. All relapses (n = 4) occurred in subjects with AP treated with steroids. A second course of steroids prevented further relapses, and no subject required long term maintenance therapy. Decreased relapse free survival was associated with presentation with AP (p = 0.05) and steroid therapy (p = 0.05).

Conclusions: Type 2 AIP often presents with acute and recurrent AP which is steroid responsive. Relapse of pancreatitis can occur after steroid therapy, but long term therapy is not needed. The clinical profile and natural history of type 2 AIP are distinct from that of type 1 AIP, suggesting it is a distinct disease.

Obstructive Jaundice in Autoimmune Pancreatitis Can Be Safely Treated With Corticosteroids Alone Without Biliary Stenting

P. Hart, Y. Bi, J.E. Clain, M.B. Farnell, F.C. Gleeson, M. L. Kendrick, R. Law, M. J. Levy, R.K. Pearson, B.T. Petersen, L.D. Pisney, T.C. Smyrk, N. Takahashi, M. D. Topazian, S.S. Vege, S.T. Chari. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Introduction: Autoimmune pancreatitis (AIP) frequently presents with obstructive jaundice for which patients undergo ERCP with biliary stenting. AIP is characterized by dramatic improvement in symptoms, liver test abnormalities, and radiographic findings after steroid treatment. We report on the effectiveness and safety of treatment of obstructive jaundice with corticosteroids alone in AIP.

Methods: From our AIP database, we identified 16 patients with AIP type 1 who had 17 episodes of jaundice managed with corticosteroids without biliary stent placement. Episodes were reviewed for efficacy, improvement in liver test abnormalities, as well as treatment-related complications.

Results: Of 17 episodes of jaundice, 9 were at initial presentation, 7 at the first and 1 at second relapse. The majority of patients were male (16/17) with mean age 67.4 (range 44–93) years. Jaundice resolved in all patients without need for biliary stenting. Follow-up liver tests at 4 days (range 1–14) of starting prednisone (20–40 mg, mean dose 36.9 mg,) were available for 13 (76.5%) episodes. Prior to corticosteroids mean values of liver tests were AST 198 u/l (4xULN), ALT 307 u/l (6xULN), alkaline phosphatase 533 u/l (5xULN), and total bilirubin 6 mg/dl (6xULN). At first follow-up the decrease was 54.9 ± 36.3% for AST, 51.6 ± 25% for ALT, 33 ± 25.2% for alkaline phosphatase and 47.2 ± 27.5% for total bilirubin (all p < 0.05). There were no episodes of cholangitis or other infectious complication during steroid treatment.

Conclusions: Obstructive jaundice in AIP can be safely and effectively treated with corticosteroids alone without biliary stenting. The role of an ultra rapid steroid trial in individuals with obstructive jaundice to distinguish AIP from pancreatic cancer needs further study.

Pancreatic Polypeptide Response to a Mixed Meal as a Marker of Pancreatic Cancer Associated Diabetes: A Pilot Study

P. Hart, E. Baichoo, Y. Kudva, S. Chari. Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN.

Introduction: Pancreatic polypeptide (PP) is a hormone predominantly secreted by islet cells in the ventral pancreas, and is believed to participate in glucose homeostasis. It has recently been proposed that blunted PP response to a mixed meal can distinguish pancreatogenic diabetes mellitus from other types of DM. We performed a pilot study to determine if PP response to a mixed meal could discriminate DM secondary to pancreatic cancer (PaCDM) from new onset type 2 DM (T2DM).

Methods: We studied 16 subjects with new onset (<12 months duration) DM; 8 had PaCDM and 8 had T2DM, matched for age and gender. We measured serum PP levels at 0, 30 and 60 minutes following ingestion of a mixed meal drink. The absolute and proportional (% over baseline) increases in PP levels were compared for the two groups using the Wilcoxon test.

Results: Baseline PP levels were similar in the two groups. In T2DM the PP increase over baseline in response to mixed meal was similar at 30 min (median 131%, IQR: 117–290) and 60 min (median 98%, IQR, 38–297). In PaC patients, the median increase in PP levels over baseline was significantly lower in those with a tumor located in the pancreatic head (n = 5) compared to the body/tail (n = 3) at 30 minutes (37% vs. 159%, p = 0.04) and possibly at 60 minutes (28% vs. 167%, p = 0.07). Compared to T2DM subjects, PaCDM subjects with a pancreatic head tumor had a smaller increase in PP levels at 30 (37% vs. 131%, p = 0.01), and possibly at 60 minutes (28% vs. 98%, p = 0.07).

Conclusions: Compared to T2DM subjects, those with PaCDM have a blunted PP response to a mixed meal, which is more prominent for those with a tumor in the pancreatic head. Whether this reflects loss of PP-producing cells due to involvement of ventral pancreas needs further study.

Cell-surface Profiling Reveals Ecto-5’-Nucleotidase (CD73) is Overexpressed in Pancreatic Cancer

R. S. Haun,1,2 C. M. Quick,3 E.R. Siegel,4 A. J. Tackett.51Central Arkansas Veterans Healthcare System; Departments of 2Pharmaceutical Sciences, 3Pathology, 4Biostatistics, and 5Biochemistry & Molecular Biology, University of Arkansas for Medical Sciences; Little Rock, AR.

Aim: To identify cell-surface markers that may be used for development as diagnostic/therapeutic targets for pancreatic cancer.

Methods: Pancreatic cancer cell lines BxPC-3, MIAPaCa-2, and Panc-1 were grown in the presence of peracetylated N-azidoacetylmannosamine to metabolically label N-linked glycoproteins. Cell-surface glycoproteins were tagged with biotin using click chemistry, purified by streptavidin-coupled magnetic beads, separated by gel electrophoresis, and identified by liquid chromatography-tandem mass spectrometry (MS). A protein identified by glycoproteome profiling, CD73, was evaluated by immunohistochemistry in sections of pancreatic ductal adenocarcinoma and non-neoplastic pancreatic tissues.

Results: MS/MS analysis of peptides from the three cell lines revealed 694 unique proteins enriched in the azido sugar samples relative to control sugar samples. A comparison of the proteins identified in each sample indicated almost 7% of these proteins were present in 2 cell lines (51 of 694) and 6 of the proteins were found in all 3 cell lines examined. Twenty three of the proteins identified in more than one cell line are predicted to reside in the extracellular space or plasma membrane. Immunohistochemical analysis of one of these proteins, CD73, in human pancreatic tissues indicates it is significantly overexpressed in pancreatic tumors compared to normal pancreas.

Conclusion: We have demonstrated that metabolic labeling with bioorthogonal chemical reporters can be used to selectively enrich and identify novel cell-surface glycoproteins expressed in pancreatic ductal adenocarcinomas.

Body Mass Index and Outcomes in a Cohort of Resected Pancreatic Cancer Patients

A. Hendifar, A. Osipov, J. Naziri, W. Yang, N. Nissen, R. Tuli. Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine, Los Angeles, CA.

Background: Although obesity is associated with increased incidence of pancreatic cancer, its effect on survival or outcomes is under investigation. Recently, in two large prospective cohorts, higher prediagnostic body mass index (BMI) was associated with statistically significantly decreased survival among patients with pancreatic cancer. We evaluated BMI and associated outcomes in a single institution cohort of resected patients with pancreatic adenocarcinoma.

Methods: We evaluated 2073 consecutive pancreatic cancer patients at a single institution, from 2008 – 2103, of which 135 underwent resection with curative intent. BMI was calculated at diagnosis and we evaluated its effect on overall survival. We then developed a multivariate cox proportional hazards model including Age, BMI, Race, tumor location, and use of adjuvant therapy.

Results: In patients with a BMI less than 30, overall survival was 14 months and in patients with BMI over 30, overall survival was 11 months. However, this difference was not significant (p = 0.4444). In univariate analysis, ca 19–9, use of adjuvant therapy, and race were significantly associated with overall survival. In multivariate analysis, only use of adjuvant therapy (p ≤ 0.001) and stage at resection (p ≤ 0.0246) were significantly associated with survival.

Conclusions: In a cohort of resected pancreatic cancer patients, our analysis suggests that BMI at diagnosis is not associated with survival. We plan on evaluating post-operative morbidity and mortality to help inform our findings. In our multivariate model, only use of adjuvant therapy and Caucasian race was significantly associated with improved outcomes suggesting socioeconomic factors may play a role.

Hypercalcemia and Pancreatitis: Experience in a Single Mexican Institution

J. Hernandez-Calleros,1 M. Janka-Zires,2 P. Almeda-Valdes,2 L.F. Uscanga- Dominguez,1 M. Pelaez-Luna.11Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico; 2Department of Endocrinology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico.

Introduction: Hypercalcemia is a rare but well established cause of acute and chronic pancreatitis. Hypercalcemia-related pancreatitis is mainly secondary to primary hyperparathyroidism (HPT). The prevalence of pancreatitis in HPT varies widely; most studies have reported an increased prevalence while others report a frequency around 1.5%, similar to the normal population. These contradictory findings suggest that additional disease-modifying factors may play a role in the development of pancreatitis in HPT. It has been described that abnormal increase of cytosolic calcium triggers acute pancreatitis. In addition, there are studies showing that a combination of both hypercalcemia and variants in the SPINK1 or CFTR genes, increase the risk to develop pancreatitis in HPT. In 1988 the prevalence of pancreatitis secondary to HPT at our Institute was 12.1%.

Objective: To describe the current prevalence of pancreatitis secondary to HPT at the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran.

Material and methods: Retrospective cross-sectional study of 390 patients diagnosed with HPT between 1987 and 2012.

Results: Among 390 cases of HPT, 30 (7.69%) cases with acute or chronic pancreatitis were documented. 73% were male, 33% had history of alcoholism, 36% had history of cholecystectomy, 40% had history of ureteral calculi, and 36% had more than one episode of pancreatitis. The average calcium level was 14.18 mg/dL (9.3 to 18.6), the mean parathyroid hormone level was 269 pg/mL (72 to 594), and the average vitamin D level was 18 ng/mL (7 to 38).

Conclusions: We found a decrease in the prevalence of pancreatitis in patients with primary hyperparathyroidism from 12.1% to 7.69%. This is probably due to an early diagnosis of asymptomatic hyperparathyroidism as a result of routine measurement of calcium in recent years.

Diet-Induced Obesity Results in Robust Differential Inflammation of Peripancreatic and Visceral Adipose Tissue Depots in the KrasG12D Mouse Model of Pancreatic Cancer

K.M. Hertzer, A. Moro, O.J. Hines, G. Eibl. Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Obesity increases the risk of pancreatic cancer (PaCa); however, the driving mechanism is poorly understood. Although previous work has shown that a high fat, high calorie diet (HFCD) increases weight gain, increases pancreatic inflammation, and accelerates neoplasia in KrasG12D mice, it is unclear how a HFCD promotes neoplasia. We were interested in further investigating the mechanisms of PaCa promotion by a HFCD and specifically to understand the effects of the HFCD on peri-pancreatic (PPF) and visceral (VF) fat to determine how they may contribute to pancreatic inflammation and the acceleration of pancreatic neoplasia seen in previous studies. Using a diet-based obesity model we focused specifically on changes in the fat depots of WT or KrasG12D mice. We found that adipose tissue gain correlated strongly with weight gain in both WT and KrasG12D mice on a HFCD. In addition, both WT and KrasG12D mice on a HFCD exhibited significant increases in inflammatory foci in the VF as well as PPF fat depots compared to animals on a CD. Using multiplex assays we measured cytokine levels in the VF and PPF of WT and KrasG12D mice. We found significant differences in >10 cytokines (including G-CSF, VEGF and IL-13) in VF and PPF depots independent of diet and >10 cytokines whose levels changed specifically in the PPF of mice fed a HFCD (including IFNγ, IL-22, and MCP-1). Our results demonstrate that a HFCD leads to obesity and inflammatory changes in the VF and PPF. In addition, we see clear phenotypic differences between VF and PPF in the cytokine profile both independent and dependent of diet, showing that these depots may be functionally different and that dietary induced changes may contribute to the acceleration of pancreatic neoplasia in HFCD-fed KrasG12D mice.

Clinical Course of Poorly Differentiated Pancreatic Adenocarcinoma after Surgical Resection

N. Hieda,1 H. Imaoka,1 N. Okuno,1 T. Yoshida,1 T. Sato,1 H. Tsutsumi,1 T. Hujiyoshi,1 T. Yogi,1 M. Ishihara,2 T. Tanaka,2 S. Hijioka,1 K. Hara,1 M. Tajika,2 N. Mizuno,1 Y. Shimizu,3 Y. Niwa,2 K. Yamao.11Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan; 2Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan; 3Department of Gastrointestinal Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan.

Background and Aim: Poorly differentiated pancreatic ductal adenocarcinoma (PPDA) is one of the subtypes of pancreatic ductal adenocarcinoma (PDAC). Despite many reports of postoperative recurrence, few studies have investigated postoperative survival. The purpose of this case–control study was to clarify the clinical course of PPDA after surgical resection.

Methods: We evaluated the clinical course and pathological characteristics of PPDA between November 2004 and October 2013. As controls, PDAC cases were also evaluated.

Result: Of 223 cases of pancreatic malignant neoplasm, 28 cases of PPDA and 195 cases of PDAC were identified. Median disease-free survival was 8.35 months in the PPDA group and 14.9 months in the PDAC group (P = 0.012). Pathologically, lymphovascular and venous invasion were more common in the PPDA group than in the PDAC group (ly0-1 vs. ly2-3, P = 0.008; v0-1 vs. v2-3, P = 0.020). Median overall survival (OS) was 21.9 months in the PDDA group and 31.4 months in the PDAC group (P = 0.918).

Conclusion: This study showed that postoperative recurrence was more common in the PPDA group than in the PDAC group. However, no significant difference in OS was seen between these pathologies.

Pancreatic Pseudocyst With Pseudoaneurysm Perforating to the Stomach: A Case Report

K. Hirose,1 M. Hattori,1 M. Tomita,1 H. Kanazawa,1 S. Isobe,1 Y. Suzuki,1 S. lshihara,2 A. Horiguchi,2 K. Inui.31Department of Gastroenterology, Yamashita Hospital, Ichinomiya, Japan; 2Department of Pancreatobiliary Surgery, Fujita Health University, Toyoake, Japan; 3Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Nagoya, Japan.

In December 2010, a 74-year-old man was admitted to our hospital because of ascites. He had been treated at another hospital for alcoholic chronic pancreatitis. In serum, the pancreatic-amylase concentration was 1022 U/L; in ascitic fluid, this was 11268. Computed tomography 4 weeks after admission disclosed a pseudocyst, 3 cm in diameter, in the body of the pancreas as well as pancreatolithiasis affecting the head. Despite treatment with a protease inhibitor for 6 weeks, the pseudocyst expanded. After endoscopic retrograde cholangiopancreatography demonstrated multiple stones and strictures involving the main pancreatic duct proximal to the pseudocyst, we performed endoscopic sphincterotomy of the minor papilla and endoscopic pancreatic stenting. When the patient manifested hematemesis 6 weeks later, emergency upper gastrointestinal endoscopy identified bleeding from an exposed artery within an active gastric ulcer located at the angular notch of the lesser curvature. After hemostasis was achieved by endoscopic clipping, interventional angiography was performed at Fujita Health University Hospital to treat a pseudoaneurysm of the right gastric artery. The gastric ulcer, pancreatic pseudocyst, and pancreatic stones resolved, while the stricture of the main pancreatic duct was found to have decreased upon removal of the pancreatic stent. Discharged 5 months after initial admission, the patient has been asymptomatic without pseudocyst recurrence for 1 year. While pancreatic pseudocysts penetrating to the gastrointestinal tract with pseudoaneurysm are rare and difficult to treat, we diagnosed and treated this man successfully using endoscopic and interventional procedures.

Metallic Biliary Stenting vs. Surgical Bypass in the Palliative Management for Malignant Distal Biliary Obstruction in Unresectable Pancreatic Ductal Adenocarcinoma

T. Hisano, Y. Nagasio, T. Suzuki, M. Furukawa. Department of Hepato-biliary-pancreatology, National Kyushu Cancer Center, Fukuoka, Japan.

The management for palliation of malignant distal biliary obstruction in patients with unresectable pancreatic adenocarcinoma comprise biliary stent placement or surgical bypass. This retrospective study compared reobustruction rate and survival in the consecutive patients. We identified a total 56 patients, of whom 20 underwent surgical bypass (bypass group) and 36 underwent endoscopic or percutaneously metallic stent placement (stent group). The bypass group is composed of 6 women and 14 men who were 48–83 years old (median 64.5 years) and the stent group is composed of 15 women and 21 men who were 41–83 years old (median 63 years). As for the number of recurrent biliary obstruction there was no case in the bypass group but 15 in the stent group after 7 to 393 days (median, 71 days) (0 vs. 41.6%). The median survival was 225 days in the stent group and was 321 days in the bypass group. There was no difference between in postoperative survival time between the bypass group and stent group (log-rank 0.6419). Stent placement is less invasive and is recommended for the treatment of biliary obstruction in patients with clinically unresectable pancreatic cancer. Because of the lower ratio of reobustruction, however, bypass surgery is acceptable for the treatment of patients diagnosed as having inoperable pancreatic cancer at laparotomy and who were observed infiltration into the duodenum and may be required bypass.

Predicting Success of Catheter Drainage in Infected Necrotizing Pancreatitis

R.A. Hollemans, T.L. Bollen, S. van Brunschot, O.J. Bakker, U. Ahmed Ali, H. van Goor, M.A. Boermeester, H.G. Gooszen, M.G. Besselink, H.C. van Santvoort for the Dutch Pancreatitis Study Group.

Introduction: Catheter drainage as the first treatment step of infected necrotizing pancreatitis is successful in at least 30% of patients. It is currently not possible to predict which patients will also need necrosectomy. We evaluated predictive factors for success of catheter drainage in infected necrotizing pancreatitis.

Methods: We performed a post-hoc analysis of 130 prospectively included patients who underwent primary catheter drainage for (suspected) infected necrotizing pancreatitis. Using logistic regression we evaluated the association between success of catheter drainage (i.e. survival without necrosectomy) and 22 factors regarding demographics, disease severity (e.g. APACHE-II score, organ failure) and morphologic characteristics on CT (e.g. percentage/distribution of necrosis). The model was internally validated by bootstrapping.

Results: Drainage was performed percutaneously in 113 patients and endoscopically in 17 patients. Infection was confirmed in 116 patients (89%). Catheter drainage was successful in 45 patients (35%). In bootstrapped multivariable regression, the following variables were associated with success of catheter drainage: male gender (odds ratio[OR] 0.27; 95%-confidence interval[CI] 0.09-0.55; P < 0.01), multi-organ failure (OR 0.15; 95%-CI 0.04-0.62; P < 0.01), percentage of pancreatic necrosis (<30%/30-50%/>50%: OR 0.54; 95%-CI 0.30-0.96; P = 0.03 and heterogeneous collection (OR 0.21; 95%-CI 0.06-0.67; P < 0.01). A prognostic nomogram including these factors yielded success probability of catheter drainage ranging from 2% (all factors present) to 91% (none of the factors present).

Conclusion: Female gender, absence of multi-organ failure, low percentage of necrosis and a homogeneity of the collection are independent predictors for success of catheter drainage in infected necrotizing pancreatitis. The constructed nomogram can be used as a tool for prognostication in clinical practice.

CCK-mediated ERK Activation is Required for Pancreatic Regeneration After Pancreatitis

B.J. Holtz1 J.A. Williams.1,21Departments of Physiology and 2Internal Medicine, University of Michigan Ann Arbor, MI.

Introduction: Pancreatic regeneration following acute pancreatitis requires acinar cell dedifferentiation, proliferation, and redifferentiation. ERK signaling contributes to many proliferative processes including CCK-mediated pancreatic adaptive growth but whether ERK is necessary for pancreatic regeneration following pancreatitis is unknown.

Aim: To evaluate the role of CCK and ERK signaling in pancreatic regeneration after injury.

Methods: Exocrine injury was induced by 8 caerulein injections over 2 consecutive days in CCK−/− or control mice. Trametinib, a novel MEK inhibitor active in vivo, was given daily by oral gavage. Inhibitors were given prior to caerulein injections and tissue was harvested at 7 d to study pancreatic acinar cell recovery. Pancreatic wet weight, protein, and DNA was measured. Mitogenesis and digestive enzymes were measured by western blot, IHC, and IF at 24 h and 7 d.

Results: Peak of exocrine injury was observed at 24 h after the last dose of caerulein when pancreatic digestive enzyme concentration was 40-60% of controls and pancreatic protein and DNA were reduced. Damage was similar in CCK−/− and WT mice. Regeneration was largely complete at 7–10 d in WT mice when acinar cell morphology and pancreatic digestive enzyme concentration were near control levels but was delayed in CCK−/− mice and blocked in Trametinib treated mice. Ki-67 and cell-cycle proteins were activated at 24 and 48 h. CCK deficiency or Trametinib caused an inhibition of mitogenesis and cell-cycle proteins at 24 h and a 35-45% reduction in pancreatic mass and a 40-50% inhibition of protein and DNA at 7 d. Pancreatic digestive enzyme concentrations were 55-70% of controls. Cell division returned to normal by 7 d in WT mice but was still elevated in CCK−/− mice.

Conclusion: ERK inhibition or CCK deficiency caused pancreatic mass, protein, and DNA to be blocked or delayed during regeneration. CCK is a major stimulator of ERK activation and in its absence regeneration is delayed.

Treitz Ligament Approach for Artery First PD

A. Horiguchi, S. Ishihara, M. Ito, Y. Asano. Department of General Surgery Pancreatic Surgery, Fujita Health University, Toyoake, Japan.

Background/Purpose: During a pancreatoduodenectomy (PD) it is important to fully understand the arcade of blood vessels in the head of the pancreas before the surgery to reduce intraoperative bleeding. In most of our patients, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, forms a short common trunk with the first jejunal artery (FJA). Thus, it is easy to locate the IPDA by locating the origin of the FJA. There are two ways to locate the IPDA: to measure the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA or to measure the distance between the origin of the middle colic artery (MCA) and that of the FJA. In this study, we measured both distances using 3D models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discussed which distance can be more easily measured to help determine the location of the IPDA.

Methods: One-hundred-forty patients underwent 64 -MD-CT to acquire early and late arterial phase images. The distance between the SMA origin and the FJA origin and the distance between the MCA origin and the FJA origin were measured.

Results: In patients whose IPDA formed a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA origin was helped determine the location of the IPDA during PD in these patients.

Conclusions: Considering that the distance between the IPDA origin and the MCA origin was short, it was demonstrated that it is effective to locate the MCA origin to determine the location of the PIPDA.

Rab27A and Rab27B Regulate Secretion in Mouse Pancreatic Acini through Different Pathways

Y. Hou, S. I. Lentz, J. A. Williams. Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI.

Background: Our previous studies have shown that the small G-proteins Rab27A and Rab27B are both present in pancreatic acinar cells and regulate secretion. However, the relationship between these two small GTPases is poorly understood. We hypothesize that Rab27A and Rab27B function in different secretory pathways in acinar cells.

Aim: To investigate the mechanism of the small G-proteins Rab27A and Rab27B, and their targeted secretory pathways.

Methods: Isolated pancreatic acini were prepared from WT, Rab27A KO or Rab27B KO mouse pancreas by collagenase digestion. Amylase release from the isolated acini stimulated by CCK or carbachol was measured. Protein expression was examined by western blot. Acinar cell secretory activities upon CCK stimulation were assessed by luminal surface labeling with anti-LAMP1 antibody for the lysosomal pathway, or apical lumen marking of exocytotic events with Dextran-Texas Red for zymogen granule secretion pathway.

Results: The expression of digestive enzymes and other Rab proteins were not affected by the deficiency of either Rab27A or Rab27B. Among the putative downstream effectors of both small GTPases, Slp1 and Slp4 protein levels were not changed in either KO acini; MyosinVc and IQGAP1, a scaffold protein that mediates endocytosis were both elevated in Rab27A and Rab27B KO acini. Rab27A KO acini showed decreased CCK-stimulated amylase release and anti-LAMP1 luminal surface labeling, compared with WT acini, indicating a deficiency in the minor regulated or lysosomal pathway. Rab27B KO acini showed decreased amylase release. Because Rab27B is present primarily on the zymogen granule membrane, we expect it to play a role in the major secretory pathway.

Conclusions: Rab27A and Rab27B are not redundant in function and may mediate secretion through different pathways. Rab27A acts through the minor regulated pathway.

Effects of a Mitochondrial-Targeted Antioxidant Mitoquinone (MitoQ) in Murine Experimental Acute Pancreatitis (AP)

W. Huang,1,2,3 N. Cash,2 L.Wen,1,3 P. Szatmary,1,2 J. Armstrong,1 M. Chvanov,2 A. Tepikin,2 M.P. Murphy,4 R. Sutton,1 D.N. Criddle.1,21NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, and 2Department of Cellular and Molecular Physiology, University of Liverpool, UK; 3Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, China; 4MRC Mitochondrial Biology Unit, Cambridge, UK.

Background and Aims: Reactive oxygen species (ROS) have been implicated in AP. We have investigated MitoQ and non-antioxidant analogue decyltriphenylphosphonium (dTPP) in experimental AP.

Methods:In vitro effects of MitoQ and dTPP were assessed on ROS production, mitochondrial membrane potential (ΔΨm) and necrosis in murine pancreatic acinar cells (PACs) and polymorphonuclear leukocytes (PMNs) using confocal microscopy and plate-reader approaches. In vivo actions of MitoQ (10 and 25 mg/kg i.p) and dTPP, were examined in cerulein hyperstimulation (CER-AP) and taurolithocholic acid 3-sulphate ductal infusion (TLCS-AP) models. Mice were sacrificed 12 h and 24 h after disease induction in CER-AP and TLCS-AP, respectively, to assess severity.

Results: In isolated PACs 1 μM MitoQ, but not dTPP, inhibited H2O2-induced ROS production. Neither MitoQ nor dTPP (1 μM) altered ΔΨm or inhibited depolarization induced by cholecystokinin-8 (10nM) or TLCS (500 μM). Both depolarized mitochondria per se at 10 μM. Neither MitoQ nor dTPP prevented TLCS- or CCK-induced PAC necrosis. In PMNs MitoQ (1 and 10 μM) reduced phorbol ester-induced early (15 min) but augmented late (40 min) ROS production, effects shared by dTPP (10 μM). Neither MitoQ nor dTPP ameliorated TLCS-AP. Both reduced pancreatic histopathology score in CER-AP, although only dTPP improved the necrosis component. Interestingly, both elevated lung myeloperoxidase and serum IL-6.

Conclusion: MitoQ and dTPP exerted variable effects in AP but did not ameliorate severe injury. An elevated ROS production in PMNs may have contributed to a worsened systemic inflammatory response.

Selective Inhibition of BET Proteins Reduces Pancreatic Damage and Systemic Inflammation in Bile Acid and Fatty Acid Ethyl Ester but not Cerulein Experimental Acute Pancreatitis

W. Huang,1,3 A.C. Haynes,2 R. Mukherjee,1 N. Smithers,2 R.K. Prinjha,2 D.N. Criddle,1 P. Jeffrey,2 R. Sutton.11NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK; 2Immuno-Inflammation Therapeutic Area Unit, GlaxoSmithKline, Stevenage, UK; 3Department of Integrated Traditional and Western Medicine, West China Hospital, Chengdu, China.

Background and Aims: I-BET-762 (GSK525762A) is a potent inhibitor of the bromodomain and extra-terminal (BET) family of proteins that bind epigenetic marks on histone proteins. We evaluated effects of I-BET-762 in experimental acute pancreatitis (AP).

Methods: AP was induced by: (i) retrograde infusion of taurolithocholic acid 3-sulphate disodium salt (TLCS, 3 mM) into the biliopancreatic duct; (ii) two intraperitoneal (i.p.) injections of ethanol (1.35 g/kg) and palmitoleic acid (POA, 150 mg/kg) administered one h apart; (iii) twelve hourly i.p. injections of cerulein (50 μg/kg). In all treatment groups, I-BET-762 (30 mg/kg, i.p.) was administered at the time of disease induction and again 12 h later. Mice were sacrificed at 24 h-post disease induction to assess severity of AP by biochemical markers and histopathology.

Results: TLCS, ethanol/POA or cerulein administration all resulted in features of AP with elevated serum amylase, pro-inflammatory cytokines, increased pancreatic trypsin and myeloperiodase activity, lung injury and histopathology. Treatment with I-BET-762 significantly reduced the severity of AP induced by TLCS or ethanol/POA, but had minimal effect in the cerulein model.

Conclusion: Inhibition of BET proteins in vivo, confirmed by the systemic IL-6 lowering effects of I-BET-762, reduced the severity of TLCS- and ethanol/POA-induced AP. These findings suggest therapeutic potential in selectively targeting bromodomains for the treatment of gallstones- or alcohol-related pancreatitis.

The Role of ER Stress, CaSR and GPRC6a in Experimental Acute Pancreatitis Induced by Amino Acids

W. Huang,1,2 M. Chvanov,1 T. Jin,2 L.Wen,1,2 D.N. Criddle,1 A.V. Tepikin,1 R. Sutton.11NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK; 2Department of Integrated Traditional and Western Medicine, West China Hospital, Chengdu, China.

Background: Large doses of basic amino acids (AAs) are used to induce murine acute pancreatitis (AP). We investigated the possible role of (1) unfolded protein response (UPR), and (2) activation of G-protein coupled calcium sensing receptor (CaR) and member 6a receptor (GPRC6a), as mechanisms of cell toxicity induced by AAs.

Methods: AR42J cells or isolated pancreatic acinar cells (PACs) were used to assess the effects of AAs on intracellular calcium [Ca2+]i, reactive oxygen species (ROS) production and cell fate. AP was induced by two intraperitoneal injections of L-arginine (3.6 g/kg) or L-histidine (4.0 g/kg) at 1 h apart. Mice were sacrificed 72 h after first L-arginine injection or 24 h, 48 h and 72 h after first L-histidine injection to assess AP.

Results: Cell stimulation with 20 mM L-arginine, L-ornithine and L-histidine led to [Ca2+]i and ROS responses in PACs, inhibited by Ppif−/− (cyclophilin D knockout) or the CaR antagonist NPS-2143 (10 μM); siRNA of CaR and GPRC6a suppressed [Ca2+]i responses in AR42J cells. L-arginine and L-ornithine caused necrotic death in PACs from 5 h, while L-histidine from 1 h. 4-phenylbutyrate a molecular chaperone and inhibitor of UPR suppressed necrosis of isolated cells caused by L-arginine and L-ornithine. In vivo, NPS-2143 mildly protected from L-arginine-induced AP and from caerulein-induced AP. Prevention of mitochondrial permeability transition by cyclophilin D disruption did not protect mice in L-arginine model but strongly protected in L-histidine-induced AP.

Conclusion: [Ca2+]i and ROS responses to L-arginine and L-ornithine play limited roles in cell death but significant roles in death caused by L-histidine. UPR and activation of receptors CaR and GPRC6a contribute to cell death and AP caused by basic AAs.

Short-Term and Long-Term Outcomes After Pancreaticoduodenectomy Using Pair-Watch Suturing Technique According To Remnant Pancreas Volume

Y. Iizawa, Y. Azumi, H. Kato, A. Tanemura, Y. Murata, N. Kuriyama, M. Kishiwada, S. Mizuno, M. Usui, H. Sakurai, S. Isaji. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.

We reported duct-to-mucosa pancreaticojejunostomy, named the “pair-watch suturing technique (PWST), to prevent postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) in 2010.

Additionally, we reported that the incidence of nonalcoholic fatty liver disease (NAFLD) after PD was significantly higher in small remnant pancreatic volume (RPV) patients (less than 10 ml) and the incidence of POPF was significantly higher in large RPV patients (10 ml or more).

The aim of present study was to reevaluate risk factors for POPF after PWST as a short-term outcome and to evaluate nutritional status and DM exacerbation as a long-term outcome, according to RPV.

Methods: Study 1: We reviewed 204 consecutive patients who underwent PD with PWST from March 2007 to December 2013. Multivariate analysis for risk factors of POPF was evaluated.

Study 2: Among 204 patients, we reviewed 135 patients who could have RPV measured at one month and had been followed for more than 6 months. RPV (CT volumetry) had been serially measured from 1 to 36 months, and according to RPV at one month these patients were classified into large-volume group (LVG) (10 ml or more, n = 83) and small-volume group (SVG) (less than 10 ml, n = 52). Pancreatic duct dilatation (DD) was also assessed after 6 months. Postoperative pancreatic functions were assessed by using several markers such as serum albumin, total cholesterol, amylase, FBS and HbA1c. Exacerbation of DM including new-onset was also analyzed.

Results: Study 1: Among 204 patients, 34 (16.7%) were identified as having POPF: 16 (7.8%) in grade A, 14 (6.9%) in grade B and 4 (2.0%) in grade C. Multivariate analysis identified soft pancreas as a significant risk factor of POPF (grades B and C).

Study 2: Incidence of pancreatic cancer was significantly higher in SVG (90.4%) than in LVG (20.5%). Incidence of POPF was significantly higher in LVG (24.1%) than in SVG (1.9%) (P < 0.01). Reduction rate of RPV reached to around 30% at 6 months in both groups, followed by no change. Serum albumin and total cholesterol were significantly lower in SVG than in LVG after 3 months. FBS and HbA1c were not significantly different between the two groups. Incidence of DM exacerbation was higher in LVG (18.1%) than in SVG (7.7%) (P = 0.09). DD was found in 14 patients (10.9%): LVG (n = 11, 13.4%) and SVG (n = 3, 6.4%) (P = 0.217).

Multivariate analysis for risk factors of DM exacerbation revealed DD and thick pancreas (before operation) as significant risk factors. We could not detect any significant risk factors for DD, including POPF.

Conclusion: PWST was proved as a reliable anastomosis technique, showing that soft pancreas was a significant risk factor of POPF. Patents with large RPV were likely to develop POPF at early period and likely to have DM exacerbation at later period, maintaining good nutritional status. Furthermore, DD was a significant risk factor of DM exacerbation.

Factors Associated With Failure in Endoscopic Treatment of Pancreatolithiasis

K. Inui, J. Yoshino, S. Yamamoto, H. Miyoshi, T. Kobayashi, Y. Katano. Department of Gastroenterology, Fujita Health University, Second Teaching Hospital, Nagoya, Japan.

Background: Since 1990 we have performed extracorporeal shock-wave lithotripsy (ESWL) and/or interventional endoscopy (including endoscopic sphincterotomy, endoscopic minor papilla sphincterotomy, endoscopic pancreatic stenting, and endoscopic drainage of associated pancreatic pseudocysts) as preferred treatments for pancreatolithiasis. Fragmentation of stones was achieved in all patients, but complete stone clearance after ESWL in combination with interventional endoscopy was accomplished in only 83%.

Aim: We sought to identify causes of failure in patients treated with ESWL plus interventional endoscopy, between 1992 and 2013.

Methods: In 86 patients, we used univariate analyses to assess influence on outcome of age; gender; etiology of lithiasis; number, size, and distribution of stones; strictures in the main pancreatic duct; pancreatic atrophy; and pancreatic pseudocyst. The median follow-up interval was 38 months (range, 1 to 415). Median age was 57 years (range, 22 to 83), and the male: female ratio was 4.2:1.

Results: Complete stone-clearance occurred in 82% of the 70 patients who underwent adjuvant endoscopic procedures with the first treatment, while 39% of patients experienced recurrence during 1 year of follow-up. In 5 of the 86 patients, including those with recurrences, surgery was required at a median of 31 months after beginning treatment (range, 20 to 54). While 3 of 78 patients without pseudocyst were treated surgically, 2 of 8 patients with pseudocyst required surgery (P = .1). Among patients with both pancreatolithiasis and pseudocyst, surgery often was needed, especially when pseudocysts exceeded 60 mm in diameter or were multiple.

Conclusions: Endoscopic treatment following ESWL for pancreatolithiasis is useful, but early surgery should be considered for patients with pseudocysts complicating pancreatolithiasis, especially when large or multiple.

Decrease in Fibroblast Growth Factor Receptor-4 Levels Inhibited the Proliferation, Migration, and Invasion of Pancreatic Cancer

T. Ishiwata,1 H. Yoshimura,1 Y. Matsuda,1,2 M. Murase,1 T. Suzuki,1 Y. Kawamoto,1 K. Kawahara,1 S. Ishiwata,3 Z. Naito.11Department of Integrated Diagnostic Pathology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan; 2Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan; 3Laboratory of Medical Pharmaceutics & Therapeutics, Division of Clinical Pharmacy, Faculty of Pharmacy, Kinki University, Osaka, Japan.

The fibroblast growth factor receptor (FGFR) family plays crucial roles in development, tissue repair, and malignant tumors. FGFR-1, −2, and −3 possess IIIb and IIIc isoforms due to alternative splicing of the extracellular domain, but FGFR-4 does not have these isoforms. FGFR-4 is reportedly over-expressed in various cancers such as breast, prostate, hepatocellular, and pancreatic cancers, wherein it contributes to tumor progression. Moreover, a single-nucleotide polymorphism (SNP) in exon 9 results in the substitution of glycine with arginine at codon 388 (R388) associated with cancer risk and poorer prognoses. Recent studies have shown that the decrease in FGFR-4 levels suppresses the aggressiveness of gastric, colorectal, and ovarian cancers. In the present study, we examined the expression and roles of FGFR-4 in pancreatic cancer. FGFR-4 mRNA was expressed in 5 pancreatic cancer cell lines at various levels, and the mutation in codon 388 was detected in 3 cell lines, including PK-1 cells. A short hairpin RNA expression vector targeting FGFR-4 was stably transfected to the PK-1 cells, which then showed lower growth rates and cell migration and invasion abilities compared to sham vector-transfected cells. Moreover, FGF-19—one of the major ligands for FGFR-4—was expressed in the 5 pancreatic cancer cell lines. These findings suggest that FGFR-4 and the most common SNP in FGFR-4, R388, contribute to the aggressiveness of pancreatic cancer. Thus, FGFR-4 may serve as a novel candidate for pancreatic cancer therapy.

Neuroendocrine Tumor of the Pancreas: A Clinicopathological Analysis of 36 Cases

J. Itakura, M. Watanabe, A. Maki, H. Amemiya, H. Kawaida, H. Kohno. Department of Surgery, University of Yamanashi, Yamanashi, Japan.

Background: According to progress in diagnostic imaging and EUS-FNA the case of p-NET is increasing in recent years. Moreover, the comparison of pathological classification and clinical course is important to establish the surgical adaptation and methods. In this study we analyses this point by p-NET cases resected in our institution.

Method: A WHO classification of 2010 and clinical findings were examined for 36 cases which underwent resection in our department from January, 2000 to July, 2013.

Result: These 36 cases were 19 male and 17 female. The average age was 60.2 years old (37–81). The location of tumor was 15 on heads and 20 on body/tail and one had multiple lesion. Of these 36 cases 4 cases indicated concomitant metastasis. Two of the four had hepatic metastasis and were G2 and non-function type. The other two cases had lymph node metastasis and the one of these was MEN-1 which had the multiple lesions in pancreas and the duodenum and was G1 in the Rindi classification with 12 mm in maximum diameter. Among the well-differentiated endocrine tumor which estimated as uncertain behavior, six cases were G1 and seven were G2. Two of the seven G2 cases showed the recurrence. One of the two cases had a local recurrence two years after surgery and the other one had lymph node metastasis three years after surgery and lymph node and hepatic metastasis six years after surgery. Seven cases were less than 9 mm, 13 cases were 10 ~ 19 mm, 6 cases were 20 ~ 39 mm and 4 cases were 40 mm or more in diameter. The average diameter of the case which had metastases or recurrence was 44.0 mm, and that of the cases which does not had no metastasis or recurrence was 14.5 mm. ROC analysis indicated that the best cut-off size to which divides metastasis and non-metastasis is 19 mm. Two cases of concomitant hepatic metastasis were died of hepatic failure, and 2 cases of concomitant lymph node metastasis and 2 cases of recurrence are survived. Two cases of the all were died of other disease, and the five-year and the ten-year survival rate were 96.8% and 72.2%.

Conclusion: The standard operation with lymph node dissection is necessary for the case of over 20 mm in diameter. Sufficient observation was necessary for the case of G2 grade. The minimal operation might be in consideration for the case of G1 grade with less than 20 mm in diameter.

PPPD Is Not Inferior to SSPPD in Postoperative Oral Intake; Propensity Score Matching Analysis on 154 Consecutive Patients Who Underwent Pancreaticoduodenectomy

T. Ito, Y. Kimura, M. Imamura, T. Kyuno, T. Nobuoka, K. Hirata. Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan.

Introduction: Post-operative dietary intake was sometime decreased in patient who underwent pancreaticoduodenectomy (PD). Several potential factors associating with it have been discussed, such as the type of PDs, reconstruction methods and other complications. A prospective consecutive study was conducted to evaluate the post PD oral intake tolerance. The occurrence of delayed gastric emptying (DGE) and the amount of dietary intake were analyzed.

Methods: Between 2005 and 2013, 154 consecutive patients underwent PDs. Perioperative data were prospectively collected in all patients. Matching propensity score with age, BMI and operative factors (blood loss and duration), 32-pairs of patients were remained to analyze. We evaluated the total amount of dietary intake (TDI; Akizuki E, et al., Ann Surg 2009) as an indicator of early postoperative oral intake tolerance. The postoperative outcomes were compared between pylorus-preserving pancreaticoduodenectomy (PPPD) and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD).

Results: There was no statistical difference with clinical and operative factors in matched 64 patients, without type of disease. The occurrence of DGE as defined by ISGPS was 16.3%(9/64; A/B/C = 3/3/3), and there was no difference between PPPD (12.5%) and SSPPD (15.6%). The daily dietary intake was gradually recovered in patients with both types of PDs, and there was no statistical difference between PPPD and SSPPD. The median TDI value in patients with PPPD (6.2) was not inferior to that with SSPPD (4.7). Univariate analysis revealed that high age, female and DGE were associated with low TDI values.

Conclusions: In our study, PPPD was not inferior to SSPPD in postoperative oral intake.

Smad4 is Associated With Differentiation of Pancreatic Ductal Adenocarcinomas

S. Izumi, S. Ichihara, T. Kubo, H. Ohtani, M. Yano, N. Tanaka, R. Ohashi, Y. Onoda, I. Suzuka. Department of Gastroenterological Surgery, Kagawa Prefectural Central Hospital, Japan.

Objectives: It was reported one of prognostic factors in pancreatic ductal adenocarcinomas (PDACs) is histological differentiation. On the other hand, the stepwise progression of genetic alterations such as MUC1, p16, p53, and Smad4 in PDACs is well known. However, the relation of histological differentiation and genetic alterations is unclear. In addition, although one of other molecules associated with tumor proliferation and differentiation is c-Jun, the role of tumor progression in PDACs is also unclear. Thus, we aimed to clarify some molecules associated with tumor differentiation in PDACs.

Materials and Methods: Fourteen well-differentiated, 18 moderately, and 5 poorly differentiated PDACs were selected from resected specimens at Kagawa Central Hospital between January 2004 to December 2013. We performed histopathological and immunohistochemical comparison of the well PDAC group with the moderately or poorly PDAC group. Additionally, we counted tumor cells showing the positive c-Jun expression at 5 hot spot areas with imaging soft wear and compared the mean cell numbers of each case in the well group to that in the moderately or poorly group. Both groups were adjusted to ensure similar mean tumor size.

Results: The frequency of MUC1, p16, p53, and Smad4 in the well group was 100, 87, 87, 7%, in the moderately group; 100, 94, 83, 50%, in the poorly group; 100, 83, 80, 100%. The well group exhibited significantly longer overall survival, lower frequency of angiolymphatic invasion, lower frequency of abnormal Smad4 expression than those in moderately or poorly PDACs. In addition, twenty-one intact Smad4 expressions group exhibited a significantly higher frequency of well-differentiation and longer overall survival than those in 15 abnormal expressions group. The mean numbers of c-Jun positive cells in both groups were high, although we are going to accumulate these data.

Conclusions: This study suggested Smad4 play a key role in tumor differentiation in PDACs.

Ultrastructural Changes in the Pancreatic Acinar Cells in the Duct Infusion Model of Acute Pancreatitis in Sprague Dawley Rats

T.G. Jacob,1 I.S. Vipin,2 P. Sahni,2 P.K. Garg,3 T.S. Roy.11Department of Anatomy; 2Department of GI Surgery; 3Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Severe acute pancreatitis (SAP) has a varied etiology, but has a uniformly high mortality. Its exact pathogenesis is still unclear. The common causes of SAP are alcohol and common bile duct (CBD) stones. The former probably forms a toxic milieu and the latter is likely to be due to obstruction. The closest animal model in which the latter can be conveniently studied is infusion of the pancreatic duct with bile salts in rats.

Aim: To study the ultrastructural features of the pancreas in the duct infusion model of SAP.

Methods: Four adult male Sprague Dawley rats were included in the study—two as controls and two in which Na- taurocholate was infused into the main pancreatic duct (MPD) after briefly obstructing the CBD. The animals were anesthetized by ketamine (5 mg/kg) and midazolam (50 mg/kg). Under aseptic conditions, the duodenum was exposed through a small (1.5 cm) incision. The CBD was clamped and then saline (controls) or 2% Na-taurocholatewas slowly infused into the MPD, using a 28G needle and syringe. The abdomen was closed in layers and postoperatively the animal was given free access to water and standard chow. The animals were sacrificed after 24 hours. The pancreata were harvested and stored in modified Karnovsky’s fixative (1%glutaraldehyde and 2% paraformaldehyde in phosphate buffer, pH 7.2). The tissues were processed for embedding in araldite, semithin sections of the blocks were cut and after delineation of the region of interest, ultrathin sections of the blocks were obtained. Thesewere stained with lead citrate and uranyl acetate and viewed under a transmission electron microscope (TEM).

Results: Both groups of animals showed evidence of expanded and distorted rough endoplasmic reticulum, abnormal mitochondria and numerous macroautophagosomes that had sequestered anomalous organelles and zymogen granules. The experimental group, in addition, showed evidence of necrotic acinar cells and numerous inflammatory cells, which were not seen in the control animals.

Conclusions: Obstruction to the CBD and infusion into the MPD leads to derangement of acinar cell organelles, however, the infusion of a detergent like Na-taurocholate worsens the pathology in this experimental model of SAP.

Qualitative Assessment Using a New Tool to Evaluate Clinical Applicability of Agents Tested in Treatment of Experimental Acute Pancreatitis

M.A. Javed,1 L. Wen,1 M. Mohan,1 P. Szatmary,1 K. Altaf,1 W. Huang,1 D.N. Criddle,1 M.M. Lerch,2 R. Sutton.111NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Liverpool, UK; 2Department of Medicine A, Ernst-Moritz-Arndt-University Greifswald, Greifswald, Germany.

Background and Aims: Experimental acute pancreatitis (EAP) may be useful to test possible therapies for human trials, but a more objective means to determine clinical applicability is required. We have devised a new scoring system for this purpose and undertaken a comprehensive analysis of studies testing agents to treat EAP.

Methods: A comprehensive search of Medline, Embase, Pubmed and the Cochrane Library was conducted to identify all studies testing agents to treat EAP to January 2013. The scoring system assessed 10 criteria: posology, clinical relevance and no. models of EAP, prophylactic vs therapeutic treatment, no. animals/group, description of husbandry, biochemical, immunological and histological markers of severity, blinding and evaluation of other organs.

Results: 366 publications were evaluated with a mean score of 5 (IQR 2). Studies were grouped according to the main mode of action of the agent: anti-inflammatory [n = 133 median 5 (IQR 2)], eicosanoids [n = 26 median 5 (IQR 1 )], enzyme inhibition 34 [n = median 4 (IQR2 )], microcirculatory modification [n = 52 median 5 (IQR 2 )], antioxidants [n = 44 median 4 (IQR 2)], antisecretory [n = 44 median 4 (IQR 2 )], miscellaneous [n = 33 median 6 (IQR 2 )]. Treatment was administered prophylactically in 290 (58.7%) and one model of AP was tested in 322 (87.9%) of studies. Only 40 studies were identified where an agent was tested therapeutically in a clinically relevant model of EAP, with adequate no./group and blinded assessment of histology.

Conclusion:Most studies testing agents in EAP have limited clinical applicability. More rigorous design and reporting are required to increase the translatability of preclinical into early phase trials in acute pancreatitis.

TRO40303 Reduces Mitochondrial Injury in Response to Fatty Acid Ethyl Esters and Ameliorates Alcoholic Pancreatitis

M.A. Javed,1,2 L. Wen,1,2 M. Awais,1,2 T. Bordet,3 M. Michaud,3 S. Schaller,3 R. Pruss,3 A. Tepikin,2 D.N. Criddle,1,2 R. Sutton.11NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital and 2Department of Cellular and Molecular Physiology, University of Liverpool, Liverpool, UK; 3TROPHOS, Marseille, France.

Background & Aims: Inhibition of the mitochondrial permeability transition pore (MPTP) is considered to be a valid therapeutic strategy for treatment of acute pancreatitis (AP). We have previously demonstrated that 3,5-seco-4-nor-cholestan-5-one oxime-3-ol (TRO40303) – an MPTP modulator - ameliorates severity of biliary and cerulein induced AP. We investigated the effects of TRO40303 on toxic injury induced by fatty acid ethyl esters (FAEE) in murine pancreatic acinar cells (PACs) and alcoholic pancreatitis.

Methods: Changes in mitochondrial membrane potential ([INCREMENT]ψM; TMRM) and cytosolic Ca2+ (Ca2+C; Fluo-4) in response to FAEE (100 μM POAEE dissolved in 5 % ethanol) were examined in freshly isolated murine PACs by confocal microscopy. AP was induced using palmitoleic acid (150 mg/kg/h IP x 2) with ethanol (1.35 g/kg/h IP x2) (FAEE-AP). Liposomal preparation of TRO40303 (3 mg/kg) was given therapeutically. AP severity was assessed by standard biomarkers and blinded histopathology.

Results: TRO40303 10 μM prevented loss of [INCREMENT]ψM induced by 100 μM POAEE and reduced cytosolic Ca2+C overload in PACs. TR040303 significantly reduced serum amylase (p = 0.043), pancreatic trypsin (p = 0.018), pancreatic and lung myeloperoxidase (p = 0.058) and blinded histopathology scores (p = 0.0058) in FAEE-AP.

Conclusion: MPTP opening plays a key role in mitochondrial injury and in the pathophysiology of PAC injury in response to POAEE. TRO40303 protects mitochondria and ameliorates the severity of alcoholic AP. MPTP modulation via TR040303 has potential in the treatment of alcoholic AP.

Isocitrate Dehydrogenase (IDH1/2), a Potential Therapeutic Target in Pancreatic Cancer

K. Jensen, S. Banerjee, O. McGinn, A. Nomura, A. Saluja. Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: Isocitrate dehydrogenase (IDH1), a metabolic enzyme in the TCA cycle has recently gained interest in cancer biology. The reaction product of IDH1 activity, 2-oxoglutarate, regulates a number of dioxygenase dependent enzymes responsible for chromatin modification and other cellular function. Overexpression of IDH1 has also been correlated with chemoresistance of the tumor. However, its status in pancreatic cancer has not been explored.

Our study shows that IDH1, while not mutated in pancreatic cancer cell lines and tumors, is overexpressed in these cells, and inhibiting it results in loss of cell proliferation and viability. Our group has been evaluating the efficacy of Minnelide, the pro-drug of triptolide as a potential therapy for pancreatic cancer. Minnelide is currently in Phase1 clinical trails at the University of Minnesota. Our current study revealed that both IDH1 expression and activity is downregulated following treatment with Minnelide.

Results: IDH1 was 5 fold overexpressed in malignant FNA samples from patients compared to those with benign FNA as seen by qRTPCR analysis. Further, IDH1 mRNA expression was 10 fold increased in AsPC1 cell line and 30 fold overexpressed in the aggressive cell line S2VP10 and S2-013 compared to normal human ductal epithelial cells. IDH1 protein levels were also increased in these cells. Overexpression of IDH1 also correlated with increased activity of this enzyme (10 fold increased compared to human ductal epithelial cells). Pancreatic tissue from patient tumor xenografts (PDX) maintained in SCID mice as well as spontaneous tumors derived from KPC mice also showed increased staining for IDH1 in IHC.

Silencing IDH1 expression using siRNA resulted in 30% -32% reduced viability in multiple pancreatic cancer cell lines. Downregulation of IDH1 also decreased proliferation in these cells as measured by BrDU uptake. When assessed in pancreatic tumors (PDX and KPC) treated with Minnelide, IDH1 expression was reduced to 48% of untreated tumors and IDH1 activity levels decreased to 53% compared to untreated tumors, resulting in production of decreased 2-oxoglutarate, thereby altering metabolic status of the cancer cells.

Conclusion: IDH1 is overexpressed in pancreatic cancer and downregulating it results in loss of cell viability and proliferation. Treatment with Minnelide decreases IDH1 expression and activity, thereby altering the metabolic status of the cell. Further study is required to develop this gene as a potential therapeutic target.

Insulin Use Before and After Pancreatectomy in Elderly Patients With Pancreatic Adenocarcinoma

C. Y. Jeon, S. J. Pandol. Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Pancreatic adenocarcinoma (PDAC) is associated with abnormal glucose control. Studies show inconsistent effects of pancreatectomy on glucose control in PDAC patients, with some showing resolution of glucose control while others show worsening glucose control.

Methods: We examined insulin use in 1188 PDAC patients reported to the Surveillance, Epidemiology and End Results registries with localized or regional disease and with a prior Medicare claim for impaired glucose tolerance or diabetes. Insulin prescriptions 3 months before and after a PDAC diagnosis were examined with consideration of receipt of a pancreatectomy. We also examined insulin use by type of pancreatectomy (total vs. partial).

Results: Among 801 who did not fill a prescription for insulin before the PDAC diagnosis, 164 (20%) filled one after the diagnosis. Patients who underwent a pancreatectomy (n = 286) were more likely to fill a prescription compared to those who did not (28% vs. 17%, p = 0.0002). Among 187 who had filled a prescription for insulin before PDAC diagnosis, 155 (83%) filled one after the diagnosis. Those who underwent pancreatectomy were equally likely to fill an insulin prescription after PDAC diagnosis as those without surgery (83% vs. 83%, p = 0.95). Total pancreatectomy was not associated with greater insulin use compared to partial resection. Among those who had not used insulin prior to diagnosis, 35% and 27% of the patients with partial and total pancreatectomy used insulin after PDAC diagnosis, respectively (p = 0.15). Among those who had used insulin prior to diagnosis, 75% and 84% patients with partial and total pancreatectomy used insulin after diagnosis, respectively (p = 0.53).

Conclusion: Pancreatectomy is associated with insulin use after PDAC diagnosis in those who had not used insulin before the diagnosis; however this increase did not vary by type of pancreatectomy. Insulin use does not decrease with a pancreatectomy in diabetes patients who were already insulin-dependent.

Comparing Liquid Based Cytology (cellprep) Methods With Conventional Smear Methods for EUS-FNA Cytology of Pancreas

H.S. Jeong,1 H.-C. Lee,2 J.-H. Han,1 H. Kim,1 J.T. Kim,1 H.B. Chae,1 S.M. Park.11Department of Internal Medicine, 2Department of Pathology, School of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea.

Background/Aims: EUS guided FNA has been used worldwide to diagnose pancreatic lesion. Until now, there is a rare study comparing cellprep (CP) with conventional smear (CS). Therefore, this study is to compare the cellprep methods with conventional smear methods in pancreas cytology.

Methods: This is the prospective study. This study was done with total 49 pts who were suspected pancreatic cancer. Pancreatic diagnosis was used by EUS guided fine needle aspiration cytology. Centesis was done more than two. The final diagnosis is done by biopsy, and clinical follow up.

Results: To 49 patients, 52 cytology were performed in our institution (among them, to two patients, it was performed twice). Two were the inadequate sample in CP, and all were adequate samples in CS. When inadequate sample, the samples were not divided equally. In CP and CS, the negative: 10% and 10%, atypical cell: 35% and 25%, suspicious: 15% and 30%, and malignant: 30% and 35%. The sensitivity of cellprep and CS : 66.7% and 83.3%, specificity: 100% and 100%, positive predictive value: 100% and 100%, negative predictive value: 66.7% and 80%, accuracy: 80% and 90%.

Conclusion: Cellprep methods were inferior than conventional smear methods, thus until liquid based cytology (cellprep) methods cannot be replaced by conventional smear methods. However, because there was selection bias, we are studying with equal sample amount.

Artery-First Approach Pancreaticoduodenectomy With En-bloc Retroperitoneal Clearance (AFPD-ERC) for Pancreatic Head Cancer

K. Jiang, J. Wu, W. Gao, J. Chen, J. Wei, F. Guo, Z. Lu, Y. Miao. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Curative resection is the only hope for long-term survival in pancreatic cancer, however, the oncological advantage of extended pancreaticoduodenectomy with intention of R0 resection is still unclear.

Aims: To investigate the feasibility and safety of AFPD-ERC.

Method: Extended retroperitoneal clearance began with an extensive Kocher’s maneuver, with left renal vein and origin of superior mesenteric artery (SMA) well exposed, No. 16th station of lymph nodes (LNs) were cleared at this step. After resectability assessed, transverse colon was lifted and peritoneum at the duodenojejunal junction was opened. SMA was identified and soft tissue around SMA was dissected with 1st jejunal branch and inferior pancreaticoduodenal artery divided. Proximal jejunum was transected according to the blood supply watershed line. After stomach transected and gall bladder mobilized, hepatoduodenal ligament was skeletonized with common hepatic duct divided. Pancreas was transected at 2-3 cm left to the origin of splenic artery. No. 7/8/9 station of LNs were cleared with celiac trunk and common hepatic artery skeletonized. Tributaries to superior mesenteric-portal vein were ligated and divided. Specimen together with retroperitoneal soft tissue containing different stations of LNs and nerve plexus were removed en-bloc.

Results: From Dec. 2013 to Jun. 2014, a total of 8 patients underwent this procedure in our center. Median operative time was 390(330–525) min with median blood loss 400(300–600) mL. Postoperative morbidity included 2 cases of grade B pancreatic fistula with null mortality. Median postoperative hospital stay was 15(10–30) days. Median number of harvested LNs was 15(8–19). All surgical margins were free of tumor cells.

Conclusions: AFPD-ERC is a safe and feasible procedure, which may increase the possibility of R0 resection and improve survival in patients with pancreatic head cancer.

Radiocontrast Exposure Provokes Post-ERCP Pancreatitis by Selectively Triggering Aberrant Ca2+ Signals and Activating Calcineurin

S. Jin, A.I. Orabi, T. Le, J.F. Eisses, S. Sah, S.Z. Husain. Pediatrics, University of Pittsburgh, Pittsburgh, PA.

Despite recent advances, the frequency of post-ERCP pancreatitis (PEP) is still approximately 4-8%, and the mechanisms by which radiocontrast induces pancreatic injury are unclear. What we do know is that pancreatitis insults that induce high amplitude, sustained Ca2+ signals within the pancreas mediate their injury through activation of the Ca2+-phosphatase calcineurin (Cn). Thus in this study, we examined whether radiocontrast exposure causes pancreatitis through a Ca2+/Cn pathway. By live confocal imaging, the ERCP radiocontrast iohexol (Omnipaque) led to high-amplitude Ca2+ signals in both mouse and human acinar cells, but had no effect on a non-pancreatic epithelial cell line (HEK293). In mouse acinar cells, using an Ad-NFAT-luciferase reporter (to assay for Cn activation), radiocontrast caused a 4.5-fold increase in Cn activation (P < 0.05), which was dependent on Ca2+ release. Using Ad-NF-κB-luciferase infection of an acinar cell line, radiocontrast led to a 125-fold increase in NF-κB activation (P < 0.05), which was mediated by PLC, IP3R Ca2+ release and, importantly, Cn. In primary acinar cells, radiocontrast induced a 6.4-fold increase in cell injury (P < 0.05), which was dependent on Cn (based on using the Cn inhibitors FK506 and cyclosporine (CsA), and CnAβ knockout cells). We also developed a novel mouse model of PEP by infusing radiocontrast into the pancreatic duct, which led to clinically relevant pancreatitis. Mice that had a knockout of CnAβ or that received FK506 or CsA were protected against PEP. The key findings were recapitulated using a second commonly used radiocontrast in ERCP, iopamidol (Isovue), and the effects were independent of osmolality. This is the first demonstration in any organ or cell type that radiocontrast induces pathologic Ca2+ signals and Cn activation leading to injury and pancreatitis. The findings point to a primary role for Cn inhibitors in preventing PEP.

Laparoscopic Total Pancreatectomy With Islet Autotransplantation (TP-IAT) Reduces Post-Operative Gastrointestinal Dysmotility and Length of Hospital Stay Compared to Open TP-IAT

G. K. John, V. K. Singh, M. Makary, K. Hirose, N. Desai, C.Walsh, R. Kalyani, E. Hall, D. Warren, P. J. Pasricha, E. M. Stein. Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD.

Aim: To compare post-operative dysmotility rates following open and laparoscopic TP-IAT

Background: Open TP-IAT surgery has been the standard approach for patients with painful intractable chronic pancreatitis. Gastrointestinal dysmotility is a common but under-recognized and poorly studied complication of the procedure. We hypothesized that post-operative dysmotility following laparoscopic TP-IAT would be lower compared to open TP-IAT.

Methods: A retrospective review of all patients who underwent TP-IAT from August 2011 to June 2014 was performed. A modified International Study Group of Pancreatic Surgery (ISGPS) clinical grading scale was used to define post-operative dysmotility and severity.

Results: A total of 32 patients with chronic pancreatitis underwent TP-IAT during the study period. The majority of TP-IAT recipients were white (97%) and women (63%) with a mean age of 41 years (range 18–65). Of the 32 procedures, 22 (69%) were open and 10 (31%) were laparoscopic. There were no differences between the patients in the two groups except that none of the laparoscopic patients had a history of prior open pancreatic surgery. Two laparoscopic TP-IATs (6%) were converted to open surgery. The prevalence of post-operative dysmotility in chronic pancreatitis patients following TP-IAT was 41%. Open TP-IAT was associated with an 11 fold higher odds (95% CI 1.16 - 100.43, p = 0.036) of post-operative dysmotility compared to laparoscopic TP-IAT. The median length of hospital stay following laparoscopic TP-IAT was 9 days compared to 14 days for open surgery (p = 0.036).

Conclusion: Laparoscopic TP-IAT significantly reduces prevalence and severity of post-operative dysmotility and length of stay compared to the open procedure.

The Diagnosis of Chronic Pancreatitis: A Systematic Review and Meta-analysis

M. Johnstone,1 R. Jackson,2 T. Hanna,1 J. Nicholson,1 J.P. Neoptolemos,1 W. Greenhalf,1 R. Sutton.11Liverpool NIHR Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospital Trust; 2Liverpool Cancer Trials Unit, Cancer Research UK Centre, Liverpool, UK.

Background: There is lack of consensus on methods to diagnose chronic pancreatitis (CP), whether by pancreatic function testing or different imaging modalities. The aim of this study was to evaluate the utility of standard tests to diagnose chronic pancreatitis.

Methods: Studies were identified from MEDLINE and Web of Science by two investigators using predefined searches and inclusion/exclusion criteria. Extracted data were pooled to estimate sensitivity and specificity using Bayesian Hierarchical Summary ROC (HSROC) methods.

Results: Of 1373 studies identified, 54 were suitable for inclusion (35 cohort studies, 19 case–control) evaluating 27 different tests. 2453/5441 (45%) of individuals had a diagnosis of CP; the prevalence of CP within cohort studies ranged from 0.12 to 0.94. Diagnostic sensitivity ranged from 0.12 to 1 and specificity from 0.16 to 1. Endoscopic retrograde cholangiopancreatography was used as a gold standard in 40 studies (74%): 19 in all patients and 21 in only a proportion.

Evaluation of endoscopic ultrasound (EUS) and magnetic resonance (MR) increased over time, accounting for 62% of publications in the last decade. EUS was evaluated in 16 studies using varying criteria, showing the highest sensitivity with an optimum pooled cut-off of 3 diagnostic criteria (sensitivity 0.85(0.56, 0.97), specificity 0.92(0.69, 0.99)). Addition of secretin improved both sensitivity (0.79(0.47, 0.92) v 0.87(0.47, 0.99)) and specificity (0.77(0.51, 0.94) v 0.88(0.58, 0.98)) of MR, but confidence intervals were too wide to draw firm conclusions.

Conclusion: EUS and secretin MRI show the highest sensitivity and specificity for the diagnosis of chronic pancreatitis making these the preferred methods, but specific criteria and algorithms remain to be defined, notably those for early disease.

The Reciprocal Role of Endosomal Trafficking and the Unfolded Protein Response in Acinar Differentiation

E.K. Jones,* S.W. Messenger,* G.E. Groblewski. University of Wisconsin, Madison, WI. (*) Co-first Authors

Damaged induced dedifferentiation of acinar cells to an acinar/ductal progenitor has been proposed as an intermediate step in the development of pancreatic ductal adenocarcinoma (PDAC). Suspension culture of acinar cells induces rapid dedifferentiation concurrent with phenotypic changes including a loss of polarity, rundown of stimulated secretion, and loss of the transcription factors spliced XBP1 (sXBP1) and Mist1. sXBP1 is a key effector of the unfolded protein response and a major acinar terminal differentiation factor. Understanding acinar “dedifferentiation” is essential to identifying mechanisms of progression towards PDAC. We recently showed 16 h culture of acini results in secretory rundown that is mediated by a loss of endosomal trafficking pathways yet the machinery regulating zymogen granule exocytosis remains unchanged. Maintaining endosomal trafficking pathways by adenoviral expression of key proteins (D52, Rab5, Rab11) increases anterograde endosomal trafficking to the plasma membrane (PM), while preventing secretory rundown, loss of polarity, and loss of sXBP1. Likewise, adenoviral expression of sXBP1 maintains D52 and Rab5 and enhances both basal and stimulated secretion. Culturing acini in the presence of the ER stress-inducing agent, tunicamycin (Tm), maintained sXBP1 levels and surprisingly prevented secretory rundown and maintained expression of D52 and Rab5. We additionally investigated if inhibiting endosome to lysosome trafficking would enhance endosome to PM trafficking and mimic effects of D52 and Rab5. Culturing acini in the presence of chloroquine, to inhibit endosome to lysosome trafficking restored stimulated secretion to 75% of freshly isolated acini, maintained the expression of endosomal proteins Rab5 and D52, and restored expression of sXBP1. These results suggest maintaining PM directed endosomal trafficking activates sXBP1 and sXBP1 conversely enhances endosomal trafficking to maintain a differentiated acinar phenotype.

Combination Therapy With Gemcitabine and a Novel Plk1 Inhibitor Causes Caspase-Independent Cell Death in Pancreatic Cancer Cells

O.P. Jones, W. Greenhalf, C. Halloran, J.P. Neoptolemos, P. Ghaneh. Institute of Translational Medicine, 5th Floor, UCD Block, Royal Liverpool University Hospital, Liverpool, UK.

Background: The trial of any novel chemotherapeutic agent is often undertaken in combination with the existing standard of care treatment. Gemcitabine is a nucleoside analogue that inhibits DNA replication and is commonly used in both the adjuvant and palliative setting of pancreatic cancer. BI 6727 is a novel, highly specific Plk1 inhibitor that induces mitotic arrest. BI 6727 has previously been shown to be effective in xenograft models of several human cancers, including pancreatic.

Methods: IC50 and isobolar analyses were carried out using the EZ4U assay. Suit-2, Miapaca-2, BXPC-3 and CFPAC were treated with BI 6727 and/or Gemcitabine with drugs administered sequentially or simultaneously. Annexin V assay was undertaken to assess apoptosis and necrosis, with Western blotting for Caspase-3.

Results: Isobolar analysis of the simultaneous addition of both drugs revealed antagonism. Treatment with the novel Plk1 inhibitor for 24 hours prior to combination therapy for 72 hours demonstrated synergy (AUC < 0.2), with FACS showing greater accumulation of G2 cells than with BI 6727 alone. Annexin V assay showed a defined population of dead cells with this combination therapy but with no evidence of caspase-3 cleavage compared to gemcitabine-alone treated cells.

Conclusion: Plk1 inhibition with this novel agent should be initiated prior to combination therapy with gemcitabine. Gemcitabine enhances the cytostatic effect of BI 6727 but cell death with this combination therapy seems to be caspase-independent.

The Glasgow Prognostic Score in Resectable Pancreatic Cancer is a Valuable Predictor for Long Term Survival and Prognosis: Results of a Retrospective Single-Center Experience

E.S. Jun, S.C. Kim, K.B. Song, J.H. Lee, D.W. Hwang, D.J. Lee, J.W. Lee, S.H. Shin, H.E. Kim, K.-M. Park, Y.-J. Lee.Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Ulsan University College of Medicine and Asan Medical Center, Seoul, Korea.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal and aggressive malignancies. Prognosis prediction after curative resection for PDAC is crucial but remains a challenge. The Glasgow Prognostic Score (GPS) was composed of both CRP and albumin had independent prognostic value in various cancers. Our aim was to retrospectively evaluate the prognostic value of the GPS in resected PDAC.

Methods: From July 2004 to October 2010, the medical records of 604 patients who underwent pancreaticoduodenectomy and distal pancreatectomy for PDAC in a single center were retrospectively reviewed. Kaplan–Meier methodology was used to evaluate the potential prognostic effects.

Results: A significant difference was detected in overall survival (OS) in patients with low and high GPS. GPS ≥1 predicted poorer overall survival (OS) compared with GPS < 1 (median OS, 17 and 22, respectively; p = 0.001). Even though the TNM stage was same, the OS was dependent on GPS in stage 2 patients. In Stage 2a patients, GPS ≥ 1 and GPS < 1 represented the OS (respectively 23.0 and 31.0; p = 0.037) And In stage 2b, the difference of OS was more predominant (respectively 15.0 and 19.0 p = 0.02)

Conclusion: To predict the prognosis for PDAC patients, we have retrospectively validated the significance of preoperative GPS. Preoperative GPS could be one of the important determinants of overall survival in PDAC patients with a variety of clinical scenarios.

Small Bowel Obstruction From Pancreatic Cancer: Beyond the Duodenum

T. Kachaamy, M. Kundranda, J. Weber. GI Oncology, Cancer Treatment Centers of America, Goodyear, AZ.

Aim: To describe the clinical presentation and endoscopic treatment of duodeno-jejunal junction (DJJ) obstruction caused by pancreatic cancer (PC).

Background: Gastric outlet obstruction (GOO) from pancreatic head tumors compressing the duodenum occurs in up to 25% of patients receiving palliative chemotherapy (CMT). It is on the rise due to improved CMT. Endoscopic stenting is safe, effective and allows prompt resumption of CMT. The ligament of Trietz arises from the right crus of the diaphragm, passes behind the body of pancreas and inserts into the duodenojejunal flexure. Large pancreatic masses involving the body of the pancreas can compress this area causing a DJJ obstruction. Patients can present with vague clinical symptoms including vomiting, weight loss and subtle findings on imaging and endoscopy making it a difficult diagnosis.

Cases: Two patients presented with vomiting and weight loss. Computed Tomography (CT) scan showed a large mass involving the body and tail of the pancreas in one and the body and head in the other. Standard EGD were normal up to the first and second portion of the duodenum (D1, D2). After diagnosis with unresectable PC they were started on CMT. Their symptoms worsened and they became malnourished. Follow up 3 months CT showed no evidence of small bowel obstruction. They presented to us for a second opinion. Repeat EGD were normal until D2. More distal endoscopic exam showed fluoroscopically confirmed severe obstruction at the DDJ. Stenting resolved their symptoms with no adverse events.

Discussion: PC causing DJJ obstruction is difficult to diagnose and requires a high index of suspicion. Imaging frequently miss this obstruction and standard endoscopic exam to D2 can also miss the obstruction. More distal exam can show the obstruction at the DDJ. Endoscopic evaluation of these patients need to routinely visualize the proximal jejunum. They can be treated endoscopically with improvement in their quality of life and nutrition.

Increased Risk of Pancreatic Cancer in Patients With Intraductal Papillary Mucinous Neoplasms of the Pancreas and a Family History or Past History of Cancer of the Pancreas or Other Organs

T. Kaise,1 K. Shimizu,1 K. Ajihara,1 J. Akao,1 T. Shioga,1 K. Nagao,1 J. Tahara,1 Y. Takayama,1 K. Shiratori,1 W. Izumo,2 T. Hatori,2 T. Furukawa.31Department of Gastroenterology, 2Gastroenterological Surgery, 3Institute for Integrated Medical Science, Tokyo Women’s Medical University, Tokyo, Japan.

A family history of pancreatic cancer is a risk factor for pancreatic carcinogenesis and important information in the medical history because it can lead to the early discovery of pancreatic cancer. In this study we investigated associations between the incidence of pancreatic cancer in patients with intraductal papillary mucinous neoplasms (IPMNs) and a family history and past medical history of pancreatic cancer and cancer of other organs. Methods: The subjects were 45 patients who were strongly suspected of having pancreatic cancer based on the International Consensus Guidelines and/or in whom cell block cytology of pancreatic juice obtained by ERP revealed high-grade dysplasia. Pancreatic resection was performed in 44 of the patients, and one patient was followed up without surgery. Results: In the 20 cases of main-duct-type IPMN (MD-type) the diagnosis was IPMC in 12 and IPMA in 8, and in the 25 cases of branch duct-type IPMN (BD-type) the diagnosis was IPMC in 9, IPMA in 15, and invasive carcinoma in 1. A high proportion of the 45 patients (10/45, 22.2%) had a first-degree relative with pancreatic cancer (IPMC: 33.3%, IPMA: 14.3%). The results according to histologic subtype showed that 51.7% of the patients with gastric-type IPMC had a first-degree relative who had been diagnosed with pancreatic cancer, and high proportions of the patients with gastric-type IPMC (42.8%) and intestinal-type IPMC (40.0%) had a relative who had been diagnosed with cancer other than pancreatic cancer. In addition, 23.8% of the IPMC patients had a past history of cancer, and many of them had been diagnosed with IPMC within several years after the diagnosis of the other cancer. Conclusion: A family history or past medical history of pancreatic cancer or cancer of another organ may increase the risk of pancreatic cancer in patients with an IPMN.

CT and MRI Assessment of Symptomatic Organized Pancreatic Fluid Collections: An Inter Reader Variability Study

A. Kamal,1 V.K. Singh,2 V. S. Akshintala,2 S. Kawamoto,1 S. Tsai,1 M. Haider,1 E. K. Fishman,1 I.R. Kamel,1 A. Zaheer.11Division of Radiology, 2Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD.

Background: Organized fluid collections associated with acute pancreatitis (AP) contain varying degrees of debris (pseudocyst vs. walled-off pancreatic necrosis (WON). The quantification of debris and presence of pancreatic duct (PD) disruption by imaging is important for management.

Aim: Compare CT and MRI for quantifying the amount of fluid/ debris and ductal involvement in organized pancreatic fluid collections and study the presence of fat globules on CT within these collections as a marker for debris.

Methods: 29 patients with 46 collections with both CECT and MRI performed within 7 days of each other were acquired after 4 weeks of symptoms onset were evaluated. CT and MRI images were interpreted by two radiologists. T2WI was used as standard for fluid quantification. Presence of fat globules within collections and Hounsfield unit (HU) attenuation on CT was noted.

Results: 34 WON and 12 pseudocysts were identified by MRI, (mean diameter 7.3 cm and 8.2 cm, respectively). Inter reader agreement on quantification of fluid in collection was 56% (κ =0.196) on CT and 70% (κ =0.55) on MRI. Accuracy of CT in quantifying amount of fluid was 65% using T2WI as standard. Fat globules were identified on CT in 65% of collections containing <75% fluid by volume (p = 0.001). Higher inter reader agreement was seen for prediction of the percentage of fluid volume, pancreatic necrosis, and PD involvement on MRI. The HU of these collections gradually decreased as the percentage of volume of fluid increased from on T2WI.

Conclusion: MRI demonstrates higher inter reader agreement for prediction of amount of fluid compared to CT. Fat within the collection on CT predicts the presence of debris on MRI. Pancreatic ductal involvement is better evaluated on MRI. Delineation of this information may be helpful to the endoscopist for pre-procedure planning.

Pancreaticoduodenectomy With Preservation of Gastroduodenal Artery: Report of Two Cases

K. Kamei, I. Matsumoto, Y. Nakata, S. Satoi, H. Ishikawa, T. Nakai, Y. Takeyama. Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan.

Introduction: With the recent advances of early diagnosis and treatment of malignant tumors, double cancer is encountered more often. We will discuss two cases of pancreaticoduodenectomy (PD) with preservation of gastroduodenal artery (GDA) after proximal gastrectomy and esophagotectomy. In both of cases, blood supply from the right gastroepiploic artery (RGEA) via GDA was essential to maintain gastric tube and the gastric remnant.

Case1: A 74-year-old man underwent proximal gastrectomy because of gastric cancer 17 years ago. The abdominal CT scan revealed multiple cysts in the pancreatic head. EUS showed multiple cysts connected to the main pancreatic duct and hypervascular nodules in the pancreatic cysts. The main pancreatic duct was also dilated. We diagnosed the branch duct type IPMN and performed pylorus-preserving PD. Although adhesion of the previous operation existed, we exfoliated the root of the RGEA and vein. We exfoliated it carefully and preserved the GDA. A postoperative course was uneventful.

Case2: 75-year-old man underwent excision of lower part esophagus and intrathoracic anastomosis with posterior mediastinum root using gastric tube because of esophageal cancer 6 years ago. He had no recurrence of disease and was followed up with a branch duct type IPMN of the pancreas in outpatients. However, nodules in the IPMN were detected. CT scan revealed the pancreatic cyst with a diameter of 3 cm in the pancreatic head. EUS showed nodules in the cyst with a diameter of 7 mm. We diagnosed the branch duct type IPMN and performed subtotal stomach preservation PD. Adhesion was mild and we could preserve RGEA and GDA. Using the ICG fluorescence method, we evaluated the gastric remnant and blood flow of the gastric tube. A postoperative course was uneventful.

As the tumor did not invade the GDA in our cases, careful dissection could be able to preserve the GDA safely without arterial reconstruction. The ICG fluorescence may be useful method for the evaluation of the blood flow in the gastric remnant and gastric tube.

Strategy Against Venous Thromboembolism After Pancreatectomy, Especially Anticoagulant Therapy

K. Kanehara, H. Shimamura, K. Takeda. Department of Surgery, Sendai Medical Center, Sendai, Japan.

Background: In perioperative period, venous thromboembolism (VTE) is one of the fatal complications. We report our strategy against VTE after pancreatectomy by focusing on the pros and cons of anticoagulant therapy.

Patients and Method: Patients who underwent pancreatectomy between January 2012 and August 2013 were included in this study. Situation of VTE, postoperative bleeding, and relationship between operative bleeding and transition of D-dimer (DD) were retrospectively examined. Our strategy for prevention of VTE were as follows. Patients should wear elastic compression stockings and intermittent pneumatic compression device unless showing symptoms of deep vein thrombosis (DVT) in legs before operation. Furthermore, enoxaparin was injected twice a day as of in the evening of 1 POD for 7 days. When DD increased over 10 μg/ml, ultrasound (US) exam in lower extremities was performed.

Results: 43 patients underwent pancreatectomy. 6 patients were excluded for some reasons. Then, 37 patients were administered enoxaparin. Postoperative bleeding was found in only one patient (2.7%), who bled from the liver biopsy point. The patient was recovered by blood transfusion with stopping administration of enoxaparin. US in lower extremities was performed for 14 patients with higher DD. US revealed thrombus formation in 2 of them. Since these thrombi were not easy-to-peel, we just observed the progress, and no VTE was occurred. Patients who underwent US (US group) were compared with that did not undergo US (non-US group) in term of intraoperative blood loss, BMI and so on. Blood loss, operative time and preoperative DD were significantly higher in US group. There was no significant difference in terms of BMI.

Conclusion: VTE after pancreatectomy did not occur. Since incidence of postoperative bleeding seemed to be rare, enoxaparin should be administered for prevention of VTE. Especially, in case with higher preoperative DD or longer operative time, anticoagulant therapy must be performed.

Fate of the Portal Vein After Pancreatoduodenectomy for Periampullary Cancers: Patency Rate and Associated Complications

M.J. Kang, J.-Y. Jang, W. Jung, J. Chang, S.-W. Kim. Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

Background & Aim: Previous studies have analyzed acute complications of pancreatoduodenectomy, but little is known about the fate of the PV, especially its long-term patency and associated complications. The purpose of this study was to explore the long-term fate of the portal vein (PV) after curative pancreatoduodenectomy, as determined by patency rate, risk factors for PV stenosis/occlusion and associated complications.

Methods: Serial CT images of 826 consecutive patients who underwent curative pancreatoduodenectomy between 2000 and 2012 were evaluated for PV stenosis/occlusion.

Results: The PV stenosis/occlusion rate after curative pancreatoduodenectomy was 19.6%, and the 5-year patency rate was 69.9%. The most frequent cause of PV stenosis/occlusion was local recurrence followed by postoperative change and PV thrombosis. Patency rate was highest in patients with ampulla of Vater cancer and lowest in patients with pancreatic cancer (p < 0.001). Patients who underwent PV resection had significantly poorer 5-year PV patency rates (17.2% vs. 72.7%, p < 0.001). Multivariate analysis showed that risk factors for PV stenosis/occlusion were primary tumor location, chemotherapy and PV resection. PV stenosis/occlusion without disease recurrence was observed in 17.3% of the patients, with PV resection and grade B or C pancreatic fistula being independent risk factors. Among patients with PV stenosis/occlusion, 13.0% developed hepaticojejunostomy or gastric varices and 2.5% experienced fatal recurrent gastrointestinal bleeding.

Conclusion: PV resection increases the risk of PV stenosis/occlusion after curative pancreatoduodenectomy. Although recurrence is the most frequent cause of PV stenosis/occlusion, a significant proportion of patients without disease recurrence experience PV stenosis/occlusion. The possibility of rare but fatal complications indicates the importance of monitoring of PV after pancreatoduodenectomy

Vanin-1 as A Biomarker for Pancreatic Cancer Associated New-onset Diabetes Has Been Proven in Clinical and Laboratory Research

M.X. Kang, X. Dong,W.J. Lu, Y.L. Wu. Department of Surgery, 2nd Affiliated Hospital, Medical School, Zhejiang University, Hangzhou, China.

Background: Recent research advances of relationship between pancreatic cancer (PC) and diabetes have provided a promising solution for the screening of early asymptomatic patients. Meanwhile, the viewpoint that the new-onset diabetes should be a potential first filter for PC screening had been advanced in recent years.

Method: To further understanding the underlying mechanisms and to find a early screening marker for PC associated new-onset diabetes (PCAND), we firstly conducted a retrospective study of 633 Asian patients with PC from 2008 to 2013 in our hospital. Next, 102 peripheral blood mononuclear cell samples were collected (including 27 PC, 25 type-2 diabetes, 25 PC with diabetes, and 25 healthy controls) and used in microarray/qPCR analysis. Finally, the functions and mechanisms of the obtained biomarker in PCAND has been further explored by the use of a co-cultured model (insulin secreting cells were co-cultured with the wild-type or the stably transduced PC cell lines).

Results: 36% (228/633) of the enrolled PC patients had diabetes, and 74% (168/228) of diabetes was new-onset. After the further microarray analysis, 23 upregulated and 35 downregulated genes were recognized. Among these genes, Vanin-1 was identified as a candidate biomarker for PCAND screening. Our in vitro and in vivo experiments demonstrated the pancreatic cancer induced islet dysfunction was dramatically exacerbated by overexpressed Vanin-1, and the suppressed concentration of GSH and PPAR-γ, and the intensified expression of ROS and cysteamine might be the primary cause.

Conclusion: Our results further demonstrated the PCAND is a paraneoplastic diabetes. Vanin-1 might is the only clinical-originated screening biomarker for PCAND as of today, and it exerted importantly biological role to the triggering oxidative stress within pancreatic microenvironment.

Efficacy, Safety and Pharmacokinetics (PK) of Weekly nab-paclitaxel (P) Plus Gemcitabine (G) in Japanese Patients (pts) With Metastatic Pancreatic Cancer (MPC): Phase I/ II Trial

A. Kasuga,1 H. Ueno,2 M. Ikeda,3 M. Ueno,4 N. Mizuno,5 T. Ioka,6 Y. Omuro,7 T. E. Nakajima,8 J. Furuse.11Department of Medical Oncology, Kyorin University School of Medicine; 2Hepatobiliary and Pancreatic Oncology Division, National Cancer Center Hospital; 3Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East; 4Division of Hepatobiliary and Pancreatic Medical Oncology, Kanagawa Cancer Center; 5Department of Gastroenterology, Aichi Cancer Center Hospital; 6Department of Hepatobiliary and Pancreatic Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases; 7Department of Chemotherapy, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital; 8Department of Medical Oncology, St. Marianna University School of Medicine Hospital, Japan.

Background: Weekly nab-P plus G regimen is one of the new first line standard chemotherapy for MPC. We conducted a phase I/II study in Japanese pts with MPC.

Methods: Eligible criteria were; definitive histologically or cytologically confirmed MPC, no prior chemotherapy, one or more metastatic tumors measurable, ECOG PS 0–1, adequate organ functions. Pts received nab-P 125 mg/m2, followed by G 1000 mg/m2 on days 1, 8 and 15 every 4 weeks. Blood samples for PK were collected. The primary endpoint was to evaluate the overall response rate (ORR) according to RECIST criteria ver 1.1 by the independent review.

Results: A total of 34 pts were enrolled. The ORR was 44.1%. The median progression free survival was 5.6 months. The PK parameter of P are AUC 4997 ng · hr/mL and Cmax 4217 ng/mL. The PK parameter of G are AUC 11973 ng · hr/mL and Cmax 20490 ng/mL. The most common adverse events of grade 3/4 were neutropenia 67.6%, anemia 14.7%, peripheral neuropathy 5.9% and diarrhea 5.9%. There were no treatment-related deaths.

Conclusion: The PKs of P and G were not altered by co-administration of nab-P plus G. Weekly nab-P plus G regimen showed promising activity with manageable toxicities in Japanese pts with MPC.

Quality of Life (QOL) Evaluation for Pancreatic Tumor Surgery Patients at the Three and Six Months After Surgery in a Single Center

Y. Katayose,1,3 N. Sato,2 F. Motoi,3 K. Nakagawa,1,3 H.Yoshida,3 T. Morikawa,3 H. Hayashi,3 M. Mizuma,3 K. Fukase,3 T. Aoki,3 K. Kawaguchi,3 T. Naitoh,3 M. Unno.1,31Integrated Surgery and Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Department of Oncology Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan; 3Hepato-Biliary Pancreatic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Objective: We have evaluated the Quality of Life (QOL) for pancreatic tumor surgery patients prospectively. This time, we report the QOL status compared with the preoperative and three or six months status in our institute.

Methods: QOL evaluation was analyzed using a two-way analysis of variance in the results of SF36v2 at the three and six months after surgery.

Results: 33 cases were analyzed. The operative procedures were as described below. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) in 17 cases, and distal pancreatectomy (DP) in 16 cases. In DP, laparoscopic DP (LaDP) was performed five cases. The median age was 62.0 years in SSPPD, and 64.5 years in DP. By comparing the pre-operative and post-operative QOL for each operation, only SSPPD showed a significant decrease in QOL at 3 months after surgery compared with the preoperative score (SF-36; PF, RP, VT, SF, RE). In the 6 months after SSPPD, the QOL status had not recovered. There was no QOL reduction in the postoperative QOL in DP. No difference was found in the QOL between LaDP and DP by open laparotomy.

Conclusion: Evaluation of postoperative QOL can be made by SF36v2. We consider that it could be evaluated objectively the differences in QOL according to surgical procedures. We are planning to integrate the cases further, and considering interventions to improve QOL.

Clinical Characteristics of Hospitalized Acute Pancreatitis Patients in our Hospital

M. Kato, T. Ito Department of Gastroenterology, JCHO Osaka Hospital, Osaka, Japan.

Aim: Acute pancreatitis is still high mortal disease in Japan. Japan Society of Pancreas revised a guideline for acute pancreatitis in 2009. Both diagnostic procedure and therapeutic strategies were recommended in this issue. Following treatment of acute pancreatitis base on this guideline, analyses on clinical features should be addressed, but it seemed not enough to be done. So, we tried to clarify clinical characteristics of this disease using this guideline.

Method: 86 patients with acute pancreatitis were enrolled. They were hospitalized in our hospital from 2010 to 2014.

Result: The enrolled patients consisted of 61 males and 25 females. Age of them was ranging from16 to 90 years old. They consisted of 36 alcoholic, 28 gall stone-related, and 17 idiopathic patients. Etiology of 5 patients was unknown. Gall stone-related pancreatitis was dominant in patients over 65 years old, while alcoholic pancreatitis was in patients under 65 years old. Using the guideline, 33 patients were diagnosed as severe acute pancreatitis; 4 cases diagnosed with only prognostic factor, 24 cases by only CT grade, and 5 cases with both prognostic factors and CT grade. All of them were alive following the recommended therapy. 5 patients were subjected to hemodialysis and infusion of antibiotics and protease inhibitors into selective pancreatic artery. There was no difference of serum lipase and amylase on admission in the comparison of mild and severe pancreatitis. Maximum CRP and urinary amylase were observed to be higher in the severe pancreatitis. The average duration of hospital stay was 15.5 days in the mild group and 27.5 days in the severe group. The average fasting period was 7.2 days in the severe group, whereas 5.3 days in the mild group.

Conclusion: Application of this guideline to acute pancreatitis could improve prognosis. In order to prevent the disease, it is important to lead less consumption of alcohol and check gallstones. It is necessary to accumulate more cases for better therapeutic strategies.

Efficacy of Repeated Cytology for Early Detection of Pancreatic Cancer: Two Cases Diagnosed Using Pancreatic Juice Cytology Obtained via Endoscopic Naso-Pancreatic Drainage Tube

S. Kato,1 K. Chinen,1 K. Kikuchi,1 T. Murakami,2 F. Kunishima.31Department of Gastroenterology, 2Surgery, 3Pathology; Okinawa Chubu Hospital, Okinawa, Japan.

Introduction: Early detection of pancreatic cancer (PC) is often challenging and difficult, but it is necessary for improving the outcome of patients. Several studies have shown the efficacy of pancreatic juice cytology obtained via endoscopic naso-pancreatic drainage (ENPD) for early diagnosis. We diagnosed two cases of early stage PC including PanIN3 by repeated ENPD cytology.

Case: Case1. An 80-year-old Japanese female with a history of recurrent pancreatitis was referred for further examination of her main pancreatic duct (PD) stricture and dilatation. Dynamic Computed tomography (CT) showed focal PD stricture on the pancreatic body without a mass lesion. We placed ENPD tube and collected pancreatic juice five times in one session. Two samples of five showed adenocarcinoma. We performed a distal pancreatectomy. Postoperative pathological examination revealed PanIN3 in a branch duct near the stricture and PanIN2 micropapillary growth in the PD including near the focal stricture. (UICC-7 stage 0)

Case2. A 73-year-old Japanese male presented with a complaint of upper abdominal pain. Laboratory findings demonstrated increased serum amylase. CT showed inflammation of the pancreas and fat. Magnetic resonance cholangiopancreatography revealed slight PD dilatation on the pancreatic body. We placed ENPD tube after his pancreatitis improved. Two samples of the seven collections revealed adenocarcinoma. Postoperative pathological examination showed carcinoma with microinvasion of <1 mm and a PanIN-3 neoplasm on a PD. Regional lymph node metastasis was also observed. (UICC-7 Stage IIb)

Discussion: PD stricture and dilatation are helpful findings to detect early stage PC. Repeated collection of pancreatic juice via ENPD tube is useful for obtaining pathological evidence of early stage PC, especially in cases without mass lesions. A Large study on this topic is recommended.

Morphology of Pancreatic Neuroendocrine Tumor (P-NET)

E. Katsuta, A. Kudo, Y. Ohata, H. Ueda, T. Sato, A. Oba, K. Akahoshi, K. Nakao, T. Furuyama, H. Ito, S. Matsumura, A. Aihara, D. Ban, T. Ochiai, T. Irie, S. Tanaka, M. Tanabe. Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

Background: Although there are some classification of P-NETs, the morphology of P-NET remains unclear.

Aim: To investigate the clinicopathological differences of P-NET according to the morphology.

Method: We enrolled 24 patients (31 tumors) who underwent pancreatectomy for P-NET at our hospital between 2008 and 2013. Tumors were classified by pathological morphology. We compared clinicopathological feature, progression-free and overall survival between these groups.

Result: The tumors were classified into 5 groups by pathological morphology; small nodular type with indistinct margin (n = 1), simple nodular type (n = 14), simple nodular type with extranodular growth (n = 11), confluent multinodular type (n = 2) and infiltrative type (n = 3). Furthermore we classified them into 2 groups; smooth surface group (n = 15) including small nodular type with indistinct margin and simple nodular type, non-smooth surface group (n = 16) including simple nodular type with extranodular growth, confluent multinodular type and infiltrative type. There was significantly greater proportion of synchronous lymph nodes metastases in non-smooth surface group (18.8% vs 0%; p = 0.026). Liver metastases and vascular invasion rete tended to be higher proportion in the non-smooth surface group (25.0% vs 0%; p = 0.058, 43.8% vs 13.3%; p = 0.070, respectively). There was no significant difference in age, sex, early enhancement with dynamic CT rate, tumor size, invasion of adjacent organs rate, mitosis index, Ki-67 index, functional tumor rate, pathological hormone-producing tumor rate and WHO 2010 classification between these 2 groups. Although there was no significant difference in overall and progression-free survival, all patients in smooth surface group were relapse-free.

Conclusion: We analyzed morphology of 31 tumors of P-NETs. Non Smooth Surface type affects recurrence or metastases.

Quantitative Targeted Proteomics in Pancreatic Cancer: Combination of Enzyme and Efflux Transporter Protein Expression are New Indicators for Gemcitabine Sensitivity

K. Kawaguchi,1 F. Motoi,1 K. Fukase,1 Y. Katayose,1,2 M. Unno.1,21Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Division of Integrated Surgery and Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Gemcitabine (GEM) has become a standard chemotherapeutic agent for pancreatic cancer. However the overall response rate of pancreatic cancer is only 10%. It would be useful to identify molecular markers to predict GEM sensitivity in individual patients.

Aim: The purpose of the present study was to search for multiple proteins that could be used to predict GEM sensitivity of pancreatic cancer tissues, by comparing the protein expression profiles of transporters and enzymes in tissues from responsive and non-responsive cases and by examining the correlation of protein expression levels with IC50 for GEM in pancreatic cancer cell lines.

Method: The expression levels of 90 membrane proteins and 15 enzymes were quantified in 9 surgical specimens and 6 pancreatic cancer cell lines, by means of multiplexed MRM analysis with LC-MS/MS.

Result: Significant differences in the expression levels of dCK and Purine-5-NT were observed between responsive and non-responsive groups of patients, although no correlation of the expression levels of these proteins with IC50 of GEM was found in the cell lines. The expression levels of ten membrane proteins in the cell lines were correlated to IC50 of GEM, however the expression levels of these proteins failed to predict the GEM sensitivity of cancer tissues. The expression ratios of various combinations of dCK, MRP1, MRP4, Purine-5-NT and/or CTPS1 were found to correlate well to IC50 of GEM in the cell lines, and further, their values were significantly different between responsive and non-responsive cancer tissues.

Conclusion: The expression ratios of multiple proteins, including transporters and enzymes, may be of clinical value for predicting tumor sensitivity to GEM in pancreatic cancer patients.

Neoadjuband Chemo-radiotherapy (NACRT) for Borderline Resectable Pancreatic Cancer

M. Kawaguchi,1 K. Takori,1 A. Nakamura,2 T. Uemura,1 M. Mizumoto,1 T. Masui,1 A. Mori,1 H. Okajima,1 M. Hiraoka,2 S. Uemoto.11HBP Surgery and Transplantation, 2Department of Radiotherapy, Kyoto University, Kyoto, Japan.

Introduction: Various “pre-surgical therapies” are tried for the better outcome of borderline resectable pancreatic cancer. We are performing NACRT for borderline resectable pancreatic cancer.

Indication: Pancreatic cancer (pathologically confirmed) with SMV or PV invasion with stenosis or regional obstruction and/or abutment to SMA (less than 180 degree), but without invasion to the root of GDA or distant metastasis. Pancreas body cancer with invasion to the root of SpA and/or CHA but without involvement of the root of CeA, GDA or PDA

Methods and Result: (One Case): 54 y.o. male. CT showed cT3N0M0, PV+, SMA- CHA-, stageIVa and adenocarcinoma was detected by EUS-FNA. Gemcitabine 1000 mg/m2 3W1R followed by CRT: GEM (1000 mg/m2) and intensity modulated radiation therapy (IMRT) (42Gy/15fr). CA19-9 level was drastically decreased from 122.7 to 16.8. After NACRT CT showed no remarkable change in the size of tumor. We performed laparoscopic staging with peritoneal cytology in order to evaluate possible peritoneal dissemination. No sign of dissemination was found and we switched to the open surgery for resection immediately. Subtotal stomach preserving pancreatoduodenectomy with resection of SMV was performed. Surprisingly pathological examination showed no residual malignant cells in the tumor. The tumor was substituted into the lamp of fibrous tissue remaining some ductal structure with slight dysplasia but no apparent malignant cells were to be seen (Grade 3). No lymph node metastasis was found.

Discussion: In this case we could successfully perform resection after NACRT although the patient had a risk of disease progression in the period of pre-treatment. IMRT (42Gy) and chemotherapy successfully diminished most of the malignant cells in the tumor and we could perform R0 resection of the tumor without any complication.

Fibroblast Activation Protein Activates Proliferation and Invasion of Pancreatic Adenocarcinoma

T. Kawase, S. Nishina, Y. Hara, F. Kishi, K. Yoshida, K. Hino. Department of Hepatology and Pancreatology, Kawasaki Medical School, Kurashiki, Japan.

Background and Aim: Fibroblast activation protein (FAP) that is expressed in cancer-associated fibroblasts (CAF) has been shown to play an important role in tumorigenesis in mouse pancreatic ductal adenocarcinoma model. The aim of this study was to assess whether FAP expression in CAF is associated with overall survival in patients with pancreatic adenocarcinoma and to investigate the mechanisms by which FAP in CAF activates tumor progression in pancreatic adenocarcinoma.

Methods: FAP expression was immunohistochemically assessed in operated pancreas that was obtained from 50 patients with pancreatic adenocarcinoma under approval by the ethics committee of the institution. FAP cDNA was synthesized from mRNA of BxPC-3 cells, cloned, and transfected into NIT-3 T3 cells. After selection using G418, stable cell lines of FAP positive NIT-3 T3 were established. Invasion assay and cell cycle analysis of MiaPaCa-2 (pancreatic adenocarcinoma cell line) were performed under co-culture with FAP positive or negative NIT-3 T3 cells.

Results: The expression level of FAP was negatively correlated with overall survival of patients (p < 0.001). Multivariate analysis showed that FAP expression level was one of significant factors associated with overall survival. The number of invasive MiaPaCa-2 was significantly greater in co-culture with FAP positive NIT-3 T3 cells than in co-culture with FAP negative NIT-3 T3 cells. Cell cycle assay using Image express (Molecular device Sunnyvale, CA) proved activation of switching from G1 to S/G2/M in MiaPaCa-2 cells co-cultured with FAP positive NIT-3 T3 cells compared with those with co-cultured with FAP negative NIT-3 T3 cells. Furthermore, western blotting revealed increased phosphorylation of Rb (inactivated Rb) in MiaPaCa-2 cells co-cultured with FAP positive NIT-3 T3 cells than those with co-cultured with FAP negative NIT-3 T3 cells.

Conclusions: The present results indicated that FAP expression in CAF is associated with overall survival of patients with pancreatic ductal adenocarcinoma be affecting tumor progression.

Data From Over 1,000 Patients Support the Inclusion of Chymotrypsin C (CTRC) Gene Testing and the Exclusion of Cystic Fibrosis Transmembrane Regulatory (CFTR) Gross Deletion and/or Duplications

S.B. Keiles, E. Chao. Ambry Genetics, Aliso Viejo, CA.

Genetic testing for hereditary pancreatitis began shortly after 1996 when mutations in the PRSS1 gene, which codes for cationic trypsinogen, were first associated with hereditary pancreatitis. Over subsequent years several other genes have also been implicated in increasing predisposition to develop recurrent acute and chronic pancreatitis. The sequencing of the serine protease inhibitor Kazal type 1 (SPINK1), CFTR and most recently CTRC genes have been clinically available for over 10 years now. We reviewed the results from over 1,000 patients tested to determine the effectiveness of including CFTR deletion duplication testing and CTRC sequencing as part of a comprehensive multi-gene test that targets patients with idiopathic, recurrent acute, chronic or hereditary pancreatitis. We included all patients received for testing from January 1, 2006 through March 31, 2014 where the physician ordered a multi gene test to determine the underlying cause of the pancreatitis in the patient and or their family. There were 1,251 patients who had a multi-gene test that included CFTR deletion/duplication testing. Results revealed that all patients were negative for a CFTR gross deletion or duplication. There were also 1,072 patients that underwent analysis of the CTRC gene as part of the requested testing. Twenty-two patients were identified as carrying a pathogenic mutation resulting in a positive rate of approximately 2.0%. Thirteen (59%) of the patients were positive for the p.R254W mutation, two (9%) carried the p.V235I mutation and the other seven (32%) patients each carried a unique mutation. The data in this population supports including CTRC gene testing while eliminating CFTR deletion/duplication testing from recommended testing panels for recurrent acute, idiopathic chronic or hereditary pancreatitis.

A Comparative Study of Laparoscopic Versus Open Pancreaticoduodenectomy for Malignant Lesions

Y. Khalid,1 J. Barrie,1 R. Deshpande,1 D. O’Reilly,1 N. De Liguori Carino,1 B.J. Ammori.21Department of Hepatopancreatobiliary Surgery, North Manchester General Hospital, Manchester, UK; 2The University of Manchester, Manchester, UK.

Background: Advances in operative techniques and technology have facilitated the implementation of laparoscopic pancreaticoduodenectomy (LPD). Well-designed studies comparing LPD to open pancreaticoduodenectomy (OPD) are limited. We present a comparative study of outcomes of LPD versus ODP.

Methods: Of 397 patients (167 female) who underwent pancreaticoduodenectomy (16 LPD, 381 OPD) between January 2002 and December 2014, 30 patients were matched on a 1:2 basis (15 LPD, 30 OPD) according to age, gender, tumour size and histopathological diagnosis. Comparison between groups was performed on intention-to-treat basis. Survival following resection for malignant disease was compared using the Kaplan Meier survival analysis with the Log-Rank significance test.

Results: LPD and OPD groups were comparable for age (65 vs. 64.3 years, p = 0.93), gender distribution (p = 1.000), tumour size (2 vs. 3.3 cm, p = 0.78) and the frequency of malignant disease (p = 1.000). LPD was associated with significantly lower blood loss (300 vs. 640 ml, p = 0.023) and shorter high dependency unit stay (2 vs. 6 days, p = 0.013) and postoperative hospital stay (9 vs. 15.4 days, p = 0.321). LPD required significantly longer operating time (470 vs. 320 minutes, p = 0.184). There was no significant difference in postoperative morbidity (21% vs. 28.3%, p = 0.478) and mortality (0% vs. 3.3%, p = 0.841) or in R0 resection margin (87% vs. 89%, p = 0.79). The 1-year and 2-year survival rates for LPD vs. OPD were (93% vs. 88%, p = 0.69 and 72% vs. 71.9%, p = 0.813 respectively) and mean duration of survival was comparable (44 vs. 39 months, p = 0.245).

Conclusion: In selected patients, LPD offers reduced operative trauma and quicker postoperative recovery without compromising oncologic resection. Long-term follow up data are needed to characterize the selection criteria for LPD.

Optimization Method for the Simultaneous Detection of Multiple Pancreatic Cancer Markers Using a Surface-enhanced Raman Scattering (SERS) Immunoassay

G. Khanderao,1 J.H. Granger,2 M.C. Granger,1,2,3 M.A. Firpo,1,2,5 M.D. Porter,2,3,4 S.J. Mulvihill.1,2,51Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT; 2Nano Institute of Utah, University of Utah, Salt Lake City, UT; 3Department of Chemical Engineering, University of Utah, Salt Lake City, UT; 4Departments of Chemistry, Pathology, and Bioengineering, University of Utah, Salt Lake City, UT; 5Huntsman Cancer Institute, Salt Lake City, UT.

There is mounting evidence that diagnostic, prognostic, and stratification accuracy for classification of pancreatic ductal adenocarcinoma (PDAC) can be improved by screening using multiple pertinent biomarkers. Multiplexed assays present unique challenges including cross reactivity, non-complementary analyte-label pairing, and nonspecific adsorption. To overcome these challenges, we have developed methodology for multiplexed assay optimization and demonstrated efficacy in a SERS-based sandwich immunoassay that simultaneously detects three PDAC biomarkers: osteopontin (OPN), tissue inhibitor of metalloproteinase 1 (TIMP-1), and carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1).

For each of the three analytes, potential antibodies were first filtered to minimize epitope homology between analytes. Candidate antibodies were then analyzed using fluorescent anisotropy to optimize kd and to explicitly test antigen cross-reactivity. Successful antibodies were then tested in sandwich assays using both enzyme-linked (ELISA) and SERS detection strategies. The resulting assays exhibited an excellent dose-dependent response to the target antigens in individual and simultaneous detection schemes. Detection limits for the SERS assay were 40.15 pg/mL for OPN, 27.89 pg/mL for TIMP-1 and 69.75 pg/mL for CEACAM1, which were comparable or improved over ELISA assays. The results demonstrate the potential for rapid, cost-effective, and small volume multiplex assays for PDAC screening.

The Impact of Diabetes Mellitus on Clinical Outcome of Acute Pancreatitis in Japan

K. Kikuta,1 A. Masamune,1 S. Hamada,1 T. Shimosegawa,1 Research Committee of Intractable Diseases of the Pancreas. 1Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: It is controversial whether diabetes mellitus (DM) affects clinical course of acute pancreatitis (AP).

Aim: To clarify the impact of DM on clinical outcome of AP.

Methods: A nationwide epidemiological survey in Japan was conducted targeting AP patients treated in 2007. Presence or absence of DM at the onset of AP was described in 1954 AP cases, and clinical characteristics, such as age, etiology, body mass index (BMI), organ failure at early phase of AP and mortality, of DM cases were compared to non-DM cases.

Results: Two hundred fifty of 1954 cases (12.8%) were suffering from DM at the onset of AP. The prevalence of DM in alcoholic AP (15.6%) was higher than biliary (10.8%) and idiopathic AP (10.7%). The mortality of DM cases was significantly higher than non-DM cases (4.0% vs. 1.7%, p < 0.05). Increased mortality of DM cases was shown notably in aged patients and in idiopathic AP, but not in alcoholic AP. DM cases were prone to renal, but not respiratory failure at early phase of AP. BMI was positively correlated with the prevalence of DM, but not mortality of AP patients.

Conclusion: DM has some impact on clinical outcome of AP patients such as aged and idiopathic cases. DM should be taken into consideration on the treatment of AP.

Comparison of International Consensus Guidelines 2012 versus 2006 in Distinguishing Benign from Malignant IPMN

D.U. Kim, G.A. Song, D.H. Baek, K.J. Lee, T.U. Kim, J.S. Lee. Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.

Objective: Since 2006, the ICG (International Consensus Guidelines) have used either immediate surgery or surveillance for IPMN patients, but their low specificity increases the number of benign IPMNs that undergo surgery. Thus, the new ICG had suggested in 2012 to reduce unnecessary surgery. We assessed IPMN patients according to the ICG 2012, which is more accurate and expected to reduce the resection rate for benign IPMN compared to ICG 2006.

Patients and Methods: Patients with branch duct type-IPMNs who were diagnosed by CT, MR, EUS or surgical resection, were identified and seen at our department from January 2005 to December 2012. The indication for resection or surveillance, verifies a posteriori for all patients according to the ICG 2006 versus ICG 2012. Sensitivity, specificity, positive or negative predictive value, and accuracy were assessed by confirming whether actual final diagnosis of malignancy or benign are matched with indication for resection or surveillance according to each guideline.

Results: 23 patients with BD-IPMNs were included in the study. 13 out of 23 patients had surgery. There were 4 benign cases and 9 malignant cases of them. Meanwhile, 10 patients were followed up; with 9 out them were diagnosed benign cases due to no change in cyst size and 1 malignant case due to enlargement in size of lesion. The sensitivity, specificity, positive and negative predictive value, and accuracy for the ICG 2006 in detecting malignancy, were 90, 53.9, 60, 87.5, and 69.6, respectively, whereas for the ICG 2012 they were 100, 76.9, 76.9, 100, and 87, respectively.

Conclusions: The ICG 2012 is more accurate than the ICG 2006 in distinguishing benign from malignant IPMNs. Even if cyst size is larger than 30 mm in an observation according to the ICG 2012, resection by ICG 2006 could reduce unnecessary surgery, unless there are any high risk stigmata of malignancy, or features of main duct involvement in EUS.

Long-Term Outcomes of Incidental Pancreatic Cystic Neoplasms

H.J. Kim,1 J.S. Kim,1 B.J. Lee,1 J.-J. Park,1 H.S. Lee,2 C.D. Kim,2 Y.-T. Bak.11Department of Gastroenterology, Korea University Guro Hospital, Seoul, Korea; 2Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea.

Background/Aims: There are few studies about the follow-up outcomes of pancreatic cystic neoplasm (PCN). PCNs have been suggested as slow-growing and favorable prognosis even in the setting of malignant degeneration. Therefore surgical treatment for PCN is still very difficult especially in elderly patients considering the perioperative morbidity.

Methods: Patients with follow-up duration > 1 year for incidentally detected PCNs between January 2005 and December 2012 were included and analyzed retrospectively.

Results: Total 201 patients were included (104 patients ≧ 65 years; older group and 97 patients < 65 years; younger group). Surgical resection was done in 68 patients with alarm features for malignancy (27 cases of the older group and 41 cases of the younger group). Malignancy after surgical resection was in only 1 case of the older group and 2 cases of the younger group. In postoperative morbidity developed in 22.2% (6/27) of the older group and 21.9% (9/41) of the younger group. 133 patients (77 patients of the older group and 56 patients of the younger group) including 26 patients with alarm feature were fallowed without surgery. The diameter of PCNs increased in total 21 patients; 18% (14/77) of the older group and 12.5% (7/56) of the younger group. In patients with alarm features, 8 patients (30.8%) showed increase of size; 5/13 of the older group and 3/13 of the younger group. Six patients of 21 patients with increase of size underwent the delayed surgery but were proved to have no cancer. In other patients without delayed surgery due to perioperative risk, there was neither malignant change nor any PCN-related mortality.

Conclusion: In patients over 65 years old with incidental PCNs, follow-up observation by imaging without surgery seems to be a rather safe option.

Which Types of Periampullary Diverticulum is Risk Factor of the Post-ERCP Pancreatitis?

H.S. Kim, J.H. Yoon, E.J. Kim, S.H. Park, C.S. Bang, Y.S. Kim, K.T. Suk, G.H. Baik, J.B. Kim, D.J. Kim. Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea.

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is now the therapeutic modality for biliary as well as pancreatic diseases. The correlation between Post-ERCP pancreatitis (PEP) and periampullar diverticulum (PD) was evaluated in several studies. However, the risk of Post-ERCP pancreatitis, according to the types of PD was not elucidated. The aim of this study was to investigate risk factors for post-ERCP pancreatitis, including three types of PD.

Methods: This is a retrospective case–control study, which included a total of 200 ERCPs, performed by four endoscopists in a single center. 62 (31%) patients with PEP, and 138 (69%) patients without PEP were enrolled. The correlation between PEP and risk factors, including PD, angle of common bile duct (CBD), endoscopic sphincterotomy (EST), canulation time, procedure time, and three types of PD were investigated by univariate and multivariate analyses. PD were classified into three types by the location of ampulla of Vater: type 1 (n = 5), inside the diverticulum; type 2 (n = 53), on the margin of diverticulum; type 3 (n = 35), outside the diverticulum.

Results: In univariate analysis, all types of PD, type 1 PD, type 2 PD, type 3 PD had variable results for PEP (Odd ratio = 1.524, 1.226, 5.885, 0.129; p = 0.170, 0.828, 0.001, 0.001, respectively). Cannulation time and total procedure time also had meaning results (p = 0.005, and 0.017, respectively). However, the angle of CBD, and EST were not meaning risk factors in this study (p = 0.676, and 0.585, respectively). Age-sex adjusted multivariate analysis showed age, type 2 PD, and cannulation time as independent risk factors for PEP (OR = 0.983, 6.707, and 1.053; p-values = 0.443, 0.001, and 0.006, respectively). In area under receiver operator characteristic curve (AUROC) for PEP, Type 2 PD and cannulation time had meaning results (AUROC = 0.692 and 0.665; p = 0.002 and 0.009, respectively), followed by all types of PD, type 1 PD, and type 3 PD (AUROC = 0.508, 0.505, and 0.302; p=, 0.895, 0.933, and 0.002, respectively).

Conclusions: Type 2 PD and cannulation time were more potent risk factors of PEP than other factors. However, this study had limitations of retrospective case–control study. Prospective randomized control study in multi-center was required.

Serum Interleukin-6 Associated With Tumor Progression Patterns in Patients With Pancreatic Adenocarcinoma

H.W. Kim,1 J.-C. Lee,1 K.-H. Paik,1 Y.S. Lee,1 J. Kim,1 J.-H. Hwang.11Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.

Objectives: Several reports showed that interleukin-6 (IL-6) might be a useful biomarker for pancreatic ductal adenocarcinoma (PDAC), although its clinical impact is still open to debate. It was recently demonstrated that patients with liver metastases had significantly worse survival as compared to other sites of metastasis. The aim of this study was to elucidate whether serum level of IL-6 could predict tumor progression pattern of PDAC, especially extensive hepatic metastasis and eventually long-term prognosis.

Methods: A total of 62 consecutive patients with PDAC were enrolled retrospectively. Tumor progression patterns were defined as follows: no or limited (<2/each sector and <10 in whole liver, limited group) and extensive hepatic metastasis (metastatic nodules or masses of ≥2/each sector or 10 or more in whole liver, extensive group). Serum IL-6 level was log-normally distributed within those groups, and hence, values were transformed to the natural logarithm (Ln).

Results: The median follow-up was 10 months. Mean serum level of Ln IL-6 was not elevated significantly in patient with extensive group compared with limited group. The Kaplan-Meier survival curve didn’t show a significant correlation (p = 0.074) between the high serum level of Ln IL-6 and the overall survival. When tumor progression patterns were reassessed in 53 patients with initial limited group, mean serum level of Ln IL-6 was elevated significantly in extensive group compared with limited group (2.51 ± 1.67 vs 1.54 ± 1.10, p = 0.025). Furthermore, multivariate analysis revealed that the elevated serum level of Ln IL-6 was independent risk factor for extensive hepatic metastasis (OR 1.705, 95% confidence interval 1.003-2.898, p = 0.049).

Conclusions: High serum IL-6 may be an independent risk factor for extensive hepatic metastasis in PDAC patients, even though not correlated with survival.

Comparison of 24-hour and 8-hour Infusion of Nafamostat Mesilate for the Prevention of Post-ERCP Pancreatitis: A Prospective Randomized Comparison Trial

S.J. Kim,1 D.H. Kang,2 H.W. Kim,1 C.W. Choi,1 S.B. Park,1 B.J. Song,1 Y.S. Shin.11Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea; 2Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea.

Background and Aims: Nafamostat mesilate is known to decrease the incidence of post-ERCP pancreatitis (PEP). The optimal duration of administration is unknown. Our aim is to compare the effects of 24-hour and 8-hour infusion of nafamostat mesilate for the prevention of PEP.

Patients and Methods: A total of 344 patients who underwent ERCP were randomly assigned to either the 24-hour or 8-hour infusion group. For 24-hour group, nafamostat mesilate 2 mg/hr infused from 30 min before ERCP and last for 24 hours. For 8-hour group, nafamostat infused for 8 hours.

Results: The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 5.5% (19/344). It occurred in 11 (6.4%) of 172 patients in 24-hour group and in 8 (4.7%) of 172 patients in 8-hour group (p = 0.479). There was no significant difference between the groups in the severity of pancreatitis.

Conclusion: There is no difference in the beneficial effects of the prophylactic administration of 24-hour and 8-hour group. In outpatient clinics, 8-hour infusion of nafamostat mesilate could be helpful to prevent PEP.

Comparison of Early Needle-Knife Fistulotomy and Double-Guidewire Technique in Patients With Repetitive Unintentional Pancreatic Cannulations

S.J. Kim,1 D.H. Kang,2 H.W. Kim,1 C.W. Choi,1 S.B. Park,1 B.J. Song,1 D.G. Kang,1 Y.S. Shin.11Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea; 2Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea.

Background and aims: Recent studies reported that early use of needle-knife fistulotomy (NKF) is safe and effective for difficult biliary cannulations. Double-guidewire technique (DGT) has also been reported to be useful. The aims of this study were to compare PEP and success rates of early NKF and DGT to achieve selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.

Patients and methods: 134 (8.1%) patients of unsuccessful 5 minutes trial of conventional method with 5 or more repetitive unintentional pancreatic cannulations between 2009 and December 2012 were enrolled.

Results: Early NKF and DGT were assigned in 67 patients each. Both techniques were compared for an extra 7 minutes of cannulation attempt. The incidence of post-ERCP pancreatitis (PEP) was low in the early NKF group than in the DGT group (4.5% [3/67] versus 14.9% [10/67]; P = 0.041). The success rates with early NKF and the DGT were 79.1% (53/67) and 44.8% (30/67), (P < 0.001).

Conclusion: In patients with repetitive unintentional pancreatic cannulations, early NKF showed a lower incidence of PEP and higher success rate of selective biliary cannulation than DGT. Therefore, these data suggest that early NKF should be considered as the first approach to selective biliary cannulation in such patients.

Minor Endoscopic Sphincterotomy to Prevent Post-ERCP Pancreatitis Before SEMS Insertion for Malignant Biliary Obstruction

S.J. Kim,1 D.H. Kang,2 H.W. Kim,1 C.W. Choi,1 S.B. Park,1 B.J. Song,1 Y.S. Shin.11Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea; 2Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea.

Background and aims: The use of self-expanding metal stent (SEMS) are used to relieve obstruction in patients with unresectable pancreaticobiliary malignancies. Endoscopic sphincterotomy (ES) is performed to decrease the post-ERCP pancreatitis (PEP) and facilitate a stent placement. But bleeding is a potential complication from ES. So, we performed this study to evaluate early post-ERCP complications, particularly PEP and bleeding, in patients who undergo minor ES before biliary drainage with SEMS.

Patients and methods: A total of 172 patients with unresectable pancreaticobiliary malignancies received SEMSs with minor ES. The etiology of malignancy was 92 patients from cholangiocarcinoma, 50 patients from pancreatic cancer, 11 patients from ballbladder cancer, and 19 patients from non-pancreaticobiliary malignancy (ampullary carcinoma, hepatocellular carcinoma, metastatic cancer).

Results: 143 uncovered SEMSs and 29 covered SEMSs were placed. The frequency of PEP was 5.2% (7/172). The frequency of PEP was similar between covered (3.5%) and uncovered (6.9%) SEMSs (p = 0.336). Bleeding after minor ES was found in 1.2% (2/172). No significant bleeding that require blood transfusion occurred.

Conclusion: The rate of PEP after the placement of SEMS with minor ES was similar with the incidence of PEP in several large clinical trials. The bleeding rate of SEMS insertion after minor ES was lower than previous report using standard sphincterotomy prior to stent placement. Minor ES was safe and effective procedure for SEMS placement in patients with malignant biliary obstruction.

Importance of the Invasive Distance in Invasive IPMN as a Prognostic Factor

K. Kimura, R. Amano, S. Yamazoe, K. Miura, G. Ohira, K. Nishio, M. Shibutani, K. Sakurai, H. Nagahara, T. Toyokawa, N. Kubo, H. Tanaka, K.Muguruma, H. Otani, K. Maeda, M. Ohira, K. Hirakawa. Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan.

Introduction: Early reports of IPMN suggested that patients resected for invasive IPMN experienced a more favorable prognosis as compared with patients with conventional ductal cancer. However, there are few reports with regard to distance of invasive component.

Aim: The purpose of this study was to characterize the clinicopathological features of invasive IPMN at our institution with detailed examination of distance of invasive component. Furthermore, we investigated ability of diagnosis using criteria about worrisome features and high-risk stigmata in international consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.

Patients and Methods: Medical records of 88 patients with IPMN resected at our department from 1989 to 2013 were retrospectively investigated. Moreover, according to infiltrating distance of carcinoma cells, we classified invasive IPMN to T1a (invasive distance ≤ 5 mm), T1b (invasive distance: 5 ~ 10 mm), T1c and ≥ T2 (invasive distance: over 10 mm). By preoperative radiologic imaging, we picked up IPMN of worrisome features and high risk stigmata according international consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.

Result: The comparison of prognosis in infiltrating distance by invasive IPMNs revealed a significant difference in infiltration distance of more than 10 mm and 10 mm or less. In addition, there was no significant difference between the prognosis of invasive IPMN with infiltration of more than 10 mm and pancreatic ductal cancer. All cases of invasive IPMNs with infiltration of 5 mm or more met the criteria of high risk stigmata.

Conclusion: These results suggested that IPMNs met the criteria of high risk stigmata should not be done a limited operation as a laparoscopic surgery.

Recurrence After Curative Resection for Well-Differentiated Pancreatic Neuroendocrine Tumors

H. Kimura,1 T. Ohtsuka,1 K. Date,1 T. Fujimoto,1 T. Matsunaga,1 Y.Watanabe,1 K. Tamura,1 Y. Miyasaka,1 D. Yamada,1 S. Takahata,1 H. Igarashi,2 T. Ito,2 Y. Oda,3 M. Tanaka.1Departments of 1Surgery and Oncology, 2Medicine and Bioregulatory Science, and 3Anatomic Pathology, Kyushu University, Fukuoka, Japan.

Aim: This study aimed to clarify characteristics of recurrence after radical resection of well-differentiated pancreatic neuroendocrine tumors (PNETs) including G1 and G2 by the World Health Organization (WHO) classification issued in 2010.

Methods: Medical records of 87 consecutive patients who underwent surgical resection of well-differentiated PNETs were retrospectively reviewed and clinical characteristics were compared between the patients with and without recurrence. Patients with synchronous distant metastasis were excluded from this study.

Results: There were 49 non-functioning PNETs (NF-PNETs), 28 insulinomas, 8 gastrinomas, one somatostatinoma, and one glucagonoma. There were 74 NETs G1 and 13 NETs G2. There were 6 patients who had recurrences (5 NF-PNETs and 1 glucagonoma), and 3 of them had a NET G1, while the remaining 3 had G2. The sites of recurrence consisted of liver in 3, lymph node in 3 (one had both), and remnant pancreas in one (metachronously multifocal). The median interval between resection and recurrence was 42 months (range, 3 to 147 months). Univariate analysis showed that WHO classification (G2, P = 0.04) and tumor size (≥20 mm, P = 0.01) were the significant risk factors for recurrence. Multivariate analysis showed that the tumor size (≥20 mm, P = 0.04) was the only independent risk factor for recurrence. Although 5 of 6 patients with recurrence had tumors size of ≥20 mm, the remaining one had G2 with the tumor size of 15 mm. Among 13 patients with G2, 6 had tumors <20 mm. On the other hand, only 2 of 12 patients with lymph node metastasis had recurrences (P = 0.19).

Conclusions: Tumor size of ≥20 mm should be recognized as a risk factor for recurrence. In addition, adequate lymph node dissection might reduce the recurrence.

Neoadjuvant Chemotherapy With Gemcitabine and S-1 for Locally Advanced Pancreatic Cancer

T. Kin, H. Maguchi, K. Takahashi, A. Katanuma, M. Osanai, K. Yane, S. Ikarashi,M. Sen-yo, R. Minami, I. Sano. Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Hokkaido, Japan.

Aims: To evaluate the efficacy of neoadjuvant chemotherapy with gemcitabine and S-1 (NAC-GS).

Methods: Among 243 patients who were diagnosed with pancreatic cancer (PC) in our center from April 2012 to March 2014, 49 (20%) patients with NAC-GS were retrospectively analyzed. The treatment protocol of NAC-GS was as follows; gemcitabine (1000 mg/m2 on day 1 and 8) and S-1 (80 mg/m2 from day 1 to 14) were administered in a 21-day cycle for more than 4 courses.

Measurement Outcomes: 1. Clinical staging of PC at the initial diagnosis, 2. Clinical outcomes of NAC-GS, 3. Adverse events, 4. Surgical outcomes of NAC-GS, and 5. Tumor recurrence

Results: 1. UICC TNM stagings of the PCs were Stage IIA in 41 (84%), IIB in 4 (8%), and III in 4 (8%). According to NCCN classification, 15 (31%) of them were resectable, 28 (57%) were borderline resectable, and 6 (12%) were unresectable. 2. Forty (82%) patients were able to receive more than 4 courses of NAC-GS. The assessments of their tumor response were PR in 22 (55%), SD in 14 (35%), and PD in 4 (10%). 3. The grade 3 or worse adverse events occurred in 32 (65%) patients. The median relative dose-intensity was 75% for GEM and 83% for S-1. 4. Twenty-six (53%) patients underwent surgical treatment, and R0 resection could be achieved in 24 (92%) of them. Pathological TNM stagings of those 26 resected patients were Stage IA in 2 (8%) patients, IIA in 11 (42%), and IIB in 13 (50%), and down-staging could be achieved in 3 (12%) patients. Pathological response to NAC-GS (Evans grade IIa/IIb/III) was demonstrated in 8 (31%) patients. 5. During 7 (range, 1–20) months of the mean follow-up period after surgery, tumor recurrence was occurred in 5 (19%) patients.

Conclusions: NAC-GS showed clinical efficacy in terms of response rate and R0 resection rate though adverse events were not less frequent. Further evaluations would be warranted to clarify survival benefit of NAC-GS.

Comparative Study on the Clinicopathological Effect Between Gemcitabine-Based and S-1/Gemcitabine-Based Chemoradiotherapy for Locally Advanced Pancreatic Ductal Adenocarcinoma

M. Kishiwada, H. Kato, Y. Murata, A. Tanemura, N. Kuriyama, Y. Azumi, S. Mizuno, M. Usui, H. Sakurai, S. Isaji. Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Japan.

Background: There have been few studies comparing clinicopathological effect between different chemoradiotherapy (CRT) regimens for pancreatic ductal adenocarcinoma (PDAC). At our institution, we have been performing chemoradiotherapy followed by surgery for locally advanced PDAC. We used gemcitabine (Gem) previously, but recently we switched to S-1/Gem combination therapy aiming at improvement of treatment outcome. The purpose of this study was to compare the clinicopathological response between the two groups.

Methods: We divided the consecutive 208 patients with cytologically/histologically proven PDAC into the two groups: Gem-CRT (the earlier period: 2005.2-2011.9, n = 124) and S-1/Gem-CRT (the latter period: 2011.10-2013.12, n = 84). CRT regimen: radiation therapy (total dose of 45 to 50.4 Gy, 25 to 28 fractions) with chemotherapy which included Gem (800 mg/m2, day1,8,22,29) or oral S-1 (active combination of tegafur, gimeracil and oteracil) (60/m2, day1-21 and day 29–49) + Gem (600 mg/m2,day8,22,36,50). Curative-intent resection was performed by reassessment after completion of CRT. Between the two groups, we compared serum CA 19–9 reduction rate after CRT, resection rate, margin-negative (R0) resection rate and the pathological effect (rate of lymph node metastasis and tumor reduction rate using Evans classification). Tumor respectability was classified into resectable (R), borderline resectable (BR) and unresectable (UR) according to NCCN guidelines.

Results: The number of R/BR/UR was 16/57/51 in Gem-CRT group and 2/43/39 in S1/Gem-CRT group, respectively. CA 19–9 reduction rate (median) was significantly higher in S1/Gem-CRT than in Gem-CRT: 65.0% vs. 46.6% (P = 0.02). Between Gem-CRT and S1/Gem-CRT groups, resection rate according to R/BR/UR was similar: 69%/78%/46% vs. 100%/83%/49%, while R0 resection rate was significantly higher in S1/Gem-CRT: 100%/79%/48% vs. 100%/94%/74% (P < 0.05). Positive rate of lymph node metastasis according to R/BR/UR showed no significant difference:11%/42%/34% vs. 0%/42%/26% (P = 0.924), while the rate of tumor destruction of more than 50% was significantly higher in S1/Gem-CRT: 44%/26%/17% vs. 0%/60%/32% (P < 0.05).

Conclusions: Significant improvements in CA 19–9 reduction, R0 resection and pathological tumor destruction rates were obtained by the introduction of S1/Gem- CRT, compared with Gem-CRT, although long-term survival benefit should be furthermore assessed.

Improvement of the Chemoradiotherapy Followed by Surgery for Advanced Pancreatic Ductal Adenocarcinoma: Comparison of the Histopathological Effect Between Single-Agent Gemcitabine and S-1/Gemcitabine Combination Therapy

M. Kishiwada, H. Kato, Y. Murata, A. Tanemura, N. Kuriyama, Y. Azumi, S. Mizuno,M. Usui, H. Ssakurai, S. Isaji. Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Japan.

Background: There are few studies on histologic response by the difference in anticancer agent for pancreatic ductal adenocarcinoma (PDAC). At our institution, we have been performing chemoradiotherapy (CRT) followed by surgery for PDAC. We used gemcitabine (Gem) previously, but recently we switched to S-1/Gem combination therapy aiming at the improvement of the treatment result. The purpose of this study was to compare the histological response in the resected specimen in both groups.

Methods: We divided 208 consecutive patients which was cytologically/histologically proven PDAC into two groups, earlier period (G-CRT: 2005.2-2011.9, n = 124) and a latter period (GS-CRT: 2011.10-2013.12, n = 84). CRT regimen: radiation therapy (total dose of 45 to 50.4 Gy, 25 to 28 fractions) with chemotherapy which included GEM (800 mg/m2, day1,8,22,29) or GEM (600 mg/m2,day8,22,36,50) + oral S-1, active combination of tegafur, gimeracil and oteracil (60/m2, day1-21 and day 29–49). The patients underwent curative-intent resection after reassessment by response of CRT completion. We compared both groups in a CA 19–9 reduction rate after the CRT, resection rate, margin-negative (R0) resection rate and the pathological effect (lymph node metastases, tumor reduction rate using Evans classification).

Results: The G-CRT 124 patients were reclassified as resectable (R) in 16 patients, borderline resectable (BR) in 57, unresectable (UR) in 51, and The GS-CRT 84 patients were also reclassified in 2/43/39 patients by NCCN guidelines classification. The CA 19–9 reduction rate (the median) was significantly improved 65.0 % in latter period compared to 46.6% in earlier period (all: P = 0.020). The resection rate was approximately similar in both groups (69%/78%/46% vs. 100%/83%/49%), however the rate of R0 resection was significantly improved in latter period (100%/79%/48% vs. 100%/94%/74%, all case: P = 0.033, especially BR: P =0.047, UR P = 0.005). There was no significant difference in the lymph node-positive rate among three groups (11%/42%/34% vs. 0%/42%/26%, P = 0.924), but rate of more than 50% tumor destruction was significant improved in latter period (44%/26%/17% vs. 0%/60%/32%, all case: P = 0.013, BR: p = 0.002).

Conclusions: The improvement of CA 19–9 reduction rate, R0 resection rate and the tumor necrosis effect were obtained in GS- CRT compared with G-CRT, and then S-1/Gem combination CRT may contributes to the improvement of the long term prognosis.

Roux-en-Y Reconstruction With Isolated Pancreaticojejunostomy Versus Single Loop Reconstruction After Pancreaticoduodenectomy: Systematic Review and Meta-Analysis

U. Klaiber, P. Probst, P. Knebel, P. Contin, M.K. Diener, M.W. Büchler, T. Hackert. Department of Surgery, University of Heidelberg, Germany.

Background: Partial pancreatoduodenectomy (PD) is a standard procedure with a mortality below 5 per cent in centers. However, postoperative morbidity ranges up to 50 per cent with postoperative pancreatic fistula (POPF) as one of the most important and potentially severe complication. The impact of different techniques of the gastrointestinal reconstruction route is still a matter of debate. The reduction of POPF by means of a Roux-en-Y reconstruction with the isolation of the pancreaticojejunostomy (PJ) from biliary drainage has been evaluated in several studies. This systematic review and meta-analysis summarizes evidence of effectiveness and safety of the isolation of the PJ compared to standard reconstruction.

Methods: Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing outcomes of Roux-en-Y reconstruction with isolated PJ and conventional single loop reconstruction were searched systematically in MEDLINE, EMBASE and CENTRAL without language restriction from inception of each database to May 2014. Meta-analyses were performed using Review Manager software.

Results: Of 83 screened trials, three RCTs and four CCTs including a total of 802 patients were included. Regarding POPF, DGE, PPH, intra-abdominal fluid collection/abscess, bile leakage, wound infection, pneumonia, overall morbidity, mortality, re-interventions, re-operations, perioperative blood loss, and length of hospital stay quantitative synthesis showed no significant statistical difference between the two procedures. Operative time was significantly longer in patients undergoing Roux-en-Y reconstruction with isolated PJ.

Conclusion: Roux-en-Y reconstruction with isolated PJ after partial PD is not superior to single loop reconstruction. Thus, additional trials investigating superiority of the Roux-en-Y reconstruction with isolated PJ are not warranted.

Resection Surgery as a Historic Milestone in Modern Surgery for Chronic Pancreatitis

V. Klymenko, A. Klymenko, A. Steshenko, D. Syvolap. Department of Faculty Surgery, Zaporizhzhia State Medical University, Zaporozhzhia, Ukraine.

Introduction: Performing the resection surgery in patients with chronic pancreatitis surgeons do not attach much importance to pancreatic ductal hypertension and its duration. Mainly considered eliminating “inflammatory mass” of the pancreatic head.

Aim: Prove that timely removal of pancreatic ductal hypertension preserves and improves the functional activity of the pancreas.

Methods: Follow-up results of surgery treatment (7 years) in 124 patients with chronic pancreatitis (women - 12 men - 112, mean age - 43 years) who underwent parenchymapreserving (longitudinal total pancreatowirsungoduodenopapillotomy with longitudinal pancreaticojejunostomy) (n = 72) and resection (Frey, Beger) (n = 52) operations. In both groups highlighted subgroups: I - Patients with pancreatic ductal hypertension, moderate and severe exocrine insufficiency; II – patients with ductal hypertension without exocrine insufficiency. Parenchymapreserving operations: I - 49 (49/72, 68.1%); II - 23 (23/72, 31.9%). Resection surgery: I - 38 (38/52, 73.1%); II - 14 (14/52, 26.9%). Patients examined with US, CT, ERCP, C-peptid, endogen insulin, HbA1, CA 19–9, Ig G, fecal elastase - 1. Quality of life in both groups was assessed by EORTC QLQ - C30, EORTC PAN28.

Results: After parenchymapreserving operations in subgroup I moderate and severe exocrine insufficiency remained at 36 (36/72; 50.0%), light - became in 13 (13/72, 18.1%); in II - exocrine insufficiency was not. After resection operations: in subgroup I remained exocrine insufficiency in all patients; in II - exocrine insufficiency appeared in all patients: average degree - in 5 (5/52, 9.6%), severe - 9 (9/52, 17.3%). Quality of life of patients with the parenchymapreserving operations was much better than after resection (p <0.05).

Conclusions: Parenchymapreserving operation in surgery for chronic pancreatitis retain exocrine pancreatic function, improve quality of life and should replace resection interventions.

Clinicopathological Study of T1 Pancreatic Cancer

G. Kobayashi,1 Y. Noda,1 K. Ito,1 S. Koshida,1 Y. Kanno,1 T. Ogawa,1 K. Masu,1 Y. Michikawa,1 Y. Iwashita,1 N. Fujita,1 T. Sawai.21Department of Gastroenterology, 2Department of Pathology, Sendai City Medical Center, Sendai, Japan.

Objectives: The aim of this study was to evaluate clinicopathological characteristics of T1pancreatic cancer (TNM classification).

Methods: Fourteen patients with T1(histologically, tumor limited to the pancreas, 2 cm or less in greatest diameter) pancreatic cancer were evaluated clinically as to (1) the prevalence of Stage1A (T1, N0, M0) pancreatic cancer, (2) 5-year survival rate, and (3) positive rates of transpapillary pancreatic juice cytology (TPC), including the cell block method performed preoperatively. The resected specimens from the 14 T1 patients (Sep.1983 to Dec. 2005) were examined histopathologically as to (1) lymphatic invasion: ly., (2) venous invasion: v., (3) nerve invasion: ne., and (4) the frequency and length of intraductal spread (IS) along the main pancreatic duct from the main T1 tumor.

Results: Of the 172 patients with ordinary pancreatic cancer who underwent surgery at our center, 14 patients (8%) were T1, and 10 patients (6%) were Stage1A. The 5-year survival rate of T1 patients reached 55%. Of the 14 patients with T1pancreatic cancer, ly0, v0 and ne0 were observed in 50%, 79% and 42%, respectively. IS was observed in 79% of the T1 and 25% of the T2-4 patients. The mean length of IS in T1 was 11.2+/− 6.3 mm. Positive rates of TPC in T1 patients and T2-4 patients were 70% and 47%, respectively.

Conclusions: The prevalence of Stage1A was 71% of the patients with T1 pancreatic cancer. IS was frequently observed in the T1 patients. Therefore, TPC seems to be promising for histological diagnosis of small pancreatic cancer.

Malignant Potential of Intraductal Papillary Mucinous Neoplasms of the Pancreas: Special Reference to Minimally Invasive Carcinoma

K. Koikawa,1 K. Nishihara,1 Y. Akiyama,1 Y. Nakashima,1 H. Matsunaga,1 Y. Abe,1 T. Nakano,1 S. Mitsuyama,1 M. Tanaka.21Department of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan; 2Department of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University, Fukuoka, Japan.

Aim: To elucidate the biological behavior of minimally invasive (T1a) intraductal papillary mucinous neoplasms (IPMNs).

Methods: Seventy patients with 71 IPMNs were operated on. There were 46 benign IPMNs (IPMA; low and intermediate grade dysplasia) and 25 malignant IPMNs (IPMC; high grade dysplasia and invasive carcinoma). There were 40 male and 30 female, and the mean age of the patients were 68.5 years.

Results: IPMNs with their main pancreatic duct (MPD) diameter ≥10 mm were 16, 5–9 mm 24, and ≤5 mm 31. IPMCs were observed in 7 of 16 patients (44%) with MPD diameter ≥10 mm, 9 of 24 those (38%) with MPD diameter 5–9 mm, and 9 of 31 (29%) with MPD diameter ≤5 mm. Among the malignant predictive factors examined, only the size of mural nodules was statistically significant (P < 0.05).

Of the 25 IPMCs, there were 6 noninvasive (high grade dysplasia), 7 T1a (stromal invasion ≤5 mm), 2 T1b (>5 to ≤10 mm), 5 T1c (1–2 cm), and 3 T2 (>2 cm). Lymph node metastases were detected in 3 T1c IPMCs and 2 T2.

Postoperative outcome of these IPMCs was compared to 132 patients with pancreatic invasive ducal carcinoma (IDC) operated on in our department from 1996. The patients with T1a or earlier IPMCs showed significantly better prognosis than those with T1 IDC (5 year survival rate; 100% vs 42%). However, the patients with T1b or more advanced IPMCs showed similar prognosis to those with T2 IDC (38.5% vs 35.0%).

Conclusions: These results justify the international consensus guidelines which recommend resection for IPMNs with MPD ≥ 10 mm and/or the mural nodule. As noninvasive and T1a IPMCs show favorable prognosis, they may be regarded as early cancers or early IPMCs.

Renalase Protects Against Acute Pancreatitis

T. Kolodecik, F. Gorelick, G. Desir, A. Reed. Department of Medicine, Yale University School of Medicine, New Haven, CT.

Background: Kidney disease predisposes to acute pancreatitis and worsens its severity. Plasma levels of renalase (RNLS), an anti-inflammatory peptide hormone secreted by the kidney, are decreased renal disease. We hypothesize that RNLS protects against acute pancreatitis.

Methods: Acini from wild type(WT) and RNLS deficient(KO) mice were treated with 0.1 or 100 nM cerulein and recombinant human RNLS(25 μg/ml) and assayed for zymogen activation. WT and RNLS (KO) mice were treated with 6 hourly intraperitoneal injections of 40 mcg/kg cerulein to induce acute pancreatitis. RNLS peptide (1.3 mg/kg) was given prior to the first cerulein injection. Severity of pancreatitis was measured by several parameters: trypsin activity(fluorogenic substrate), edema(%wet weight), apoptosis(TUNEL), neutrophil(Ly-6B) and macrophage(F4/80) infiltration, and histologic severity. Ca2+ signals were measured by confocal microscopy after loading with fluo-4.

Results:In vitro, RNLS treatment decreased cerulein-induced zymogen activation in acini from WT and RNLS KO mice. In vivo, cerulein-induced pancreatitis decreased serum RNLS levels. RNLS peptide ameliorated cerulein-induced pancreatitis in vivo. Trypsin activation, edema, histologic severity, macrophage and neutrophil infiltration were all significantly improved in WT mice pretreated with RNLS peptide. Conversely, trypsin activation, edema, histologic severity, macrophage and neutrophil infiltration were all significantly worse in RNLS KO mice compared to WT controls with cerulein pancreatitis. To understand the mechanism underlying these effects, Ca2+ signals in isolated wild-type acini were examined. RNLS treatment significant increased the rate of Ca2+ efflux from WT mouse acini.

Conclusion: RNLS protects against pancreatitis responses in vitro and in vivo in mice.

L1156F-CFTR Associated With Alcoholic Chronic Pancreatitis in Japanese

S. Kondo,1 K. Fujiki,2 S. B. Ko,3 A. Yamamoto,1 M. Nakakuki,1 Y. Ito,4 M. Kitagawa,2 S. Naruse,5 H. Ishiguro.11Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Department of Nutrition, Nagoya University of Arts and Sciences, Nisshin, Japan; 3Department of Systems Medicine, Keio University School of Medicine, Tokyo, Japan; 4Division for Medical Research Engineering, Nagoya University Graduate School of Medicine, Nagoya, Japan; 5Miyoshi Municipal Hospital, Miyoshi, Japan.

Introduction: Although cystic fibrosis is rare in Japanese, measurement of sweat Cl has suggested mild dysfunction of cystic fibrosis transmembrane conductance regulator (CFTR) in some patients with chronic pancreatitis. In the present study, we have investigated the association of CFTR variants and chronic pancreatitis in Japanese and the functional characteristics of a Japanese-, and pancreatitis-specific CFTR variant, L1156F.

Materials and Methods: Seventy patients with alcoholic chronic pancreatitis, 18 patients with idiopathic chronic pancreatitis, and 180 normal subjects participated. All exons and their boundaries and promoter region of the CFTR gene were sequenced. HEK 293 cells and CFPAC-1 cells were transfected with 3 CFTR variants (M470V, L1156F, and M470V + L1156F). The protein expression was examined in HEK 293 cells. CFPAC-1 cells were loaded with BCECF and the activity of Cl-

exchange was estimated from changes in intracellular pH upon removal of bath Cl. An atomic model of CFTR protein was constructed by homology modeling using Discovery studio.

Results: Cystic fibrosis-causing mutations were not found. The allele frequencies of L1156F and Q1352H in alcoholic chronic pancreatitis (5.0 and 7.9 %) were significantly (p < 0.01) higher than those in normal subjects (0.6 and 1.9 %). L1156F was linked with a world-wide CFTR variant M470V. The expression of M470V + L1156F-CFTR was reduced to ~60% of wild-type CFTR. The expression of M470V-CFTR and L1156F-CFTR was not significantly different from that of wild-type CFTR. The Cl-

exchange activity of M470V + L1156F-CFTR was reduced to 50 ~ 60% of wild-type CFTR. A homology model of CFTR in the inward-facing conformation showed M470 and L1156F are not close to each other.

Conclusion: The Japanese-specific CFTR variant L1156F causes mild dysfunction of CFTR and increases the risk of alcoholic chronic pancreatitis in Japanese.

Long-Term Results of Combined ESWL and ERCP Treatment of Chronic Calcific Pancreatitis

T. Korpela, M. Udd, A. Tenca, O. Lindstrom, J. Halttunen, L. Kylanpaa. Helsinki University Hospital, Helsinki, Finland.

Background: Extracorporeal shock wave lithotripsy (ESWL) combined with endotherapy (ET) is the standard of care for the treatment of pancreatic duct stones (PDS) in chronic pancreatitis (CP). There are few reports of long term outcome of these patients. Our aim was to report the efficacy and the complications of ESWL combined with ET in the treatment of PDS.

Methods: Between 2004–2013, 83 patients had symptomatic PDS (81 abdominal pain, 1 obstructive jaundice, 1 pancreatic fistula) consecutively treated with ESWL and ET at Helsinki University Hospital. Etiology was alcohol in 53 (64%), biliary stones in 3 (4%) and idiopathic in 27 (32%) cases. Success was defined i) technical: PDS fragmentation and clearance obtained; ii) clinical: improvement/resolution of pain.

Results: Treated PDS were located in the head, body or in the tail of the pancreas in 78, 4 and 1 patients, respectively. The median size was 10 mm (range 5–25 mm). MPD was dilated (>3 mm) in 67 (81%) patients and in them the median diameter was 6 mm (range 4–15 mm). Of the patients 74 (89%) had ET before ESWL. Each patient had a median of 1 ESWL session (range 1–4). Technical success occurred in 69 patients (83%) whereas clinical success in 66 patients (80%). In 14 patients ESWL and the ET were unsuccessful in clearing the stones. Still, 8 of them became free of pain. Clinical success for the treatment is finally 66 + 8 = 74 (89%). No complications occurred. Eleven patients (13%) died during follow-up (median 42 months, range 6–124). We could contact 64 (89%) of the remaining patients by telephone, 36 (56%) of them were still smoking. Total of 19 (36%) of alcoholic CP patients had stopped alcohol consumption.

Conclusion: ESWL combined with ERP is an effective and safe treatment for CP patients with PDS.

The Validation Analysis of Our Prediction Method for Postoperative Pancreatic Fistula After Pancreas Head Resection

H. Kosaka, Y. Asano, K. Suzumura, H. Sueoka, N. Uyama, T. Okada, T. Hirano, Y. Iimuro, J. Fujimoto. Dept of Surgery, Hyogo College of Medicine, Nishinomiya, Japan.

Introduction: Drains are indispensable to detect and treat postoperative pancreatic fistula (PF) after pancreatic head resection, while early drain removal became common in patients who didn’t develop PF. The precise discrimination method for PF occurrence is required to manage drains appropriately. In this study, we had verified a precision of our prediction method for PF occurrence.

Method: We prospectively applied our cPF prediction method to 44 consecutive patients who underwent pancreas head resection from 2012. Our PF prediction method is simple: WBC (73.6 × 102 μ/l),CRP (9.3 mg/dl) and drain amylase (647U/I) on postoperative day 4 are set as reference value. If more than two values are high from reference value, prospective occurrence of clinically relevant PF (cPF) is expected, whereas if one or non values are high, cPF is not expected. ISGPF grade B and C were considered as cPF.

Results: cPF was occurred in 50.0 percent. Overall accuracy was 88.6 percent: sensitivity, specificity, positive predictive value and negative predictive value were 81.8, 95.5, 94.7 and 84.0 percent. We failed to predict in 5 cases: 4 cases failed to predict non-cPF occurrence and 1 case failed to predict cPF occurrence. One of possible reasons of incorrect prediction was drain trouble such as dislocation: in such case, drain amylase level was evaluated lower than real value. Other reason might be intra-abdominal infection which caused by unnecessary drain detainment: a delay of drain removal caused infection in 5 of non-cPF predicted cases. Among those, 1 case required more than 3 weeks drain insertion that is one of criteria of cPF.

Conclusion: The fine accuracy indicates our prediction model is trustworthy in practical use. However, appropriate drain management is required to use this method. Additionally, early drain removal could be recommended in non-cPF predicted cases to avoid intra-abdominal infections.

Increasing the Inflammatory Competence of Macrophages With IL-6 or With Combination of IL-4 and LPS Restrain the Invasion of Pancreatic Cancer Cells

A. Koski,1 H. Mustonen,1 S. Vainionpää,1 Z. Shen,2 E. Kemppainen,1 H. Seppänen,1 P. Puolakkainen.11Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland; 2Department of Gastroenterological Surgery, Peking University People’s Hospital, Beijing, China.

Introduction: Recent studies suggest that pro-inflammatory type M1 macrophages work against tumor progression and that anti-inflammatory M2 macrophages enhance it. The aim of this study was to examine the interaction of type M1 and M2 macrophages with pancreatic cancer cells.

Methods: We studied the migration rate of fluorescein stained pancreatic cancer cells in Matrigel cultured alone or with GM-CSF differentiated M1 macrophages or with M-CSF differentiated M2 macrophages. Macrophage differentiation was confirmed with flow cytometry. We studied the changes the pancreatic cancer cells induced in the differently stimulated macrophages’ cytokine expression with cytokine array.

Results: Both GM-CSF (M1) and M-CSF (M2) differentiated macrophages increased the migration rate of primary pancreatic adenocarcinoma cell line (MiaPaCa-2) and metastatic cell line (HPAF II). Stimulation with IL6 or IL4 + LPS abolished the macrophages’ increasing effect on the migration rate of MiaPaCa completely and partly of HPAF. Co-culture with MiaPaCa reduced the inflammatory cytokine expression of GM-CSF differentiated M1 macrophages. Adding IL6 or IL4 + LPS to the cell culture with MiaPaCa and GM-CSF or M-CSF differentiated macrophages increased the expression of inflammatory cytokines in macrophages.

Conclusion: Pancreatic cancer cells have an ability to inhibit the inflammatory cytokine expression of GM-CSF differentiated M1 macrophages. This explains why both GM-CSF (M1) and M-CSF (M2) differentiated macrophages promoted the invasion of pancreatic cancer cells. IL6 and IL4 + LPS activated the inflammatory cytokine expression in macrophages and this could contribute to the reversion of the macrophage induced increase of cancer cell migration rate.

A 5-year Nationwide Analysis of Trends, Complications and Mortality of Acute Pancreatitis (AP) in Post-Bariatric Surgery Status (BRS)

S.G. Krishna,1 A. Hinton,2 D. L. Conwell.11Section of Pancreatic Disorders, Department of Gastroenterology, Hepatology and Nutrition, 2Division of Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: BRS patients have a high incidence of gallstones and ERCP can be difficult. There are no large studies addressing outcomes in post-BRS patients admitted with AP (BRS-AP).

Aim: To evaluate morbidity and mortality associated with BRS-AP.

Methods: The Nationwide Inpatient Sample (2007–2011) was reviewed for all adult patients (≥18 years) with primary diagnosis of AP. Univariate analysis (demographics, hospital factors, AP-etiologies) and multivariate analysis [mortality, length of stay (LOS) and total hospitalization charges (total$)] were performed.

Results: There were 1,349,842 admissions for AP among which 1.07% (14,386) was BRS-AP. There was an increase in frequency of BRS among AP-patients (0.73% to 1.39%, p < 0.001).

Univariate analysis (BRS-AP vs. non-BRS AP): BRS-AP was more frequent in women (82.5% vs. 47.5%, p < 0.01), gallstone related-AP (24.8% vs. 22.4%, p < 0.01), and in those with BMI > 30 (37.5% vs. 9.8%, p < 0.01) while non-BRS AP was more frequent with alcohol related-AP (20.9% vs. 17.1%, p < 0.01). BRS-AP patients underwent fewer ERCPs (4.2% vs. 7.7%, p < 0.01) albeit more cholecystectomies (14.1% vs. 11.9%, p < 0.01).

Multivariate analysis: Complications of pseudocyst (5.8% vs. 3.2%, OR 1.61 [95% CI 1.23, 2.08]), respiratory failure (3.4% vs. 1.3%, OR 2.70 [1.85, 3.85]) and acute kidney failure (7.8% vs. 3.9%, OR 1.41 [1.14, 1.72]) were all associated with non-BRS AP. The mortality rate although lower for BRS-AP did not reach significance (0.22% vs. 0.96%, OR 0.5 [0.23, 1.16]). However LOS (4.4 vs. 6.3 days, p < 0.01) and total$ (28 K vs. 32 K, p < 0.01) were significantly lower in BRS-AP.

Conclusion: Gallstone related-AP was more common BRS-patients. Although admissions for BRS-AP are increasing and ERCP is challenging, these patients have shorter LOS, lower total$, and lower AP-related morbidities compared to non-BRS patients.

Cystic Fibrosis in the United States: Trends in Healthcare Utilization and Resource Expenditures

S. Krishna, P. Hart, S. ElDika, R. Groce, S. Jones, A. Hinton, D.L. Conwell. Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Columbus, OH.

Background: Advances in cystic fibrosis care has resulted in increased survival. Limited data exist in the adult CF population.

Aim: Describe the resource utilization of CF in the United States.

Methods: Nationwide Inpatient Sample (NIS) query of ICD-9 coding for cystic fibrosis (ICD9-CM 277.0) from 2003 – 2011. Demographics, costs, charges, hospital location, hospital type and region of country evaluated.

Results: The overall trend (p < 0.0001) and number of CF discharges has increased from 8,456 to 12,104 (p < 0.0001 ). The mean age for CF_PULM and CF_GI admissions was 29 yr and 30 yr, respectively. The total number of CF_PULM (p <0.0001) and CF_GI manifestations (CF_GI, p = 0006) has statistically increased. Likewise, the charges associated with a CF inpatient admission has doubled (45,000 vs 91,000 dollars; p < 0.0001) AND the age distribution for CF has also shifted toward the later life categories at a statistically significant level (p < 0.0001) for the: 18–44 yr, and 45–64 yr groups. Furthermore, the overall percentage of adults (>18 years old) with CF_GI has increased 2-fold from 38% to 79% (p < 0.0001).

Conclusion: This data highlights the need for training and further development of Adult Cystic Fibrosis Transition Programs within Pancreas Centers of Excellence (PCOE) across the United States.

Morbid Obesity (MO) is an Independent Predictor of Mortality in Acute Pancreatitis (AP): A 5-year Analysis of the Nationwide Inpatient Sample (NIS)

S.G. Krishna,1 A. Hinton,2 D. L. Conwell.11Section of Pancreatic Disorders, Department of Gastroenterology, Hepatology and Nutrition, 2Division of Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: MO (BMI ≥ 40) adversely influences the prognosis of AP. There are no population-based studies assessing impact of MO on the outcome of acute pancreatitis (AP).

Aim: To evaluate health care utilization and outcomes of AP in MO (MO-AP).

Methods: Using the NIS, we analyzed all adult patients (≥18 years) hospitalized with principal diagnosis of AP from 2007–2011. Post-bariatric surgery patients were excluded. Outcomes [mortality, procedures, length of stay (LOS) and total hospital charges (total$)] of AP were analyzed after adjusting for demographic (age, gender, race, income, insurance, comorbidities), hospital (teaching status, location, size) and etiological differences.

Results: MO was associated with 52,659 (3.94%) of all AP (1,337,431) admissions. Overall in-hospital mortality for MO-AP was significantly greater than non-MO AP (1.17% vs 0.95%, p = 0.04).

Univariate analysis (MO-AP vs. non-MO AP): MO-AP was more frequent in gallstone related-AP (35.5% vs. 21.5%, p < 0.01) while non-MO AP was more common with alcohol related-AP (21.43% vs. 7.01%, p < 0.01). Consequently, MO-AP patients underwent more cholecystectomies (21.05% vs. 11.54%, p < 0.01) and ERCPs (10.6% vs 7.9%, p <0.01). Notably, acute kidney failure (11.0% vs. 7.6%, p < 0.01), and respiratory failure (5.4% vs. 3.3%, p < 0.01) were more common in MO-AP.

Multivariate analysis: MO was an independent predictor of mortality (OR 1.62; 95% CI 1.31, 2.01) in AP. Additionally, MO-AP patients had a higher LOS (>0.8 days, p < 0.01) and total$ (> $8 K, p < 0.01).

Conclusion: MO is an independent predictor of mortality in AP and negatively impacts inpatient healthcare resource utilization. With increasing rates of MO, future research should consider evaluating its role in risk stratification scores for AP.

The Effect of Leptin for PDX-1 Promoter Activity in the Islet Beta Cell Specific Manner

A. Kurosawa,1,2 A. Miki,1,2 W. Nishimura,3 T. Kimura,2 K. Nanmoku,2 Y. Sakuma,1,2 Y. Sanada,1 H. Sasanuma,1 K. Morishima,1 N. Kasahara,1 T. Yagisawa,2 N. Sata,1 Y. Yasuda.11Department of Surgery, Jichi Medical University, Tochigi, Japan; 2Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Tochigi, Japan; 3Department of Metabolic Disorder, Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan.

Background: A novel reporter system using secreted Gaussia princeps luciferase under the control of a Pdx1 promoter was constructed (Endocrinology 2013). Leptin is an adipokine associated with glucose metabolism secreted from adipose tissue. Few reports investigate the effect of leptin to islet function in the islet beta cell specific manner. Aim of this experiment is to assess the effect of leptin to Pdx1 promoter activity with Pdx1-GLuc mouse islet.

Materials and Methods: Pdx1-GLuc mouse islet were isolated by collagenase and incubated with leptin for 24 hours. Pdx1 activity was assessed by the luciferase intensity. Viability was assessed with colorimetric cell viability assay with tetrazolium salt.

Results: Pdx1 promoter activity measured by lucifease intensity was reduced by the addition of leptin to islet culture medium (62% control, P = 0.03). Viability showed no significant difference.

Conclusion: Pdx1 promoter activity was measured by the newly reporter system with Pdx1-GLuc mouse in islet beta cell specific manner. Leptin might reduce Pdx1 promoter activity.

The Clinical Implication of Repeat Pancreatectomy for Recurrent Pancreatic Cancer in the Remnant Pancreas After Initial Pancreatectomy

T. Kyuno, Y. Kimura, M. Imamura, T. Ito, T. Nobuoka, T. Mizuguchi, T. Furuhata, K. Hirata. Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan.

Background: Repeat pancreatectomy for recurrent pancreatic cancer in the remnant pancreas after initial pancreatectomy is umcommon in comparison with chemotherapy. The aim of this study was to clarify the clinical implication of repeat pancreatectomy for recurrent Invasive Ductal Carcinoma of pancreas (IDC) or Intraductal Papillary Mucinous Neoplasm (IPMN).

Methods: We retrospectively analyzed 7 patients who underwent repeat pancreatectomy for recurrent pancreatic cancer through April in 2004 to December in 2013 at our hospital. They were 6 male and a female, and their median age was 69.3 (range 50–88). The pathological diagnosis at their initial pancreatectomy was 5 IDC and 2 Intraductal Papillary Mucinous Carcinoma. Four of these 7 patients underwent pancreaticoduodenectomy (PD), and the other distal pancreatectomy (DP). There was no residual cancer at initial pancreatectomy in all cases.

Result: The median time between the initial resection and the repeat pancreatectomy was 655 days (203–1324). Operative methods were 5 total remnant pancreatectomy, 1 DP, and 1 gastric partial resection. Among them, the number of the operation which there was no residual cancer was 5. The median survival time after repeat pancreatectomy was 362 days and that after the initial resection was 961 days (646–1403). Two patients are alive now. In 6 cases, there was no difference between the histology of the tumor at the initial resection and that at the repeat pancreatectomy. And in 5 cases of IDC at initial pancreatectomy, there were perineural invasion. We experienced no main complications intra or post operation.

Conclusion: Repeat pancreatectomy might bring about beneficial effects on prognosis in selected patients with recurrence in the remnant pancreas after initial pancreatectomy for pancreatic cancer without increased operative morbidity or mortality.

200 Consecutive Pancreatico-Duodenectomies With the Finnish Binding Pancreaticojejunostomy (FBPJ): The Prospective Trial Shows a Low Frequency of Pancreatic Fistula

J. Laukkarinen, I. Nordback, J. Sand. Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Background: Post-operative pancreatic fistula (POPF) remains the most challenging complication after pancreaticoduodenectomy (PD). We have developed a novel Finnish binding pancreatico-jejunal anastomosis (FBPJ), where the mobilized pancreatic stump is slid 2–3 cm inside the jejunal limp with the aid of 6–8 peripancreatic sutures, after which the bowel is tightened over the pancreas with a purse string. The aim of this prospective trial was to analyze the outcome of 200 consecutive PDs with this novel anastomosis.

Methods: 202 consecutive patients underwent PD in Tampere University Hospital. FBPJ was technically achievable in all but two (99%). Prospective follow-up included repeated serum and drain output measurements and daily urine trypsinogen test. POPF, hemorrhage (PPH) and delayed gastric emptying (DGE) were defined strictly according to the International Study Group classifications.

Results: 30-day mortality was 1.5%. The incidence of clinically relevant Grade B-C POPF was 6.8%. PPH occurred in 1.2-0.5-6.3% (Grade A-B-C) and DGE in 33-12-3.7% (Grade A-B-C) of the patients. 33% developed clinically relevant post-operative trypsinogen release (positive ≥2 days; suggesting mild pancreatitis), which had a moderate correlation (Pearson 0.52) to Grade B-C POPF and a weak correlation (Pearson 0.25) to Grade B-C DGE.

Conclusions: The rate of clinically relevant POPF is decreased to 6.8% with the novel FBPJ. This is low compared to our historical controls (15%) and results from others. Even though a randomized trial is warranted, based on this prospective trial of 200 consecutive patients it is a safe and secure technique and can be recommended for routine pancreatico-jejunal anastomosis after PD.

Discovery and Validation of Biomarkers for the Differential Diagnosis of Pancreatic Cysts Using a Mass Spectrometry-Based Comprehensive Proteomics Approach

J.K. Lee,1 K.H. Lee,1 K.T. Lee,1 J.S. Park,2 S.Y. Lee.21Departments of Medicine, 2Department of Laboratory & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background and Aim: The use of advanced imaging technologies for the identification of pancreatic cysts has become widespread; however, accurate differential diagnosis between mucinous and nonmucinous neoplasms remains a challenge. Thus, it is necessary to develop novel biomarkers for the differential diagnosis of pancreatic cysts.

Methods: An integrated proteomics approach yielded differentially expressed proteins in mucinous cyst fluids that were subsequently verified in 56 pancreatic cysts (17 pseudocysts, 18 mucinous and 21 nonmucinous neoplasms) using GeLC-Stable Isotope Dilution-Multiple Reaction Monitoring-mass spectrometry (GeLC-SID-MRM-MS) and immunoassay techniques. Statistical analysis was performed to prioritize which of the differential markers would be useful for predicting mucinous neoplasms.

Results: A total of 223 proteins were identified using nanoscale liquid chromatography coupled to tandem mass spectrometry (nano LC-MS/MS). Nine candidate biomarkers, including polymeric immunoglobulin receptor (pIgR), neutrophil gelatinase-associated lipocalin (NGAL), IgGFc-binding protein (FCGBP), lithostathine-1-alpha (REG1A), afamin (AFM), chymotrypsin-C (CTRC), pancreatic alpha-amylase (PA), galactin-3-binding protein (G3BP), and elastase-3A (ELA3A) were successfully evaluated as biomarker candidates for mucinous neoplasms. Four markers (AFM, REG1A, pIgR and NGAL) were significant discriminate markers for mucinous cystic lesions relative to benign cystic lesions (P < 0.05).

Conclusion: Using a MS-based comprehensive proteomics approach, we developed a diagnostic panel consisting of four AFM, REG1A, pIgR and NGAL biomarkers to differentiate mucinous cysts from pseudocysts or benign nonmucinous neoplastic cysts.

Flavokawain B, a Kava Chalcone, Inhibits Growth of Human Pancreatic Cancer Cells Through G2/M Cell Cycle Arrest and Apoptosis

S.H. Lee,1 J.M. Lee,2 K.H. Chung,1 B.S. Lee,1 W.H. Paik,3 D.W. Ahn,4 J.K. Ryu,1 Y.T. Kim.11Departments of Internal Medicine, Seoul National University Hospital, Seoul, Korea; 2Department of Internal Medicine, Myongji Hospital, Goyang, Korea; 3Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea; 4Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.

Background and Aims: Flavokawain B (FKB) is a kava extract possessing therapeutic potential against several cancers. However, the antitumor effect of this natural compound on pancreatic cancer has not been determined yet. This study was designed to identify antitumor activity and molecular mechanisms of FKB in pancreatic cancer cell lines. Finally, we investigated whether the combination of FKB and gemcitabine had an additional therapeutic effect compared to gemcitabine single regimen in pancreatic cancer cell lines.

Methods: Pancreatic cancer cell line were cultured and treated with different concentrations of FKB. Cell viability was determined by MTT assays and the IC50 was estimated. Fluorescent-activated cell sorting analysis of apoptosis and cell cycle was performed. Real-time RT-PCR and western blot analysis were utilized to evaluate differences in the expression of apoptotic markers.

Results: FKB caused the G2/M cell cycle arrest of pancreatic cancer cells that was mediated through reductions in the levels of cyclin D1 and cyclin-dependent kinase 4. FKB also induced apoptosis through the down-regulation of Bcl-2 with the activation of apoptotic proteins, including Bax and Bak in pancreatic cancer cell lines. The G2/M cell cycle arrest and apoptosis in combination treatment was significantly higher than that in FKB or gemcitabine single treatment (P < 0.05).

Conclusions: Our results suggest the antitumor potential of FKB for the prevention and treatment of pancreatic cancer. In addition, the combination of FKB to gemcitabine enhanced antitumor efficacy through cell cycle arrest and apoptosis in pancreatic cancer.

Upregulation of Atg4B Mediates Inhibition of Pancreatic Autophagy by Ethanol

G.E. Lee,1,2 J. Ni,1 S.W. French,2 A.S. Gukovskaya,1,2 I. Gukovsky,1,2 O.A. Mareninova.1,21VAGLAHS and University of California at Los Angeles; 2Southern California Research Center for ALPD and Cirrhosis, Los Angeles, CA.

Background & Aims: Autophagy plays a key role in the pathogenesis of non-alcoholic pancreatitis; however, the effects on autophagy of alcohol, a major risk factor for pancreatitis, are largely unknown. Here we show that ethanol downregulates pancreatic autophagy through its effects on Atg4B, a protease that delipidates (inactivates) LC3-II, a key mediator of autophagosome formation.

Methods: Mice were pair fed for 6 wk ethanol or control Lieber-DeCarli diet followed by low-dose cerulein (CR). In ex-vivo model, acinar cells were transduced with mock or Atg4B-shRNA adenovirus and incubated with ethanol (50–100 mM) followed by 100 pM CCK-8. Immunoblot, immunofluorescence, electron microscopy, and enzymatic assays were used to measure autophagy parameters and the effects of manipulating Atg4B on acinar cell death.

Results: Ethanol inhibited autophagosome formation in both in vivo and ex-vivo pancreatitis models, measured with EM and by a decrease in LC3-II. In both tissue and cells, ethanol treatment up-regulated protein level and activity of Atg4B (the latter measured by using LC3-vinyl sulfone, a probe directed at the Atg4B active site). Atg4B activity correlated with changes in its protein level. Atg4B shRNA knockdown restored LC3-II and autophagosome formation in ethanol-treated acinar cells. In contrast to ethanol alone and alcoholic pancreatitis, CR (or CCK) alone did not stimulate Atg4B activity, and increased LC3-II level. The combination of ethanol and low-dose CR or CCK resulted in impaired autophagy manifest by accumulation of large vacuoles and deficient clearance of p62-mediated protein aggregates in acinar cells.

Conclusions: Results indicate a key role for Atg4B in regulating autophagosome formation in acinar cells. By stimulating Atg4B-mediated LC3-II delipidation, ethanol downregulates autophagy, thus predisposing to pancreatitis.

Gremlin is a Novel Mediator of Pancreatic Fibrosis in Chronic Pancreatitis

K. Liu,1 Y. Cao,1,2 G. Greeley,, Jr,2 T.C. Ko.1,21Dept. of Surgery, UTHSC-H, Houston, TX; 2UTMB, Galveston, TX.

Background: Our laboratory has shown that pancreatic level of gremlin, an endogenous bone morphogenetic protein (BMP) antagonist, is elevated in both human and mouse chronic pancreatitis (CP). Deletion of gremlin in mice attenuates CP-induced fibrosis. These results suggest that gremlin is pro-fibrogenic in CP. However, the underlying mechanism is unknown. We hypothesize that gremlin blocks the anti-fibrogenic BMP signaling, leading to pancreatic fibrosis in CP.

Objective: Determine the role of BMP signaling in gremlin-induced pancreatic fibrosis.

Methods: PSCs were isolated from wild-type (wt) and BMP receptor type II knockout mice (BMPR2+/−). The cultured PSCs were treated with vehicle, gremlin1 (500 ng/ml), BMP2 (50 ng/ml), TGF-β1 (1 ng/ml), or various combined treatments. Activation of BMP signaling was assessed by measuring phospho(p)Smad1/5 level using Western blotting. Fibronectin (FN), an extracellular matrix protein, was measured by immunofluorescence as a functional outcome of fibrosis.

Results: In wt PSCs, compared to vehicle, BMP2 induced pSmad1/5, which was inhibited by gremlin (12.5- vs 2.9-fold with the treatment of BMP2 vs Gremlin + BMP2, p < 0.05). TGF-β induced FN, BMP2 inhibited TGF-β’s effect, and gremlin blocked BMP2’s effect (4.7-, 1.2-, 4.8-fold with the treatment of TGF-β, BMP2 + TGF-β, Gremlin + BMP2 + TGF-β respectively, p < 0.05). Furthermore, gremlin alone induced FN by 2.3-fold in wt PSCs and this effect was attenuated by 78% in BMPR2+/− PSCs (p < 0.05).

Conclusions: Gremlin promotes pancreatic fibrosis through its blockade of BMP signaling and BMPR2 is required for gremlin’s pro-fibrogenic function. Together, we have identified gremlin as a novel mediator of pancreatic fibrosis in CP. Strategies to target pancreatic gremlin may release repression of BMP signaling, leading to an innovative CP therapy.

Impact of the Number of Positive Lymph Nodes and Lymph Node Ratio on Prognosis in Resected Pancreatic Adenocarcinoma

Z.-Q. Liu, Z.-W. Xiao, G.-P. Luo, L. Liu, C. Liu, J. Xu, J. Long, Q. Ni, X.J. Yu. Pancreatic Cancer Institute, Fudan University; Department of Pancreatic & Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.

Background: The prognostic factors related to lymph node involvement (lymph node status, number of positive lymph nodes, lymph node ratio (LNR)) and the number of nodes evaluated in patients with pancreatic adenocarcinoma following pancreatectomy are poorly defined.

Methods: We included 167 patients with pancreatic adenocarcinoma who underwent resection with a standardized histopathological evaluation from February 2010 to August 2011. Univariate and multivariate analyses were used to determine the relationship between the variables related to nodal involvement and the number of nodes and survival.

Results: The median (range) number of total nodes examined was 10 (0–44) for the entire cohort. The median (range) number of total nodes examined in node-negative (pN0) patients was similar to the number of nodes examined in node-positive (pN1) patients. Patients with pN1 diseases had significantly worse survival than pN0 patients (P = 0.000). Patients with three or more positive nodes had a poorer prognosis compared with the node negative patients (P = 0.000). The prognoses of the patients with one to two positive nodes and the node negative patients were similar (P = 0.516). The median survival of the patients with a LNR ≥ 0.4 was shorter than the patients with a LNR < 0.4 in the pN1 cohort (P = 0.014). No significance was found between the number of total nodes examined and the prognosis, regardless of the cutoff of 10 or 12 and in the entire cohort or the pN0 and pN1 groups. Based on the multivariate analysis of the entire cohort and the pN1 group, the nodal status, the number of positive nodes and the LNR were all determined to be associated with survival.

Conclusions: In addition to the nodal status, the number of positive nodes and the LNR can be more comprehensive factors to evaluate nodal involvement. This approach may be more effective for predicting the survival of patients with pancreatic adenocarcinoma following pancreatectomy.

Epigenetic Regulation Downstream of KRAS by the HP1-Histone Methyl Transferase Pathway Mediates Pancreatic Cancer Growth

G. Lomberk, A. Mathison, R. Urrutia. Epigenetics and Chromatin Dynamics Laboratory, Translational Epigenomics Program (CIM), GIH Division, Department of Medicine, Mayo Clinic, Rochester, MN.

Epigenetic mechanisms working downstream of oncogenes are critical for establishing the development and pathobiological behavior of PDAC. We show that HP1γ, and its associated HMT G9a, one of the most important epigenetic pathways described to date, is upregulated in human PDAC and the p48-Cre/LSD-KrasG12D PDAC mouse model. In fact, we find that HP1γ is activated by pancreatitis and PDAC-associated signaling pathways, such as cerulein and EGF, in a KRAS-dependent manner, synergizes with KRAS to stimulate PDAC cell growth in xenografts, and antagonizes PanIN formation in p48-Cre/LSD-KrasG12D mice. Combined, genome-wide ChIP-Seq studies and expression arrays demonstrate that HP1γ mediates the epigenetic regulation of growth-promoting gene expression networks downstream of KRAS by binding to gene bodies, consistent with mRNA elongation. Immunoprecipitation of the Kras-activated HP1γ found that it forms a complex with G9a, as well as the active elongating form (P-Ser2) of RNA pol II. Utilizing stable HP1γ knockdown in BxPC3 cells, we found that shHP1γ cells had reduced recruitment of P-S2-RNA pol II and its associated factor, SF2, to the gene body of a well-known KRAS and HP1γ target gene model, IL-8, by ChIP, further implicating HP1γ in mRNA elongation. Inhibition of the HP1-associated HMT, G9a, hinders PDAC cell growth in cultured cells and xenografts in vivo (see accompanying abstract by Mathison, et al). Thus, HP1γ functions as an epigenetic regulator downstream from KRAS to promote pancreatic cell growth by regulating expression of proliferative gene networks via mRNA elongation. As new drugs targeting both the KRAS and HP1-HMT pathways are being tested in clinical trials, these results build the rationale for applying these tools to the management of patients affected with deadly pancreatic diseases, thereby bearing significant relevance to the field.

Necroptosis is the Primary Mode of Caerulein- or TLCS-Induced Mouse Pancreatic Acinar Cell Death

J. Louhimo, M. Steer, G. Perides. Dept of Surgery, Tufts Medical Center, Boston, MA.

Background: The mechanisms responsible for acinar cell death during acute secretagogue or biliary pancreatitis are poorly understood.

Aim: To determine whether apoptosis or necrosis are important modes of acinar cell death during secretagogue or biliary pancreatitis.

Methods: Wild type and RIP3−/− mouse pancreatic acinar cells were freshly prepared and incubated with 100nM caerulein or 250 μM taurolithocholic acid 3-sulfate disodium salt (TLCS) in the presence or absence of the caspase inhibitor ZVAD-fmk, or the RIP1K inhibitor necrostatin. Cell death was evaluated by quantitating propidium iodide incorporation. In preliminary in-vivo studies, secretagogue-induced pancreatitis was elicited by administration of 6 hourly i.p. doses of caerulein (50 μg/kg) while biliary pancreatitis was elicited by retrograde intraductal infusion of 10 mM TLCS. Mice were sacrificed 6 hrs after pancreatitis induction and pancreatitis severity was quantitated as follows: edema, by measuring pancreatic water content; inflammation, by quantitating pancreatic myeloperoxidase levels; and acinar cell injury by histologically quantitating acinar cell necrosis.

Results: Acinar cells from RIP3−/− mice were protected from caerulein or TLCS induced cell death compared to acinar cells from wild type mice. Necrostatin treatment provided protection from caerulein- or TLCS-induced cell death. Pretreatment with ZVAD-fmk did not protect the cells. Combination of necrostatin and ZVAD-fmk did not provide any additional protection. The severity of caerulein- or TLCS-induced pancreatitis in wild type mice pretreated with necrostatin or isolated from RIP3−/− mice was reduced compared to that of wild type mice while the severity of acute pancreatitis was not affected by the caspase inhibitor ZVAD.

Conclusions: Necroptosis is the primary mode of acinar cell death in caerulein- or TLCS-induced experimental acute pancreatitis. Apoptosis appears to play a minor, if any, role.

Change in Bone Mineral Density in the First Year After TPIAT for Chronic Pancreatitis

Y. Lu, G.J. Beilman, T.B. Dunn, T.L. Pruett, M.L. Freeman, M. Arain, P. Ptacek, K.L. Berry, K.E. Ensrud, L.E. Polgreen, M.D. Bellin. University of Minnesota, Minneapolis, MN.

Background: Little is known about bone mineral density (BMD) after total pancreatectomy and islet autotransplant (TPIAT) for chronic pancreatitis. In addition to exocrine insufficiency, these patients may have nutritional risks related to altered luminal gastrointestinal anatomy.

Methods: 48 adults (age 39 ± 11 yrs, 41 fm, 44 Caucasian) underwent Dual-energy X-ray absorptiometry (DXA) at baseline (BL) and at 1 year (1y) after TPIAT, for assessment of BMD at the lumbar spine, total hip, and total body, and measurement of lean and fat body mass. Serum samples were analyzed for 25-hydroxyvitamin D (25-OHD) and collagen type 1 cross-linked C-telopeptide (CTX).

Results: Weight loss was observed from BL to 1y: 70.7 ± 19.7 kg vs 65.4 ± 15.6 kg (p < 0.001), accompanied by a reduction in fat body mass (p < 0.001) with a median change of −21% (interquartile range −33,+6). From 1 y to BL, percent change in BMD, expressed as median and interquartile range was: total body −1.7% (−3.8,-0.8); left hip −3.2% (−5.5,-0.9), and lumbar spine −1.9% (−6.0,+2.5). In univariate regression modeling, weight loss (p = 0.60, p < 0.001) and change in fat mass (r = 0.47, p < 0.001) were significantly associated with change in total body BMD. In mutli-logistic regression, change in fat and change in lean body mass (p ≤ 0.01), but not smoking, gender, age, and menopausal status, were associated with change in total body BMD. Change in fat mass (p = 0.01), but not change in lean mass, was independently associated with change in hip BMD.

25OHD was unchanged (p = 0.24) and serum CTX was greater at 1y versus BL (p = 0.01). Neither of these biomarkers was associated with BMD change.

Conclusions: BMD was reduced by as much as 3% at the hip in the first year after TPIAT, greater than the expected average 0.6% yearly decline in older adults. Loss of weight and fat mass were strongly associated with the rate of bone loss, potentially suggesting a nutritional component.

Subtle Abnormalities in Glucose Regulation and Islet Function In Non-Diabetic Adults with Chronic Pancreatitis

R. Lundberg, G.J. Beilman, T.B. Dunn, T.L. Pruett, M.L. Freeman, M. Arain, P. Ptacek, K.L. Berry, J.J. Wilhelm, M.D. Bellin. University of Minnesota, Minneapolis, MN.

Introduction: Diabetes mellitus (DM) is often a consequence of chronic pancreatitis (CP). Our understanding of islet cell function in CP prior to the onset of DM is incomplete. The objective of the current study was to better understand pancreatic islet function and glucose control in CP prior to the onset of DM.

Methods: 25 non-diabetic CP patients (19 female, age 34.2 ± 2.4 yrs, BMI 24.7 ± 0.9 kg/m2) undergoing TPIAT were compared to 25 healthy controls matched for age, gender, and BMI. CP was pathology-confirmed at time of TP-IAT. Subjects underwent frequent sample IV glucose tolerance testing (IVGTT) and mixed meal tolerance testing (MMTT) to assess islet function (prior to TP-IAT in CP group).

Results: Causes of pancreatitis were genetic (n = 10), idiopathic (n = 6), or obstructive (n = 9). Mean fasting glucose was 89.5 ± 2.3 in CP patients and 84.4 ± 1.2 mg/dL in healthy controls (p = 0.04). In the MMTT, the CP patients had a higher area under the curve (AUC) glucose (p ≤ 0.01), but a similar AUC C-peptide (p = 0.6). However, MMTT stimulated C-peptide at 30 minutes was lower in CP patients (p = 0.04). The CP group had higher AUC glucagon (p ≤ 0.01); GLP-1 and GIP did not differ between groups. From the IVGTT, 63% of CP patients had ≥2.5 fold increase in C-peptide, compared to 84% of controls (p = 0.08). Mean insulin sensitivity index calculated from the IVGTT (Minmod software) was lower in CP group (p ≤ 0.01), indicating lower insulin sensitivity.

Discussion: Non-diabetic CP patients with primarily non-calcific disease demonstrated subtle islet dysfunction. CP patients had higher fasting and meal-stimulated glucose levels, without compensatory increase in insulin secretion. In contrast to the classic description of glucagon deficiency and heightened insulin sensitivity in diabetic patients with advanced CP, our CP cohort had relative hyperglucagonemia and were less insulin sensitive than controls.

NMR-based Urine and Serum Metabolomics of ERCP-Induced Pancreatitis

E. Lusczek,1 K. Colling,1 J.J. Glover,1 D. Conwell,3 M. Freeman,2 G. Beilman.11Depts. of Surgery and 2Medicine, University of Minnesota, Minneapolis, MN; 3Dept. of Internal Medicine, Ohio State University, Columbus, OH.

Introduction: Endoscopic Retrograde cholangiopancreatography (ERCP) is a risk factor for developing acute pancreatitis (AP). Using ERCP-induced AP as a model, we hypothesize that metabolomics can distinguish patients developing post-ERCP AP, and that biomarkers associated with AP can be identified.

Methods: Patients at risk for post-ERCP pancreatitis were prospectively enrolled at UMN from Oct 12-Feb 14. Criteria were sphincter of Oddi dysfunction (SOD), suspected SOD with planned manometry, precut sphincterotomy, known difficult cannulation, or history of post-ERCP AP. Urine and serum were collected pre-ERCP, 2 hours post-ERCP and daily thereafter if patients were admitted to the hospital with AP (abdominal pain and amylase/lipase elevated 3 times normal). Pancreatitis severity was calculated with BISAP and Modified Glasgow scores (MGS). Controls (n = 18) were matched to patients (n = 9) by age and gender. Urine and serum metabolites were profiled with NMR spectroscopy. Partial least squares discriminant analysis (PLS-DA) and metabolic network models were constructed to probe relationships among metabolites for cases and controls.

Results: Of 107 enrolled patients, 9 developed mild AP according to BISAP and MGS. PLS-DA showed differences between pre- and post-ERCP metabolic profiles in urine and serum, but no biomarkers predicting development of AP were identified. Metabolic networks differed between cases and controls both pre- and post-ERCP. Aspartate and asparagine were well-connected hubs in post-ERCP serum networks of cases and were correlated with AST levels. This was not evident in controls. Serum aspartate was elevated in cases relative to controls (p = 0.03).

Conclusions: ERCP induces changes in urine and serum metabolomes. Study in larger patient populations are required to examine active mechanisms and identify biomarkers associated with risk of developing AP.

Prosurvival Effect of Autophagy in Pancreatic Cancer Cells is Determined by Kras and p53 Mutational Status

S. Maertin,1,2,3 C.J. Nitsche,3 J.M. Elperin,1 M. Sendler,3 P.J. Grippo,4 G. Eibl,2 J. Mayerle,3 M.M. Lerch,3 A.S. Gukovskaya.1,21VA Greater Los Angeles and 2University of California Los Angeles, CA; 3University of Greifswald, Germany; 4University of Illinois, Chicago, IL.

Background & Aims: Clinical trials of autophagy inhibitors in pancreatic cancer (PaCa) had mixed results. One reason for this is that the effect of PaCa cells’ mutational profile on autophagy is poorly understood. Here we show that Kras/p53 mutational status regulates autophagy and its prosurvival function in PaCa cells subjected to metabolic stresses.

Methods: Human PaCa cells with oncogenic Kras/normal p53 (CAPAN-2), normal Kras/mutated p53 (BxPC-3) and oncogenic Kras/mutated p53 (PANC-1), and normal pancreatic ductal cells stably expressing oncogenic Kras, were subjected to amino acid (AA) depletion or hypoxia. We measured cell survival (MTT and apoptosis assays) and metabolism (Seahorse), autophagy parameters, ROS levels, and mTOR activity. To manipulate autophagy, we used lysosomal protease inhibitors and siRNAs against Atg5 or Beclin1.

Results: We find that signaling pathways mediating autophagy in PaCa cells, and how it is affected by metabolic stresses, depends on Kras/p53 mutational status. In cells with oncogenic Kras, metabolic stresses activate autophagy via Beclin1-dependent pathway. Differently, in cells with mutated p53 autophagy is Beclin1-independent (“non-canonical”), and is activated by neither AA depletion nor hypoxia. Autophagy is pro-oxidant in cells with oncogenic Kras, but in cells with mutated p53 it acts as anti-oxidant mechanism, combatting ROS induced by the metabolic stresses. Correspondingly, in conditions of metabolic stress autophagy does not increase the survival of PaCa cells with oncogenic Kras/normal p53 but protects cells with mutated p53.

Conclusions: Properties and the prosurvival effect of autophagy in PaCa cells are determined by Kras/p53 mutational status, which should be considered when designing/applying autophagy inhibitors for PaCa treatment.

Multicenter Prospective Surveillance Study of BD-IPMN in Japan: Objectives and Registration Status in 2014

H. Maguchi,1,2 T. Ohtsuka,2 S. Tanno,2 G. Kobayashi,2 W. Kimura,2 T. Yamaguchi,2 T. Hatori,2 M. Tada,2 S. Hijioka,2 H. Uehara,2 K. Hanada,2 K. Yamaguchi,2 M. Sugiyama,2 M. Tanaka.21Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan; 2The working group of Japan Pancreas Society (JPS).

Introduction: Patients with BD-IPMN who do not have any signs of malignancy can be managed conservatively. However, pancreatic ductal adenocarcinoma (PDAC) often develops independently in the pancreas with IPMN, and therefore, careful attention should be paid to the possible occurrence of PDAC during surveillance of BD-IPMN.

Aim: The JPS organized a working group to prospectively survey the patients with BD-IPMN.

Methods: The patients who underwent MRCP, CT and EUS during the initial assessment for BD-IPMN from August 2012 to July 2014 (2 years) at 74 Japanese institutions can be enrolled. The maximum diameters of the cysts and MPD are measured by MRCP and presence of mural nodules (MNs) is determined by EUS. All the enrolled patients having BD-IPMN with and without resection will be surveyed for 5 years using alternate enhanced CT and MRCP / EUS with blood examination every 6 months. The findings such as an increase in cyst size ≥ 10 mm, an increase in MPD ≥ 2 mm, development or enlargement of MNs ≥2 mm are regarded as progression. The collected data include patient’s age, sex, past history, family history, blood chemistry, tumor marker, findings of imaging, pathology of resected specimen, and development of new lesions. Primary end points are frequency of progression of BD-IPMN and occurrence of concomitant PDAC. Secondary end point is prognosis, and factors predictive of PDAC are also assessed. This study was registered as UMIN 000007349.

About 2,000 patients have been enrolled, and this study is expected to provide a high quality evidence regarding the natural history of BD-IPMN and prevalence of PDAC concomitant with BD-IPMN, and to clarify the efficacy of our surveillance protocol for the early detection of concomitant PDAC.

Double Contrast-Enhanced Ultrasonography Improves the Detection and Localization of Occult Lesions in the Pancreatic Tail

G. Mai,1 S.M. Xie,1 Y.H. Cheng,1 X.R. Wen,2 H. Zhuang,2 Y.Z. Li,2 X. Zhou.21Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; 2Ultrasound Department, West China hospital, Sichuan University, Chengdu, Sichuan, China.

We reviewed our experience with double contrast-enhanced ultrasonography (DCEUS) in the evaluation of small, pancreatic tail tumors and compared the diagnostic performances of DCEUS and contrast-enhanced magnetic resonance imaging (MRI). We retrospectively reviewed the medical records of nine consecutive patients (five women; mean age, 38 years) who underwent surgery for pancreatic tail tumors. All patients underwent preoperative DCEUS and MRI. The imaging data were analyzed for tumor conspicuity and enhancement in different contrast phases, and for differences in the onset of contrast phases. All tumors were detected on DCEUS, but only seven were detected on MRI. Tumor conspicuity and enhancement were similar between DCEUS and MRI, but the contrast-phase onset was significantly earlier on DCEUS. DCEUS is a promising technique for the detection of occult pancreatic tail lesions and is possibly superior to contrast-enhanced MRI. If MRI is used to evaluate such lesions, a specific image-acquisition setup must be selected.

Triptolide Induces Epigenetic Modification in Pancreatic Cancer

K. Majumder, R. Chugh, S. Modi, N. Arora, S. Banerjee, A. Saluja, V. Dudeja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: Triptolide is markedly effective against pancreatic cancer cells in vitro and in vivo. Downregulation of Hsp70 (Heat shock protein 70) has been studied as one of the many mechanisms of action of triptolide. Post-translational modification of histones such as methylation represses gene transcription whereas acetylation activates gene transcription. Chromatin modifying enzymes include histone acetyltransferases (p300/CBP, PCAF), histone demethylases (LSD1, JMJDs) and histone methyltransferases (EZH2, SUV39H1). EZH2 (Enhancer of zeste homolog 2) specifically methylates Histone H3 at Lys27 and has been implicated in silencing expression of tumor suppressor genes.

Methods: Pancreatic cancer cells (MIA Paca2 and S2-VP10) were treated with triptolide (0-200nM). Protein and mRNA were extracted and analyzed by western blotting, RT-PCR and PCR array for chromatin modifying enzymes. EZH2 was silenced using siRNA and viability was assessed and protein and mRNA were extracted.

Results: Dose dependent increase of tri-methyl histones (H3Lys27, H3Lys9 and H3Lys4) and a concurrent decrease of acetylated histones (Acetyl histone H3Lys9 and H3Lys18) were observed on western blotting. PCR array showed decrease in histone acetyltransferases, histone methyltransferases and histone demethylases after 12 hours of treatment with 100nM triptolide which was validated by RT-PCR [SUV39H1: 12 ± 0.2 % and EZH2:25 ± 4.6 %]. Western blotting showed time and dose dependent decrease in levels of chromatin modifying enzymes with triptolide. Silencing EZH2 resulted in significantly decreased viability at 72 hours (MIA Paca2: 72.9 ± 5 % S2-VP10: 77.3 ± 0.7%) and decreased Hsp70 mRNA (MIA Paca2: 31 ± 22%) and protein levels after 48 and 72 hours of transfection.

Conclusion: Triptolide affects chromatin modifying enzymes at mRNA and protein level. Epigenetic modulation such as downregulation of EZH2 may be the mechanism of anti-tumor action of triptolide.

CFTR Loss of Function After Alcohol Consumption and in Alcoholic Pancreatitis

J. Maléth,1 P. Pallagi,1 L.V. Kemény,1 Z. Balla,1 B. Kui,1 A. Balázs,1 L. Judák,2 I. Németh,3 Z. Rakonczay,1 V. Venglovecz,2 I. Földesi,4 Á. Somorácz,5 K. Borka,5 D. Perdomo,6 G.L. Lukacs,6 M.A. Gray,7 S. Monterisi,8 M. Zaccolo,8 M.M. Lerch,9 M. Sahin-Tóth,10 P. Hegyi.1,111First Dept. of Medicine, University of Szeged, Hungary; 2Department of Pharmacology and Pharmacotherapy, University of Szeged, Hungary; 3Department of Dermatology and Allergology, University of Szeged, Hungary; 4Department of Laboratory Medicine, University of Szeged, Hungary; 52nd Department of Pathology, Semmelweis University, Budapest, Hungary; 6Department of Physiology McGill University, Montréal, Canada; 7Institute for Cell & Molecular Biosciences, Newcastle University, Newcastle upon Tyne, United Kingdom; 8Department of Physiology, Anatomy and Genetics, Oxford University, Oxford, United Kingdom; 9Department of Medicine A, University Medicine Greifswald, Greifswald, Germany; 10Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA; 11MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary.

Background: Excessive ethanol consumption is one of the most common causes of acute and chronic pancreatitis. It is also documented that genetic defects of CFTR can lead to pancreatitis, however the effects of alcohol consumption on CFTR function in the pancreas is not known.

Aim: Our aim was to investigate the role of CFTR in the pathogenesis of alcohol-induced pancreatitis.

Materials & Methods: The effects of ethanol, fatty acids and fatty acid ethyl esters on CFTR function and expression were examined in human (volunteers, patients and cell lines) and in animal models (guinea pigs and CFTR−/− mice).

Results: Sweat chloride concentration was increased in alcohol intoxicated patients but not in healthy volunteers, indicating impaired CFTR function. Loss of CFTR expression was found in pancreas specimens from patients with acute or chronic alcohol-induced pancreatitis. In functional studies, we detected strong inhibitory effects of alcohol and fatty acids on CFTR activity and

secretion in pancreatic ductal epithelial cells. The inhibition was mediated by intracellular calcium overload, decreased cellular cAMP levels and ATP depletion. We reproduced the alcohol-induced decrease in CFTR expression in cultured pancreatic epithelial cells and in vivo in guinea pigs, which was caused by a combination of reduced CFTR mRNA levels, decreased cell surface stability and folding defect of CFTR. Finally, genetic deletion of CFTR lead to more severe pancreatitis in CFTR knock-out mice induced by ethanol and fatty acids.

Conclusion: The findings indicate that alcohol-induced loss of CFTR function is critical in the development of alcoholic pancreatitis; therefore, correcting CFTR function should offer therapeutic benefit.

GSK3 Inhibition Regulates the Master Regulator of Autophagy and Lysosomal Biogenesis TFEB in Pancreatic Cancer Cells

B. Marchand, A. Raymond-Fleury, M.-J. Boucher. Dept. of Medicine/Div. of Gastroenterology, Univ. of Sherbrooke, Sherbrooke, Canada.

We recently demonstrated that GSK3 inhibition induces apoptosis in pancreatic cancer cells. In addition to triggering apoptotic signals, we observed that GSK3 inhibition concomitantly elicits the activation of the autophagy/lysosomal network. Interfering with this network sensitizes pancreatic cancer cells to GSK3 inhibition-induced apoptosis suggesting the existence of pro-survival signals to counterbalance the death signals upon GSK3 inhibition. However, the mechanisms involved remain unknown. The aim of this study was to identify potential pro-survival/autophagic signals induced upon GSK3 inhibition.

Methods: Experiments were performed in PANC1, MIA PaCa2, and BxPC3. The GSK3 inhibitors CHIR99021 and SB216763, the JNK inhibitor SP600125 and the mTOR inhibitor Torin1 were used.

Results: 1) Inhibition of the JNK-cJUN pathway prevented the apoptotic response but not the autophagic response upon GSK3 inhibition excluding a major contribution of JNK-cJUN activity in the induction of autophagy upon GSK3 inhibition. The activity of the mTOR pathway, well known to modulate autophagy, was then assessed. 2) Inhibition of GSK3 reduced the activity of S6K1, a direct substrate of the mTOR complex I, suggesting an inhibition of the mTORC1-S6K1 axis upon GSK3 inhibition. mTORC1 was recently shown to regulate autophagy through its impact on the transcription factor EB, TFEB. GSK3 or mTOR inhibition led to 3) the nuclear translocation of TFEB, 4) and to an acceleration of the electrophoretic mobility of TFEB. 5) Pre-treatment of cells with a serine/threonine phosphatase inhibitor prevented the shift in TFEB mobility suggesting that GSK3 inhibition triggers TFEB dephosphorylation. 6) Quantitative mass spectrometry analyses revealed a dissociation of TFEB from 14-3-3 proteins and an increased association of TFEB with nuclear proteins upon GSK3 or mTOR inhibition. 7) Finally, shRNA-mediated reduction of TFEB expression sensitized pancreatic cancer cells to GSK3 inhibitor-induced apoptosis.

Conclusion: Our results demonstrate that GSK3 inhibition leads to TFEB dephosphorylation and nuclear translocation. Our results also suggest that the GSK3 inhibition-mediated impact on TFEB provides pro-survival signals upon GSK3 inhibition.

Are IPMN of the Pancreas Associated to an Increased Prevalence or Incidence of Extra-Pancreatic Neoplasms? A Multicentre European Observational Study

G. Marchegiani,1 J.G. D’Haese,2 M. Keskin,3 P. Wenzel,4 L. Pugliese,5 G. Malleo,1 A. Borin,1 L. Nilsson,6 V. Benning,2 N. Oruc,3 R. Segersvard,6 R. Salvia,1 G.O. Ceyhan,2 M. del Chiaro.61Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy; 2Department of Surgery, Klinikum rechts der Isar, Technische Universitat Munchen, Munich, Germany; 3Division of Gastroenterology, Department of Internal Medicine, Ege University, Izmir, Turkey; 4Department of Gastroenterology, Klinikum rechts der Isar, Technische Universitat Munchen, Munich, Germany; 5Unit of General Surgery 2, Department of Surgery, IRCCS Policlinico San Matteo, Pavia, Italy; 6Division of Surgery, CLINTEC, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden.

This study was conducted as a project of the 6th Pancreas2000 education and research program.

Although different studies showed an association between pancreatic IPMN and extrapancreatic neoplasms (EPN), the available data remain inconclusive. This multicentre observational study assessed the prevalence and the incidence of EPN in patients with IPMN.

Methods: Patients diagnosed with IPMN from 2000 to 2013 were assessed for EPN prevalence. For the incidence analysis, patients with an EPN previous or synchronous to the IPMN, and patients with a follow-up <12 months were excluded. Tumor prevalence and the incidence of EPN that developed during follow-up were compared with European cancer data. The standardized prevalence and incidence ratios (SPR, SIR), and the 5- and 10-year incidence rates were calculated.

Results: The study population included 1340 patients. At the time of IPMN diagnosis, 289 patients developed at least one previous or synchronous EPN (prevalence of 21.6%). The EPN prevalence was greater than the general population (SPR = 4.04, 95%CI 3.61-5.51). 816 patients were included in the incidence analysis. At a median follow-up of 44 months, 50 patients developed an EPN (cumulative incidence of 6.1%). The incidence of EPN was not greater than expected (SIR = 1.16, 95% CI 0.85-1.54), with a 5- and 10-year incidence rate of 5.9% and 20.1%.

Conclusions: The prevalence of EPN at the time of IPMN diagnosis is greater than expected by 4-fold, likely because cancer patients are at increased medical screening and are diagnosed with IPMN more frequently. This concept is substantiated by the fact that the incidence of new EPN during the follow-up period was not greater in comparison with the general population.

Oncocytic Type IPMN: A Unique Malignant Subset With Good Long-Term Prognosis

G. Marchegiani,1 M. Mino Kenudson,2 C. Ferrone,1 A.L. Warshaw,1 K. Lillemoe,1 C. Fernandez-del Castillo.11Departments of Surgery and 2Pathology, Massachusetts General Hospital, Boston, MA.

The different epithelial phenotypes of Intraductal Papillary Mucinous Neoplasms (IPMNs) are predictors of tumor biology and post surgical outcome. Oncocytic type (O-IPMN) seems to have a unique natural history, but few data are available due to its exceptionality. We sought to describe the characteristics of a cohort of resected O-IPMNs focusing on their long term outcome after surgery.

Methods: Retrospective review of demographics, pathology, and survival after resection for IPMN from 1990 to 2013. Comparison between O-IPMN and other IPMN subtypes.

Results: 20/400 patients (5%) who underwent surgical resection for IPMN were O-IPMN. O-IPMNs was more common in males (70% vs. 45%, P = 0.03) and more frequently involved the main pancreatic duct (MD-IPMN) (70% vs 43%, P = 0.01). The majority of cases (95%) were malignant, and 60% were invasive (compared to only 19% of the other epithelial subtypes (P < 0.001). Only one case had metastatic lymph nodes. Following resection, the 5-year recurrence rate for O-IPMNs was 33% vs. 17% of other IPMNs (P = 0.01). These recurrences occurred 7 months to 11 years after the initial resection, on average significantly later than other IPMNs (P = 0.002), and 4 of them were reoperated resulting in total pancreatectomy. At survival analysis, none of the O-invasive IPMNs died of the disease, compared to 36% of tubular invasive IPMNs and 30% of colloid invasive tumors.

Conclusions: O-IPMN occurs mostly in the main pancreatic duct and is malignant. Compared to other IPMN subtypes, it tends to recur more often but later in time. Reoperations for recurrent O-IPMN are often feasible and have excellent results in terms of survival.

The Proteome of Surgical Pancreatic Juice

G. Marchegiani,1 J.A. Paulo,2 K. Sahora,1 C. Fernández- del Castillo.11Department of Surgery, Massachusetts General Hospital, Harvard Medical School; 2Department of Cell Biology, Harvard Medical School, Boston, MA.

The study of the pancreatic proteome provides key information about the organ functional status. The proteome of the pancreas after surgical resection has never been assessed. The aim of this study was to evaluate the spectrum of proteins present in the pancreatic juice (PJ) after pancreatectomy.

Methods: PJ samples were obtained during surgical resection and at different time points during the postoperative period. Proteins were identified and quantified by mass spectrometry-based protein quantification technology and compared to published data on the proteome of the non-operated pancreas. Subgroup analyses of the proteome were done in patients with pancreatic ductal adenocarcinoma (PDAC), in patients receiving neoadjuvant chemotherapy, and in others with a history of smoking.

Results: A total of 518 proteins were identified in the postoperative PJ encompassing all the main organ functions. 67 of these proteins were also present in the published data of the non-operated pancreas and 7 had significant variation of concentration during the postoperative period. Growth factors that have been described in post-surgical regeneration of the liver were not found to be over-expressed, whereas clusterin did increase postoperatively, confirming the finding of previous experimental studies on pancreatic regeneration. Several proteins involved in immunomodulation and organ functions were differently expressed depending on PDAC, neoadjuvant therapy, and smoking.

Conclusion: The proteome of the pancreas after surgical resection contains factors related to all main organ functions, changes over time, and is different in patients with PDAC, in those who received neoadjuvant therapy, and in those who smoke. The pancreas reacts to the surgical trauma by producing proteins that protect the organ and stimulate the restoration of its function.

Inactivation of the AurkA-HP1γ-G9a Pathway Synergistically Inhibits PDAC Cell Growth by Triggering Cell Death via Mitotic Catastrophe

A. Mathison, M. Williams, R. Urrutia, G. Lomberk. Epigenetics and Chromatin Dynamics Laboratory, Translational Epigenomics Program (CIM), GIH Division, Department of Medicine, Mayo Clinic, Rochester, MN.

Aurora Kinase A (AurkA) is overexpressed and functions as an oncogene for many tumors, including PDAC, where it is being clinically tested as a target for chemotherapy. Inactivation of AurkA in PDAC cells has two important cytostatic effects, namely G2/M arrest and senescence. Although cytostatic effects improve outcomes, potentially harmful properties, such as a secretory phenotype (e.g. IL-8) of senescent tumor cells, which is indicative of their potential role in late tumor promotion, make their quantitative elimination desirable. We have characterized a novel pathway in which the Heterochromatin Protein 1 γ (HP1γ)- Methyltransferase (G9a) epigenetic complex acts as a downstream mediator of AurkA. Thus, we have started to explore the potential for improved combinatorial PDAC therapy at the level of the two enzymes within this pathway, AurkA and G9a. We find that treatment of PDAC cells with AurkA and HP1γ-G9a inhibitors, alone or in combination, inhibit cell growth. Increased nuclear and cell body size, as well as positive β-gal staining, revealed that individually, these drugs induce senescence (cytostatic), which is almost abolished by their combination. Interestingly, confocal and electron microscopy demonstrated that this effect was due to a dramatic induction of mitotic cell death. At the molecular level, while AurkA inhibition alone triggers a Chk1-Cdc25c-Cdk1-dependent G2/M arrest, the combination with HP1γ-G9a inhibition regulates checkpoint proteins, bypassing this G2/M arrest with downregulation of Chk1-p53 pathway to culminate in mitotic catastrophe. Therefore, our data demonstrate that the combined targeting of the AurkA and the HP1γ-G9a complex decreases their individual cytostatic effects while increasing their cytotoxicity via a mechanism that involves mitotic catastrophe, which is a desirable therapeutic outcome.

A Prospective Randomized Comparison Between Pylorus- and Subtotal Stomach-Preserving Pancreatoduodenectomy on Postoperative Delayed Gastric Emptying Occurrence and Long-Term Nutritional Status

I. Matsumoto,1,2 M. Shinzeki,2 H. Toyama,2 S. Asari,2 T. Goto,2 S. Shirakawa,2 T. Ajiki,2 T. Fukumoto,2 Y. Ku.21Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan; 2Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.

Background and Objectives: Pylorus-preserving pancreatoduodenectomy (PPPD) has been associated with a high incidence of delayed gastric emptying (DGE). There are few studies comparing DGE associated with PPPD and subtotal stomach-preserving pancreatoduodenectomy (SSPPD). Moreover, differences between the procedures with respect to long-term results have not been reported. A prospective randomized study was conducted to compare perioperative complications and long-term nutritional status with PPPD and SSPPD.

Methods: One hundred patients with periampullary lesions were randomized to receive either PPPD (n = 50) or SSPPD (n = 50). All patients were followed up for 3 years after surgery or to the time of recurrence to evaluate nutritional status for the study. The effects of the procedure, age, and malignancy on changes in nutritional indicators were estimated with linear mixed models. This study was registered at UMIN Clinical Trials Registry (UMIN 000012337).

Results: The incidence of DGE assessed by the International Study Group of Pancreatic Surgery was 20% with PPPD and 12% with SSPPD (P = 0.414). There were no significant differences between the two procedures on postoperative serum albumin levels, serum total cholesterol levels, and body mass index during the 3-year follow-up period.

Conclusions: SSPPD is equally effective in DGE occurrence rate and long-term nutritional status comparing to PPPD.

Severe Acute Pancreatitis as a Delayed Complication Following Radiofrequency Ablation (RFA) for Hepatocellular Carcinoma (HCC)

Y. Matsumura, T. Ito. Department of Gastroenterology JCHO Osaka Hospital, Osaka, Japan.

RFA is applied for early stage HCC leading to good local disease control in Japan. In our hospital, this procedure was performed for 764 HCC tumors from 2001 to 2013. We experienced 1 peritoneal seeding case and 5 peritoneal bleeding cases. Recently, a female patient had severe acute pancreatitis following RFA for HCC. We reported clinical course and characteristics.

An 83-year-old woman with chronic hepatitis C (Child-Pugh A) received RFA for HCCs in the right lobe twice in last five years. This time RFA was done for 13 mm in the left lobe after transarterial chemoembolization one month prior to the therapy. On postoperative (post-RFA) day (POD) 1, she had slight right upper abdominal pain with slight serum amylase elevation. These findings were improved on POD 2. CT showed enough margin around ablated tumor and normal pancreas. She was discharged on POD 4. On POD 15, she was emergently hospitalized due to high fever and severe abdominal pain. CT revealed cystic lesion close to ablated tumor and typical acute pancreatitis. Laboratory findings showed severe inflammation and serum pancreatic enzymes’ elevations. Percutaneous abscess drainage was performed under ultrasonography, and we started the treatment for acute pancreatitis and infection immediately. Cyst contained high concentration of amylase. These data revealed this cyst was the infected pseudocyst caused by acute pancreatitis. An endoscopic pancreatic stent was inserted for cyst drainage, because cystography revealed cyst communicated with pancreatic duct. Three weeks intensive therapy could lead to recovery without complication related to pancreas.

RFA might be a comparatively safe procedure, but ablation effect would be broader than we expected. We should recognize rare occurrence of acute pancreatitis following RFA according to this. Severe acute pancreatitis is well known to be high mortal, rapid and precise diagnosis for acute pancreatitis can be helpful to apply appropriate therapy.

A Minimally Invasive Screening Test to Detect Pancreatic Ductal Adenocarcinoma Using Biomarkers in the Duodenal Gluid: an Up-to-Date Report

T. Matsunaga,1 T. Ohtsuka,1 K. Asano,2 T. Fujimoto,1 K. Date,1 H. Kimura,1 Y. Watanabe,1 K. Tamura,1 K. Ohuchida,1 S. Takahata,1 K. Mizumoto,1 S. Guha,3 M. Raimondo,4 M. Tanaka.11Department of Surgery and Oncology, and 2Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan; 3Division of Gastroenterology, Hepatology, and Nutrition, The University of Texas Medical School and University of Texas Health Science Center, Houston, TX; 4Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL.

Background and Aim: We previously reported that the assessment of carcinoembryonic antigen (CEA) level in the duodenal fluid (DF) obtained with a side-view endoscope could be useful for pancreatic ductal adenocarcinoma (PDAC) screening. Now, we assessed the diagnostic utility of duodenal markers in pancreatic diseases obtained with a forward-view endoscope during upper gastrointestinal (GI) exam.

Patients and Methods: We prospectively enrolled 223 patients, including 68 with PDACs, 66 with intraductal papillary mucinous neoplasms (IPMNs), 19 with chronic pancreatitis (CP), 28 with other pancreatic diseases and 42 normal individuals as controls, who underwent upper GI endoscopy at Kyushu University Hospital and Mayo Clinic Jacksonville from October 2011 to February 2014. DF was collected without secretin stimulation and the CEA and S100P levels were measured.

Results: The S100P levels in PDAC and CP were significantly higher than that in controls (both, p < 0.001). Of note, most significant difference was observed between stage 0/I/IIPDAC and controls. The sensitivity and specificity to predict stage 0/I/IIPDAC were 59 and 83%, respectively, when a cut-off value of S100P was set at 81,243 pg/mL, and the area under the curve generated from receiver operating characteristic was 0.74. The CEA levels in any pancreatic diseases were not significantly different from that in controls.

Conclusions: The analysis of S100P level in the DF is an easy, safe and useful screening method especially to detect early stage PDAC.

The Oncologic and Long-Term Outcomes of Laparoscopic Pancreatectomy for Pancreatic Cancer

A. Matsushita,1 Y. Nakamura,1 A. Katsuno,1 H. Sumiyoshi,1 T. Kanda,1 T. Shimizu,1 Y. Mizuguchi,1 M. Yoshioka,1 K. Yamahatu,2 T. Yokoyama,3 N. Taniai,1 Y. Mamada,1 E. Uchida.11Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan; 2Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan; 3Department of Surgery, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan.

Introduction: The recent advances of surgical techniques and technology allow minimally invasive surgery to be applied in patients with benign and malignant diseases of the pancreas. With regards to malignancy, we still have concerns regarding the oncologic adequacy of laparoscopic pancreatectomy, with fewer studies reporting oncologic outcomes. We report the oncologic outcomes and long-term outcomes of laparoscopic pancreatectomy for pancreatic cancer.

Methods: From January 2004, patients who had been diagnosed with the tumor in the pancreas without suspicion for vascular involvement were eligible for laparoscopic pancreatectomy at Nippon Medical School. In Lap-PD for PC patients, we apply laparoscopic left mesentery spreading approach, which enables both accurate laparoscopic lymph node retrieval and complete pancreatic nerve plexuses dissection to achieve R0 resection. In Lap-DP for PC patients, we perform retroperitoneal tissue dissection, which often includes adrenalectomy.

Results: We have experienced laparoscopic pancreatectomies in 207 patients including 43 PC patients. The patients were treated with either Lap-PD (n = 17) or Lap-DP (n = 26). In 43 PC patients, the mean number of retrieved lymph nodes was 23.6 (6–57). Metastasis to the lymph nodes was observed in 13 patients (31%). R0 resection was performed in 38 patients (88%). The median follow-up period was 19.7 months (1–71 months). Nine of the 42 patients died of PC. Among surviving 31 patients, 4 patients had liver metastasis and the others had no recurrence.

Conclusion: Laparoscopic pancreatectomy for pancreatic cancer is feasible and seems to achieve similar oncologic and long-term outcomes to open approach.

The Absence of Pancreatic Ductal Dclk1 Entirely Reverses the Progression of Cerulein-Induced ADM in Mice

R. May,1 D. Qu,1 N. Weygant,1 S. Sureban,1 S.A. Lightfoot,2 J.T. Maple,1 C. W. Houchen.11Department of Medicine, 2Center for Cancer Prevention and Drug Development, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Aim: To determine the functional role of ductal Dclk1 in cerulein-induced pancreatitis and its effects on acinar-to-ductal metaplasia (ADM) progression.

Background: Dclk1 is a pancreatic stem cell marker, overexpressed in human pancreatitis and pancreatic tumors. Dclk1 regulates important features in pancreatic cancer such as oncogenes, pluripotency and EMT related transcription factors and is functionally significant in chemosensing tuft cells.

Methods: Pdx-1-Cre;Dclk1fl/fl compound mice (pancreatic ductal deletion – confirmed via IHC) were developed with Dclk1fl/fl littermates used as controls. Both groups (n = 5) were administered cerulein at a dose of 50 μg/kg hourly x7 for 2 days (14 total doses). Mice were killed 0, 5, 10 and 21 days post-administration. Pancreata were removed, fixed, weighed and processed for histologic examination.

Results: Mice killed 5 days post-cerulein administration had similar levels of inflammation, areas of ADM foci (25% of pancreas) and intense Dclk1 (protein) expression in the new metaplastic ductal cells. Dclk1fl/fl mice killed 10 days post-cerulein had further ADM progression totaling 50% of the pancreas, while the ADM in the Pdx-1-Cre;Dclk1fl/fl mice had regressed to 5%. At 21 days post-cerulein the Dclk1fl/fl mice had 90% of their pancreas replaced by metaplastic and inflammatory cells. Whereas Pdx-1-Cre;Dclk1fl/fl pancreas were histologically normal (no ADM or inflammation) but had a 400% increase in weight from baseline relative to a 50% decrease in Dclk1fl/fl mice (p = 0.0345).

Conclusion: Dclk1 plays a vital role governing the pancreatic inflammatory process and associated metaplastic progression. These findings in pancreatitis should be further explored, including the potential development of therapeutics designed to attenuate pancreatitis severity and complications including subsequent neoplasia.

Triptolide Results in Accumulation of HIF-1α but Reduces its Activity in Pancreatic Cancer

O. McGinn, S. Banerjee, A. Nomura, K. Jensen, S. Vickers, A.K. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: The role of tumor hypoxia has become a major focus in cancer research since it influences both local and systemic tumor growth. The major transcription factor upregulated in response to hypoxia is HIF-1α. During hypoxia, HIF-1α stabilizes and transcribes genes involved in metabolism and other cell functions. Previous studies from our laboratory have shown that triptolide, a compound derived from a Chinese herb, decreases viability of pancreatic cancer cells in vitro. Minnelide, the pro-drug of triptolide reduces the size of pancreatic tumors in several mouse models. Pancreatic tumors contain numerous hypoxic regions. Thus far, little is known about the effect of triptolide on HIF-1α in pancreatic cancer. The aim of this study is to address the relationship between triptolide and HIF-1α in pancreatic cancer.

Methods: Pancreatic cancer cell lines MiaPaca-2 and S2VP10 were treated with triptolide. Tissue samples of Minnelide treated human xenografts and KPC (tp53-pdxCre) tumors were analyzed by immunofluorescence. Protein and mRNA levels of HIF-1α were measured as well as HIF-1α binding partners p300 and HIF-1β. HIF-1α DNA binding activity and transcriptional activity were measured in response to triptolide. Levels of HIF-1α target genes were measured as well.

Results: HIF-1α protein was higher in Minnelide treated human xenografts and KPC mice compared to saline treated ones. HIF-1α protein increased in MiaPaca-2 and S2VP10 cell lines in response to triptolide. Triptolide did not decrease HIF-1α binding activity, but HIF-1α transcriptional activity decreased after 24 h of triptolide treatment (22.0% of control). Downstream targets of HIF-1α decreased at the protein and mRNA level in both cell lines (11.0-32.0% of control). Additionally, mRNA levels of p300 (24.4%; 12.7%) and HIF-1β (27.9%; 16.3%) decrease in response to triptolide in S2VP10 and MiaPaca-2 respectively.

Conclusion: Triptolide increases HIF-1α protein levels in pancreatic tumors, but reduces its transcriptional activity by inhibiting formation of co-activator complexes required for transcriptional activity of HIF-1α.

Acute Pancreatitis in Pregnancy: A Report From the Nationwide Inpatient Sample

J. McNabb-Baltar,1 L. Lee,1 V. Kadiyala,1 S.L. Suleiman,1 P.A. Banks,1 D.L. Conwell.21Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; 2Ohio State University, Columbus, OH.

Background: Pregnancy is a physiologic state associated with increased incidence of gallstone disease and may predispose to acute pancreatitis (AP). The aim of this study was to assess the cause and outcomes of AP in pregnancy, and assess if they vary according to race/ethnicity.

Methods: Within the Nationwide Inpatient Sample, we focused on women 18 to 50 years old admitted with AP (1998–2010). Pregnancy status was then ascertained. Models were fitted to predict the likelihood of in-hospital mortality and prolonged length of stay.

Results: Between 1998 and 2010, a weighted sample of 1,041,148 women admitted for AP was identified, of which 10,897 (1%) were pregnant at the time of admission. Pregnant women were younger than non-pregnant women (median 27 vs. 38 years old). The etiology of pancreatitis differed according to pregnancy status: biliary pancreatitis was present in 50.6% of pregnant women vs. 29.9% non-pregnant women (p < 0.001), alcohol was present in 1.4% of pregnant women vs. 11.5 in non-pregnant women (p < 0.001). Race-ethnicity differed according to pregnancy status: pregnant women were more likely to be Hispanic (31.6 vs. 16.8%, p < 0.001) and Asian (3.8 vs. 1.5%, p < 0,001) vs. non-pregnant women. In patients with AP, pregnant women were less likely to die during admission vs. non-pregnant women (0.3 vs. 0.9%, p < 0.001), but they were more likely to experience a length of stay beyond 7 days (30.1 vs. 24.1%, p < 0.001). In multivariable analysis assessing mortality in pregnant women with AP, Hispanics (OR = 2.8, p = 0.011) and Asians (OR = 4.1, p = 0.011) were more likely to die than Caucasians.

Conclusion: AP in the pregnant women is frequently caused by biliary disease. Relative to non-pregnant women, pregnant women are less likely to die when presenting with AP, but are more likely to experience a prolonged hospitalization. Relative to Caucasians, Hispanic and Asian women are more likely to present with AP during pregnancy, and are more likely to die.

Roux-en-Y Reconstruction of Pancreaticojejunostomy as a Salvage Procedure for Severe Pancreatic Fistula After Pancreaticoduodenectomy

Y. Miao, W. Gao, K. Jiang, J. Wu, J. Chen, F. Guo, J. Wei, Z. Lu, S. Lin. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.

Background: Severe postoperative pancreatic fistula (POPF) secondary to the disruption of pancreaticojejunostomy (PJ) represents the most life-threatening complication after pancreaticoduodenectomy (PD) when it is complicated with hemorrhage and/or intra-abdominal abscess. Relaparotomy is often mandatory when conservative or interventional measures failed, but the optimal surgical strategy remains controversial, as most of reported procedures still brought high mortality. We proposed that Roux-en-Y reconstruction of pancreaticojejunostomy (RYPJ) could be a feasible and effective salvage procedure in this situation.

Methods: The disrupted PJ was identified in relaparotomy for complicated POPF, when in situ revision of the original PJ is impossible; jejunal loop was dismantled from the pancreatic stump, and transected between the hepaticojejunostomy and PJ. A new isolated Roux-en-Y PJ is reconstructed with jejunum distal to duodenojejunostomy with or without external drainage of the pancreatic duct.

Results: We applied RYPJ in four patients with complicated POPF. Of the four patients, three survived from this procedure, except one died of disseminated intravascular coagulation after relaparotomy. Two patients recovered well without further POPF, intra-abdominal abscess or hemorrhage, while one experienced prolonged POPF, but recovered two months later. Exocrine and endocrine functions of the pancreas were well preserved in all three patients after long-term follow-up.

Conclusions: Reconstructive RYPJ is a novel salvage procedure for the management of complicated severe POPF with dehiscence of PJ after PD. RYPJ is not intended to totally prevent POPF after reoperation, but to avoid the tissue and vessel erosion of POPF, by avoiding mixture and activation of pancreatic juice with bilio-enteric secretions.

Telomere Length Shortening Associated to the Malignant Potentials in Intraductal Papillary Mucinous Neoplasm (IPMN)

A. Miki,1,2 Y. Sakuma,1 J. Aida,2 N. Izumiyama-Shimomura,2 Y. Sanada,1,2 Y. Kawano,2 H. Sasanuma,1 K. Morishima,1 N. Kasahara,1 N. Ishikawa,2 K. Nakamura,2 Y. Matsuda,2 N. Fukushima,3 K. Takubo,2 N. Sata,1 Y. Yasuda.11Department of Surgery, Jichi Medical University, Tochigi, Japan; 2Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology, and Department of Pathology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan; 3Department of Pathology, Jichi Medical University, Tochigi, Japan.

Background: Intraductal papillary mucinous neoplasm (IPMN) is relatively common disease with multistage carcinogenesis associated to invasive carcinoma. Telomere length varies in a process of the carcinogenesis. However, the relationship between telomere length and pathological subcategory of IPMN has not been clear.

Materials and Methods: We examined the samples of IPMN from 24 patients who undergone pancreatectomy from 2009 to 2012 at Jichi Medical University and estimated the telomere length of each chromosome arm using Q-FISH in comparison with each IPMN subcategory. Q-FISH and image analysis were performed as described previously (J Pathol 2011). The fluorescence intensities of telomeres were analyzed with the TFL-Telo V2 software package. Telomere length was calculated with telomere:centromere ratio (NTCR).

Results: Telomere length of high grade IPMN and associated invasive carcinoma were significantly shorter than that of normal pancreas duct (mean-NTCR 0.70 p = 0.0083, 1.19 p = 0.0196 respectively). Telomere length of gastric type was shorter than that of intestinal type in low grade IPMN (p = 0.0417).

Conclusion: Telomere length shortening occurs in the category of IPMN, which could represent the multistep carcinoma sequence in IPMN.

Natural History of Branch Duct Intraductal Papillary Mucinous Neoplasms With or Without Mural Nodule

R. Minami, H. Maguchi, T. Kin, K. Takahashi, A. Katanuma, M. Osanai, K. Yane, S. Ikarashi, M. Sen-yo, I. Sano, H. Yamazaki. Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan.

Aim: The aim of this study was to evaluate the long-term follow-up results in cases of BD-IPMNs with or without mural nodule (MN).

Methods: We retrospectively analyzed 374 follow-up patients (170 men and 204 women, mean age, 67.4) for more than one year who had undergone EUS at the initial diagnosis in our center. Median cyst size and MPD diameter at the initial diagnosis were 22 mm, and 3.1 mm. 321(85.8%) patients had no MN and 53(14.1%) patients had MN of less than 10 mm. Disease progression of BD-IPMNs was defined as follows; cyst size increased ≥ 10 mm, main pancreatic duct (MPD) diameter increased ≥ 2 mm, new development of MN, or MN size increased ≥ 2 mm.

Evaluation points:

  1. Clinical outcome of BD-IPMNs
  2. Comparison of morphological change between BD-IPMN with and without MN
  3. Prognosis


  1. Observation periods ranged 1 to 15.7 years (median 3.3). 46 (12.3%) of 374 BD-IPMN patients exhibited progression during follow-up. 17 patients of them underwent surgery, leading to a pathological diagnosis of low- or intermediate-grade dysplasia in 8, non-invasive carcinoma in 5, and invasive carcinoma in 4. On the other hand, 9 (2.4%) patients developed pancreatic ductal adenocarcinoma (PDAC) concomitant with IPMN during follow-up periods.
  2. 5-year and 10-year cumulative progression rates in BD-IPMNs without MN were 7.8% and 29.7%, respectively. Those in BD-IPMNs with MNs were 28.6% and 51.0%, respectively.
  3. 32 patients died during follow-up periods. 27 of them died from other disease, 5 of them died from PDACs concomitant with BD-IPMNs, and no patient died from IPMN.

Conclusions: BD-IPMNs without MN have a low risk of progression and malignant transformation. They are suitable for management without surgery and do not need short interval surveillance. However, special attention should be paid to the occurrence of PDAC in the entire pancreas when performing follow-up examinations in patients with BD-IPMN, and shorter interval surveillance is required.

Significance of Ductal Region in Anaplastic Pancreatic Cancer

K. Miura, K. Kimura, R. Amano, S. Yamazoe, G. Ohira, K. Nishio, M. Shibutani, K. Sakurai, H. Nagahara, T. Toyokawa, N. Kubo, H. Tanaka, K. Muguruma, H. Otani, M. Yashiro, K. Maeda, M. Ohira, K. Hirakawa. Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan.

Introduction: Anaplastic pancreatic cancer (APC) is classified as a subtype of pancreatic ductal adenocarcinoma (PDA) in Japan. APC is a very rare and poorer prognosis than conventional PDA. Furthermore, APC consists of undifferentiated region (UR) largely but has a little ductal region (DR). Although this is proposed that APC may be derived from PDA, there is no definite answer to this hypothesis.

Purpose: In this study, we compare the expression of molecular markers in DR and UR, and try to reveal the origin of APC.

Methods: Tissues from primary APC were obtained from 6 patients who were operated at our institution. Formalin fixed paraffin embedded blocks were made from the each tissue. Each block was sliced for staining with Hematoxylin and Eosin (H&E) and immunohistochemistry (IHC) for E-cadherin and vimentin. IHC was performed by standard procedures. Using H&E slice, each sample was divided from cancerous regions and non-cancerous regions. Furthermore, cancerous regions were divided from DR and UR. And then, for E-cadherin and vimentin, the intensity of staining of UR was compared with that of DR in all field of each slice. The intensity was scored from 0 to 3.

Results: The proportion of DR to all cancerous regions was 0.5% to 32%. Although the expression of E-cadherin was almost negative in UR, DR showed various score, which score was nearly 1 to 3. Regarding staining for vimentin, the intensity in UR was largely 2 and 3. In contrast, the expression of vimentin of DR was weakly confirmed in a few cases but not observed in most cases.

Conclusion: It was suggested that EMT might induce APC by varying DR into UR. But to conclude that APC is derived from PDA, we need further examinations about the concordance and the difference of molecular marker expressions and gene mutations between DR and UR in APC.

Intravenous Injection of Fiber-Redesigned Oncolytic Adenovirus Eliminates PDAC Tumors In Vivo

Y Miura,1,2 M Sato,1 M. Yamamoto.11Department of Surgery, University of Minnesota, Minneapolis, MN; 2Third Department of Medicine, Toyama University, Toyama, Japan.

Oncolytic viruses show strong in vivo oncolytic effect and intratumoral replication/spread, and have high potential as potent systemic therapeutics against pancreatic ductal adenocarcinoma (PDAC). Adenovirus (Ad) is one of the most popular platforms for oncolytic viral agents, but its targeted delivery to the tumor upon systemic injection has been difficult to date because incorporation of specific targeting motif into Ad virion has been extremely difficult. We recently developed a way to identify the Ad targeting ligand by high throughput screening of high diversity (10^10) targeting motif library (random 7 amino acids) expressed in the fiber region of Ad. Screening with mesothelin (MSLN) positive cells achieved a motif to target adenovirus to those pancreatic cancer cells (VTINRSA).

Intratumoral injection of the oncolytic Ad (OAd) with this motif (AdML-VTIN) showed significant anti-tumor effect selectively in MSLN positive PDAC (Panc-1) xenografts. Upon intravenous injection, AdML-VTIN showed less than 1/10 liver sequestration after injection and more than 1000 times of the viral copy number in the tumor at day 7, compared to the OAd without targeting. Systemic injection of low dose AdML-VTIN (3 x 10^9 vp) in the mice with Panc-1 subcutaneous xenografts exhibited significant tumor regression, and four out of ten tumors were eliminated at day 15. Such effect was not observed for OAd without targeting. Moreover, the repeated injection AdML-VTIN suppressed 4 out of 6 regrown tumors and all mice survived more than 75 days, while all mice in the control group were sacrificed before day 45 due to tumor overgrowth.

OAd with MSLN targeting motif has significant in vivo targeting capability to MSLN positive pancreatic cancer upon systemic injection. This new oncolytic Ad enabling systemic therapy may embody efficient treatment for PDACs which are mostly found with spread or metastatic lesions.

Complications Associated With Endoscopic Ultrasound-Guided Fine Needle Aspiration of Solid Pancreatic Lesions

H. Miwa,1 K. Sugimori,2 T. Ishii,2 T. Kaneko,2 K. Numata,2 K. Tanaka,2 S. Maeda.11Division of Gastroenterology, Yokohama City University School of Medicine, Yokohama, Japan; 2Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan.

Background and Aim: The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the pathological diagnosis of solid pancreatic lesions is becoming widespread. However, reports on the complications remain limited. We aimed to evaluate the frequency and characteristics of complications associated with EUS-FNA of solid pancreatic lesions.

Methods: From May 2006 to March 2014, 248 patients underwent 260 EUS-FNA procedures for solid pancreatic lesions. Of these patients, 176 had pancreatic cancer, 50 had mass-forming pancreatitis, and 22 had other kind of disease. We retrospectively evaluated the complications and their characteristics.

Results: In total, 129 (49.6%) lesions were located in the pancreatic head, and the mean lesions diameter was 31.2 mm (range, 6–83 mm). The mean number of needle passes was 2.5 (range, 1–7). Regarding needle gauges, 19-, 22-, and 25-gauge needles were used in 7%, 75%, and 18%, respectively. Complications after EUS-FNA occurred in 11 patients (4.2%), which included 5 cases of acute pancreatitis (AP) and 6 cases of peripancreatic fluid collections (PFCs). PFCs were defined as the presence of effusion around the pancreas without the elevation of pancreatic enzymes. No cases of major hemorrhage and perforation were noted. Of these 12 patients, 11 recovered by conservative treatment, whereas 1 case with PFC required percutaneous drainage. The mean duration for diagnosis was longer for cases with PFCs (5.7 days) than AP (1 day) (p < 0.05). The mean lesions diameter was higher in the “complications group” than “no complications group,” although this difference was not statistically significant (p = 0.11). In addition, no obvious predictors of complications were identified.

Conclusion: EUS-FNA of solid pancreatic lesions may occasionally leads to AP and PFC.

Phase I Clinical Trial Using Peptide Vaccine for Human Vascular Endothelial Growth Factor Receptor 2 in Combination With Gemcitabine for Patients With Advanced Pancreatic Cancer

M. Miyazawa, M. Tani, M. Kawai, S. Hirono, K. Okada, A. Shimizu, Y. Kitahata, H. Yamaue. Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan.

Vascular endothelial growth factor receptor 2 (VEGFR2) is an essential factor in tumor angiogenesis and in the growth of pancreatic cancer. Immunotherapy using epitope peptide for VEGFR2 (VEGFR2-169) that we identified previously is expected to improve the clinical outcome. Therefore, a phase I clinical trial combining of VEGFR2-169 with gemcitabine was conducted for patients with advanced pancreatic cancer. Patients with metastatic and unresectable pancreatic cancer were eligible for the trial. Gemcitabine was administered at a dose of 1000 mg[Fraction Slash]m2 on days 1, 8, and 15 in a 28-day cycle. The VEGFR2-169 peptide was subcutaneously injected weekly in a dose-escalation manner (doses of 0.5, 1, and 2 mg[Fraction Slash] body, six patients [Fraction Slash] one cohort). Safety and immunological parameters were assessed. No severe adverse effect of grade 4 or higher was observed. Of the 18 patients who completed at least one course of the treatment, 15 (83%) developed immunological reactions at the injection sites. Specific cytotoxic T lymphocytes (CTL) reacting to the VEGFR2-169 peptide were induced in 11 (61%) of the 18 patients. The disease control rate was 67%, and the median overall survival time was 8.7 months. This combination therapy for pancreatic cancer patients was tolerable at all doses. Peptide-specific CTL could be induced by the VEGFR2-169 peptide vaccine at a high rate, even in combination with gemcitabine. From an immunological point of view, the optimal dose for further clinical trials might be 2 mg[Fraction Slash] body or higher.

A Case of Surgical Resection for Pancreatic Gastrinoma and Synchronized Multiple Liver Metastasis

H. Mizukami, J.-I. Tanaka. General and Gastroenterological Surgery Showa University Fujigaoka Hospital, Yokohama, Japan.

A 76 years old woman was admitted to our hospital with severe epigastric pain for an emergency. At upper gastrointestinal endoscopy, she was diagnosed a hemorrhagic duodenal ulcer. Abdominal computed tomography revealed pancreas tail tumor with a diameter of 20 mm and multiple hyper vascular lesions of the liver. A Serum level of gastrin at 33410 pg/ml was elevated. At EUS-guided fine needle aspiration, both pancreas tumor and liver tumor were diagnosed gastrinoma pathologically. We performed distal pancreatectomy and left lobectomy of the liver. After surgery, we performed transcatheter arterial embolization for remnant gastrinoma of right lobe of the liver and started the dosage of octeotide acetate to her. She is alive without recurrence for two years nine months after surgery. Liver metastasis of pancreatic gastrinoma should be treated with combined therapy including aggressive surgery for long-term survival.

MinnelideTM and Paclitaxel is an Effective Combination Against Pancreatic Cancer

S. Modi, K. Majumder, S. Banerjee, R. Chugh, A. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: Pancreatic cancer is resistance to most conventional chemotherapies. Monotherapy with any agent leads to selection of resistant clones and systemic toxicity. MinnelideTM at a dose of 0.42 mg/kg has already been shown to be very effective against pancreatic cancer in preclinical models. We aimed to study the efficacy of paclitaxel and MinnelideTM in combination at low doses to avoid any potential toxicity. We also investigated the possible mechanism of action of this combination.

Methods: Highly aggressive pancreatic cancer cell line (S2VP10) was treated with paclitaxel (0-25nM) and triptolide (25nM) and a combination of both for 24-72 h. Cell viability was evaluated using WST-8 cell viability assay; apoptosis by caspase 3 activation and PARP cleavage and proliferation by ECIS. In vivo: 6 week old athymic nude mice were injected with 1*106 S2VP10 cells subcutaneously. After tumor reached 200 mm3, mice were randomized in four groups (N = 5) as: DMSO (vehicle); MinnelideTM 0.21 mg/kg/day ip; Paclitaxel 10 mg/kg/week in DMSO ip and combination of MinnelideTM and Paclitaxel. The experiment was terminated after 21 days of treatment and tumors were harvested.

Results: Triptolide (25nM) greatly potentiated the apoptosis induced by paclitaxel in S2VP10 cancer cells. Cleaved PARP, data expressed as % of Control, mean ± SEM (48 h): triptolide (25nM) – 266 ± 31%, paclitaxel (10nM) – 318 ± 70%, triptolide (25nM) + paclitaxel (10nM) – 1268 ± 144%. Caspase 3, data expressed as % of Control, mean ± SEM (48 h): triptolide (25nM) – 116 ± 22%, paclitaxel (10nM) – 184 ± 45%), triptolide (25nM) + paclitaxel (10nM) – 798 ± 135%. Proliferation of S2VP10 cells was markedly inhibited on ECIS with combination. Triptolide augmented the G2/M cell cycle block induced by paclitaxel by increasing phospho-stathmin. In vivo, combination of MinnelideTM and paclitaxel had a significant reduction on growth of the tumors than either agent alone after 21 days of treatment. Tumor size, data expressed as % of control group, mean ± SEM: MinnelideTM – 75.4 ± 25 %, Paclitaxel – 30 ± 3%, MinnelideTM + Paclitaxel – 11 ± 1%. TUNEL positive cells were markedly increased in tumors treated with combination indicating apoptosis as a cause for cell death.

Conclusion: Combination of MinnelideTM and paclitaxel at low doses has immense potential to emerge as novel therapeutic strategy against pancreatic cancer.

Autophagy Inhibitors Enhance TRAIL-Induced Antitumor Effects on Human Pancreatic Cancer Cells

H. Monma,1,2 N. Harashima,3 Y. Hari,2,3 S. Kishi,1 Y. Tajima,2 M. Harada.31Department of Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan; 2Department of Surgery, Shimane University Faculty of Medicine, Shimane, Japan; 3Department of Immunology, Shimane University Faculty of Medicine, Shimane, Japan.

Background: Autophagy has received much attention as a mechanism of therapy-resistance in cancer cells. Its fundamental role in cells is cytoprotection under starvation and stress conditions, whereas this protective function renders cancer cells therapy-resistant. In support of this, many reports suggest that inhibition of autophagy in cancer cells can restore their susceptibility to anti-cancer therapies. Alternatively, TNF-related apoptosis-inducing ligand (TRAIL), a member of the TNF superfamily, can induce apoptosis in cancer cells while causing almost no cytotoxicity to normal cells. Although TRAIL has been applied in several clinical trials, some cancer cells acquire TRAIL-resistance and therapeutic efficacy has been limited.

Purpose: We determined whether autophagy inhibitors could enhance TRAIL-induced antitumor effects on human pancreatic cancer cell lines: MiaPac-2 and Panc-1.

Methods and Results: TRAIL treatment increased type-II LC3, an autophagy indicator, in cancer cells, and siRNA-mediated knockdown of Beclin-1, an autophagy-related molecule, increased their susceptibility to TRAIL. Of note, combination with either pifithrin-µ or chloroquine, as an autophagy inhibitor, significantly enhanced TRAIL-induced apoptosis and decreased their colony-forming capacities. These two inhibitors induced growth arrest in cancer cells. In a xenograft mouse model, the combination of TRAIL and either of autophagy inhibitors inhibited the tumor growth in vivo.

Conclusions: These results indicate that autophagy contributes to TRAIL-resistance of human pancreatic cancer cells and that autophagy inhibitors can enhance their sensitivity to TRAIL. Autophagy inhibitors show promise for use in therapies intended to overcome resistance of various anti-cancer therapies.

Osteoprotegerin is a Pro-tumorigenic Factor for Pancreatic Cancer

S. K. Morvaridi,1,2 H. Kanzaki,1,3 M. Edderkaoui,1,2 S. J. Pandol,1,2 R. Murali.11Department of Biomedical Sciences, 2Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 3Department of Pharmacy, Okayama University Hospital, Okayama, Okayama, Japan.

Tumor necrosis factor receptors super family (TNFRsf) play a central role in immunity and cellular growth. Dysregulation of these receptors promote tumor growth, metastasis and resistance to therapeutic treatments. Among the TNFRsf, death receptors, DR4 (TRAIL-R1), DR5 (TRAIL-R2) and Fas (CD95) are activated by death ligands, TRAIL and FasL, and induce apoptosis. Decoy receptors, DcR1, DcR2 and osteoprotegerin (OPG) competitively bind to TRAIL while DcR3 binds to FasL and there by prevent death receptor mediated apoptosis. The role of decoy receptors in pancreatic disease is unknown and remains to be explored.

We hypothesize that decoy receptors act as tumor survival factors for pancreatic adenocarcinoma (PDAC). Also, we hypothesize that in a Kras-dependent manner, OPG/DcR3 will be overexpressed and prevent TRAIL/FasL-induced apoptosis. To uncover the role of OPG in PDAC, we initiated studies to examine the expression of DR4, DR5, Fas, FasL, TRAIL, OPG, and DcR3 in tissues from chronic pancreatitis (CP) and pancreatic cancer patients by immunohistochemistry. Preliminary analysis shows that in pancreas, OPG is copiously expressed only in luminal surface of each acinus, and in CP it is expressed in islets and some acinar cells. In PDAC tissues, OPG is not expressed anywhere in the tissue; perhaps OPG is secreted out of the cell compartments. Accordingly, panel of pancreatic cancer cell lines with KrasG12D overexpress OPG and expressed variable levels of DR4 and DR5 as measured by RT-PCR, Western blot, and ELISA. Downregulation of Kras by siRNA decreased OPG expression and sensitized cells to TRAIL induced apoptosis. Also, ablation of OPG by siRNA decreased cancer cells’ migration. These studies evidence that decoys promote pancreatic cancer growth and metastasis.

Acute Pancreatitis (AP) Incidence is Increasing, but AP-Related Population Mortality Remains Constant

S. Munigala,1 D. Yadav.2Divisions of Gastroenterology, 1St. Louis University, St. Louis, MO; 2University of Pittsburgh, Pittsburgh, PA.

Background: Although an increase in the incidence of and decreased case fatality from AP is known, trends for AP-related population mortality are unknown.

Aim: To evaluate trends in the incidence of, case fatality and population mortality related to AP in the US population.

Methods: We used the National Hospital Discharge Survey to calculate age, sex and race standardized incidence of and case fatality rates from inpatient discharges for AP, and the vital statistics for AP-related population mortality from 1982–2010, using 2010 US census as the reference population.

Results: Overall, there were ~5 and 7.4 million discharges with primary and any AP diagnosis with a case fatality of 1.8% and 2.9% respectively. Discharges/100,000 with primary AP diagnosis doubled from 40.7 (95% CI 40.5-40.9) in 1982 to 89.3 (95% CI 88.9-89.6) in 2010. Case fatality showed fluctuations with a decreasing trend from 3.3 in 1982 to 0.7% in 2010. Discharges and case fatality increased with age but not by sex. Discharges were 2.1 times higher among blacks (93.8 vs. 44.1 in whites) but case fatality was similar. Overall, AP accounted for only 0.11% of all deaths. AP-related deaths (primary, any cause) increased from 2195 and 4948 in 1982 to 3045 and 5808 in 2010. However, population mortality rate per million from AP as primary cause remained stable at 9.5 (95% CI 9.1-9.8) in 1982 and 9.9 (95% CI 9.5-10.2) in 2010; and, from AP as any cause decreased minimally from 21.4 (95% CI 20.8-21.8) in 1982 to 18.8 (95% CI 18.3-19.3) in 2010.

Conclusion: Continuing increase in AP incidence is likely related to a combination of detection bias, over diagnosis and true increase. In addition to detecting milder cases, improved intensive care for organ failure in part explains the decrease in case fatality. The lack of reduction in population mortality underscores the urgency to develop innovative strategies for improving outcomes and reducing mortality in AP.

Etiological Distribution of Pancreatic Cystic Lesions Identified on CT/ MRI Using EUS

S. Munigala, S. B. Javia, B. Agarwal. Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO.

Background: Pancreatic cysts are frequently detected in asymptomatic patients. Data on the etiologic distribution of these cysts is largely derived from surgical databases and reflects subset of patients in whom clinical and morphologic findings prompted surgery. A vast majority of patients with pancreatic cysts however do not undergo surgery and hence are not represented in the published studies. Knowledge of etiologic distribution would help in designing optimal strategies for further evaluation and management of these patients.

Aim: To determine distribution of etiology of pancreatic cysts using established criteria/markers with high specificity in published literature.

Methods: This retrospective study is based on all patients from our database who underwent EUS exam for evaluation of a focal pancreatic lesion found on abdominal CT scan/MRI/Ultrasound and were noted to have a cystic pancreatic lesion by EUS/FNA. Etiology of the cyst was determined based on morphology, cyst fluid analysis and cytology (both exfoliative and targeted FNA of focal wall thickening). Published criteria/markers with high specificity were used to determine etiology of cysts. Etiologic distribution was studied in all patients 1) with cysts ≥10 mm in size, 2) those with size ≥ 3 cm (criteria for consideration for surgery) and ) in patients with h/o acute pancreatitis (AP). Patient characteristics, symptoms and EUS morphology features were noted.

Results: In the entire cohort of 643 patients, the etiology of the pancreatic cysts was: Mucinous cyst/SB-IPMN/MCN (53.6%), pseudocyst (20.2%), serous cystadenoma (12.9%), simple cysts (6.1%), mucinous cyst adenocarcinomas (5.6%) and other (1.6%). About 37% (n = 240) of the cysts were ≥ 3 cm and their diagnoses included: Mucinous cysts/SB-IPMN/MCN (33.3%), pseudocyst (28%), serous cystadenoma (21.7%), mucinous cyst adenocarcinoma (11.3%) and simple cyst (5%). In 165 patients with known history of acute pancreatitis, the diagnosis of cysts included pseudocyst (67.3%), mucinous cyst/SB-IPMN/MCN (18.2%), benign/simple cyst (10.3%) and mucinous cystadenocarcinoma (2%).

Conclusion: In patients with cystic pancreatic lesion noted on cross sectional imaging, about half of the patients have lesions without malignancy or malignant potential and therefore not requiring surveillance. EUS can identify these lesions preoperatively with high level of certainty. EUS evaluation of the pancreatic cysts can help optimize management of patients noted to have cystic lesion in the pancreas on cross sectional imaging.

Gallstone Disease and Risk of Digestive and Non-Digestive System Cancers: A Retrospective, Population-Based, Veterans Administration Study

S. Munigala B. Agarwal. Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO.

Background: Although gallstone disease is a known risk factor for gallbladder cancer, the association with other gastrointestinal, non-gastrointestinal cancers and chronic conditions is rather limited or not well known.

Aims: To evaluate the association of gallstone disease and the risk of various gastrointestinal, non-gastrointestinal cancers and chronic conditions.

Methods: Retrospective analysis of patients who sought care in Veterans Health Administration (VHA) from 1998–2007 (n = 534,956). Gallstone disease (ICD codes 574, 5741, 5743, 5745, 5747, 5748, 5749) and controls (without gallstone disease) were identified. ICD9 codes were used to identify patients with cancer diagnoses. Demographic characteristics (age, gender, & race), h/o smoking and alcohol were recorded. Statistical analysis. Odds ratio (OR) with 95% confidence intervals (CI) were calculated. SAS version 9.2 was used.

Results: A total of 15,097 VA patients had gallstone disease (2.8%). Mean age of gallstone disease patients and controls was 58.8 and 53.6 years (p <0.014). Gallstone disease patients had a higher OR [95% CI] of pancreatic cancer 4.70 [3.93, 5.61], gastric cancer 2.71 [2.15, 3.41], esophageal cancer 2.47 [2.01, 3.05], colon cancer 2.15 (1.92, 2.41), lung cancer 1.57 (1.42, 1.68), tongue cancer 1.44 (1.06, 1.96), hypertension 1.32 (1.27, 1.36), coronary artery disease 1.79 (1.71, 1.87) and asthma 1.57 [1.47, 1.68] when compared to Controls. Brain and testicular cancers were not associated with higher OR compared to controls.

Conclusions: In this large cohort of VA patients, presence of a gallstone disease was associated with elevated risk of gastrointestinal, non-gastrointestinal cancers and other chronic conditions like asthma and hypertension. It is likely that gallstone disease is a manifestation of a systemic metabolic disorder that is also associated with increased risk of these cancers and other chronic disorders.

Pancreatic Cystic Lesions Referred for Surgery Based on EUS Criteria: Correlation With Surgical Pathology

S. Munigala, S. B. Javia, M. Mehra, B. Agarwal. Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO.

Background: Mucinous cysts of pancreas are known to have malignant potential. Surveillance is currently recommended to look for early morphologic features suggestive of malignant transformation prompting surgical resection.

Aim: To compare and correlate surgical pathology findings with EUS findings in patients with mucinous cystic lesion.

Methods: This retrospective study is based on 937 patients from our database who underwent EUS exam for evaluation of a focal pancreatic lesion found on abdominal CT scan/MRI/Ultrasound and were noted to have a cystic pancreatic lesion. In 458 patients, the pancreatic cyst was diagnosed to be a mucinous cyst based on EUS-FNA. Surgery was recommended in 155 patients due to presence of focal wall thickness, thickened septa, cyst size ≥ 3 cm, cellular atypia or adenocarcinoma on cytology or cyst fluid CEA > 500 ng/ml. Surgical data/surgical pathology were available on 78 patients who were included in the final analysis.

Results: The final diagnoses in study patients based on surgical pathology were: adenocarcinoma (19), IPMN (39), MCN (13), serous cyst adenoma (2), pseudocyst (3), mucinous solid-cystic lesion of indeterminate type (1) and mesenteric cyst (1). Cysts with focal wall thickening ≥3 mm (p = 0.0008), diffuse dilation of pancreatic duct (not just beyond the lesion) (p = 0.0067) and cyst size ≥3 cm (p = 0.016) had significantly higher risk of adenocarcinoma. None of the patients without any of these morphologic features had cancer. History of acute pancreatitis, jaundice or weight loss was unhelpful.

Conclusion: In patients with mucinous cysts of the pancreas being evaluated by EUS, focal wall thickening, cyst size ≥3 cm and dilation of PD are important predictors of malignancy. We believe that these findings could help identify patients most likely to benefit from surgery and should routinely be evaluated during surveillance EUS exam.

Local Immunological Effect of Neoadjuvant Chemoradiotherapy in Patients With Borderline Resectable Pancreatic Cancer

T. Murakami,1 R. Mori,1 R. Matsuyama,1 Y. Homma,1 M. Nakazawa,2 Y. Tanaka,1 K.Miyake,1 Y Sawada,1 Y Oota,1 Y. Hiroshima,1 T. Kumamoto,1 M. Ueda,1 K. Takeda,1 Y. Ichikawa,1 K. Tanaka,1 I. Endo.11Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan; 2Department of Experimental Animal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.

Background: Little is known about the immunological modification due to neoadjuvant chemoradiotherapy (NACRT) in the tumor microenvironment of pancreatic cancer. We had previously reported that high accumulation of CD8+ tumor-infiltrating lymphocytes (TILs) might be a good predictor for pancreatic cancer treated with NACRT. However, the mechanism of immunological modification of NACRT has not been fully elucidated. The aim of this study was to investigate the local immunological effect of NACRT for patients with pancreatic cancer.

Methods: The population comprised of 85 patients who underwent resection for pancreatic cancer between January 2006 and December 2012. NACRT was administered to 52 patients with borderline resectable pancreatic cancer, whereas the other 33 patients with resectable pancreatic cancer underwent surgical resection without NACRT. The resected specimens were analyzed for the presence of CD8+ TILs, calreticulin, heat shock protein 70 (Hsp70), and major histocompatibility complex class I-related chain A/B (MICA/B) using immunohistochemical staining.

Results: The number of CD8+ TILs and the expression of calreticulin, Hsp70, and MICA/B were significantly higher in patients treated with NACRT. In the NACRT group, patients with a high accumulation of CD8+ TILs experienced longer survival than those with a low CD8+ TILs.

Conclusions: We have shown that NACRT induce immunological effect both in the tumor cell and tumor microenvironment for patients with pancreatic cancer.

Pancreatoduodenectomy With Resection of the Splenic Artery and Left Gastric Artery for Pancreatic Head and Body Cancer: Preservation of the Remnant Pancreatic Function via the Blood Supply From the Posterior Epiploic Artery

Y. Murata, M. Usui, S. Mizuno, A. Tanemura, H. Kato, N. Kuriyama,Y. Azumi, M. Kishiwada, H. Sakurai, S. Isaji. Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Japan.

Background: We previously reported that remnant pancreatic function could be preserved via the blood supply from the posterior epiploic artery (PEA) even when pancreatoduodenectomy (PD) with resection of splenic artery (SA) and splenectomy was performed for pancreatic double cancers after total gastrectomy. Recently we developed a new surgical technique of proximal subtotal pancreatectomy with splenic artery resection, so-called PD-SAR for the tumors with invasion of the SA. Here we present a case of locally advanced pancreatic head and body cancer who underwent chemoradiotherapy (CRT) and chemotherapy (CTX) followed by adjuvant surgery, in which a PD-SAR with resection of left gastric artery (LGA) combined with total gastrectomy and splenectomy was performed while successfully preserving pancreatic endocrine function by maintaining blood flow to the remnant pancreas via the PEA.

Case: A 66-year-old female was pointed out a pancreatic mass by ultrasonography at an annual health check-up. MDCT revealed a pancreatic head and body tumor with involvement of SMA, CA, CHA, and PV, and the origin of SA and LGA, which was histologically proven to be adenocarcinoma by EUS-FNA. The tumor was evaluated as locally advanced unresectable tumor, and then treated with S1/Gemcitabine (GS) based CRT following 13 cycles of GS. MDCT showed a reduction in the tumor size and serum level of CA19-9 decreased to within the normal range, and she underwent operation on 388 days after the initial treatment.

Surgical Procedure: According to the anterior approach, we transected pancreas first along the left side of aorta, and divided SA, LGA and splenic vein. After total exposure of SMA, CA and CHA, and the resection of PV, en bloc resection was completed, and total gastrectomy and splenectomy were done, paying attention to the root of mesocolon to ensure that we did not divide the PEA.

Result and Discussion: The postoperative course was uneventful, and the glucose tolerance was preserved even after oral intake was started. She was discharged 26 days after surgery. We have experienced 3 cases of PD-SAR with resection of LGA, preserving pancreatic tail for pancreatic head-body cancer. In all cases, the postoperative CT demonstrated no hypoperfusion of the remnant pancreas, and the exogenous insulin treatment was not required. PD-SAR with resection of LGA, preserving the remnant pancreas is a feasible and beneficial procedure for pancreatic head-body cancer with invasion of SA and LGA to preserve remnant pancreatic function and sustain quality of life.

Smoking-Induced DNA Damage Results in ATM-Dependent Phosphorylation of Histone H2AX in Pancreatic Cancer

N. Nagathihalli,1,4 K. Honnenahally,1 H. Tanjore,1 F. Revetta,1 X. Chen,3 J. Castellanos,1 C. Shi,2 N. Merchant.1,4Departments of 1Surgery, 2Pathology, 3Biostatistics and 4Cancer Biology, Vanderbilt University School of Medicine, Nashville, TN.

Background: Smoking is contributing to the rising rate of pancreatic cancer (PDAC). ATM phosphorylates histone H2AX (γH2AX) upon DNA damage resulting in chemoresistance. We studied whether ATM-dependent phosphorylated H2AX has a role in smoke-induced DNA damage repair and pathogenesis of PDAC.

Methods: HPDE6 and PanIN cells were treated with tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and subjected to RNA sequencing (RNA-seq). Gene network, pathway and functional analyses were conducted. We characterized the expression of γH2AX and RAD51 proteins in human pancreatic tissues and cell lines generated from a genetic mouse model of PDAC. Overall survival (OS) and Chi-squared analysis were performed to determine the significance of γH2AX expression amongst smokers and non-smokers. Cells were treated with NNK or radiation (4Gy) with or without ATM kinase inhibitor KU-55933. Accumulation of γH2AX by ELISA, γH2AX foci and co-localization of γH2AX and RAD51 using confocal microscopy and DNA strand breaks (DSBs) by comet assay was assessed.

Results: Whole-transcriptome alteration in NNK treated cells showed significant increase in the expression of genes related to DNA damage repair pathway. Expression of γH2AX and RAD51 increase in the progression from normal pancreas to advancing grade of PDAC. γH2AX expression was significantly higher in smokers when compared to non-smokers (p < 0.0001). OS in patients with high γH2AX expression was significantly decreased compared to low γH2AX expression (11 vs 36 months, p = 0.0007). NNK-induced DSBs, generation of γH2AX, increased expression of phosphorylated ATM and CHK2, and co-localization of γH2AX and RAD51 were inhibited when treated with KU-55933 confirming the role of γH2AX in the recruitment of DNA repair factors to the site of DNA damage.

Conclusion: Nuclear accumulation of γH2AX in the human pancreatic tumor tissues and in smokers reflects oncogenic stress associated with genomic instability. This data suggest that γH2AX is necessary for DNA damage repair and its activation is dependent on ATM/CHK2 signaling in pancreatic cancer providing a target to enhance chemoradiation sensitivity in PDAC.

Pancreatic Tuft Cells Principally Reside in the Ampulla and Proximal Intrapancreatic Biliary Duct in Mouse and Exhibit Increased Expression and Altered Localization in Response to Inflammatory Injury

A. Nakagawa,1 M. Mino-Kenudson,2 K.D. Lillemoe,1 C. Fernández- del Castillo,1 A.L. Warshaw,1 S.P. Thayer,1 A.S. Liss.11Warshaw Institute for Pancreatic Cancer Research and Departments of Surgery and 2Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Background: Tuft cells are chemosensory cells with a role in intestinal epithelial repair. While recent studies suggest that pancreatic tuft cells drive the progression of preneoplastic PanIN lesions into invasive ductal adenocarcinoma, the normal location of pancreatic tuft cells and their response to inflammatory injury is unknown.

Methods: Murine pancreata were embedded in paraffin blocks and their pancreato-biliary ductal systems were captured in approximately 60 5 mm sections. Every third section was analyzed for tuft cells by immunostain using antibodies specific for DCLK1 and Cox-1. The expression of these markers was analyzed in the pancreata from normal mice and those with a cerulein inflammatory injury model of pancreatitis.

Results: In normal mice, DCLK1+/Cox-1+ tuft cells were abundant in the ampulla compared to progressively diminished levels in the distal pancreato-biliary duct system (common channel > bile duct > pancreatic duct). In response to acute pancreatitis, there was a sustained increase in the levels of tuft cells throughout the duct system, with elevated levels still observed more than one month after injury. The number of tuft cells significantly increased in the ampulla as early as 1 day of recovery from injury, with lower levels and delayed kinetics observed in the common channel, bile duct and pancreatic duct. Tuft cells were less commonly seen in the peri-biliary glands (PBG) and pancreatic ductal glands (PDG), even after inflammatory injury.

Conclusion: The ampulla contains abundant tuft cells and may potentially be the source of the increased number of DCLK1+/Cox-1+ cells that are observed in the pancreato-biliary system in response to inflammatory injury.

Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach- Preserving Pancreaticoduodenectomy

T. Nakamura,1 Y. Ambo,2 M. Takada,2 F. Nakamura,2 N. Kashimura,2 S. Hirano.11Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan; 2Department of Surgery, Teine-Keijinkai Hospital, Teine-ku, Sapporo, Japan.

Objective: This study aims to evaluate whether the incidence of delayed gastric emptying (DGE) can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD).

Summary Background Data: One of the most common morbidities of pancreaticoduodenectomies is DGE. The recent advent of SSPPD attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%.

Methods: A total of 160 consecutive patients who had undergone SSPPD were enrolled in this study. After SSPPD, reconstruction was done using conventional Child procedure, and gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group) and the greater curvature side-to-side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively.

Results: The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different.

Conclusions: The greater curvature side-to-side anastomosis of gastrojejunostomy has proven to be effective in reducing the incidence of DGE after SSPPD.

Incidence and Exocrine Pancreatic Function of Cystic Fibrosis in Japan

S. Naruse,1 H. Ishiguro,2 A. Yamamoto,2 S. Kondo,2 M. Nakakuki,2 M. Hoshino,1 K. Fujiki,3 M. Kitagawa,3 K.Yoshimura,4 T. Shimosegawa.51Departments of Medicine and Pediatrics, Miyoshi Municipal Hospital, Miyoshi; 2Laboratory of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya; 3Nagoya University of Art and Sciences, Nagoya; 4Omori Red Cross Hospital, Tokyo; 5Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Cystic fibrosis (CF) is an extremely rare disease in Japanese.

Aim: The aim of this study is to elucidate the incidence and exocrine pancreatic function in patients with CF in Japan.

Methods: The Research Committee for Intractable Pancreatic Disease supported by the Ministry of Health, Labour and Welfare (MHLW) of Japan conducted a national survey of CF in 2009. The questionnaires were sent to 688 institutions that included all the hospitals with beds over 400 and children hospitals in Japan. The response rate was 81.8%. The annual number of live births during the period of 1990–2009 was obtained from a summary of vital statistics of MHLW. Fecal elastase was measured in 16 patients (8 males: age 0–34 years) on the Japan CF registry in 2013 and 110 healthy children (64 males: age 1–6 years). Fecal elastase <200 μg/g stool was considered pancreatic insufficient (PI).

Results: The number of patients with CF was 13 (95% confidence interval: 10–16) in 2009. The national surveys in 1999, 2004, and 2009 revealed that 39 patients were born during the period of 1990–2009. The incidence was calculated to be 1.68/1,000,000 live births. Fecal elastase in all the healthy children but one was >200 (range: 174–784) μg/g. Fecal elastase in 11 patients showed PI (median 20, range: 16–75 μg/g), while 5 patients were pancreatic sufficient (PS) (median 804, range: 239–852 μg/g). The median age of PI patients (7.5 years) was lower than that of PS patients (25.5 years).

Conclusion: The incidence of CF was approximately 1 in 590,000 live births in Japan. Approximately 70% of patients exhibited pancreatic insufficiency.

Histone Deacetylase Inhibitors Unleash a Pro-inflammatory Tumor-Supportive Phenotype in Pancreatic Cancer Fibroblasts

A. H. Nguyen,1 S. Patel,1 M. Vogelauer,2 P. A. Toste,1 N. Wu,1 L. Li,1 D. W. Dawson,3 S. K. Kurdistani,2 T. R. Donahue.11Department of Surgery, 2Department of Biological Chemistry, 3Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Histone deacetylase inhibitors (HDACi) are currently being investigated in early phase clinical trials for patients with pancreatic ductal adenocarcinoma (PDAC). Although there have been measurable responses in patients with hematologic malignancies treated with HDACi, similar results have not been demonstrated for solid organ tumors. We hypothesize that tumor associated fibroblasts (TAFs), the predominant cell type in the PDAC stoma, may contribute HDACi therapy resistance.

Results: PDAC TC (PANC-1, MIA PaCa-2) viability was significantly decreased (p < 0.01) by all tested class I and II HDACi’s (vorinostat, entinostat, panobinostat) using an MTT assay. However, slowly dividing primary TAFs showed neither growth arrest nor upregulation of CDKN1A, despite an appropriate increase in global levels of H3ac and H4ac. As compared to naïve TAFs, HDACi treatment (i) enhanced TC invasion (modified Boyden chambers, p < 0.001) and viability (MTT assay, p = 0.05) in co-culture; and (ii) increased secretion of numerous “pro-inflammatory” proteins (p = 0.05) including CXCL1, IL-6, IL-8, and SPP1, by upregulating NFκB target genes (p < 0.01). HDAC2 ChIP-seq of primary TAF pro-inflammatory gene poised enhancer regions, defined by published H3K4me1 ChIP-seq of normal fibroblasts, revealed the uniform presence of HDAC2, suggesting HDAC inhibition may allow for expression of these genes. These regions are occupied by the active enhancer mark H3K27ac in cells that normally express them. The promoter regions for these “inflammatory” genes both show motif and ChIP-seq data supporting expression from STAT3- and NFκB-mediated factors.

Conclusion: HDACi’s induce a tumor supportive phenotype in primary PDAC TAFs by causing expression of secreted pro-inflammatory genes. Our studies may explain the ineffectiveness of HDACi therapy and are beginning to uncover the mechanism of this detrimental response in PDAC TAFs.

Extraction of Chinese Herbal Recipe Modified Da-Cheng-Qi Decoction Could Alleviate Severe Acute Pancreatitis in Mice

J. Ni,1 D. Su,1 B. Zhang,1 Y. Wang,1 B. Hao,1 W. Liu,3 Y. Wu,2 X. Feng.31Department of Gastroenterology, 1st Affiliated Hospital to Nanjing Medical University, Nanjing, Jiangsu, China; 2Yangzhou University, Yangzhou, Jiangsu, China; 3Zhongshan Botanic Research Institute, Nanjing, Jiangsu, China.

Backgrounds and Aims: To investigate if extraction of Chinese herbal recipe Modified Da-Cheng-Qi Decoction could treat severe acute pancreatitis (SAP) in mouse.

Methods: 36 male Balb/c mice were randomly divided into 3 groups, i.e., sham operation, control and treatment group. SAP in the control and treatment groups was induced by retrograde infusion of 3.5% sodium taurocholate into the biliopancreatic ducts. Mice of the sham operation group were infused with physical saline instead. After the induction of pancreatitis, the mice of the treatment group were given chemical extraction of Chinese herbal recipe Modified Da-Cheng-Qi Decoction (rheum officinale, Magnolia officinalis, fructus aurantii immaturus, Glauber salt and Scutellaria baicalensis) via intragastric administration. Three or six hours after biliopancreatic infusion, samples of the blood, pancreas and lungs were harvested. Plasma amylase and lipase were determined, pancreatic histological scoring for pancreatitis was graded, and damages of the lungs were assessed independently by two pathologists.

Results: Mice of The treatment group showed lower levels of plasma amylase and lipase, lower histological scores, and lighter lung damages comparing with those of the control group (P < 0. 05).

Conclusions: Administration of chemical extraction of Chinese herbal recipe Modified Da-Cheng-Qi Decoction after induction of SAP could attenuate inflammation in mice.

HGF May Modulate the Total ROS Level, Mitochondrial Function and Death Pattern of Pancreatic Acinar Cells in Cerulein-Induced Acute Pancreatitis in Mice

J. Ni,1 R. Shi,1 W. Liu,1 Y. Wu,1 Y. Yuan.211st Affiliated Hospital to Nanjing Medical University, Nanjing, Jiangsu, China; 2Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China.

Backgrounds and Aims: Previous studies have shown that HGF could alimeorate the pancreatic damage of cerulein-induced acute pancreatitis in mice maybe through diminishing inflammatory factors production and facilitating cell aopotosis in pancreas. Here we try to disclose the probable relations between mitochondrial function and the death pattern of pancreatic acinar cells.

Methods: 4 times injections of 100μg/g b.w. of Cerulein into peritoneum or 10^-7 of CCK-8 incubation with primarily isolated pancreatic acinar cell culture from mice were to replicate mild acute pancreatitis or acinar cell damages. HGF was administrated subcutaneously to mice or co-incubated with CCK-8, both before and during the induction of pancreatic damages, while neutral HGF antibody also used additionally and respectively to try to eliminate the effect of HGF (called blocker groups). The total ROS level, free calcium in cytospasm([Ca]i), mitochondrial membrane potential (MMP), cytochrome c, and the cellular apoptosis were measured in pancreatic tissues and cultured acinar cells 3hrs after the end of cerulein injection or the initiation of primary cell culture.

Results: HGF treatment groups revealed relatively lower ROS levels, lower [Ca]i, higher MMP and higher apoptosis level than cerulein or cell damage groups, while blocker groups had similar ROS level, MMP and apoptosis level as damage group, P<0.05.

Conclusions: There might be correlations among the total ROS level, mitochondrial function and the cell death pattern in acute pancreatic damage, and HGF may have the function to modulate their levels.

HMGB1 and Acetylated HMGB1 as Predictive Markers of Severe Acute Pancreatitis

A. Nieminen,1 A. Rouhiainen,2 H. Tukiainen,2 J. Kuja-Panula,2 L. Kylänpää,1 P. Puolakkainen,1 H. Rauvala,2 H. Repo.31Department of Surgery, Helsinki University Central Hospital, Finland; 2Neuroscience Center, University of Helsinki, Finland; 3Department of Bacteriology and Immunology, University of Helsinki, Finland.

Aim: To immunologically detect circulating HMGB1 and acetylated HMGB1 (Ac-HMGB1) levels and analyze their predictive value in patients with acute pancreatitis (AP).

Background: HMGB1 is a cell death marker, which also functions as an inflammatory cytokine. Previous findings suggest that HMGB1 can function as an indicator of severe AP.

In liver failure study Ac-HMGB1 was a better marker of worse prognosis than HMGB1. Therefore, different molecular forms of HMGB1 might be useful also in predicting severe AP.

Methods: This is a prospective study of 81 non-consecutive patients with AP admitted to Helsinki University Central Hospital within 72 hours after the onset of symptoms within 2003–2007. According to the revised Atlanta classification 24 patients had severe AP. The plasma levels of HMGB1 and Ac-HMGB1 were measured on admission, and the values of C-reactive protein were used for comparison.

Results: HMGB1 levels were lower in the patients with severe AP compared to the patients with mild or moderately severe AP (p=0.021). HMGB1 and CRP had similar statistical parameters in predicting severe AP (sensitivity 46 % and 42 %, specificity 89 % and 88 %, positive likelihood ratio 4.3 and 3.5 and diagnostic odds ratio 7.1 and 5.2, respectively). The Ac-HMGB1 was detected only in 38.3 % of patients. The values were very low, and they did not correlate with disease severity.

Conclusion: We demonstrate that low plasma HMGB1 levels on admission may predict the development of severe AP. The role of HMGB1 in AP needs further studies.

Pancreatic Lipases Have a Redundant Role in Inducing Lipotoxic Cell Death

P. Noel,1 R.N. Trivedi,1 K. Patel,1 M. Lowe,2 V.P. Singh.11Department of Medicine, Mayo Clinic, Scottsdale, AZ; 2Division of Pediatric Gastroenterology, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

Background: Unsaturated fatty acids increased in human pancreatic necrosis (PN) worsen acute pancreatitis (AP) outcomes in mechanistically dissimilar models (PMID: 24854864, 22049070), and are generated via hydrolysis by pancreatic lipases (PLs). The pancreas expresses pancreatic triglyceride lipase (PTL), pancreatic lipase related protein-2 (PLRP2) and bile salt dependent lipase (BSDL). We aimed at determining the PL that needs to be targeted.

Methods: Bile salts were measured in human PN. Fat pads of mice with severe AP were western blotted for PL. PLs were added exogenously or transfected in PL naïve cells (HEK293 or parotid acini). These cells or pancreatic acini from PTL or PLRP2 knockout mice (KO) were exposed to the triglyceride glyceryl trilinoleate GTL (300-600 µM) alone or in the presence of the PL inhibitor orlistat (50 µM). Lipase activity, glycerol generation and cell death (LDH leakage) and necrosis (propidium iodide uptake and ATP levels) were measured.

Results: Bile salt concentrations in 15 PN collections (biliary AP= 14) were low (mean=0.6+/−0.6 μM, median=0). PTL and PLRP2 were increased in fat necrosis. BSDL unlike PTL and PLRP2 did not generate glycerol, or induce cell death at sodium taurocholate concentrations <30 μM. PTL or PLRP2 knockout acini expressed the other lipase. In the presence of GTL, glycerol generation (>8 fold vs. without GTL, p<0.05) and necrosis (>60%, vs <10% without GTL p<0.05) in the KOs were similar to wild types. Exogenous addition of pancreatic lysates or expression of PTL or PLRP2 resulted in an increase in lipase activity (>300U/L, vs. <10U/L in controls, p<0.05), glycerol generation (>3 fold control) and >80% necrosis in the presence of GTL, all of which were prevented by orlistat.

Conclusions: Pancreatic lipases have a redundant role in lipotoxic cell death requiring their collective inhibition to improve outcomes in severe AP.

CD133 Drives Invasion Through IL-1 Mediated NF-kB Activation

A. Nomura, R. Chugh, V. Dudeja, O. McGinn, A.K. Saluja, S. Banerjee. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

CD133 has previously been shown to mark a population of cancer stem cells (CSCs) capable of tumor initiation, progression, and metastasis. In pancreatic cancer, we have previously shown CD133+ cells express high levels of epithelial-mesenchymal transition (EMT) genes and show elevated activation of NF-kB activity, as compared to CD133 cells. However, the contribution of CD133 surface expression to this phenotype is unclear. In this study, we overexpressed CD133 in a cell line with minimal endogenous CD133 surface expression. Overexpression of CD133 increased cellular invasiveness in vitro by 5.9 fold, as compared to controls. This also significantly increased the degree of metastasis in vivo, where CD133 overexpression led to extensive metastasis to the spleen, lymph nodes, liver, abdominal wall, and diaphragm, with little metastasis in control groups. This increased invasiveness was mediated by activation of NF-kB upon CD133 overexpression. NF-kB activation increased the expression of EMT transcription factors snail1 (2.9 fold) and zeb1 (7.7 fold) and mesenchymal markers vimentin (2.5 fold), n-cadherin (2.2 fold), and MMP9 (4.8 fold). CD133 overexpression induced NF-kB activation through increased IL-1 signaling. Blocking IL-1 signaling decreased in vitro invasion and decreased expression of EMT markers. In conclusion, this study demonstrated a functional role of CD133 in pancreatic cancer. Its expression increased tumorigenicity and additionally increased cellular invasiveness through IL-1 signaling mediated NF-kB activation.

The Epidemiology and Outcome from Pancreatoduodenal Trauma in the U.K. 1989–2013

D.A. O’Reilly,1,2 O. Bouamra,2 A. Kausar,1 D.J. Malde,1 E.J. Dixon,4 F. Lecky.2,31Department of Surgery, North Manchester General Hospital; 2Trauma Audit & Research Network (TARN) The University of Manchester; 3 EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield. 4West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, UK.

Background: Pancreatic and duodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with a high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained pancreatoduodenal trauma in the UK from a large trauma registry, over the period 1989–2013.

Materials: The Trauma Audit and Research Network (TARN) database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both.

Results: 1,155 of 350,000 (0.33%) trauma cases sustained PD trauma. Median age was 27 (IQR: 16–45) for blunt trauma and 27.5 (IQR: 21–40) for penetrating trauma. The male to female ratio was 2.5:1. Blunt trauma was the commonest type of injury seen, with a ratio of blunt to penetrating PD injury of 3.6:1. Road traffic collision was the commonest mechanism of injury, accounting for 673 (58.3%) of cases. The Injury severity scores (ISS) were 25 (IQR: 14–35) for blunt trauma and 14 (IQR: 9–18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were: increasing age, ISS, hemodynamic compromise and not having undergone an operation.

Conclusion: Isolated pancreatic injuries are uncommon; most co-exist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from that of series from the USA and South Africa. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.

Oral Udenafil and Aceclofenac for the Prevention of Post-ERCP Pancreatitis in High-Risk Patients: A Randomized, Placebo-Controlled, Double Blind, Multicenter Study

H.-C. Oh,1 J.S. Choi,2 T.Y. Lee,3 T.J. Song,4 J.H. Do,1 Y.K. Cheon.31Division of Gastroenterology, Chung-Ang University College of Medicine, Seoul, Korea; 2Division of Gastroenterology, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea; 3Division of Gastroenterology, Konkuk University College of Medicine, Seoul, Korea; 4Division of Gastroenterology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea.

Background: Acute pancreatitis is a common complication of ERCP. Combination therapy with oral udenafil and aceclofenac may reduce the occurrence of post-ERCP pancreatitis by targeting different pathophysiological mechanisms underlying acute pancreatitis. This study aimed to determine whether combining udenafil and aceclofenac reduces the rates of occurrence of post-ERCP pancreatitis.

Methods: A prospective, randomized, double-blind, placebo-controlled, multicenter study was conducted in four academic medical centers. Between January 2012 and June 2013, a total of 216 patients who underwent ERCP were analyzed for the occurrence of post-ERCP pancreatitis. Patients were determined to be at high risk for pancreatitis on the basis of validated patient and procedure-related risk factors.

Results: Demographic features, indications for ERCP, and therapeutic procedures were similar in each group. There was no significant difference in the rate (15.8% [17/107] vs. 16.5% [18/109], p = .901) and severity of post-ERCP pancreatitis between the udenafil/aceclofenac and placebo groups. One patient in each group developed severe pancreatitis. On multivariate analyses, suspected sphincter of Oddi dysfunction and endoscopic papillary balloon dilatation without sphincterotomy were associated with post-ERCP pancreatitis.

Conclusions: Combination therapy with udenafil and aceclofenac was not effective for the prevention of post-ERCP pancreatitis.

The Drain Management after Laparoscopic Distal Pancreatectomy

T. Okada, Y. Iimuro, T. Hirano, Y. Asano, K. Suzumura, I. Nakamura, Y. Kondo, H. Kosaka, S. Hai, H. Sueoka, J. Fujimoto. Dept of Surgery, Hyogo College of Medicine, Nishinomiya, Japan.

Introduction: Although the progress of operative equipment and technique for a decade, pancreatic fistula (PF) after laparoscopic distal pancreatectomy (LDP) is still frequently occurred. The appropriate drain insertion is indispensable to manage PF safely. In this study, we demonstrated our recent result of LDP regarding to the management of PF.

Method: Among our 25 consecutive patients who underwent laparoscopic pancreatic resection, 15 cases of fully laparoscopically achieved distal pancreatectomy was reviewed. LDP was performed with three ports. Following the pressing of cut line for 10 minutes, pancreas resection was performed by autosutures. We formerly placed a drain via 5mm port scar of upper abdomen in the early days. Nowadays we do not hesitate to make new scar for keeping straight line of drainage route. A drain was fixed at two points to avoid drain dislocation by tunneling under the peritoneum: two points were peritoneum of inserting portion of drain and retroperitoneum near pancreas stump. PF was graded according to the ISGPF definition. Grade B and C were considered as clinically relevant PF (cPF).

Results: Among 15 patients who underwent LDP for benign pancreatic tumors, laparoscopic spleen preserving distal pancreatectomy (LSPDP) was performed in 12 cases. The averaged operative time was around 4hr and intraoperative blood loss was a little. cPF was occurred in 20.0% (3/15 cases) of patients, and postoperative hospital stays was three-times prolonged in cPF cases (45 vs 14 days). In these 3 patients who developed cPF, drain was not dislocated and fine drainage was performed. Therefore we didn’t experience any severe postoperative course such as grade C.

Conclusion: LDP caused considerable rate of pancreatic fistula occurrence; nevertheless the straight drainage route and two points drain anchoring realized appropriate drain management to avoid severe postoperative course.

Prognostic Factors of Intraductal Papillary Mucinous Carcinoma

Y. Okamura, T. Sugiura, T. Ito, Y. Yamamoto, K. Uesaka. Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan.

Background and Objectives: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is considered a premalignant lesion that progresses from adenoma to carcinoma. IPMN is known to have favorable prognosis; however, some have reported a poor prognosis of invasive intraductal papillary mucinous carcinoma (IPMC), which was comparable to that of conventional pancreatic ductal adenocarcinoma (PDC). The prognostic factors of IPMC are still unclear, and the objectives of this study are to clarify the surgical outcomes and prognostic factors of IPMC.

Patients and Methods: The present study included 99 patients who underwent pancreatectomy for IPMN between September and August 2013. In situ carcinoma was included in intraductal papillary mucinous carcinoma (IPMA) in the present study. The IPMC was identified in 41 patients, and retrospectively analyzed the treatment outcomes and the prognostic factors for IPMC.

Results: Nine patients had a recurrence, and two patients underwent remnant pancreatic resection. Eight patients (19.5%) were died between follow-up period (4.3-132.6 months). The causes of deaths were identified as following: IPMC, 5; other disease, 3. Other diseases included 2 patients with other malignant neoplasms. Postoperative 3-, and 5-years overall survival rates of IPMC were 87.4%, and 76.0%, respectively. In univariate analysis, CA19-9≥42 (P=0.018), biliary invasion (P=0.002), lymph vessel invasion (P<0.001), venous vessel invasion (P=0.001), perineural invasion (P=0.001), and lymph node metastasis (P<0.001) were identified as the prognostic factors after surgery. These factors were included in multivariate analysis, the presence of venous vessel invasion and lymph node metastasis were independent negative prognostic factors (hazard ratio [HR] 13.7, confidence interval [CI] 2.06-91.3, P=0.007 and HR 11.8, CI 1.97-70.8, P=0.007, respectively).

Conclusion: The overall outcome of IPMC is comparatively good, however, some patients were died of other malignant neoplasms. It is important to pay attention the occurrence of other malignant neoplasms between follow-up period.

Vitamin A-Binding Liposome Containing Heat Shock Protein 47 siRNA Regulates Pancreatic Regeneration

S. Ota,1,2 T. Mizuguchi,1 M. Nishimura,2 M. Ishii,1 K. Okita,1 T. Nishidate,1 T. Nobuoka,1 Y. Kimura,1 Y. Niitsu,2 K. Hirata.1Dept. of 1Surgery and 2Molecular Target, Sapporo Medical University, Sapporo, Japan.

Introduction: Activated pancreatic stellate cells (aPSCs) play an important role in regulating tissue reconstruction in the pancreatic regeneration (PR). Heat Shock Protein (HSP) 47 regulates collagen production in PSCs. Vitamin A liposomes (VA-lip) are taken up by PSCs specifically, and HSP47 siRNA conjugation (VA-Lip-siRNA-HSP47) is a novel drug to regulate aPSCs. The aim of this study was to investigate whether VA-Lip-siRNA-HSP47 regulates PR in a 90% pancreatectomy (PTx).

Methods: Six-week-old male Sprague–Dawley rats were divided into three groups (N=10 each): sham (Sham), non-treatment (NT), and treatment (TR). NT and TR underwent 90% PTx. All rats received bromodeoxyuridine (BrdU) 3 hr before sacrifice on days 3 and 5 after PTx. Immunohistochemical analysis of BrdU and αSMA was conducted. Specific pancreatic acinar cells (Acs) and stellate cells (Scs) were cultured or co-cultured to assess molecular regulation using flow cytometry.

Results: BrdU uptake in Acs and islet cells (Ics) was significantly increased in the NT on day 3 (11.2-fold and 3.7-fold, respectively) and day 5 (11.1-fold and 2.3-fold, respectively), although no uptake was seen in the sham. They were significantly decreased in the TR on day 3 (7.8-fold in Acs and 2.8-fold in Ics). The Ac proliferation rate showed a positive correlation with HSP47-positive Scs (r=0.68) and collagen fibers (r=0.66). BrdU uptake in vitro experiment, Ac proliferation (19.7%) was stimulated by co-culturing with Scs (30.5%). However, Ac proliferation was totally inhibited by siRNA-HSP47 knock-down in the co-cultured cells (21.6%, P<0.01).

Conclusion: Acs and Ics vigorously proliferated after 90% PTx and Acs proliferation was facilitated by co-culture with Scs. HSP47 activation in Scs was necessary to promote the proliferation of Acs, which was totally blocked by HSP47-specific siRNA delivery in vivo and in vitro.

β-catenin and MUC4 in in the Pathogenesis of Pancreatic Cancer

P. Pai, S. Das, S. Rachagani, M. A. Macha, S. K. Batra. Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE.

Background: Mucins are high molecular weight glycoproteins expressed by the polarized epithelial cells lining the luminal surfaces of digestive, respiratory and reproductive tracts. MUC4 is a large transmembrane mucin that is expressed de novo in PC. The cause for this increase in expression is uncertain. β-catenin is a signaling molecule at the crux of the Wnt signaling pathway and is deregulated in PC. The MUC4 promoter contains three putative binding sites for TCF/LEF-1, known as transcriptional co-activators and mediators of β-catenin signaling, leading us to hypothesize that β-catenin can modulate MUC4 expression. In addition, MUC4 has been proposed to alter the localization of β-catenin, suggesting a complex relationship between the two molecules.

Methods and Results: Immunohistochemical analysis showed an increased staining and nuclear localization of β-catenin and increased MUC4 staining in PC tissue in comparison to normal pancreas. Immunoblot analysis of PC cell lines showed that β-catenin expressing cell lines also expressed MUC4 whereas cell lines that expressed low levels of β-catenin did not express MUC4. When β-catenin was knocked down in T3M4 and CD18 PC cell lines, there was a decrease in MUC4 protein and RNA levels in the β-catenin knockdown cells in comparison to the scrambled vector transfected control cells. MUC4 promoter luciferase constructs and stabilized β-catenin transfection studies showed that MUC4 is regulated by β-catenin. Cytoplasmic and nuclear extraction, immunoblot analysis and confocal microscopy of MUC4 scrambled control and knockdown PC cells did not show any alteration in β-catenin localization.

Conclusions: β-catenin mediated signaling may be involved in increasing the expression of MUC4 during PC progression. Future directions include ascertaining the precise mechanism of β-catenin mediated MUC4 regulation in PC.

Effect of Guggulsterone and Resveratrol on Prevention of Acute Pancreatitis in Mouse Model

J. M. Park,1,2,3 S. H. Lee,1,2 K. H. Chung,1,2 J. K. Ryu,1,2 Y-T. Kim,1,2 N. Y. Kim.41Departments of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; 2Departments of Internal Medicine, Seoul National University Hospital, Seoul, Korea; 3Department of Internal Medicine, Kangwon National University School of Medicine, Kangwon National University Hospital, Chuncheon, Korea; 4Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea.

Background: Guggulsterone and resveratrol have been shown to have anti-inflammatory properties. Resveratrol was reported to alleviate the severity of acute pancreatitis in previous studies. It is unknown, however, whether guggulsterone is effective for the prevention of acute pancreatitis. Therefore, we investigated effects of guggulsterone monotherapy and combination therapy with resveratrol on prevention of acute pancreatitis in mouse model.

Methods: Guggulsterone, resveratrol, and combination treatment were performed for mice. Acute pancreatitis was induced in these mice by intraperitoneal injection of cerulein. After injection of cerulein, serum amylase activity and histologic score of the pancreas were measured for evaluation of severity of pancreatitis.

Results: Serum amylase levels were as follows; control group: 992.3±35.5, guggulsterone group: 967.8±242.7, resveratrol group: 711.7±43.5, combination group 811.0±90.9 IU/L. Guggulsterone did not reduce serum amylase level. Amylase levels tended to be lower for resveratrol group (P=0.065). Pancreatitis histologic scores were as follows; control group: 8.0±2.2, guggulsterone group: 5.0±1.8, resveratrol group: 2.7±0.5, combination group 2.7±1.4. Pancreatitis was histologically less severe for guggulsterone group than control group, although it was not statistically significant (P=0.065). Resveratrol and combination treatment reduced severity of pancreatitis histologically (P=0.002).

Conclusion: Guggulsterone did not reduce the severity of cerulein-induced acute pancreatitis in mouse model.

Grave Clinical Course of Pancreatic Invasive Carcinoma Derived From Branch Duct-Type IPMN: A Case Series

S.M. Park, J.G. Park, K.B. Kim, J.Y. Lee, M.J. Kim, J.-H. Han, S.M. Yoon, H.B. Chae, S.J. Youn. Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.

Background: Branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMN) showed good prognosis. However, invasive carcinoma is more aggressive than that derived from main duct-type IPMN, once invasive morphological change takes place.

Aim: We report three patients with invasive carcinoma derived from BD-IPMN who showed grave clinical courses.

Methods: The patients’ medical records and image studies were retrospectively analyzed based on clinical symptoms, biochemical data, and hospital courses.

Results: All patients were diagnosed as BD-IPMN without any malignant stigmata by MRCP, EUS, or abdominal CT scan at the initial diagnosis. Invasive ductal adenocarcinoma was detected at 3.2, 3.6, and 4.1 years later in each patient. All patients showed locally advanced invasive ductal adenocarcinoma and pathologic diagnosis was done by EUS-FNA in 2 patients and brush cytology by ERCP in one patient. All patients were treated with only conservative management and they died at 2, 3, and 6 months after the diagnosis of invasive ductal adenocarcinoma.

Discussion: Further studies are needed about proper follow up interval and identification of risk factors in the patients with BD-IPMN of the pancreas.

Conclusions: Metachronous or transformed invasive ductal carcinoma from BD-IPMN are not rare and they showed aggressive clinical course.

HDAC Inhibitors in Combination With Gemcitabine Induce the Epithelial–Mesenchymal Transition in Pancreatic Carcinoma Cells

S.M. Park, M. Ji, E.J. Lee, J.G. Park, K.B. Kim, J.Y. Lee, M.J. Kim, J.-H. Han, S.M. Yoon, H.B. Chae, S.J. Youn. Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.

Background: Histone deacetylase (HDAC) inhibitors augmented the inhibitory effects of gemcitabine (GEM) on pancreatic cancer cell growth. However, recent studies reported that HDAC inhibitors enhance the epithelial-mesenchymal transition (EMT) in various cancers.

Aims: We investigated the EMT phenotypes in pancreatic cancer cells when challenged HDAC inhibitors trichostatin A (TSA) and valproic acid (VPA) with or without gemcitabine treatment.

Methods: EMT phenotypes were measured in PANC-1 and MIA-PaCa-2 via the expression of E-cadherin or ZO-1 as epithelial cell marker and vimentin as mesenchymal cell marker using Western blot, and immunofluorescence following treatment with TSA (200 nM) or VPA (0.5 mM) with or without gemcitabine (50 nM) for 24 h. Biological EMT phenotypes were also measured by cell morphology and migration assay.

Results: Pancreatic cancer cells changed from round shapes to spindle shapes and increased migration via TSA or VPA in combination with GEM treatment. Confocal microscopy revealed membranous attenuation or cytoplasmic expression of E-cadherin and enhanced expression of vimentin by TSA or GEM treatment. TSA or VPA induced mesenchymal features in pancreatic carcinoma cells by decreasing E-cadherin or ZO-1 and increasing vimentin expression in the western blot. The susceptibility to EMT changes induced by TSA or VPA was comparable in PANC-1 and MIA-PaCa-2. EMT changes were augmented by dual treatment with HDAC inhibitors TSA or VPA and GEM.

Discussion: HDAC inhibitors require caution for their application as new anticancer drugs in pancreatic adenocarcinomas.

Conclusion: TSA or VPA induced a mesenchymal phenotype in pancreatic carcinoma cells and this effect was augmented in the presence of GEM.

Pyogenic Pancreatic Abscess Mimicking Pancreatic Neoplasm: A Case Series

S.M. Park, J.G. Park, K.B. Kim, J.Y. Lee, M.J. Kim, J.-H. Han, S.M. Yoon, H.B. Chae, S.J. Youn. Department of Internal medicine, Chungbuk National University College of Medicine, Cheongju, Korea.

Background: Pyogenic pancreatic abscess mimicking pancreatic neoplasm in the absence of acute pancreatitis is difficult to diagnosis.

Aim: We report four patients presented with an isolated pancreatic mass at pancreas head or body mimicking malignancy.

Method: The patients’ medical records and image studies were retrospectively analyzed based on clinical symptoms, biochemical data, and hospital courses.

Results: Presenting symptoms were abdominal pain and febrile sense in three patients and weight loss in two patients. Abdominal CT scan revealed low density round mass at pancreas body or head without lymphadenopathy. PET-CT scan showed hot uptake mass with high SUV index, suspicious malignancy. Comorbid diseases were identified in two patients; chronic pancreatitis and portal vein thrombus in one patient and duodenal fistula in one patient. Three patients were diagnosed by needle aspiration by laparoscopy or EUS and treated with drainage and antibiotics. Forth patient presented with round enhancing mass at pancreas head was diagnosed multiple micro-abscess caused by duodenal fistula. He treated with antibiotics and proton pump inhibitors. All patients improved clinical symptoms and pancreatic images.

Conclusion: Pancreatic mass mimicking malignancy in patients with high fever needs pathologic diagnosis before decision of major surgery.

Selective Utilization of ERCP for Gallstone Pancreatitis in the Era of Endoscopic Ultrasound

S.M. Park, J.G. Park, K.B. Kim, J.Y. Lee, M.J. Kim, J.-H. Han, S.M. Yoon, H.B. Chae, S.J. Youn. Department of Internal medicine, Chungbuk National University College of Medicine, Cheongju, Korea.

Background: EUS is an accurate diagnostic tool to detect common bile duct (CBD) stones in the patients with acute pancreatitis.

Aim: This study was to evaluate the necessity for performing endoscopic retrograde cholangiopancreatography (ERCP) in the patients with suspicious gallstone pancreatitis associated with microlithiasis or none in the CBD by endoscopic ultrasound (EUS).

Methods: Consecutive fifty-three patients (M:F, 30:23; mean age, 57±18 years) with suspicious gallstone pancreatitis and no evidence of CBD stones by MDCT underwent EUS within 24 hours of admission between 2012 and 2014. Immediate ERCP (within 24 hours after EUS) was performed in the patients with CBD stones, microlithiasis, or CBD dilation by EUS findings. The patients’ medical records were retrospectively analyzed based on clinical symptoms, biochemical data, and hospital courses.

Results: CBD stones, microlithiasis, and none were identified in 21(39.6%), 7(13.2%), and 25(47.2%) patients by EUS. ERCP was performed in 21 patients with CBD stones, 7 patients with microlithiasis, and 8 patients with only CBD dilatation without stones. CBD stones were extracted by ERCP in 15 out of 21 (71.4%) patients, 1 out of 7 (14.3%) patient, and 1 out of 7 (12.5%) patient, respectively. All patients were improved and hospital days were not different with or without ERCP. However, 4 patients who performed ERCP in the condition of microlithiasis or CBD dilation only showed transient aggravation of acute pancreatitis after ERCP.

Discussion: The proper indication of ERCP in patients with biliary pancreatitis in the era of accurate diagnosis of cholelithiasis using EUS.

Conclusions: Half of patients with gallstone pancreatitis showed no evidence of CBD stones and they improved with only conservative management. Immediate ERCP in patients with microlithiasis or CBD dilation only is not necessary in the EUS era.

Impact of Genetic Testing in Children With Idiopathic Pancreatitis

A. Parniczky,1 N. Lasztity,1 C. Andorka,2 G. Veres,2 J. Czelecz,3 R. Szmola,4 B. C. Nemeth,5 A. Balazs,5 E. Hegyi,5 I. Hritz,5 P. Hegyi,5 M. Sahin-Tóth,6 on be half of the Hungarian Pancreatis Study Group. 1Heim Pal Children’s Hospital Budapest, Hungary; 21st Dept. of Pediatrics, Semmelweis Univ., Budapest, Hungary; 3Bethesda Children’s Hospital, Budapest, Hungary; 42nd Dept. of Medicine, Semmelweis Univ., Budapest, Hungary; 52nd Dept. of Medicine, Univ. of Szeged, Szeged, Hungary; 6Dept. of Molecular and Cell Biology, Boston Univ. Medical Center, Boston, MA.

Background: Etiology of pancreatitis should be determined in all patients. Despite extensive work-up, etiology often remains unidentified and pancreatitis is classified as idiopathic. The latest IAP/EPC guideline (Pancreatology, 13 (2013) e1-15) suggests that patients having a second attack of idiopathic pancreatitis should undergo genetic testing.

Aim: The aim of this study was to investigate whether this recommendation can be used in a pediatric patient population.

Methods: The national registry of the Hungarian Pancreatic Study Group (HPSG) contains 13 patients under age 18 who suffered from acute pancreatitis. The etiology of pancreatitis was determined in all cases. In all idiopathic cases genetic testing was performed.

Results: The etiology of pancreatitis in the 13 children was as follows: biliary:1, drug:1, trauma:1, dietary:1, postERCP:1, idiopathic: 8. Genetic alterations in idiopathic pancreatic patients: Patient (P)-No1: SPINK1 (p.N34S, heterozygous) and CTRC (p.G60G, homozygous), P-No2: CFTR (p.F508del, heterozygous) and CTRC (p.G60G, homozygous), P-No3&P-No4: CTRC (p.G60G, homozygous), P-No5: SPINK1 (p.N34S, heterozygous), P-No6: PRSS1 (p.R122H, heterozygous), P-No7: PRSS1 (p.R122H, heterozygous) and CTRC (p.G60G, heterozygous), P-No8: mutation could not be detected. In summary, genetic risk factors were identified in seven of eight idiopathic pancreatic children.

Conclusions: These data clearly suggest that genetic testing should be performed after the first attack of pancreatitis of unknown etiology in children. This study was supported by OTKA, TAMOP and MTA grants.

Peri-Pancreatic Fat Necrosis (PPFN) Worsens Inflammation and Outcomes in Acute Pancreatitis (AP), Independent of Pancreatic Necrosis

K. Patel, P. Noel, R. Trivedi, V. P. Singh Department of Medicine, Mayo Clinic - Arizona, Scottsdale, AZ.

Background: The revised Atlanta criteria for moderate or severe AP include peripancreatic necrosis; a distinct risk factor often including fat necrosis (PMID: 23100216, 22773550). Elevated unsaturated Fatty Acids (UFA), IL-1β and IL-8 were noted in human pancreatic necrotic collections (HPNC). We, therefore, investigated their role in PPFN and multisystem organ failure (MSOF).

Methods: AP was induced with caerulein (CER; 20mcg/kg, IP, BID) on 3 consecutive days in rats. Other groups included co-administration of (A) 3ml triolein (3% body weight; which equals visceral fat in obese humans) (B) triolein with Orlistat (50mg/kg), (C) IL-1β and KC/GRO at concentrations equivalent to HPNCs (6 doses, 200 ng/kg/dose and 6.0 μg/kg/dose respectively) and (D) controls. Rats were followed till mortality or electively sacrificed at day 3. Serum and tissues were harvested. Values are reported as mean ± SEM. p<0.05 was considered significant.

Results: 7/8 rats co-administered triolein died within 48 hours vs. 0/8 in other groups over 3 days (p<0.05). At necropsy, there was no evidence of pancreatic necrosis in any of the groups and only rats co-administered triolein had strands of saponified intraperitoneal fat, significant hypocalcemia (serum calcium 7±0.2 vs.11.9±0.5 mg/dl), elevated serum oleic acid (349±272 vs.16 μM, p<0.05), IL-1β (622±101 vs. 20±4 pg/ml, p<0.05), KC/GRO (40±11 vs. 0.5±0.07 ng/ml, p<0.05), lung injury (TUNEL positive 15.9±1 vs. 0.8±0.2 cells/HPF, p<0.05) and renal injury (blood urea nitrogen 51.3±6.5 vs. 14.2±2.4 mg/dl, p<0.05) vs controls. These adverse outcomes were prevented by orlistat, without affecting parameters of AP induction (>3 fold increase in Serum amylase or lipase in all groups).

Conclusion: These observations suggest that lipotoxicity from the fatty acids generated by visceral peri-pancreatic triglyceride hydrolysis worsen inflammation and MSOF, independent of local pancreatic necrosis.

Serous Cystadenomas Follow a Benign Course and Minimal Growth Rate

M. Pelaez-Luna,1,2 L. Uscanga-Dominguez,1 J. Hernandez-Calleros.11Pancreas Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran; 2Research Division, School of Medicine, Universidad Nacional Autónoma de México, Mexico City, Mexico.

Background: Serous cystadenoma (SCA) is a benign pancreatic cystic neoplasm. Conservative management is encouraged. We analyzed clinical and radiological characteristics and examine the natural history of SCA diagnosed at our institution. The information is part of a multinational study sponsored by the International Association of Pancreatology.

Methods: We retrospectively collected demographic, clinical, imaging, surgical and pathology data at the moment of diagnosis, surgery and last follow up (FU) from all SCA diagnosed between 2000 and 2013 at our institution.

Results: We included 22 cases; mean age at diagnosis 63 years (range 28–83), 18 (82%) were females. Diagnosis was incidental in 13 (59%), unspecific abdominal pain 4 (18%), unexplained weight lost 3 (14%), gastrointestinal obstructive symptoms 1 (4.5%) and cholangitis 1 (4.5%). Imaging showed that SCA were microcystic in 12 (55%), macrocystic 2 (9%) and mixed type 8 (36%). Location was uncinate 2 (9%), head 7 (32%), body 8 (36%) and tail 5 (23%). Mean size at diagnosis 37± 23 SD mm (range 14–97). Five cases underwent surgery at diagnosis; 3(14%) due to symptoms and 2 (9%) incapacity to rule out malignancy. Initial size did not significant differ between surgical and FU group 39±17SD vs. 37±27SD mm (p=0.9). Four cases were lost in FU; 13 continued conservative management; mean FU 54 months (range 22–107). FU group initial size remained similar 29mm (range 18–80) when compared to the last FU size 33mm (range 20–80), p=0.9. Only 6 (46%) cases presented significant growth during FU (mean initial size 25mm (range 18-48mm) vs. final FU 36mm (range 25-63mm); p>0.05). All patients were asymptomatic on last visit. No malignant transformation or SCA related death was registered.

Conclusions: SCA follow an indolent course. Malignant transformation and cyst related death is nil. Growth rate is minimal.

Infiltration of Stellate Cells in Pancreas of Human Chronic Pancreatitis is Coupled to Hyperactive CXCR4/Lyn Chemokine Signaling

H. Pham,1 S. Liu,1 V. Cirulli,2 S.J. Pandol,1,3 A. Ptasznik.11Cedars-Sinai Medical Center, Los Angeles, CA; 2University of Washington, Seattle, WA; 3Veterans Affairs, University of California, Los Angeles, CA.

Aim: To assess the expression and function of CXCR4 and Lyn in primary stellate cell cultures, and define the in situ expression pattern in pancreatic specimens. We postulate that CXCR4/Lyn axis plays a critical role in promoting stellate cells movement and infiltration in chronic pancreatitis (CP).

Methods: Primary stellate cell isolated from pancreata of donors with or without CP were assessed for expression and function of CXCR4 and Src family kinases by qPCR, Western Blot, in vitro kinase assay, flow cytometry, and cell migration assay to SDF-1. Immunocolocalizations of CXCR4, αSMA (marker of activated stellate cells), CD68 (macrophage marker), and Lyn, in pancreatic specimens, were evaluated by immunofluorescence. Extensive morphometric and statistical analysis was performed on 150 images per tissue group (3 CP versus 3 normal pancreata) collected from a total of 180 tissue sections.

Results: Cultured Primary Stellate Cells. SDF-1-dependent chemotaxis, percentage of CXCR4 surface-positive cells, expression and activity of Lyn and Src kinases, were significantly increased in cells isolated from CP compared to cells from normal subjects. Notably, Lyn tyrosine kinase activity was dramatically increased (10.7 fold) in cells from CP patients, as compared to cells isolated from normal pancreata. Pancreatic Tissue. A striking finding of our morphometric studies is the significant colocalization of CXCR4 with αSMA, CXCR4 with CD68, and Lyn with CD68, reaching approximately 15, 7 and 14 fold increase, respectively, in CP, as compared to normal pancreata.

Conclusions: Infiltration of pancreas with stellate cells and macrophages in patients with CP is likely due to excessive movement of CXCR4(+) cells with hyperactive Lyn kinase activity. These results indicate that CXCR4/Lyn axis can be a targetable pathway for the treatment of CP.

Cyst Fluid Kynurenine May Predict IPMNs Among Pancreatic Cysts

K. Pham,1 T. Zikos,1 A. Chen,1 S. Banerjee,1 S. Friedland,1 M. Dua,2 J.A. Norton,2 G. Poultsides,2 B. Visser,2 R. Stafford,1 W.G. Park.11Department of Medicine and 2Department of Surgery, Stanford University School of Medicine, Stanford, CA.

Background: Previous work with metabolomic profiling of pancreatic cyst fluid demonstrated kynurenine to have potential diagnostic utility in pancreatic cysts. The aim of this study was to further validate this observation using a commercially available ELISA assay.

Methods: Using a bio-repository of pancreatic cyst fluid, kynurenine was measured using samples with a histological diagnosis (N = 49). By histology, there were 36 mucinous cysts (MCN = 8, IPMN = 20, mucin cancer = 8) and 13 non-mucinous cysts (SCN = 7, pseudocysts = 6).

Results: Median (IQR) kynurenine values (pmol/ml) were the following: MCN 58,234 (6,102 – 157,241), IPMN 2,875 (1,587 – 99,264), mucin cancer 71,243 (9,076 – 219,414), SCN 7,382 (1,727 – 115,368), and pseudocysts 114,940 (22,090 – 230,965). Cyst fluid kynurenine levels between IPMN and non-IPMN lesions were significantly different (p = 0.009). There was no significant difference when comparing 1) mucinous from non-mucinous cysts and 2) mucinous cystic cancers from all other cysts.

Conclusion: Using a simple ELISA assay, cyst fluid kynurenine may have potential clinical utility in the diagnosis and management of pancreatic cysts. Specifically, it may accurately diagnose IPMN lesions. Further evaluation is warranted.

High Fat Accelerates Pancreatic Cancer Development via Activation of Oncogenic K-Ras and COX2 Expression

B. Philip,1 C. L. Roland,2 J. Daniluk,5 Y. Liu,1 D. Chatterjee,2 S. B. Gomez,1 B. Ji,6 H. Huang,1 H. Wang,3 J. B. Fleming,2 C.D. Logsdon,1,4 Z. Cruz-Monserrate.11Department of Cancer Biology, 2Surgical Oncology, 3Pathology, 4GI Medical Oncology, UT, M. D. Anderson Cancer Center, Houston, TX; 5Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland, 6Mayo Clinic, Rochester, MN.

Obesity is a risk factor for Pancreatic Ductal Adenocarcinoma (PDAC), but the molecular mechanisms involved are unclear. Oncogenic mutation of K-Ras occurs early and nearly universally in patients with this disease. However, recent evidence indicates that oncogenic Ras is not constitutively active and a stimulus is required to generate Ras activity above a threshold sufficient to engage a Ras-inflammation feed-forward loop. We hypothesized that high-fat acts as an inflammatory stimulus, increasing K-Ras activity above this threshold and that cyclooxygenase −2 (COX2) expression is required to maintain the inflammation. LSL-K-Ras mice were crossed with elastase-CreER or Pdx1-Cre. Elastase-CreER -Ras mice were crossed with COX2 conditional knockout mice. All mice were fed isocaloric diets with either high or low fat and with or without a COX2 inhibitor. Pancreata were analyzed for Ras activity, phospho-ERK levels, inflammation, fibrosis, PanINs and PDAC. We observed that consumption of a high fat diet (HFD) led to increased K-Ras activity, PanIN formation, fibrotic stroma and PDAC development compared to a control diet. Additionally, we observed a significant reduction in the survival of mice fed a HFD. Genetic deletion of COX2 in acinar cells or treatment with a COX2 inhibitor prevented the HFD-induced pathological effects. These findings support a model in which a HFD stimulates activation of oncogenic K-Ras and initiates an inflammatory feed-forward loop requiring the expression of COX2 leading to pancreatic inflammation, fibrosis, PanINs and PDAC. This mechanism may explain the PDAC risks associated with consumption of a HFD.

mTOR Mediates p62/SQSTM1 Synthesis in Pancreatic Acinar Cells

M. Pimienta, G.E. Lee, A.S. Gukovskaya, I. Gukovsky, O.A. Mareninova. VA Greater Los Angeles, University of California Los Angeles, and Southern California Research Center for ALPD and Cirrhosis, Los Angeles, CA.

Background & Aims: p62/SQSTM1 is a multifunctional signaling protein that plays a key role in autophagy. p62 is specifically degraded via autophagy; it also serves as a chaperone for autophagic clearance of protein aggregates. Recently p62 was shown to mediate ER and oxidative stress in a genetic model of pancreatitis caused by IKKα deficiency. However, little is known on regulation of p62 in pancreas. Here we show that p62 level in pancreatic acinar cells is determined by its autophagic degradation and synthesis, which are both regulated by the protein kinase mTOR.

Methods: Autophagy markers/mediators and p62 level were measured in pancreas of mice with non-alcoholic and alcoholic pancreatitis, and in acinar cells from wild type and genetically modified mice incubated with 100 nM CCK-8 and/or 50–100 mM ethanol. Pancreatitis was induced by i.p. injections of 50 μg/kg cerulein or by 6-wk feeding of Lieber-DeCarli diet followed by low-dose (5 μg/kg) cerulein.

Results: p62 level increased dramatically in both non-alcoholic and alcoholic pancreatitis. Correspondingly, ethanol+CCK treatment up-regulated p62 in acinar cells. Blocking autophagic degradation (with lysosomal protease inhibitors) increased, whereas blocking protein synthesis greatly decreased p62 level. Thus, p62 increase in pancreatitis is mediated by both decreased degradation and increased synthesis. Pharmacologic inhibition of mTOR stimulated p62 degradation and blocked its synthesis in acinar cells. mTOR stimulated p62 synthesis via eIF2α/ATF4-dependent mechanism. Differently, genetic deletion of NF-κB or pharmacologic activation of NRF2, a key anti-oxidant transcription factor, had no effect on pancreatic p62.

Conclusions: mTOR both inhibits p62 autophagic degradation and stimulates its synthesis (which was not known in general). The results suggest mTOR inhibition as an approach to inhibit ER and oxidative stress in pancreatitis.

Epigenetic Reprogramming in Patients With Pancreatic Ductal Adenocarcinoma

C. Pin,1 K. Leslie,2 T. Ponich,3 N. Hussain,3 C. Johnson.11Children’s Health Research Institute, Depts. of Pediatrics, Physiology and Pharmacology, and Oncology, 2Surgery, or 3Medicine, Western University, London, ON, Canada.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is the 4th leading cause of cancer related deaths in North America, with 94% of patients dying 5 years after initial diagnosis. Therefore, it is critical to identify the events that promote PDAC. Studies to date have focused on genetic factors that increase the risk for PDAC. However, the highest risk factor for PDAC is chronic or hereditary pancreatitis. We have shown that pancreatic injury promotes epigenetic reprogramming of acinar cells based on altered enrichment of histone post translation modifications linked to gene activation (H3K4Me3) or repression (H3K27Me3). Many of these reprogrammed genes affect the progression of pancreatitis and PDAC.

Goal: Identify the epigenetic pathways that reprogram acinar cells during PDAC.

Methods: Pancreas adjacent to PDAC was obtained during tumor resection. RNA, chromatin, tissue and protein were isolated for analysis. Chromatin Immunoprecipitation (ChIP) for H3K4Me3, H3K27Me3, or the protein complexes that promote these epigenetic modifications, was followed by qPCR or Next Generation Sequencing. qRT-PCR and IHC were used to validate gene epigenetic enrichment.

Results: ChIP-qPCR identified specific enrichment of H3K27Me3 at genes that protect against pancreatic injury correlating to decreased expression of these genes. Members of PRC2 and MLLs, known to be responsible for promoting these epigenetic events, exhibit altered expression and enrichment in PDAC samples. We identified increased enrichment for silencing marks at genes that promote pancreatic differentiation, and activating marks genes that promote PDAC.

Discussion: Epigenetic reprogramming occurs within the pancreatic tissue of patients with PDAC, consistent with reduced expression for genes that promote pancreatic differentiation. Future work will determine whether these changes predate tumor formation.

Transcriptome Analysis of Activating Transcription Factor 3 During Acute Pancreatitis

C. Pin,1–3,5 C. Young,1,2,5 W. MacDonald,4,5 C. Johnson.1,5Depts. of 1Paediatrics, 2Physiology and Pharmacology, 3Oncology, and 4Biochemistry, Western University; 5Children’s Health Research Institute, London, Ontario, Canada.

Introduction: Pancreatitis affects >100,000 people each year in North America. Chronic pancreatitis is one of the main risks for pancreatic ductal adenocarcinoma (PDAC). Therefore, understanding the pancreatic response to injury would provide insight into pancreatitis and PDAC. Activating Transcription Factor 3 (ATF3), expressed only after inducing pancreatic injury, represses Mist1, a key factor required for maintaining the acinar cell phenotype. However, ATF3 also activates genes that promote inflammation in other tissues. The goal of this project was to define the ATF3 transcriptome during pancreatic injury.

Hypothesis: ATF3 mediates changes in acinar cell gene expression that promote pancreatitis.

Methodology: Cerulein-induced pancreatitis (CIP) was initiated in C57 Bl6, and congenic Atf3+/− and Atf3−/− mice. Pancreatic injury was assessed by histological, biochemical and molecular analysis from 4 to 32 h after injury. The relationship of ATF3 to pancreas gene expression was assessed by chromatin immunoprecipitation (ChIP) or RNA isolation followed by Next Generation Sequencing (ChIP-seq and RNA-seq). Enrichment and gene expression were confirmed by ChIP-qPCR and qRT-PCR.

Results: 4 hours into CIP, ATF3 targets genes involved in acinar cell organization, cell communication, and development. Recruitment of ATF3 to these genes coincided with altered expression, with subsets of genes showing increased or decreased expression. In the absence of ATF3, many of these changes do not occur with Atf3−/− mice having decreased severity of CIP.

Conclusions: ATF3 is a central regulator of the pancreas response to injury, enhancing inflammation pathways and repressing the acinar cell phenotype. ATF3 contributes directly to gene activation and repression, suggesting ATF3 exists within multiple transcriptional complexes during CIP.

Nurse Practitioner in a Team Model Provides Enhanced Patient Access with High Patient Satisfaction in Pancreas Clinic

L.D. Pisney, S.T. Chari, J.E. Clain, T. Dahl, F.C. Gleeson, A. Gossard, P. Hart, M.J. Levy, R.K. Pearson, B.T. Petersen, M.D. Topazian, S.S. Vege. Department of GI/Hepatology, Mayo Clinic Rochester, MN.

Background: Pancreas Clinic at Mayo Clinic Rochester is a daily half day Clinic operating within the larger GI Division. To streamline care and increase patient access, a team-based approach was initiated in 10/2012 employing one attending physician, a Nurse Practitioner (NP), a GI/Pancreas fellow, a registered nurse (RN), desk assistant, and appointment coordinator. The NP saw patients and presented to the attending and agreed upon an intended plan of care. The attending then saw the patient and reviewed key elements of history and management plan. After testing was completed, the NP saw her patients in return for review of the results and recommendations for ongoing care. The complexities of the patients was high, commiserate with the tertiary care center that they were referred to.

Goal: To examine the role of a Nurse Practitioner and her integration into a team-based approach to patient care in a highly specialized Pancreas Clinic in an academic setting.

Methods: The number of patients seen was evaluated for access to care before and after the addition of the NP. A sampling of the patients seen was sent a survey asking them to rate the NP’s quality of care and quality of time spent during their visit.

Results: The total number of patients seen in 2011 was 2052, compared to 3563 after the addition of the NP. This included 1361 new patient consults in 2011, compared to 1798 in 2013; internal consults; 470 in 2011 and 596 in 2013; and 221 established patients in 2011 and 1169 in 2013. The sample surveys were sent to the NP’s patients and her care was rated as excellent and the quality of time spent as excellent to very good.

Conclusions: Employing a nurse practitioner in a specialty pancreas clinic improved access, reduced wait times for patients, and allowed attending physicians to meet increasing practice demands. Patient satisfaction remained high.

Routine Antibiotic Prophylaxis in Pancreatic Necrosis: Are We Done Yet?

E. Psaltis,1 J. Enright,2 E. Villatoro,1 M. Larvin.21 King’s Mill Hospital, Mansfield, UK; 2Graduate Entry Medical School, University of Limerick, Limerick, Ireland.

Introduction: Infection of pancreatic necrosis increases mortality. Randomized controlled trials (RCTs) show conflicting results in its reduction with the use of antibiotics.

Methods: RCTs that used intravenous contrast-enhanced CT to establish pancreatic necrosis as an entry criterion were sought in MEDLINE, EMBASE and CINAHL, together with hand searching of conference proceedings. A systematic review was conducted according to international Cochrane Collaboration standards, performing meta-analysis using “RevMan 5.2” software.

Results: 11 published RCTs were identified, 8 doubly blinded. Antibiotics varied, 8 evaluating betalactams, and 3 quinolone/nitroimidazoles. Meta-analysis found non-significantly reduced mortality in treatment group (33/319, 10%) versus controls (42/323, 13%) odds ratio (OR) 0.75 and 95% confidence intervals (CI) 0.46-1.22. Infected necrosis was non-significantly reduced in the antibiotic group (65/319, 20%) v controls (73/323, 23%); OR 0.87 and 95% CI 0.66-1.65. Extra-pancreatic infection was not significantly decreased with prophylaxis (61/236, 26%) v controls (78/240, 33%); OR 0.67, 95% CI 0.45-1.00. All sites infections were also non-significantly reduced with antibiotics (108/276, 39%) v controls (127/280, 45%). Adverse events were poorly reported. Fungal infections were non-significantly increased with antibiotics (14/233, 6%) v controls (13/230, 5.65%); OR 1.06, 95% CI 0.51-2.22. Operative rates showed a non-significant increase with antibiotics (77/306, 25%) v control (73/310, 24%); OR 1.02 95% CI 0.70-1.49.

Conclusion: Antibiotic prophylaxis in patients with identified pancreatic necrosis was not associated with statistically significant improvement of outcome. No RCT was adequately powered, and studies were heterogeneous. Better powered, doubly-blinded studies of higher quality are required. Present evidence suggests that antibiotics should be used for treatment when clinically indicated.

Serum DCLK1 Levels are Elevated in Early Stage Pancreatic Cancer Patients

D. Qu,1 P. Chandrakesan,1 J. Johnson,1 N. Weygant,1 R. May,1 A. Rhim,2 B. Stanger,3 S.M. Sureban,1 C. W. Houchen.11Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK; 2Department of Internal Medicine, University of Michigan, Ann Arbor, MI; 3Department of Medicine, University of Pennsylvania, Philadelphia, PA.

Aim: To determine whether DCLK1 can be detected in the bloodstream and if its levels in archived serum samples could be quantitatively assessed in pancreatic ductal adenocarcinoma (PDAC) patients.

Background: Doublecortin-like kinase 1 (DCLK1) has been identified as a tuft cell marker with stem-like properties in the pancreas. It is overexpressed in pancreatic cancer and correlated to PanIN stage. Recent studies demonstrated that DCLK1 is a CSC marker and DCLK1+ PDAC cells can initiate pancreatic tumorigenesis. In this study, we evaluated DCLK1 levels in the serum of PDAC patients and in the KPC mice. We also assessed DCLK1 expression in the stromal cells and tumor epithelial cells of PDAC tissues.

Methods: ELISA assay was performed to detect DCLK1 and CA19-9 levels in the archived serum samples of PDAC patients. Western blotting was also performed to detect DCLK1 levels in the serum samples of PDAC patients and from KPC mice. Circulating DCLK1+ cells were isolated from KPCY mice by flow cytometry. Immunohistochemistry (IHC) analysis was done to detect DCLK1 in the PDAC tumor tissues.

Results: DCLK1 levels in the serum were elevated in early stages of PDAC (stages I and II) compared to healthy volunteers. No differences were observed between stages III/IV and normal controls. In resected surgical tissues, DCLK1 expression intensity in the stromal cells was significantly higher than that observed in tumor epithelial cells. Circulating tumor cells were isolated from KPCY mice and approximately 70% of these cells were positive for Dclk1 staining. Dclk1 levels in the serum of KPC mice were also elevated.

Conclusion: Our results suggest that DCLK1 may be used as a potential marker for early detection and perhaps a therapeutic target for pancreatic cancer.

Important Considerations in Mouse L-Arginine-Induced Acute Pancreatitis

Z. Rakonczay,, Jr,1 B. Kui,1 Z. Balla,1 E.S. Kormányos,1 B. Vasas,2 B. Iványi,2 T. Takács,1 P. Hegyi.11First Department of Medicine; 2Department of Pathology, University of Szeged, Szeged, Hungary.

Introduction: To investigate the pathomechanism and potential treatment of acute pancreatitis (AP), we rely on animal models such as that induced by large intraperitoneal injections of L-arginine. However, we found only mild inflammation in Balb/c and high mortality in FVB/n and C57BL/6 mouse strains with the originally published method (2x4 g/kg, 8% L-arginine).

Aim: To characterize the strain-, concentration and dose-dependency of L-arginine-induced AP.

Methods: AP was induced with different doses (2x4, 3x3, 4x2,5 g/kg) and concentrations (0-10%) of intraperitoneal L-arginine administration in Balb/c, FVB/n and C57BL/6 mice. Serum amylase and pancreatic myeloperoxidase activities, edema, necrosis and leukocyte infiltration were measured to determine AP severity. The effectivity rate (ER) of disease induction was calculated as the number of mice with AP/all mice.

Results: In Balb/c mice, the i.p. injections of 2x4 g/kg 10% L-arginine injection resulted in moderate morbidity and low mortality (ER=90%). In FVB/n strain, 2x4 g/kg 5% L-arginine treatment caused low mortality with severe AP (ER=90%), whereas 10% L-arginine caused greater mortality (ER=25%). C57BL/6 mice developed mild disease with low mortality due to 5% L-arginine (ER=90%), however, disease severity and mortality were higher in case of 10% L-arginine administration (ER=35%). In all three strains, the injections with 3x3 or 4x2.5 g/kg L-arginine caused similar AP severity with lower mortality vs the 2x4 g/kg dose.

Conclusions: Mouse strains show different sensitivities to L-arginine and there is a fine borderline between effective and lethal L-arginine doses and concentrations.

This study was supported by OTKA, MTA, Campus Hungary and TÁMOP.

Whipple Procedure: Pancreatic Jejunostomy Presentation of a Novel Anastomosis

C.E. Rodríguez, J. Targarona, G. Coayla, L. Barreda. Department of Surgery, Pancreatic Division, E. Rebagliati M. Hospital Essalud, Lima, Peru.

Pancreatojejunostomy leakage is the major cause of complications after duodenopancreatectomy. This study assessed a new technique of pancreatic jejunal anastomosis (Blumgart anastomosis, BA), avoiding the cutting forces during suture tying.

We performed a descriptive, prospective and cross- sectional assessment of patients with periampullary neoplasms during December 2009 to November 2010.

The results showed a postoperative mortality of 3%, 8.82% presented pancreatic leak, with an average hospital stay of 11 to 20 days.

The reconstruction of the pancreatic stump with the Blumgart technique seems to be fast, easy and safe for pancreatico-jejunal anastomosis. Reduced leakage rates and surgical complications after proximal pancreaticoduodenectomy could be achieved with it.

A Novel Paraneoplastic Fat Redistribution in Pancreatic Cancer (PC) Induced Weight Loss Distinct From Non-PC Cachexia

R.P. Sah, S. Nagpal, N. Ahmed, N. Takahashi, J. Miles, D. Mukhopadhyay, S.T. Chari. Div. of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Background: We have previously reported that weight loss in the absence of cachexia precedes pancreatic cancer (PC) diagnosis. Here, we explore the nature of this paraneoplastic weight loss by evaluating relative changes in Visceral (VAT) and Subcutaneous Adipose Tissue (SAT) in PC Vs cachexia due to other cancers.

Methods: We identified 151 PC and 86 Non-PC cancer patients (26 cholangiocarcinoma, 60 colon cancer) with abdominal CTs at diagnosis and at least one year (median 3.1, 2.4 respectively) prior to the diagnosis of cancer. Abdominal circumference (AC), area of VAT and SAT were measured at L3-L4. AC change was used as surrogate for weight loss based on its excellent correlation with absolute weight loss data available in 60% patients (R2 0.71, p<0.0001). Differences across groups between the time-points were analyzed accounting for within subject comparisons with matched-pair Wilcoxon test and medians are reported.

Results: Among patients with moderate (<15%) weight loss (55% PC, 63% Non-PC), there was 6% greater loss of SAT than VAT in PC compared to 4% greater loss of VAT than SAT in Non-PC (P=0.04); VAT proportion increased by 2% in PC Vs 1% decrease in Non-PC (P=0.04) and VAT/SAT ratio increased by 3.3x10−2 in PC Vs decrease by 5.3x10−2 in Non-PC (P=0.008). Together, these multiple measures indicate fat redistribution favoring VAT in PC. A similar trend was seen in extreme weight loss (14% PC, 7% Non-PC) group; no differences were noted in patients without weight loss (~30% per group). Among PC group, no significant differences were seen by diabetes status.

Conclusion: In the majority of PC patients with weight loss, VAT is relatively preserved while SAT is preferentially shed which is distinct from Non-PC cachexia, suggesting a dynamic fat redistribution favoring VAT. This novel paraneoplastic phenomenon induced by PC likely promotes insulin resistance and diabetes and needs to be explored further.

Initial Change in Mesenteric Blood Flow as Studied by Pulse Doppler and Contrast-Enhanced US in Acute Pancreatitis

J. Sakagami, K. Kataoka, H. Yasuda, Y. Sogame, R. Kato, T. Doi, Y. Itoh. Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Background: It is well known that acute pancreatitis can cause mesenteric ischemia. Non-occlusive mesenteric ischemia is one of fatal complications in severe acute pancreatitis. However, little is known about early change of the mesenteric hemodynamics in this disease. Recent advances in ultrasonography (US) make it possible to measure blood flow volume (FV) and intestinal circulation time (ICT).

Aim: The aim of our study was to determine how mesenteric blood flow changes in early stage of acute pancreatitis by using the recent US technique.

Methods: 63 patients who underwent transabdominal US at the onset of acute pancreatitis were included in our study. The patients were classified by 2008 JPS criteria into forty nine mild (MAP) and fourteen severe acute pancreatitis (SAP). 154 subjects without any apparent abdominal disease were served as controls (NC). FV of portal vein (PV FV) and splenic vein (SpV FV) were calculated. We defined mesenteric FV as a difference between PV FV and SpV FV. When the mesenteric root was clearly visualized, we measured pulsatility index of superior mesenteric artery (SMA PI) as indicator of vascular resistance. After the measurement of SMA PI, bolus injection of perflubutane (0.015ml/kg) was made to obtain time intensity curve of SMA and SMV. The difference between arrival time of the contrast agent in SMA and SMV was considered as intestinal circulation time (ICT).

Results: In SAP patients, SMA PI was significantly lower than those of MAP and NC (P<0.01, P<0.005, respectively). Mesenteric FV in SAP was also lower than NC subjects (P<0.05). ICT of SAP was relatively shorter than both those of MAP and NC (P=0.06, P=0.08, respectively).

Conclusion: In the early stage of severe acute pancreatitis, diminished mesenteric blood flow volume may occur without vascular resistance augmentation or prolonged intestinal circulation time.

Surgical Treatment of Solid-Pseudopapillary Neoplasm of the Pancreas: A Single Institution Experience

S. Sakuraba, Y. Toyoki, K. Ishido, D. Kudo, N. Kimura, K. Hakamada. Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.

Background: Solid-pseudopapillary neoplasms (SPN) of the pancreas are rare epithelial tumors of low malignant potential. SPNs account for 0.9-2.7% of all exocrine pancreatic neoplasms. The aim of this study is to report our experience with SPN of the pancreas.

Methods: A retrospective analysis was performed of 6 patients diagnosed and treated for SPN in our institute over the past 12 years (2000 to 2012). An institutional database of the characteristics of these patients was searched, including age, gender, tumor location and size, type of surgery, and histopathological and immunohistochemical features.

Results: All patients were females (100%), with a mean age of 34.2 years (range 17 to 59). The most common symptoms were aware of abdominal mass. Two patients (33.3%) were aware of abdominal mass, one patient (16.7%) complained of abdominal pain, one patient (16.7%) presented with dry mouth due to hyperglycemia and two patients (33.3%) were asymptomatic with the diagnosis found incidentally on routine examination. Abdominal ultrasonography and computed tomography and magnetic resonance imaging showed the typical features of SPN in four (66.7%) of the patients. Three patients underwent distal pancreatectomy with splenectomy, one patient underwent a tumor enucleation, one patient underwent pancreaticoduodenectomy, and one patient underwent subtotal pancreatectomy with splenectomy and partial resection of portal vein. Only 1 of the 6 patients developed liver metastasis 27months after the surgery. The patient was low expression of galectin-3 in immunohistochemical staining.

Conclusions: SPNs are rare neoplasms that mainly affect young women. The prognosis is favorable even in the presence of distant metastasis after initial surgery. Although surgical resection is generally curative, a careful follow-up is necessary for the patients of low galectin-3 expression.

Pancreatic Stellate Cells With Limited ZEB1 Expression Show Inefficient Activation, Increased Vulnerability to Apoptosis and Reduced Pro-tumoral Effects

I. Sangrador,1 E. Samper,2 L. Visa,3 S. Villazala,1 A. Molero,4 E.C. Vaquero.51Fundació Clínic, Barcelona, Spain; 2CiberEHD, Spain; 3Oncology Department, Hospital Clínic, Barcelona, Spain; 4Gastroenterology Department, Hospital Universitari Vall d’Hebron, Spain; 5Gastroenterlogy Department, Hospital Clínic, Barcelona, Spain.

Introduction: Tumor stroma provides an optimal environment for the establishment of neoplastic and pancreatic stellate cells (PSCs) interactions favoring tumor proliferation, spreading and chemoresistance. The transcription factor ZEB1 is overexpressed in cancer cells with invasive properties as well as in activated fibroblasts.

Aims: To investigate the effects of limited ZEB1 expression on activation, resistance to apoptosis and protumoral attributes in PSCs.

Methods: PSCs were isolated from wild type (WT) and ZEB1+/− mice, cultured until complete cellular activation and examined for α-smooth muscle actin (αSMA), collagen 1α and ZEB1 expression by qRT-PCR and immunofluorescence, proliferation by total DNA quantification, migration by wound closure assay and apoptosis by DNA fragmentation. Migration of Ela-Myc (murine pancreatic cancer cells) was assessed upon exposure to either WT or ZEB1+/− conditioned media (CM).

Results: Expression of ZEB1, collagen 1α and αSMA was reduced in ZEB1+/− as compared to WT PSCs, indicating a lower basal activation and fibrogenic capacity of ZEB1+/− PSCs. Both basal and PDGF-BB stimulated ZEB1 deficient PSCs showed reduced proliferation. ZEB1+/− PSCs also exhibited inefficient wound gap closure both at basal conditions and upon TGFß1 stimulation, denoting limited migratory capacity. TNFα+cycloheximide and tocotrienols significantly enhanced apoptosis in ZEB1+/− PSCs as compared with their WT counterparts. Protumoral potential was also weakened in ZEB1+/− PSCs, as Ela-Myc exposed to CM from ZEB1+/− migrated less efficiently than when exposed to CM from WT PSCs.

Conclusions: ZEB1 expression is required for PSCs to achieve complete competent activation and to facilitate greater motile behavior in cancer cells.

Tumor-Stromal Co-Dependencies as Actionable Targets in Pancreatic Cancer

V. Sangwan,1,2 S. Ricoult,5 D. Juncker,5 A. Saluja,6 B. Haibe-Kains,7 M. Park.1–41Goodman Cancer Research Center; 2Departments of Oncology, 3Medicine, 4Biochemistry, 5Biomedical Engineering, McGill University, Montreal, Quebec, Canada; 6Department of Surgery, University of Minnesota, Minneapolis, MN, USA; 7Department of Medical Biophysics, University of Toronto, Ontario, Canada.

Pancreatic cancer is associated with the presence of desmoplastic stroma, believed to support tumor formation. However, the lack of success of stroma-targeting drugs in the clinic underscores our lack of understanding of functional interactions between the tumor epithelia and its surrounding milieu. It is therefore critical to understand tumor-stromal interactions in the context of the local microenvironment in pancreatic cancer. To address this question, we have developed a “lab-on-a-chip” bioengineering approach to evaluate the reciprocal responses of tumor cells vs. normal and cancer-associated fibroblasts under co-culture conditions.

Tumor cells (S2-VP10 and AsPC-1) grown in a low oxygen environment were co-cultured with normal fibroblasts (IMR-90) in a collagen-coated chamber containing a micro-fabricated silicone gasket separating the two cell types. Upon cell adhesion, the gasket was removed, allowing cell-cell interactions to occur. Cells were cultured until contact was observed, and then fixed. Laser capture microdissection was performed to isolate four cellular compartments: i) tumor cells in direct contact with fibroblasts, ii) tumor cells distal from fibroblasts, iii) fibroblasts in direct contact with tumor cells, iv) fibroblasts distal from tumor cells. As controls, tumor cells and fibroblasts were also grown as monocultures under the same conditions. Laser capture microdissection was followed by RNA isolation. Samples with RIN >7 were processed for microarray-based gene expression profiling to establish the differential gene signatures associated with each compartment identified above. The differences in the tumor or fibroblast gene expression profiles induced by indirect or direct co-culture vs. monoculture will give insight into the biological changes of each compartment to the presence of the other cell type. Results obtained from these studies will be extended using patient tumor derived epithelial cells co-cultured with matched CAFs.

The aim of this study is to identify key co-dependencies in tumor-stromal signaling that can potentially be targeted for therapeutic benefits.

Endoscopic Retrograde Cholangiopancreatography Brush Cytology for Invasive Pancreatic Ductal Cancer: A Method to Improve the Diagnostic Accuracy Rate

T. Sanuki,1 M. Kinoshita,1 H. Sakai,1 Y. Yamada,1 A. Sasaki,1 K. Tanaka,1 T. Yoshie,1 J. Hori,1 H. Sawa,2 D. Kuroda,2 M. Kanzawa,3 Y. Zen.31Department of Gastroenterology; 2Department of Surgery; 3Department of Diagnostic Pathology, Kita-Harima Medical Center, Ono, Japan.

Background and Aim: The diagnostic accuracy rate of endoscopic retrograde cholangiopancreatography (ERCP) brush cytology has been reported to be low. We report our method for improving the diagnostic accuracy rate of ERCP brush cytology.

Methods: The subjects were 27 patients who underwent ERCP brush cytology in our hospital between April 2011 and May 2014. In all cases, cancer progress and main pancreatic duct [MPD] and/or common bile duct [CBD] strictures were evaluated by enhanced computed tomography and/or magnetic resonance cholangiopancreatography. The brush cytology procedure was conducted by abrasion, 40–100 times, as quickly as possible at the stricture under fluoroscopy. Endoscopic biliary stenting (EBS) was performed as needed. The cytological diagnosis was performed by experienced pathologists.

Results: The cancer site was found at the pancreatic head, body, and tail in 14, 9, and 4 patients, respectively. Regarding the patients with cancer in the pancreatic head and body, 87% (13/15) and 75% (6/8) of patients who underwent MPD and CBD brush cytology, respectively, were diagnosed with malignancy. However, the accuracy rate of pancreatic tail cancer was low at 50% (2/4). EBS was performed after brush cytology at the same session in 15 patients. Only one patient presented hyperamylasemia, but neither ERCP pancreatitis nor bleeding were observed.

Discussion: A high accuracy diagnostic rate of ERCP brush cytology was obtained by our procedure. In addition, cancer of the pancreatic head and body is often accompanied by biliary obstruction; therefore, ERCP brush cytology, which allows simultaneous EBS, is an effective method.

Natural Course and Outcomes for Suspected Pancreatic Cystic Tumors of the Pancreas

S. Sanyal,1 A. Siriwardena,1 R.J. Byers.21Department of Hepatopancreatobiliary Surgery; 2Department of Pathology, Manchester Royal Infirmary, Manchester, UK.

Background: There is a paucity of data on the prospective long-term follow up of pancreatic cystic tumors based on a large cohort of patients. The current study was undertaken to assess the natural history and risk of progression to cancer in this group of patients.

Methods: Patients with suspected pancreatic cystic tumors were prospectively reviewed and followed up over 3 years. Patient demographics, radiological features, cyst characteristics, management and outcomes were measured.

Results: Ninety-nine patients met the study inclusion criteria, with a mean age at time of diagnosis of 65 years (range 35–89). There was a female preponderance (60%) (p<0.05). Comorbidities were classified as mild, moderate and severe with 56% having moderate or severe systemic dysfunction. Median period of follow up was 24 months (0–124 months). Forty-two patients were asymptomatic at presentation. Mean cyst size was 28.5 (7–99) mm, with 47% presenting with either diffuse or multifocal pathology. Complex cysts were seen in 43%. Cystic tumors comprised of 13 main duct IPMN, 40 branch duct IPMN, 11 MCN and 8 adenocarcinomas among others. The complete cohort showed an overall risk if adenocarcinoma of 8%. Main duct IPMN showed a cumulative risk of 46% with evidence of progression in a further 23%. The associated mortality in MD IPMN was related to underlying carcinoma and was 38% in our group. The incidence of adenocarcinoma in branch duct IPMN was 11% with disease progression seen in 13.8%. Evidence of extra-pancreatic malignancy was seen in 37.7% of patients with IPMN.

Conclusions: Main duct IPMN should be resected whenever possible, however, the clinical decision making regarding branch duct IPMN is more difficult and should be based on age, comorbidities and risk of surgery. A third of patients with IPMN have some evidence of an extra-pancreatic malignancy and therefore patients should be closely followed up.

Triptolide Inhibits NF-κB Mediated Pro-Inflammatory Cytokines Production in Macrophage and Acinar Cells

A. Sareen, R. Dawra, A.K. Saluja. Division of Basic and Translational Research, Department of Surgery, University of Minnesota, Minneapolis, MN.

Introduction: Controlled regulation of inflammatory genes is a key factor in regulating the disease progression or regression. Pancreatitis is one of inflammatory diseases caused by unregulated activation of inflammatory genes. NF-κB is firmly established as the epicenter of inflammatory signals network. Triptolide is a diterpenoid epoxide extracted from plant Tripterygium wilfordii and has been reported to inhibit inflammation. However, its mechanism of action is not clear.

Aim: The objective of the study was to investigate if NF-κB activation and downstream expression of pro-inflammatory cytokines observed during initiation of pancreatitis is inhibited by triptolide in macrophages and acinar cells.

Methods: Mouse macrophage cell line, RAW 264.7 or mouse pancreatic acinar cell line, 266–6 were treated with lipopolysaccharide (LPS) or carbachol respectively to initiate NF-κB activation and inflammatory cytokines expression. Effect of triptolide pre-treatment on NF-κB activation was evaluated by following IκBα degradation, re-synthesis and p65 nuclear translocation by ELISA and EMSA. Cytokines expression was evaluated by q-PCR.

Results: Stimulation of RAW264.7 with LPS resulted in robust NF-κB activation. Pre-treatment (30 min) with triptolide did not inhibit LPS induced IκBα degradation. After 6h of LPS treatment alone, IκBα levels were back to basal indicating down regulation of NF-κB signaling. However, in presence of triptolide, IκBα levels were not restored. The ELISA binding assay and EMSA showed that triptolide does not inhibit the binding of NF-κB to consensus sequence. Interestingly, pro-inflammatory cytokines IL-1β and TNFα expression in response to LPS were inhibited as a result of pre-treatment with triptolide. Similar to RAW 264.7, triptolide pretreatment of acinar cells (266–6), resulted in inhibition of carbachol (1mM) induced pro-inflammatory cytokines gene expression but NF-κB activation was not affected.

Conclusion: Triptolide does not inhibit activation of NF-κB or its binding to response elements but still down regulates the transcription of pro-inflammatory cytokines.

A Case of Chronic Pancreatitis in Child With the Point Mutation in SPINK1

Y. Sasaki, H. Nagata, T. Shinkai, S. Nakada, Y. Shinzato, T. Tamae, K. Maeshiro. Okinawa Chubu Tokusyukai Hospital, Okinawa, Japan.

We report a case of chronic pancreatitis with the point mutation in SPINK1. A 10-year-old girl had repeated upper abdominal pain and treated by conservative management for 7 years. Postprandial upper abdominal pain due to the acute pancreatitis has persisted since she was 3 years old and endoscopic retrograde cholangio-pancreatography(ERCP) has been performed for investigating a cause for her acute pancreatitis.

Abdominal ultrasonography revealed calcification in pancreatic head, and ERCP showed protein plug in the duct of Santorini whereas it doesn’t revealed pancreatobiliary maljunction (PBM).

She suffered from abdominal pain after taking fatty food at summer vacation, and admitted our hospital with decision for the recurrence of chronic pancreatitis.

Chronic pancreatitis is rare condition in children. Autoimmune pancreatitis, anatomic anomalies, multisystem disorders are unfavorable in this case. So we performed genetic analysis and identified as having a point mutation in SPINK1.

Chronic pancreatitis caused the point mutation of SPINK1 are known to place patients at high risk of diabetes mellitus, pancreatic exocrine insufficiency, and even pancreatic cancer. Therefore, chronic pancreatitis need strict long term follow up.

Endoscopic Papillary Large Balloon Dilatation for Removal of Common Bile Duct Stones Does Not Increase the Risk of Post-ERCP Pancreatitis

A. Satoh,1,2 S. Asonuma,1 K. Umemura,1 M. Hirota,3 H. Konishi,2 T. Arai,2 H. Tamagawa,1 K. Takahashi,1 M. Onuma,1 M. Miura.11Department of Gastroenterology, South Miyagi Medical Center, Ohgawara, Japan; 2Department of Internal Medicine, Kurihara Central Hospital, Kurihara, Japan; 3Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background & Aim: Pancreatitis is one of the most common and serious complications of ERCP. Endoscopic papillary large balloon dilation (EPLBD) is developed as an alternative technique of endoscopic sphincterotomy (EST) applied in removal of common bile duct (CBD) stones. However, there are not many studies so far concerning the procedure related post-ERCP pancreatitis. The aim of the present study was to evaluate the efficacy and safety of EPLBD for large CBD stones.

Methods: Patients who were hospitalized for choledocholithiasis at South Miyagi Medical Center and Kurihara Central Hospital were prospectively enrolled. The patients with large CBD stones (≥10 mm) were divided into two groups: 68 patients underwent EPLBD following limited EST and 78 patients underwent conventional EST, and outcomes were compared regarding stone clearance, use of mechanical lithotripsy and complications.

Results: EPLBD compared with EST resulted in similar outcomes with regards to successful complete stone removal (94.1% vs 94.9%). No fatal complication occurred in either the EPLBD or the EST group and there was no significant difference in the incidence of overall complications. Post-ERCP pancreatitis diagnosed according to Cotton’s criteria occurred in 3.7% of the EPLBD group and 3.8% in the EST group, respectively. All post-ERCP pancreatitis patients had mild pancreatitis that resolved with conservative therapy. Patients undergoing EST were more likely to require mechanical lithotripsy for stone extraction (35.9%) compared to EPLBD (4.4%).

Conclusions: These results demonstrate that EPLBD is a safe and effective technique for the removal of large CBD stones.

Two Cases of Pancreatic Neuroendocrine Tumor Diagnosed by Endoscopic Ultrasonography-Fine Needle Aspiration Biopsy

H. Sawa,1 T. Sanuki,2 E. Fukuoka,1 K. Murata,1 Y. Mii,1 D. Otsubo,1 S. Oka,1 Y. Iwatani,1 D. Kuroda.11Department of Surgery, Kita-Harima Medical Center, Ono, Japan; 2Department of Gastroenterology, Kita-Harima Medical Center, Ono, Japan.

Introduction: Histological diagnosis of pancreatic neuroendocrine tumor (P-NET) prior to treatment is required for precise surgical therapy and chemotherapy. Endoscopic ultrasonography-fine needle aspiration biopsy (EUS-FNAB) has recently assumed a significant role in the histological diagnosis of pancreatic tumors, including P-NET. Here, we report two cases of P-NET diagnosed by EUS-FNAB.

Case 1: A 73-year-old asymptomatic man had a history of distal gastrectomy for gastric cancer. Computed tomography (CT) revealed a hypervascular tumor, and EUS revealed a hypoechoic tumor at the pancreatic tail. EUS-FNAB was performed using a 25-G needle, and the lesion was diagnosed as a mixed adenoneuroendocrine carcinoma. Therefore, distal pancreatectomy and total gastrectomy with splenectomy, including lymph node dissection, were performed. The final diagnosis was mixed adenoneuroendocrine carcinoma.

Case 2: A 72-year-old asymptomatic man underwent CT, which revealed a hypervascular tumor, and EUS, which revealed a hypoechoic tumor with irregular margins at the pancreatic tail. EUS-FNAB was performed using a 22-G needle, and the lesion was diagnosed as acinar endocrine carcinoma. Distal pancreatectomy with splenectomy and lymph node dissection was performed. The Ki-67 index of the resected specimen was approximately 10%. The final diagnosis was P-NET (G2) with focal acinar differentiation.

Conclusion: Pre-operative evaluation of P-NET by EUS-FNAB enabled precise surgical treatment.

Optical Method for Real-Time Diagnosis of Pancreatic Cancer

J.M. Scheiman,1 R.H. Wilson,2 M. Chandra,2 D. Simeone,3 B. McKenna,4 J.M.G. Taylor,5 O.E. Lee,5 W.R. Lloyd,2 S.Y. Lee,2 M.-A. Mycek.21Dept. of Internal Medicine, Div. of Gastroenterology; 2Dept. of Biomedical Engineering; 3Dept. of Surgery; 4Dept. of Pathology; 5Dept. of Biostatistics; Univ. of Michigan, Ann Arbor, MI.

Background: Failure to diagnose early stage resectable pancreatic cancer contributes to its poor prognosis. While endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can provide a tissue diagnosis, it fails in at least 20% of patients; chronic inflammation lowers sensitivity further. A more accurate method for pancreatic tissue diagnostics remains an unmet medical need.

Methods: We developed a clinically-compatible optical spectroscopy technique, which was employed to measure reflectance and fluorescence data from freshly-excised pancreatic tissues (immediately following removal at surgery) from 18 patients (105 unique sites: 39 normal, 34 chronic pancreatitis, 32 adenocarcinoma). Rigorous statistical analysis of these data provided tissue classification via a novel hybrid mathematical algorithm. During surgery on 6 additional patients, we collected optical data in vivo.

Results: Our approach accurately distinguished pancreatic cancer from benign tissues (sensitivity=91%, specificity=88%, PPV=76%, NPV=96%). Site-matched in vivo and ex vivo data agreed qualitatively and quantitatively. Quantified differences between adenocarcinoma and normal tissues in vivo were consistent with the ex vivo results.

Conclusions: Our method can be used to interrogate pancreatic tissues during minimally invasive endoscopic procedures, including EUS-FNA. The portable technology reported here acquires data rapidly and does not require the administration of exogenous contrast agents to patients. These promising results show that optical spectroscopy has the potential to provide a real-time diagnosis of pancreatic cancer, guide tissue acquisition at EUS-FNA, and thereby improve diagnostic accuracy for cancer.

Impact of Preoperative EUS in Patients Undergoing Surgery for Solid and Cystic Lesions of the Pancreas

A. Schlachterman,1 J.B. Williamson,1 S. S. Chauhan.11Department of Internal Medicine, Division of Gastroenterology, University of Florida College of Medicine, Gainesville, FL.

EUS is a standard modality in characterization of pancreatic lesions, especially in those patients who may undergo surgical resection. Our aim was to evaluate the impact of preoperative EUS in patients who underwent surgical resection of pancreatic solid and cystic lesions.

Methods: This was a single center retrospective study. Using CPT codes, patients with pancreatic lesions were identified over a 4 year period. ICD-9 codes were further utilized to determine which patients underwent EUS, surgery or both. Data analyzed included patient’s clinical history, imaging and laboratory analysis.

Results: 96 patients had both preoperative EUS and surgical resection. Of these 96 patients, final surgical pathological diagnoses resulted in 53 solid tumors, 43 patients had non-solid lesions. Analysis of patients with solid lesions showed that preoperative EUS cytology was positive in 31/53 patients. Of these patients the final surgical pathology correlated in 18/31(58%) patients. In 9/31(29%) patients, EUS cytology was indeterminate or atypical. Finally in 4/31(13%) patients EUS and surgical pathology did not correlate. In patients with non-solid lesions 22/24 had positive EUS cytology. EUS cytology diagnoses and surgical pathology matched in 6/22 (27%) patients. In 9/22 (41%) patients the EUS and surgical diagnoses did not correlate and 7/22 (32%) had atypical cytology on EUS.

Conclusion: Based on our data, EUS has better preoperative accuracy for solid lesions. The decreased accuracy of EUS for non-solid lesions could be attributed to the low specificity of cyst cytology and CEA level. Improved modalities and tools are needed for better diagnosis of non-solid lesions. Further analysis of this data may reveal which patients did not benefit from preoperative EUS. Furthermore, the application of the revised Sendai criteria to our patient population will be studied.

The True Impact of Neural Invasion on Survival and Tumor Recurrence in Patients with Pancreatic Ductal Adenocarcinoma: A Systematic Review and Meta-Analyses

S. Schorn,1 IE. Demir,1 B. Haller,2 H. Friess,1 G. O. Ceyhan.11Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany; 2Institute of Statistics and Epidemiology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.

Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a bad overall-survival/OS-rate and an early tumor recurrence. Perineural invasion (Pn), a histopathological hallmark of PDAC, occurs in the majority of PDAC and has been shown to have a negative influence on survival and recurrence. However, a consensus on the impact of Pn in PDAC and its implication in daily routine therapy regimes are still missing. Therefore, we aimed to assess the true impact of Pn on survival and tumor recurrence in PDAC.

Materials and Methods: For this purpose, Pubmed, Cochrane library, Ovid and Google Scholar were searched for the terms “pancreatic ductal adenocarcinoma”, “pancreatic cancer”, “survival”, “tumor recurrence” and “perineural invasion” and a systematic review and meta-analyses was performed according PRISMA guidelines. All articles meeting predefined criteria were analyzed on relevance and meta-analyses pooling univariate and multivariate hazard ratios/HR were performed.

Results: A total of 110 from 1122 studies were identified analyzing the influence of PDAC on OS, Disease-free-survival/DFS and Recurrence-free-survival/RFS. The meta-analyses demonstrate a negative prognostic influence of PN in PDAC. The pooled univariate (1.86; CI 1.67-2.08; p<0.00001) and multivariate HRs (1.50; CI 1.36-1.65; p<0.00001) showed a major impact of Pn on OS in PDAC. Likewise, the pooled multivariate HR of DFS (HR: 2.23, CI 1.13-4.41; p<0.05) and PFS (HR: 2.82; CI 1.97-4.04; p<0.00001) demonstrated a negative correlation between PN and disease progression.

Conclusions: This is the first systematic review and meta-analyses, which analyzes the impact of neural invasion on OS, DFS and PFS in PDAC. It is evident hat neural invasion is an independent and not neglectable prognostic factor among PDAC tumor progression. Therefore, the phenomenon of neural invasion in PDAC should receive increased attention for improved patient stratification and be considered more intensively in the development of current and novel therapeutic algorithms.

Newcastle Disease Virus Mediated Tumor Lysis of Murine Pancreatic Adenocarcinoma

T. Schwaiger,1 M. Knittler,2 M. Sendler,1 C. Grund,2 A. Römer-Oberdörfer,2 T. C. Mettenleiter,2 M.M. Lerch,1 U. Blohm,2 J. Mayerle.11Department of Internal Medicine A, University Medicine, Ernst-Moritz-Arndt-University Greifswald; 2Federal Research Institute of Animal Health Care, Friedrich-Loeffler-Institut, Riems (Greifswald).

Background: Pancreatic cancer remains the solid malignancy with the poorest prognosis. In 1957 an oncolytic effect of Newcastle disease virus (NDV) on human tumor cells was first reported. Several studies have demonstrated NDV-mediated oncolysis, but only little is known about the underlying mechanisms.

Aim: To investigate the oncolytic effect of NDV and its underlying pathomechanism in a murine pancreatic cancer model.

Methods: 6606PDA cells were employed in a syngenic orthotopic tumor model. A single dose NDV was administered i.v. 7 days after tumor inoculation. Tumor size was monitored for 100 days. NDV replication was tested by RT-PCR. Immunomonitoring was performed by FACS-analysis or immunolabelling.

Results: A single dose of NDV inhibited tumor growth in mice and prevented recurrence. Viral particles were not detectable from d4 pi onwards. NK-cells, cytotoxic T-cells and T-helper cells were significantly increased systemically and in tumor-tissue. Initial anti-tumor response was mediated by NK-cells via missing MHC I expression on tumor cells. As NDV-infection at least partially restored MHC I expression T-cells were activated enhancing a tumor-directed immune response. In addition, viral infection led to an increase in IgG2, which, in turn, bound surface proteins on tumor cells.

Conclusion: These results indicate that arrested tumor growth and induced tumor lysis is mediated by anti-tumor immune response upon NDV-infection. Direct oncolysis is rather unlikely because a single NDV dose prevented relapse over 100 days. The early phase immune response is composed of NK and cytotoxic T-cells, then shifts to the production of antibodies. In conclusion, NDV mediated tumor lysis is a potent treatment option in murine pancreatic cancer.

Lymphotoxin Promotes Acinar Cell Reprogramming and Accelerates Pre-Neoplastic Conversion in Kras Induced Pancreatic Tumorigenesis

G. Seleznik,1 T. Reding,1 S. Sonda,1 M. Heikenwälder,2 R. Graf.11Swiss HPB Center, Visceral & Transplantation Surgery, University Hospital Zurich, Switzerland; 2Institute for Virology, Helmholtz-Centre Munich, Germany.

Introduction: Pancreatic inflammation is a well-known risk factor for pancreatic ductal adenocarcinoma (PDAC) development in humans. PDAC initiation is linked to activating mutations in KRAS oncogene. Pancreatic acinar cell transdifferentiation results in acinar-to-ductal metaplasia (ADM), which can give rise to pancreatic intraepithelial neoplasia (PanIN), the most common PDAC precursor.

Aim: To explore the inflammatory mechanisms promoting ADM and PanIN development.

Methods: We established a new genetic model (LTKP) by intercrossing p48+/Cre;Kras+/G12D (KP) model for pancreatic tumorigenesis, to a transgenic mouse developing spontaneous pancreatitis, due to Lymphotoxin (LT) overexpression.

Results: Lymphotoxin overexpression in mice harboring an activating Kras mutation in the pancreas (LTKP) dramatically accelerates the development of premalignant PanIN lesions compared to KP animals. Already after 6 weeks extensive ADM and PanIN development are observed in LTKP mice. This coincides with significant upregulation of inflammatory genes and increased Ras activity. These molecular and phenotypic changes were observed around 16 weeks in Kras animals. In vitro experiments show that LT overexpression in wt acinar cells is sufficient to initiate spontaneous transdifferentiation. Furthermore, acinar cells derived from LTKP-animals form ADMs significantly faster than acini from KP animals.

Conclusion: We conclude that Lymphotoxin may contribute to the initiation PDAC precursor formation: By (1) inducing inflammatory environment and by (2) regulating cell autonomous acinar transdifferentiation, leading to accelerated PanIN development.

Standardization of Distal Pancreatectomy

H. Shimamura, A. Endo, K. Kanehara, H. Kodama, K. Takeda. Department of Surgery, Sendai Medical Center, Sendai, Japan.

Introduction: There is no standard method on how to resect pancreas and treat the stump of remnant pancreas in distal pancreatectomy (DP). From the viewpoint of reducing the incidence of postoperative pancreatic fistula (POPF), standardization of DP is preferable. Here we report our effort of standardization of DP in our institute.

Patients and Methods: Patients underwent DP in our institute between May 2000 and September 2013 were included. We divided the whole cases into four periods; the 1st period: every operator chose his favorite method either using or not automatic surgical staplers (staplers), the 2nd period: without using staplers, the 3rd: basically using staplers, the 4th period: using staplers under the critical rule (soft and gradual compression of pancreas parenchyma taking more than 10 min, gradual firing of staplers taking more than 15min and no additional suture for the cut end). Incidence of POPF was compared among these 4 periods.

Results: Ninety-four cases were enrolled. In the 1st period, incidence of POPF in the stapler group (n=29) was 58.6%, whereas that in the non-stapler group (n=8) was 25%. In the 2nd period (all in the non-stapler group, n=23), incidence of POPF was 43.5%. In the 3rd period, incidence of POPF in the stapler group (n=15) was 46.7%, whereas that in the non-stapler group (n=4) was 25%. In the 4th period, incidence of POPF in the stapler group (n=15) was decreased to 13.3%. There was no significant difference in the incidence of POPF depending on the type of staplers used.

Conclusion: Our standard way to resect pancreas in DP is as follows; soft and gradual compression of pancreas parenchyma taking more than 10 min, gradual firing of staplers taking more than 15min and no additional suture for the cut end.

Treatment Strategy for Patients With SMA Plexus Invasion on Preoperative CT Diagnosis in Pancreatic Head Cancer

A. Shimizu, M. Tani, M. Kawai, S. Hirono, K. Okada, M. Miyazawa, Y. Kitahata, H. Yamaue. Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan.

Background and Aim: Currently, neoadjuvant therapy(NAT) is widely utilized to Borderline resectable pancreatic cancer (BRPC). However, adverse effect of NAT may make it difficult to perform surgery or increase postoperative complication. Therefore, the appropriate management of BRPC remains controversial. In this study, we evaluate how the degree of neural plexuses invasion around superior mesenteric artery (SMA) diagnosed by preoperative CT examination affect survival in patients with pancreatic head cancer undergoing surgery-first.

Methods: A total of 150 patients undergoing pancreatoduodenectomy for pancreatic cancer were enrolled in this study. The degree of neural plexuses invasion around SNA were classified based on preoperative CT into following 3 categories; patients without SMA abutment (non BR-SMA group, n=112), with SMA abutment less than 90 degrees (BR-SMA<90° group, n=19), with SMA abutment greater than 90 degrees (BR-SMA≥90° group, n=19), and survival among each groups were compared.

Results: Median survival time(MST) of non BR-SMA, BR-SMA<90° and BR-SMA≥90° were 20.1, 17.2 and 13.1 months, respectively. MST of BR-SMA≥90° was significantly poor compared to non BR-SMA (P=0.001), whereas, MST of BR-SMA<90° had a similar prognosis (P=0.252). By Cox proportional hazards model demonstrated that BR-SMA≥90°, intraoperative transfusion and lymph node metastasis were independent prognostic factors of pancreatic cancer(Odds ratio(OR) 1.998, 95%Confidence interval(CI) 1.061-3.763, P=0.032; OR 2.057, 95%CI 1.311-3.227, P=0.002; OR 1.999, 95%CI 1.313-3.045, P=0.001).

Conclusion: Surgery-first may be available for patients with SMA abutment less than 90 degree. However, if with SMA abutment greater than 90 degree, neoadjuvant therapy may be a reasonable approach.

Validation of a Nomogram for Predicting the Probability of Carcinoma in Patients with Intraductal Papillary-Mucinous Neoplasm in 180 Pancreatic Resection Patients at 3 High Volume Centers

Y. Shimizu,1 H. Yamaue,2 H. Maguchi,3 K. Yamao,4 S. Hirono,2 M. Osanai,3 S. Hijioka,4 Y. Kanemitsu,5 T. Sano,1 Y. Senda,1 V. Bhatia,6 A. Yanagisawa.71Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan; 2The Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan; 3Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan; 4Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan; 5Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan; 6Department of Medical Hepatology, Institute of Liver and Biliary Sciences, Delhi, India; 7Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Objectives: We previously published a nomogram for prediction of carcinoma in patients with intraductal papillary mucinous neoplasm (IPMN). The objective of the current study was to validate this nomogram in an external cohort of patients at multiple institutions.

Methods: Clinical details of 180 patients with IPMN who underwent a pancreatic resection at 3 hospitals, was collected. Four significant predictive factors (gender, lesion type, nodule height and pancreatic juice cytology) were analyzed.

Results: Of the 180 patients, 66 (36.7%) had main pancreatic duct (MPD) type, and 114(63.3%) had branch pancreatic duct (BPD) type IPMN. Final pathological diagnosis was benign IPMN in 95 (52.8%) and malignant IPMN in 85(47.2%) patients. The area under the receiver operating characteristic curve (AUC) for the model was 0.760. The AUC of the IPMN nomogram for prediction of malignancy was 0.747 in MPD type and 0.752 in BPD type. The sensitivity and specificity of the model were 80.0% and 57.9%, respectively, when the predictive probability of >10% was used to indicate the presence of carcinoma.

Conclusion: This nomogram for predicting the probability of carcinoma in patients with IPMN was accurate in an external validation patient cohort.

Oral S-1 With Concurrent Radiotherapy Versus S-1 Alone in Patients With Locally Unresectable Pancreatic Cancer

H. Shinchi,1 S. Takao,2 K. Maemura,3 Y. Mataki,3 H. Kurahara,3 K. Hiwatashi,3 S. Ino,3 M. Sakoda,3 S. Ueno,4 S. Natsugoe.31School of Health Sciences, 2 Frontier Science Research Center, 3Department of Gastroenterological Surgery, and 4Department of Clinical Oncology, Kagoshima University, Kagoshima, Japan.

Purpose: S-1 is a new oral fluoropyrimidine anticancer agent shown to be effective for pancreatic cancer. In a previous phase I and phase II trial, we have confirmed the efficacy and safety of S-1 combined with radiotherapy in patients with locally advanced and unresectable pancreatic cancer (Br J Cancer 2007; JHBP Sciences 2012). This randomized phase III trial was conducted to evaluate the survival benefit of S-1 combined with radiotherapy compared to S-1 alone.

Methods: Eligible patients had locally advanced and unresectable pancreatic cancer without distant metastases, an ECOG performance status of 0–1, adequate organ and marrow functions, and no prior anticancer therapy. Patients were randomized to receive S-1 combined with radiotherapy versus S-1 alone. S-1 was given orally at a dose of 80 mg/m2/day twice daily on days 1 to 21 in both groups. Radiotherapy was delivered in fractions of 1.25 Gy twice daily, 5 days per week for 4 weeks (total dose: 50 Gy in 40 fractions). In both groups, S-1 was administered for 14 days followed by a 14-day rest period as maintenance therapy until disease progression or unacceptable toxicity. The primary endpoint was overall survival.

Results: A total of 33 patients were evaluated. Seventeen patients received S-1 combined with radiotherapy, and 16 patients received S-1 alone. There was no treatment-related death or grade 4 toxicity in the both groups. Median overall survival of 19.7 months in the S-1 with radiotherapy group was significantly better than 14.9 months in the S-1 alone group (p = 0.073). Survival rates at 1 and 2 years were 79% and 32% in the S-1 with radiotherapy group and 67% and 10% in the S-1 alone group, respectively.

Conclusions: Combination therapy with S-1 and radiation is considered a promising, well-tolerated regimen that can be recommended as a more effective treatment compared to S-1 alone for locally advanced pancreatic cancer.

Locally Advanced Cancer of the Pancreatic Tail Adjacent to Malignant Lymphoma of the Spleen

S. Shirakawa,1 D. Lee,1 S. Tsuchida,1 K. Teramura.21Department of Surgery and 2Pathology, Yodogawa Christian Hospital, Osaka, Japan.

Introduction: We report a case of highly invasive tumor around the pancreatic tail and spleen that was difficult to diagnose preoperatively.

Case: A 64 year-old male with abdominal pain and vomit was referred to our institution. Plain computed tomography (CT) revealed the obstruction of transverse colon due to a large tumor of left upper quadrant and the ileus tube was placed by the transanal route. Contrast enhanced multidetector CT revealed poorly-marginated tumor around the pancreatic tail that infiltrated the spleen, transverse colon, mesocolon, posterior wall of the stomach, and retroperitoneal fat. Enlarged lymph node of 2cm in diameter was noted in splenic hilum. No metastasis was found. Biopsy from transverse colon showed adenocarcinoma. Serum CA19-9 and soluble IL2 receptor were elevated.

Operation: En-bloc tumor resection was performed by distal pancreatectomy including resection of retroperitoneal fat, seromuscular layer of posterior wall of the stomach, left adrenal grand, and transverse colon with D2 + #16a2 lateroaortic lymphadenectomy with the diagnosis of locally advanced pancreatic cancer. He had uneventful postoperative course with pancreatic fistula of ISGPF grade A and was discharged 15 days after surgery.

Histology: The tumor was diagnosed of pancreatic ductal adenocarcinoma that infiltrated the spleen, all layers of transverse colon, retroperitoneal fat, and the stomach. Immunostaining showed CK7(++), CK20(+), and Cdx2(−) cells in the tumor. Diffuse large B cell lymphoma classified as anaplastic type according to WHO criteria was found adjacent to the pancreatic adenocarcinoma in the spleen. No lymph node metastasis of adenocarcinoma was noted despite of malignant lymphoma was found in regional lymph node.

Discussion: Double malignancies in contiguous foci are rare and difficult to diagnose preoperatively and determine postoperative therapeutic strategy. In this case, highly advanced pancreatic adenocarcinoma was thought to carry poorer prognosis than malignant lymphoma of the spleen and adjuvant chemotherapy for pancreatic adenocarcinoma was administered.

Conclusion: The rare case of locally advanced pancreatic ductal carcinoma of the pancreatic tail adjacent to malignant lymphoma in the spleen was reported.

The Role of a Multidisciplinary Tumor Board in the Management of Complex Pancreatic Disease

L.A. Shirley, L. Malhotra, M. Bloomston, C.R. Schmidt, E.C. Ellison, E. Haverick, D.L. Conwell, P. Muscarella. Departments of Surgery and Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: The creation of Pancreas Centers of Excellence (PCOE) has led to the development of multidisciplinary tumor boards, where representatives from various disciplines meet to form a consensus on diagnostic and management questions. A lack of studies evaluating such meetings for pancreatic disease led us to assess our own experience.

Methods: We reviewed all patients presented at our weekly hour-long tumor board from its inception in 2011. We assessed diagnosis and plan prior to discussion, reason for discussion, change in plan after discussion, and if new plan was followed. Plan change was graded mild (change in imaging /follow-up schedule), moderate (new diagnostic work-up, medical therapy), or major (change in operative plan, hospice initiation).

Results: A total of 273 patients (314 discussions) were evaluated. Diagnosis was 36.3% adenocarcinoma, 35.5% cystic lesion, 20.9% other, and 7.3% unknown. There was a change in plan in 42.3% of cases, with grade of change 30.8% minor, 36.1% moderate, and 33.1% major. Following consensus, 74.1% of plans were implemented. Plans not followed were due to clinician decision in 41.6%, loss to follow-up in 32.5%, patient morbidity/mortality in 20.8%, and patient decision in 5.2%. A change in initial plan was associated with decreased likelihood of following the tumor board’s recommendations (79.4% if no change, 66.1% if change made, P=0.006). Also, grade of change was associated with following through on tumor board plan (75% adherence if minor change, 68.8% if moderate, 56.8% if major, P=0.019).

Conclusion: Multidisciplinary discussions can have an impact on decision-making in the care of patients with pancreatic disease. Nonetheless, a significant proportion of changed plans were not implemented, especially if major changes were recommended. A follow-up process to assess outcomes of recommendations is needed.

Protein Expression in Benign Biliary Strictures Before and After Treatment With Metal and Biodegradable Biliary Stents

A. Siiki,1 R. Jesenofsky,2 M. Löhr,3 I. Nordback,1 M. Kellomäki,4 J. Mikkonen,5 H. Gröhn,5 J. Sand,1 J. Laukkarinen.11Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; 2Dept. of Medicine II, University of Heidelberg, Mannheim, Germany; 3Gastrocentrum, Karolinska University Hospital, Huddinge, Sweden; 4Department of Biomedical Engineering, Tampere University of Technology, Tampere, Finland; 5Dept. of Clinical Physiology, University of Kuopio, Kuopio, Finland.

Background: Benign biliary strictures (BBS), caused e.g. by chronic pancreatitis, are primarily treated endoscopically, increasingly with covered self-expandable metal stents (CSEMS). Biodegradable biliary stents (BDBS) have shown promising results in animal models and may be the future of endoscopic therapy of BBS. Tissue response in BBS to different stents is largely unknown.

Aim: To assess the expression of proteins related to tissue healing in BBS compared to the intact bile duct (BD), to study the protein expression after therapy with CSEMS or BDBS.

Materials and methods: Swine with ischemic BBS were endoscopically treated either with BDBS or CSEMS. Tissue samples were harvested from swine with intact BD (n=5), untreated BBS (n=5) and after six months of therapy with BDBS (n=4) or CSEMS (n=5). Immunohistochemical analysis and 2D electrophoresis were performed to evaluate protein expression patterns at these stages. More than twofold change in protein expression was considered significant.

Results: In BBS, levels of Galectin-2 and Annexin-A4 decreased compared to the intact BD. BDBS treatment normalized Galectin-2 level, but with CSEMS therapy it remained low. Annexin-A4 expression remained low after both treatments. Transgelin expression, which was low in intact BD and in the BBS, remained low after BDBS treatment but increased after CSEMS therapy.

Conclusion: The expression of proteins related to tissue healing in BBS is different after treatment with BDBS and CSEMS. Treatment with BDBS may bring the protein expression towards what is seen in the intact BD. These findings suggest future therapeutic implications.

Prior Manipulation of Walled-Off Pancreatic Necrosis (WOPN) is a Significant Risk Factor for Infected Necrosis

K.A. Singer, S. Gaddam, A.L. Carlson, F.M. Murad. Department of Medicine, Washington University School of Medicine, St. Louis, MO.

Background: Infection of WOPN causes significant morbidity and mortality. Limited data suggest one-third of patients have infected WOPN, although the etiology and predisposing factors for infection remain unclear.

Aim: The aim of this pilot study is to evaluate factors that predispose WOPN to infection.

Methods: A single-center retrospective case–control study of patients undergoing endoscopic ultrasound for evaluation of WOPN was performed. WOPN was determined by contrast-enhanced CT imaging in addition to direct endoscopic pancreatic necrosectomy (DEPN). Demographics, size of WOPN, prior intervention, antibiotic use, and objective data including presence of fever, WBC count, and whether ≥2 SIRS criteria met were recorded. Prior manipulation was defined as a cholangiogram on ERCP, FNA, or percutaneous (IR) drain placement before DEPN. Fluid aspirates were sent for gram stain and culture and this was considered gold standard for presence of infection. Univariate analysis was performed using Fisher’s exact test and Mann–Whitney U test.

Results: A total of 26 patients with WOPN who underwent endoscopic evaluation were included in the analysis. Within this group, 21 patients (80.8%) had culture-proven infection. Patients with infected WOPN were more likely to have undergone a prior intervention compared to patients without infection (71.4% vs. 0%, p<0.01). Age (63 vs. 60), Caucasian race (95% vs. 100%), and male gender (67% vs. 60%), mean WBC count (11,350/mm3 vs. 6,740/mm3), fever (13.0% vs. 16.7%), SIRS criteria (43.8% vs. 33.3%), mean size of WOPN (12cm vs. 18cm), and antibiotic use (62% vs. 60%) were not statistically (all p=NS) different between the two groups.

Conclusions: Among patients with walled-off pancreatic necrosis, prior manipulation of the necrotic collection was significantly associated with secondary infection. Fever, leukocytosis, and SIRS criteria were not reliably associated with infected WOPN.

New-onset Diabetes Mellitus as a Potential Initial Marker of Resectable Pancreatic Cancer: Data From EUS Registry

J. Singh, D.A. Parikh, S. Urayama. Division of Gastroenterology, University of California Davis, Sacramento, CA.

Background: New-onset diabetes (DM) has been reported frequently in patients diagnosed of pancreatic adenocarcinoma (PDAC). Studies have suggested that 30–80 % PDAC patients have a new-onset DM. However, whether new-onset DM is associated with resectable PDAC stage has not been delineated. For consideration of potential for this phenotypic characteristic as initial surrogate/selection marker of PDAC for possible intervention, we have investigated the pattern of developing DM in patient population with resectable diagnosis of PDAC in our EUS registry data.

Methods: We reviewed our IRB-approved UC Davis Pancreas Registry (11/02–11/13) retrospectively for identification of resectable PDAC (stages I & II) with DM diagnosis and the duration; onset of DM less than 3 yrs prior to index PDAC diagnosis was considered as new-onset DM. Other associated variables -age, gender, BMI- were also reviewed. Comparison of the categorical groups (new-onset vs long-history DM with age, gender, BMI) was evaluated with Fisher exact test (significance, p<0.05).

Results: A total of 181 pts had resectable disease and of that, 144 pts had clinical data for classifying into new-onset DM, DM more than 3 yrs, or no DM. Eighty-two (56.9%) of the resectable cancer cases had new-onset DM, 17 (11.8 %) had DM for more than 3 yrs and 45 (31.25%) had no DM. Within the new-onset DM (Stage IA (n=9), IB (n=17), IIA (n=12), and IIB (n=44)), 79.2 % (n=65) of patients had the diagnosis made within 1 yr of PDAC diagnosis. There was no statistically significant difference in the age (p-value=0.58), gender (p-value=0.18) and BMI (p-value=1) between the new-onset and long-history of DM groups.

Conclusion: The new-onset DM has a potential as an initial surrogate marker, for capturing a significant number of PDAC patients still at resectable stage. Studies are needed to curtail the screening subset further, in conjunction with additional biomarker(s) associated with the early PDAC stage.

Predictors of Post-Operative Pain Relief in Patients With Chronic Pancreatitis Undergoing the Frey or Whipple Procedure

A. Sinha,1 Y.A. Patel,1 M. Cruise,2 K. Matsukuma,2 A. Zaheer,3 D. Yadav,4 M.A. Makary,5 K. Hirose,5 D.K. Andersen,6 V.K. Singh.11Division of Gastroenterology, 2Department of Pathology, 3 Department of Radiology, 5 Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; 4Division of Gastroenterology, University of Pittsburgh, Pittsburgh, PA; 6National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.

Background: Post-operative pain relief in chronic pancreatitis (CP) is variable.

Objective: To determine which clinical, imaging or histopathologic feature(s) predict post-operative pain relief in CP patients undergoing the Whipple or Frey procedure.

Methods: All patients who underwent a Whipple(n=30) or Frey procedure(n=30) for painful CP between 1/03-9/13 were reviewed. A toxic etiology was defined as a history of alcohol abuse and/or smoking. The pre-operative abdominal CT scan was evaluated for calcifications and main pancreatic duct(MPD) dilation(≥5 mm). The post-operative histopathology was evaluated for degree of fibrosis. Post-operative pain relief was assessed on the last recorded follow-up visit. Clinical, imaging and histopathologic features were evaluated as predictors of post-operative pain relief using univariate and multivariate regression.

Results: A total of 60 patients(age 51.6 ± 12.5 years, 53% males) were included in our study, of whom 42(70%) reported post-operative pain relief over a mean follow-up of 1.1 years. There were 37(62%) patients with toxic etiology, 36(60%) with calcifications, and 36(60%) with MPD dilation. Toxic etiology, calcifications, and severe fibrosis were associated with post-operative pain relief on univariate analysis (all p<0.01), but only toxic etiology was an independent predictor of post-operative pain relief (OR 5.7, 95% CI 1.3, 24.5, p=0.02).

Conclusion: Only a toxic etiology, and not imaging or histopathologic characteristics, independently predicts post-operative pain relief in CP patients undergoing the Whipple or Frey procedure.

Suppression of the PI3K/mTOR Pathway Promotes ERK Pathway Activation in Human Pancreatic Cancer Cells

H. Soares, M. Ming, J. Sinnett-Smith, E. Rozengurt. Division of Digestive Diseases and CURE: Digestive Diseases Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA.

Background: The phosphatidylinositol 3-kinase (PI3K)/Akt/mTORC1/S6K pathway plays a pivotal role in the proliferation and survival of pancreatic ductal adenocarcinoma (PDAC). In addition to growth-promoting signaling, mTORC1/S6K also mediates negative feedback loops that restrain upstream signaling. Suppression of these feedback loops by mTORC1 inhibitors (e.g. rapamycin) over-activates PI3K/Akt that opposes the anti-proliferative effects of mTORC1 inhibitors. This prompted the development of active-site mTORC1/2 inhibitors and dual PI3K/mTOR inhibitors (e.g. NPV-BEZ235). We found that treatment of PDAC cells with mTOR inhibitors revealed a novel negative feedback loop leading to increased activity of MEK/ERK pathway in PDAC.

Results: Exposure of PDAC cells (MiaPaca-2 and PANC-1) to NPV-BEZ235 potently blocked mTORC1 activation (S6K and S6 phosphorylation) and mTORC2-mediated Akt phosphorylation at Ser-473, in a concentration-dependent manner. Unexpectedly, treatment with NPV-BEZ235 markedly increased ERK activation at doses that coincided with complete inhibition of Akt phosphorylation (produced at 50–500 nM NPV-BEZ235). Similar results were obtained with active-site mTORC1/2 kinase inhibitors. ERK over-activation was also seen when PDAC cells when a different dual PI3K and mTOR inhibitor (e.g. PKI-587) was used instead of NPV-BEZ235. Treatment with the MEK inhibitors U126 or PD0325901 prevented ERK over-activation induced by mTOR inhibitors. The combination of NPV-BEZ235 and PD0325901 caused a more pronounced inhibition of PDAC cell proliferation than that produced by each inhibitor added individually.

Conclusion: Collectively, our results highlight the importance of discovering novel feedback loop to anticipate mechanisms of tumor resistance to new drugs and to assist in developing strategies for designing novel combination therapies in PDAC.

A Comprehensive Biopsychosocial (BPS) Assessment of Patients With Pancreatobiliary Disorders (PD) Illuminates Mechanisms Underlying Symptoms and Alters Clinical Decision-Making

A.H. Soll, L.A. Keefer, D.L. Streiner, M.L. Lee, S.D. Freedman, D. Mahvi, J. Buxbaum, S. Pandol, S. Lo. UCLA, Los Angeles, CA; Northwestern, Chicago, IL; BIDMC, Boston, MA; Cedars-Sinai, Los Angeles, CA; USC, Los Angeles, CA.

The care and investigation of patients with PD are confounded by difficulty discriminating symptoms generated from active disease vs. augmented sensory processing (ASP), including neuropathic pain, and psychosocial and behavioral factors. In 3 academic GI clinics, patients performed an online, comprehensive, BPS self-assessment (CarePrep) before clinic. Among 154 consecutive patients, the 28 patients with the most severe symptoms had a median of 6 (of 9 possible) visceral symptoms. Abdominal pain frequently had typical neuropathic features (e.g., dysesthesias and expanded and cross referral). Increasing visceral symptom severity was associated with increased severity of non-visceral symptoms; fatigue and poor sleep; psychological symptoms; stress; and health concerns (p < 10−6 for all comparisons), implicating greater prevalence of BPS factors with severe symptoms. Factor analysis indicated that symptoms and health concerns loaded on a “symptom distress” factor, whereas psychological symptoms and stress loaded on a “psych distress” factor. These patterns were similar in the subset of 20 patients with chronic pancreatitis. Users judged the online assessment to be feasible in practice settings. Clinicians indicated that the BPS assessment discovered issues that often impacted clinical decision-making, most dramatically demonstrated in 12 patients with pain and suspected chronic pancreatitis referred for pancreatectomy and islet cell transplantation–all of whom had surgery canceled or postponed based upon these data.

Conclusions: Finding multiple, severe symptoms plus neuropathic features implicates the contribution of ASP to symptom generation. Patients with severe GI symptoms associated with pancreatitis and other causes have much higher prevalence of BPS issues that may be contributing to or resulting from symptom severity. A comprehensive evaluation appears to elucidate BPS mechanisms and change decision-making and appears especially useful for guiding care in complex cases such as those thought to have refractory chronic p