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of ten (15%) patients. One patient with liver metastases did not proceed to surgery. In twopatients, the identification of liver metastases by PET altered chemotherapy goals fromneoadjuvant to palliative. In one patient, PET revealed a synchronous colon cancer whichwas resected at the time of the patient's pancreaticoduodenectomy. In four cases of diagnosticuncertainty, PET resulted in an earlier diagnosis of pancreatic adenocarcinoma and shortertime to surgical resection. In two patients, PET was performed to follow lymphoma andresulted in a secondary diagnosis of pancreatic adenocarcinoma. One patient proceeded tosurgical resection, and the other had metastatic disease. Conclusions: In cases of knownpancreatic adenocarcinoma, PET rarely altered clinicalmanagement and resulted in additionaltests and procedures. In our series, PET was most useful in cases of diagnostic uncertainty.

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One Hundred Forty Six Resections for Intraductal Papillary MucinousNeoplasm of the PancreasMegan D. Winner, Minna K. Lee, Joseph DiNorcia, James A. Lee, Beth Schrope, John A.Chabot, John D. Allendorf

Background: Intraductal Papillary Mucinous Neoplasm (IPMN) is increasingly diagnoseddue to the ubiquity of cross-sectional abdominal imaging and a growing awareness of thepathology. The treatment algorithm for IPMN remains controversial and depends heavilyon the malignant potential of the disease and anticipated outcomes. Methods: We evaluatedall patients who underwent surgical resection for IPMN between January 1997 and December2009. Adenomas and moderately dysplastic lesions were classified as benign. High gradedysplastic lesions, carcinoma in situ (CIS), and invasive cancer were considered malignant.Pathology reports were retrospectively reviewed to distinguishmain-duct, mixed, and branch-duct types. Continuous variables were compared using Student's t test and categoricalvariables were compared using Fisher's exact tests. Results: Between 1997 and 2009, 146patients underwent surgical resection for IPMN. During this period 88 patients were surveyedfor suspected IPMN, and 278 underwent pancreatectomy for other cystic neoplasms. Themajority of patients with IPMN presented as an incidental finding (42.6%), followed byabdominal pain (19%) and pancreatitis (17%). Patients with benign disease were on averageyounger than those with malignant disease (66.4 vs. 70.6 years, p=0.01). The majority werefemale (54%) and white (86.2%). Most resections were partial pancreatectomies (82%), but27 patients required a total pancreatectomy. Main-duct type was identified in 33%, branch-duct type in 23%, and mixed-type in 39% of patients. Of the main-duct and mixed lesions,39% harbored malignancy, 50% of which were invasive carcinomas. Eight (24%) branch-duct lesions were high-grade dysplastic or CIS, but none were invasive carcinomas. Theoverall rate of malignancy for IPMN patients was 35%. IPMN was identified on the finalsurgical margin in 25% of patients. Five patients have undergone completion pancreatectomyat an average of 17.8 months after their initial surgery (range 8.7-27.5). Lesions requiringreoperation were either main-duct or mixed and tended to be malignant (p=0.05). None ofthese patients had IPMN at the original surgical margin. Three additional patients haverecurred, two with locally advanced disease. Conclusions: Our series confirms a low rateof malignancy in branch-duct pathology and supports the judicious surveillance of thesepatients. Risk of recurrence necessitates continued surveillance after surgery. Patients withmalignancy were older, suggesting a four year lag-time between adenoma and invasive disease.

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Long Term Complications in Patients Undergoing PancreaticoduodenectomyWith PancreaticogastrostomyEileen Bock, Michael G. Hurtuk, Margo Shoup, Gerard V. Aranha

INTRODUCTION: While perioperative complications of pancreaticoduodenectomy(PD)have been well documented, long-term complications of PD have not been well characterized.In this study, we investigate complications experienced by patients status post PD withpancreaticogastrostomy (PG) reconstruction more than 12 months after the procedure.METHODS: We performed a retrospective review of patients who underwent PD with PGmore than 12 months prior the study period. Data was collected by chart review as well asa mailed survey. We performed a retrospective analysis assessing the incidence of newdiagnoses of diabetes mellitus (DM) and the use of pancreatic enzyme replacement in patientsmore than one year after PD at a single institution from 1990 to 2010. The main outcomemeasures were a diagnosis of DM based on random and fasting blood glucose measurements,and patients' requirements for pancreatic enzyme replacement for control of steatorrhea andmalabsorption. RESULTS: Our cohort included 92 patients who underwent PD with PGmore than 12 months prior to the beginning of the study. The median length of follow upwas 4.2 years after the procedure. Preoperative diagnoses included periampullary tumorsin 59 (63%) of the patients, cystic tumors in 14 (15%) of the patients, neuroendocrinetumors in 9 (10%) of the patients, chronic pancreatitis in 6 (7%) of the patients, and otherpathology in 5 (5%) of the patients. Of the 92 patients, 45 (48.9%) now require pharmacologictherapy with pancrelipase for symptoms of steatorrhea and malnutrition. Twelve patientshad been diagnosed with diabetes mellitus prior to undergoing the procedure and wereexcluded from the second part of the study; of the remaining 80 patients, 18 (23%) becamediabetic after the procedure. Seven of these patients (39%) now require insulin therapy fordiabetes management, while twelve (67%) are controlled on oral pharmacologic agents only.In total, 20 of the 92 patients underwent adjuvant chemotherapy and 19 underwent adjuvantradiation therapy. Of the 18 patients who developed diabetes, 5 (28%) underwent adjuvantchemotherapy and 4 (22%) underwent adjuvant radiation therapy. Of the 45 patients whonow require pancrelipase therapy, 11 (24%) underwent adjuvant chemotherapy and 11(24%) underwent adjuvant radiation therapy. CONCLUSIONS: Symptomatic malabsorptionrequring pancreatic enzyme therapy is a long-term complication of PD with PG. Thesepatients should be monitored for malabsorption. After PD with PG, patients are as likely asthe general population to develop diabetes mellitus.

S-1022SSAT Abstracts

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Prospective Comparison of Longterm Outcomes in Patients of Severe AcutePancreatitis Managed by Operative and Non-Operative MeansPrasanna Chandrasekaran, Rajesh Gupta, Yalakanti R. Babu, Mandeep Kang, Surinder S.Rana, Deepak K. Bhasin, Rajinder Singh

BACKGROUND: The present study reports the long term functional and morphologicalchanges following severe acute pancreatitis and compares the patients managed by operativeand non-operative methods. METHODS: 30 patients who had completed one year of followup after recovery from attack of acute pancreatitis were evaluated. 72 hours fecalfat analysis,glucose tolerance test and pancreatic morphology (MRI) were examined and recurrences ifany were noted. RESULTS:Etiology was alcohol (15) , gall stones (10) ,and idiopathic (5). Twelve patients were managed non-operatively, out of which five patients needed pigtaildrainage . 18 patients required open necrosectomy. Mean follow up was 28.2 months. 16patients (62%) had readmissions . 11 patients (36.7%) had exocrine deficiency and 14patients (46.7%) had endocrine deficiency , 7 patients had both. 82.8% patients had morpho-logical changes in pancreas. Patients undergoing necrosectomy had higher incidence ofendocrine dysfunction (61.1% of patients in surgical group and 25% in non-operative group(p= 0.057).Exocrine abnormality was also significantly higher in surgical group compare tonon-operative group(55.6% versus 8.3%, p= 0.010). Morphological changes in pancreaswere also higher in operated group but was not statistically significant. CONCLUSION:Patients of severe acute pancreatitis on follow up had significant functional, and morpholo-gical changes with 62% patients requiring readmission. Patients who were managed non-operatively had lesser incidence of exocrine and endocrine deficiencies, though there wasno significant difference in pancreatic morphological changes .

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Pre Resection Gastric Bypass Reduces Post Resection BMI but Not LiverDisease in Short Bowel SyndromeJon Thompson, Rebecca A. Weseman, Fedja A. Rochling, Wendy J. Grant, Jean Botha,Alan Langnas, David F. Mercer

Abstract: Patients who develop short bowel syndrome (SBS) while morbidly obese maintaina higher BMI and are more likely to develop hepatobiliary complications than non-obesepatients. The mechanisms for these findings are unknown. Our aim was to determine theeffect of pre resection gastric bypass (GBP) on postresection BMI and the incidence of liverdisease in SBS patients. Methods: We reviewed 100 adult patients with SBS: 55 patientswith initial BMI <35 were controls; 28 patients with initial BMI >35 were the obese group;and 17 patients had undergone GBP prior to SBS. Results: There were no differences in age,gender, or intestinal anatomy. Obese patients were more likely to weaned off PN (44%vs25% control and 12% GBP, p<.05). Overall 38% of patients have undergone ostomyclosure, intestinal lengthening and intestinal transplantation with a similar occurrence in allgroups 11 (68%) of the GBP patients had gastric continuity reestablished. Pre resection BMIin controls was significantly lower than obese and GBP groups (26 vs 43 and 37). BMI at1, 2, and 5 years was similar in control and GBP groups (23, 23, and 23 versus 23 24 and26). Obese patients had a persistently increased BMI (37, 32, and 32 at 1, 2, and 5 years).% IBW trends were similar. 7 (41%) of the GBP patients had a pre resection BMI >35. BMIand %IBW were similar at 1,2, and 5 years in those GBP patients with BMI >35 and those<35 (26, 26, and 26 vs 22, 20, and 26).Cholelithiasis and cirrhosis occurred to a similarextent in all 3 groups. Radiographic fatty liver tended to be higher in the GBP group (41%vs 16% controls and 32% obese groups). End stage liver disease occurred only in patientson PN >1 year and tended to be higher in obese and GBP patients compared to controls(33% and 33% vs 17%). Conclusions: GBP prevents the nutritional benefits of obesity inSBS patients. This occurs independent of pre SBS BMI suggesting that GBP itself rather thansurgically induced weight loss is the important factor. However, GBP does not appear toeliminate the increased risk of hepatobiliary disease observed in obese SBS patients.

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Neoadjuvant Treatment of Duodenal Adenocarcinoma: A Rescue StrategyEdwin O. Onkendi, Sarah Y. Boostrom, David M. Nagorney, John H. Donohue, MichaelL. Kendrick, Michael B. Farnell, Michael G. Sarr, Kaye M. Reid Lombardo, Michael G.Haddock, Florencia G. Que

Background: Recent advances in chemotherapy have been shown to downsize initiallyunresectable colon cancers. The role of neoadjuvant therapy in duodenal adenocarcinoma,especially its effect on resectability, disease-free survival (DFS) and overall survival (OS) isunknown. Our aim was to evaluate the long-term outcome in initially unresectable patientswith duodenal adenocarcinoma following neoadjuvant chemotherapy and rescue surgery.Methods: A retrospective review between 1/1994-1/2010 of all patients who underwentrescue duodenectomy following neoadjuvant therapy was performed. Results: Ten patientsreceived neoadjuvant chemotherapy prior to surgical resection (7 men, 3 women) with amean age of 54 years (range 45-67 years). Reasons for unresectable disease were vascularencasement in 6 patients, retroperitoneal extension of tumor abutting on the aorta or inferiorvenacava in 3 patients and bulky local disease causing malignant bowel obstruction in 1patient. Six were primary presentations and 4 were local recurrences. Of the 6 primarypresentations, 4 received neoadjuvant therapy with FOLFOX, one with chemoradiation with5-FU and one with CPT-11, oxaliplatin and capecitabine. Of the 4 patients with locallyrecurrent disease, one had radiotherapy with 5-FU and capecitabine, one had FOLFIRI, onehad CPT-11, 5-FU and leucovorin, and one had FOLFOX. All 10 patients underwent R0resection following neoadjuvant therapy. Histologic evaluation revealed that 2 patients hadcomplete pathologic response (1 on FOLFOX and 1 on chemoradiation with 5-FU) and onepatient had only 10% viable tumor remaining after FOLFOX. Two patients had >50%decrease in tumor size. The average tumor size was 3.4 cm (range <1 cm- 4.6 cm). Eightpatients had grade 3 tumors and 2 patients had grade 4 tumors. Three patients had positivelymph nodes and 7 had negative lymph nodes. Five patients had T3 tumors, 3 had T4tumors, one had T2, and one had no residual tumor identified on pathologic evaluation.