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Purpose: To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting. Case Report: A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging. Conclusion: It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients. [ABSTRACT FROM AUTHOR]

Background: Despite the well-established diagnostic and therapeutic applications of endoscopic ultrasound (EUS) in adults, data about its use in children are limited. In this study, we tried to assess the feasibility, safety, and clinical impact of EUS in pediatric patients. Methods: Data of pediatric patients (<18 years) referred for EUS over a 3-year period to the endoscopy units of four Egyptian tertiary centers were retrospectively analyzed. Significant impact was defined as a new diagnosis or treatment attributed to the EUS procedure. Results: Twenty-four diagnostic and five therapeutic EUS procedures were conducted in 29 children with a median age of 9 years. Indications for EUS included assessment of solid pancreatic mass (n = 3), pancreatic cyst (n = 2), suspected chronic pancreatitis (n = 9), pancreatic pseudocyst (PPC) (n = 5), recurrent hypoglycemia (n = 1), bile duct mass (n = 1), subepithelial lesion (esophageal, duodenal or anorectal) (n = 4), mediastinal mass (n = 1), pelvic mass (n = 3), and mass at splenic hilum (n = 1). Therapeutically, five patients underwent cystogastrostomy for symptomatic PPC with 100% technical and clinical success. EUS was able to diagnose 21 out of the other 24 patients. EUS-guided tissue acquisition was performed in 11 patients with definitive histopathological diagnosis in 10 patients (91%). There was no procedure-related major complication, while minor complications occurred in two cases (transient pain in one case, temporary fever, and vomiting in two cases). Conclusion: Standard linear EUS equipment and accessories can be used safely and effectively in selected pediatric patients for diagnostic and therapeutic purposes. [ABSTRACT FROM AUTHOR]

Castleman disease (CD) is a lymphoproliferative disorder that rarely occurs in the pancreas. We reported a 46-year-old man was admitted to our hospital due to recurrent minor epigastric pain for 7 days. The abdominal enhanced CT showed irregular foci in the body of the pancreas with abundant blood supply considered a neuroendocrine tumor. The patient was subsequently diagnosed with pancreatic neuroendocrine tumor by an ultrasound-guided fine needle aspiration biopsy. Therefore, he underwent an open pancreatic mass resection. The ultimate diagnosis was CD and belonged to hyaline vascular type based on the postoperative pathology. After a 13-month follow-up, no recurrence of abdominal pain or lesions was observed. This case suggests that fine needle aspiration biopsy is not conclusive and unsuitable for pancreatic CD and highlights the importance of routine pathology due to the absence of typical signs and symptoms. [ABSTRACT FROM AUTHOR]

Background: Oral microbiota reported to be associated with pancreatic diseases, including pancreatic cancer. However, the association of oral microbiome and pancreatic cancer has not been reviewed systematically. Objectives: To systematically investigate the association between the oral microbiome and pancreatic cancer risk. Design: A systematic review and meta-analysis. Data Sources and Methods: Systemic searches were conducted using PubMed, Medline, Cochrane Library, and Embase databases without any language restriction from conception to August 29, 2020. The studies that evaluated the association of oral microbiome and pancreatic cancer risk were included in this meta-analysis. Results: The six included studies encompassed a total of 863 pancreatic cancer cases and 906 controls. Four studies reported the overall oral microbiome in pancreatic cancer cases. A total of 12-17 species/clusters were correlated with pancreatic cancer. Three studies reported the odds ratios (ORs) or relative abundance of several oral microbiomes pieces/clusters, and the majority were associated with pancreatic cancer. Conclusions: Overall, this study supports the hypothesis of associations of variations of patients' oral microbiota to pancreatic cancer. Nonetheless, due to all included studies were conducted in USA or Europe, additional original studies and meta-analysis particular studies from other countries are essential for an in-depth investigation into the role of oral bacteria in pancreatic cancer. [ABSTRACT FROM AUTHOR]

We investigated the relationship between pancreatic fat accumulation and markers of atherosclerosis among patients with nonalcoholic fatty liver disease (NAFLD). Patients with NAFLD have been reported to be at an increased risk of vascular events. We grouped 183 patients in whom we detected and graded hepatosteatosis (HS) on transabdominal ultrasonography into 2 groups based on the presence/absence of pancreatic fat. There were 85 participants (50 female; mean age: 53.6 ± 9.7 years) who were nonalcoholic fatty pancreas disease (NAFPD) positive and 98 participants (56 female; mean age: 51.4 ± 9.3 years) who were NAFPD negative. Carotid intima media thickness (cIMT) was significantly greater in the group where HS was accompanied by NAFPD (0.51 [0.40–0.62] vs 0.45 [0.35–0.55] mm; P <.001). Multivariable analyses showed that the independent predictors of increased cIMT were age (odds ratio [OR]: 1.108; 95% CI: 1.059–1.158, P =.001), hypertension (OR: 2.244; 95% CI: 1.099–4.579, P =.026), and the presence of NAFPD (OR: 3.078; CI 95% CI: 1.531–6.190, P =.0002). In the present study we demonstrated that, in patients with NAFLD, pancreatic fat accumulation was significantly associated with cIMT, a marker of early atherosclerosis. NAFPD may increase the risk of vascular events associated with NAFLD. [ABSTRACT FROM AUTHOR]

Introduction: We undertook this study to describe the number and variety of robotic operations undertaken for hepatopancreatic and esophageal disorders.Methods: Data from 2015 through March of 2018 were analyzed for da Vinci™ robot application for hepatopancreatic disorders, gastroesophageal reflux disease (GERD), and achalasia.Results: From 2015 through 2017, robotic hepatopancreatic operations increased 49%, robotic hepatic operations increased 107%, and robotic pancreatic operations increased 26%. Quarter after quarter, robotic application increased for hepatopancreatic operations, hepatic operations, and pancreatic operations (P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 12% of robotic hepatopancreatic operations in 2015-71% in 2018 (1075% increase in numbers). From 2015 through 2017, robotic fundoplications and myotomies increased by 55%, robotic fundoplications increased by 59%, and robotic Heller myotomies increased by 211%. Quarter after quarter, robotic application increased for fundoplications and Heller myotomies (P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 13% of these robotic operations in 2015-64% in 2018 (935% increase in numbers). Less than 10% of hepatopancreatic operations, fundoplications, and myotomies are undertaken robotically.Conclusions: There has been an accelerating increase in the number of robotic operations for hepatopancreatic disorders, GERD, and achalasia over the past 3 ¼ years. Application of the Xi robot has dramatically increased, both absolutely and relatively. Still only a small proportion of operations for hepatopancreatic disorders, GERD, and achalasia use the robotic platform; this is changing fast. [ABSTRACT FROM AUTHOR]

Purpose: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. Methods: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. Results: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. Conclusion: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations. [ABSTRACT FROM AUTHOR]

Pancreatic heterotopia is a well-described entity occurring at multiple abdominal sites, most commonly the stomach and small intestine. They can develop similar disease processes as the pancreas ranging from acute pancreatitis, cyst formation, or neoplasms, most commonly ductal adenocarcinoma. Neuroendocrine tumors (NETs) arising in pancreatic heterotopias are exceedingly rare with only 3 prior published cases. In this article, we describe the first reported case of a NET arising in a jejunal pancreatic heterotopia in a 59-year-old woman presenting with abdominal pain and diarrhea. The submucosal tumor was composed of a well-differentiated NET (World Health Organization grade 1) directly intermixed with a heterotopic pancreas consisting of acinar cells, islet cells, and ducts. This case illustrates that NETs can occur in association with pancreatic heterotopias at any site. Also, the importance for pathologists to recognize that pancreatic heterotopias can give rise to a variety of neoplasms and is not limited to ductal adenocarcinoma. [ABSTRACT FROM AUTHOR]

Rosai-Dorfman disease (RDD) is primarily a disease of massive lymphadenopathy and sinus histiocytosis. It has been documented across extranodal organ systems, but it rarely has been described in the gastrointestinal tract only. Here is the unique case of 2 primary extra-nodal masses found simultaneously in the pancreas and right colon of a patient without the classical concomitant lymphadenopathy. We also reviewed the literature and found 11 additional cases of pancreatic RDD. This is the first male case and 1 of only 2 cases of RDD presenting synchronously in 2 distinct locations within the gastrointestinal system. Furthermore, we discuss the potential use of fine needle aspiration (FNA) and core sample biopsies in confirming a diagnosis of RDD. [ABSTRACT FROM AUTHOR]

The role of artificial intelligence and its applications has been increasing at a rapid pace in the field of gastroenterology. The application of artificial intelligence in gastroenterology ranges from colon cancer screening and characterization of dysplastic and neoplastic polyps to the endoscopic ultrasonographic evaluation of pancreatic diseases. Artificial intelligence has been found to be useful in the evaluation and enhancement of the quality measure for endoscopic retrograde cholangiopancreatography. Similarly, artificial intelligence techniques like artificial neural networks and faster region-based convolution network are showing promising results in early and accurate diagnosis of pancreatic cancer and its differentiation from chronic pancreatitis. Other artificial intelligence techniques like radiomics-based computer-aided diagnosis systems could help to differentiate between various types of cystic pancreatic lesions. Artificial intelligence and computer-aided systems also showing promising results in the diagnosis of cholangiocarcinoma and the prediction of choledocholithiasis. In this review, we discuss the role of artificial intelligence in establishing diagnosis, prognosis, predicting response to treatment, and guiding therapeutics in the pancreaticobiliary system. [ABSTRACT FROM AUTHOR]

The role of artificial intelligence and its applications has been increasing at a rapid pace in the field of gastroenterology. The application of artificial intelligence in gastroenterology ranges from colon cancer screening and characterization of dysplastic and neoplastic polyps to the endoscopic ultrasonographic evaluation of pancreatic diseases. Artificial intelligence has been found to be useful in the evaluation and enhancement of the quality measure for endoscopic retrograde cholangiopancreatography. Similarly, artificial intelligence techniques like artificial neural networks and faster region-based convolution network are showing promising results in early and accurate diagnosis of pancreatic cancer and its differentiation from chronic pancreatitis. Other artificial intelligence techniques like radiomics-based computer-aided diagnosis systems could help to differentiate between various types of cystic pancreatic lesions. Artificial intelligence and computer-aided systems also showing promising results in the diagnosis of cholangiocarcinoma and the prediction of choledocholithiasis. In this review, we discuss the role of artificial intelligence in establishing diagnosis, prognosis, predicting response to treatment, and guiding therapeutics in the pancreaticobiliary system. [ABSTRACT FROM AUTHOR]

Background: Recent studies have demonstrated that alcohol consumption can modulate the immune system by directly activating natural immunity and triggering inflammatory processes in the central nervous system and in peripheral organs, such as the liver and pancreas. Patients with alcohol use disorders have an elevated frequency of comorbid mental disorders and gut diseases (i.e. fatty liver and pancreatitis) that complicate diagnosis, treatment and prognosis. Aims: The present study aims to explore possible associations in circulating plasma cytokine concentrations in abstinent patients diagnosed with alcohol use disorders. Methods: To this end, 85 abstinent subjects with alcohol use disorders from an outpatient setting and 55 healthy subjects were evaluated for both substance and mental disorders. The plasma levels of cytokines interleukin 1 beta, interleukin 4, interleukin 6, interleukin 17A, interferon gamma and tumour necrosis alpha were determined and their association with (a) history of alcohol consumption, (b) psychiatric comorbidity and (c) liver/pancreas comorbidities was explored. Results: We found that plasma concentrations of interleukin 1 beta, interleukin 6 and tumour necrosis alpha were increased, whereas plasma concentrations of interleukin 4, interleukin 17A and interferon gamma were decreased in abstinent alcohol use disorder patients as compared with control subjects. Moreover, we found that changes in interleukin 6 and interleukin 17A plasma concentrations in alcohol use disorder patients were associated with the presence of liver and pancreatic diseases. Conclusion: The present results suggest alcohol use disorder is associated with alterations of plasma cytokines, being interleukin 6 and interleukin 17A potential biomarkers of the presence of comorbidities of digestive organs. The clinical relevance of these findings is discussed in the context of alcohol-induced inflammatory processes. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 9 months of age with chronic nonbloody, mucus-like diarrhea, severe malnutrition and Failure to thrive (FTT). It discusses that initially diagnosed with cow milk protein intolerance and gastroesophageal reflux, with no resolution of symptoms following ranitidine and trials of both soy-based and elemental formulas. It also mentions central and peripheral hypotonia with head lag and gross motor delay including inability to sit unsupported.

Surgical site infection (SSI) and incisional hernia are common complications after major pancreatectomy. We investigated the effects of negative pressure wound therapy (NPWT) on short- and long-term wound outcomes in patients undergoing pancreatectomy. A randomized controlled trial comparing the effect of NPWT with standard surgical dressing (SSD) on wounds was performed in 265 patients undergoing open gastrointestinal resections from 2012 to 2016. We performed a subset analysis of 73 patients who underwent pancreatectomy. Wound complications in the first 30 days and incisional hernia rates were assessed. There were 33 (45%) female patients in the study and the average BMI was 27.6. The pancreaticoduodectomy rate was 68 per cent, whereas 27 per cent of patients underwent distal or subtotal pancreatectomy, and 4 per cent total pancreatectomy. Incisional hernia rates were 32 per cent and 14 per cent between the SSD and NPWT groups, respectively (P = 0.067). In the SSD (n = 37) and NPWT (n = 36) cohorts, the superficial SSI, deep SSI, seroma, and dehiscence rates were 16 per cent and 14 per cent (P > 0.99), 5 per cent and 8 per cent (P = 0.67), 16 per cent and 11 per cent (P = 0.74), and 5 per cent and 3 per cent (P ≥ 0.99), respectively. After adjusting for pancreatic fistula and delayed gastric emptying, no statistically significant differences in the primary outcomes were observed. These findings were true irrespective of the type of resection performed. Short- and long-term wound complications were not improved with NPWT. We observed a trend toward decreased incisional hernia rates in patients treated with NPWT. Owing to the multifactorial nature of wound complications, it is yet to be determined which cohorts of pancreatectomy patients will benefit from NPWT. [ABSTRACT FROM AUTHOR]

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases. [ABSTRACT FROM AUTHOR]

Postoperative pancreatic fistula (PF) remains one of the most significant complications after pancreaticoduodenectomy (PD). Recently, studies have suggested that post-PD serum hyperamylasemia (HA) may be a risk factor. In this study, we evaluate the relationship of pancreas texture and post-operative serum amylase levels in determining PF risk. This retrospective cohort study evaluated all patients who underwent PD at Thomas Jefferson University from 2009 to 2014. The highest postoperative serum amylase level from postoperative day (POD) 0 to POD 5 was obtained. Chi-square analyses and odds ratio (OR) evaluated the relationship between pancreas texture, serum amylase level, and the development of PF. Data from 524 consecutive patients were analyzed. Serum amylase threshold value of 165 IU/L yielded greatest accuracy from the receiver operating characteristic curve analysis (Sensitivity, 0.70; specificity, 0.72). Grade B or C PF were more common among HA patients (20 vs 3%; P < 0.001). HA was associated with increased rates of PD-associated complications. On multivariable analysis, early postoperative serum HA was more predictive of PF risk (OR, 4.87; P < 0.001) than either pancreatic duct size ≤3 mm (OR, 2.97; P = 0.01) or pancreas texture (OR,1.87; P = 0.05).Conclusion: The presence of HA on POD 0 or POD 1 is more predictive than soft pancreas texture or small pancreas duct size alone. [ABSTRACT FROM AUTHOR]

Background In unclear pancreatic lesions, a tissue sample can confirm or exclude the suspected diagnosis and help to provide an optimal treatment strategy to each patient. To date only one small study reported on the outcome of computed tomography (CT) fluoroscopy-guided biopsies of the pancreas. Purpose To evaluate technical success and diagnostic rate of all CT fluoroscopy-guided core biopsies of the pancreas performed in a single university center during a 10-year period. Material and Methods In this retrospective study we included all patients who underwent a CT fluoroscopy-guided biopsy of a pancreatic mass at our comprehensive cancer center between 2005 and 2014. All interventions were performed under local anesthesia on a 16-row or 128-row CT scanner. Technical success and diagnostic rates as well as complications and effective patient radiation dose were analyzed. Results One hundred and one patients (54 women; mean age, 63.9 ± 12.6 years) underwent a total of 104 CT fluoroscopy-guided biopsies of the pancreas. Ninety-eight of 104 interventions (94.2%) could be performed with technical success and at least one tissue sample could be obtained. In 88 of these 98 samples, a definitive pathological diagnosis, consistent with clinical success could be achieved (89.8%). Overall 19 minor and three major complications occurred during the intra- or 30-day post-interventional period and all other interventions could be performed without complications; there was no death attributable to the intervention. Conclusion CT fluoroscopy-guided biopsy of pancreatic lesions is an effective procedure characterized by a low major complication and a high diagnostic rate. [ABSTRACT FROM AUTHOR]

The author reflects on non-alcoholic fatty pancreas disease (NAFD) by citing a study on patients with both hepatic steatosis (HS) and NAFD. Based on the results, the patients showed greater carotid intima media thickness (cIMT) compared to patients with HS only. Other topics include non-alcoholic fatty liver disease (NAFLD) and the abnormal peri-organ or intra-organ fat (APIFat) deposition as risk factor for metabolic and vascular diseases.

Research participants often report wanting to help as a reason for participation, but who they want to help and why is rarely explored. We examined meanings associated with helping among 21 adults with cystic fibrosis (CF)—a group with high participation in research. Meanings included helping to advance research, helping others with CF, helping as their job, helping themselves, helping because they are special, and helping to give back. While some meanings were primarily oriented toward helping others, some also involved hoping for benefits for oneself, and some included feelings of responsibility. Despite indicating that they understood that research is not designed to help them directly, participants nevertheless hoped that it might. We discuss implications for research ethics oversight. [ABSTRACT FROM AUTHOR]

It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD. [ABSTRACT FROM AUTHOR]

Use of drain remains frequent following pancreaticoduodenectomy (PD) due to concern for postoperative pancreatic fistula (POPF) and anastomotic leak development. Despite controversy, a recent randomized trial suggested omitting drainage would result in a large increase in operative mortality. This study sought to comprehensively examine the effects of forgoing drainage in the large cohort of patients undergoing PD. A prospective cohort study of two consecutive groups undergoing PD was constructed. The initial group had operative drains placed in cases subjectively concerning for POPF development; the second cohort did not undergo operative drainage. Outcomes including POPF incidence, need for reintervention, and overall morbidity were examined. A total of 106 patients were evaluated in two consecutive cohorts of 53; in the first group, 30 per cent had operative drains placed; 22.6 per cent developed POPF versus 7.5 per cent of patients in the no drainage group (P = 0.06). Despite this, no significant difference in major morbidity (Clavien ≥3, 20.8% versus 17.0%) or need for procedural reintervention (18.9% versus 15.1%) was observed. A subsequent validation cohort of 237 additional patients where drains were used only in exceptional circumstances was examined. Operative drains were placed in only 3 per cent of patients (n = 7) and 90-day mortality was 1.3 per cent (n = 3). Incidence of POPF was 8.0 per cent and the overall major complication rate was 14.8 per cent. Given such findings, it appears that drainage after PD can be avoided resulting in acceptable operative morbidity and mortality in most cases. [ABSTRACT FROM AUTHOR]

The article presents case study of a 17-year-old white children with known cystic fibrosis (CF), associated pancreatic insufficiency, and congenital hypothyroidism. The patient reported having an upper respiratory infection 1 week prior to fevers, and chest X-ray showed underlying chronic changes of CF with no new or acute process, and abdominal and pelvic ultrasound revealed a large multilocular left ovarian cyst. Lower incidence of appendicitis was found to be affecting diagnosis.

Readmission rates after pancreaticoduodenectomy (PD) are among the highest of any surgical procedure. The purpose of this study was to identify those factors present at discharge that may predict readmission after PD. All patients undergoing PD between 2010 and 2015 at a very high (>35 PD/year) volume center were entered into a prospective database. Twenty factors present at discharge from index admission identified on univariate analysis were subjected to multivariate analysis to identify those independently predictive of 30-day hospital readmission. A total of 220 patients underwent PD during the study period, 88 per cent of which had cancer. Mean age was 64.4 ± 11.7 years with slight male preponderance (54.5%) and significant African American representation (33.2%). Surgical complications occurred in 67.3 per cent of patients the most common of which included infectious/leak (30%), gastrointestinal (29%), cardiorespiratory (13%), other (13%), minor complications (7%), multi system failure (5%), and new onset diabetes (3%). The 30-day readmission rate was 27.3 per cent and was due to infection (89%), failure to thrive (32%), nausea/vomiting (15%), or other (15%). On multivariate analysis, presence of pancreatic leak/fistula at discharge was the only significant predictor of readmission, present in 62.5 per cent of all readmitted patients (P = 0.001). Comorbidities, length of stay, insurance status, obesity, smoking, and discharge to a care venue other than home did not predict readmission. Patients manifesting pancreatic fistula after PD are at high risk for hospital readmission. Enhanced scrutiny regarding suitability for discharge should be exercised in these patients and measures taken to minimize readmission whenever possible. [ABSTRACT FROM AUTHOR]

This study investigates the preventive effect of caffeic acid phenethyl ester (CAPE) on pancreatic damage induced by vancomycin (VCM) in rats. Rats were equally divided into three groups: group I (control), group II (only VCM-treated group) and group III (VCM + CAPE-treated groups). VCM was intraperitoneally administered at a dose of 200 mg kg−1twice daily for 7 days. CAPE was administered orally at 10 µM mL−1 kg−1 dose once daily for 7 days. The first dose of CAPE administration was performed 24 h prior to VCM injection. Blood and pancreas tissue samples were removed and collected after the study. Serum alkaline phosphatase (ALP), amylase, γ-glutamyl transferase (GGT) and lipase activities were determined. Pancreas tissue samples were evaluated with the light microscope. Group II significantly increased serum ALP, amylase, GGT and lipase activities when compared with the control group. Group III significantly decreased serum ALP, amylase, GGT and lipase activities when compared with group II. In histopathological examination, it has been observed that there was a significant pancreatic damage in group II. CAPE exerted prominent structural protection against VCM-induced pancreatic damage and this effect was statistically significant. CAPE caused a marked reduction in the extent of pancreatic damage. We have concluded that it may play an important role in the VCM-induced pancreatic damage and reduce the pancreatic damage both at the biochemical and histopathological aspects. [ABSTRACT FROM AUTHOR]

Background: Blunt pancreatic trauma is an uncommon injury with high morbidity and mortality. Retrospective analyses of computed tomography (CT) performance report CT to have variable sensitivity in diagnosing pancreatic injury. Both a prospective analysis of multidetector CT (MDCT) performance and diagnostic utility of magnetic resonance imaging (MRI) in acute blunt pancreatic injury remain unexplored. Purpose: To prospectively evaluate the utility of MDCT with MRI correlation in patients with blunt pancreatic trauma using intraoperative findings as the gold standard for analysis. Material and Methods: The contrast-enhanced CT (CECT) scans of patients admitted with blunt abdominal trauma were prospectively evaluated for CT signs of pancreatic injury. Patients detected to have pancreatic injury on CT were assigned a CT grade of injury according to American Association for Surgery of Trauma classification. MRI was performed in patients not undergoing immediate laparotomy and MRI grade independent of CT grade was assigned. Surgical grade was taken as gold standard and accuracy of CT and MRI for grading pancreatic injury and pancreatic ductal injury (PDI) was calculated. A quantitative and qualitative comparison of MRI was also done with CT to determine the performance of MRI in acute pancreatic injury. Results: Thirty out of 1198 patients with blunt trauma abdomen were detected to have pancreatic injury on CT, which was surgically confirmed in 24 patients. Seventeen underwent MRI and surgical correlation was available in 14 patients. CT and MRI correctly identified the grade of pancreatic injury in 91.7% (22/24) and 92.86% (13/14) patients, respectively. Both CT and MRI correctly identified PDI in 18/19 and 11/12 patients, respectively, with good inter-modality agreement of 88.9% (kappa value of 0.78). MRI also qualitatively added to the information provided by CT and increased diagnostic confidence in 58.8% of patients. Conclusion: MDCT performs well in grading pancreatic injury and evaluating pancreatic ductal injury. MRI is useful in evaluation of acute pancreatic trauma as it can increase diagnostic confidence and provide more qualitative information regarding the extent of injury. [ABSTRACT FROM AUTHOR]

The article examines the effectiveness of diffusion-weighted magnetic resonance imaging (MRI) for recognizing intrapancreatic accessory spleen (IPAS) and small hypervascular neuroendocrine tumor (NET) of the pancreas. It highlights the use of MRI in patients with IPAS and NET. It also emphasizes the interpretation of the MRI findings as well as its comparison to the first stage of findings in patients with IPAS and NET.

Mucinous cystic neoplasms (MCNs) of the pancreas in male patients are very rare. Though few cases of MCNs in male patients have been reported, it is difficult to reveal them preoperatively. The first patient was a 50-year-old man and was incidentally found to have a cystic mass of 51 mm in the tail of the pancreas. We performed a distal pancreatectomy. The second patient was a 73-year-old man, incidentally found to have a cystic mass of 25 mm in diameter in the tail of the pancreas and a carcinoma of the bile duct. We performed a subtotal stomachpreserving pancreaticoduodenectomy and distal pancreatectomy. In both cases, the cystic lesion was diagnosed pathologically as MCNs. Since MCNs have the risk of malignancy, a resection is recommended. Cases of MCNs in male patients exhibit features that are similar to MCNs in women. We should recognize that MCNs of the pancreas in male patients exists. [ABSTRACT FROM AUTHOR]

Patients undergoing pancreatic resection are at risk for developing postoperative exocrine dysfunction. We sought to determine the incidence of and clinical factors associated with exocrine dysfunction after pancreatectomy. A retrospective review of a prospective database composed of patients undergoing pancreatic resection between 2004 and 2013 was performed. Logistic regression was used to identify preoperative factors that influenced postoperative exocrine insufficiency. One hundred sixty-one patients with complete follow-up were identified. The mean age was 64.1 ± 12.65 years. The majority were: female (51%), white (66%), tobacco users (61%), nondrinkers (68%), nondiabetic (71%), and without preoperative exocrine dysfunction (96%). Average body mass index was 27.8 ± 6.32 kg/m². Most underwent a pancreaticoduodenectomy (67.3%) for pancreatic cancer (59.6%). Pancreatic fistula occurred in 6.8 per cent. Seven patients were on enzyme replacement therapy preoperatively. Forty-four patients (27%) had postoperative exocrine dysfunction (five of whom were on enzyme replacement therapy preoperatively). Two of seven (29%) of patients with preoperative exocrine dysfunction had complete resolution of their exocrine dysfunction. On univariate analysis, only the type of operation (Whipple) was significantly associated with exocrine dysfunction (P = 0.04). On multivariate analysis, both female gender and type of operation were independently associated with postoperative exocrine dysfunction (P = 0.05). Pancreatic exocrine dysfunction occurred less frequently in this population than what is commonly reported in the literature. Female patients undergoing resection of the pancreatic head have significantly increased risk of exocrine dysfunction. [ABSTRACT FROM AUTHOR]

Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing. [ABSTRACT FROM PUBLISHER]

The nonneoplastic diseases of the human pancreas generally comprise the inflammatory and degenerative conditions that include acute and chronic pancreatitis, with cystic fibrosis being arguably one of the most important diseases that induce the condition. Both acute and chronic conditions vary in severity, but both can be life threatening; and because of this fact, the study of their progression, and their responsiveness to therapy, is largely conducted by indirect means using serum markers of damage and repair such as amylase and lipase activities that normally occur at very low levels in the circulation but can be significantly increased during inflammatory episodes. Progress in the understanding the pathogenesis of both conditions has therefore been largely due to time course studies in animal models of pancreatitis, and it is in this context that animal model development has been so significant. In general terms, the animal models can be divided into the invasive, surgical procedures, and those induced by the administration of chemical secretagogues that induce hypersecretion of the pancreatic enzymes. The former include ligation and/or cannulation of the biliopancreatic ducts with infusion of solutions of various kinds, or the formation of closed duodenal loops. Secretagogue administration includes administration of caerulein or l-arginine in various protocols. An additional model involves administration of dibutyltin dichloride, which induces a partial blockage of the pancreatic ducts to induce pancreatic disease through enzymic reflux into the gland. The models have been invaluable in generating testable hypotheses for the human diseases. These hypotheses for the production of cellular damage as the initiating events in the disease include (1) intracellular chemical activation, (2) pancreatic secretion reflux, (3) intracellular production of reactive oxygen species, and (4) intracellular production of free radicals. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the potential of magnetic resonance imaging (MRI) in differentiating ectopic pancreas from submucosal tumors in the upper gastrointestinal tract (UGI) tract. It is inferred that the gastric body was the most common location for submucosal tumors and the duodenum for ectopic pancreas. According to the study, MRI with diffusion-weighted imaging (DWI) is a valuable tool for differentiating ectopic pancreas from submucosal tumors.

Solid pseudopapillary neoplasms of the pancreas (SPN) have been reported increasingly; however, series focusing on portal-superior mesenteric vein (PV/SMV) or adjacent organ resection are limited in the literature. The aim of this study was to present our experience in treating patients with SPN who underwent this extensive resection. Ten eligible patients were retrospectively reviewed and analyzed. Eight females and two males with a median age of 23 years (range, 11 to 58 years) and a median tumor diameter of 12 cm (range, 4 to 20 cm) were observed. All patients had imaging signs of vascular and/or adjacent organ involvement. Resection with curative intent was performed in all patients; eight underwent synchronous PV/SMV resection and two underwent synchronous left nephrectomy. Malignant SPN was confirmed in seven patients. Postoperative mortality was nil and morbidity occurred in five patients. At a median follow-up of 67.5 months (range, 12 to 110 months), nine patients were alive with no evidence of disease and one died of liver metastases. In conclusion, malignant SPN are low-grade tumors with good prognosis. More aggressive attitude should be adopted when PV/SMV or adjacent organ involvement is indicated on preoperative imaging. En bloc synchronous PV/SMV or adjacent organ resection should be applied, when necessary, to achieve complete resection. [ABSTRACT FROM AUTHOR]

Retropancreatic retroperitoneal tumors (RRTs) are seldom encountered in clinical practice. The lack of characteristics on clinical presentation and imaging make preoperative diagnosis difficult and surgical management remains a challenge. This retrospective report surveys the presenting diagnosis and surgical management of 38 patients with RRTs presenting at our center between August 1981 and May 2012. Six patients were misdiagnosed on the basis of computerized tomography and one each by magnetic resonance imaging and magnetic resonance cholangiopancreatography. Tumors were localized posterior to the pancreatic head and uncinate process (n = 18); posterior to the neck and body of the pancreas (n = 9); or posterior to the body and tail of the pancreas (n = 11). Thirty-three patients underwent surgical resections. Operative approaches were chosen on the basis of tumor size and localization. The tumors were mostly commonly originating from neurogenic tissue (n = 16). There were 25 benign neoplasms (65.8%)/ 10 malignant tumors (26.3%), and three undefined tumors. The morbidity of postsurgical complications was 21 per cent (eight of 38). The number of patients who underwent follow-up was 21, and the mean follow-up time was 35 months (range, 2 to 90 months). Three patients died during follow-up. The morbility of local recurrence was 10.5 per cent (four of 38). Definitive diagnosis of RRTs is made at laparotomy. Complete resection remains the fundamental objective of disease management. Different operative approaches should be used according to tumor localization and size. [ABSTRACT FROM AUTHOR]

Management of infected pancreatic necrosis (IPN) has for decades been based on early operative débridement. This approach is associated with mortality rates as high as 58 per cent. Recently, the care of these patients has evolved and emphasizes delayed operation and early intervention with percutaneous drainage. In 2002, we began to incorporate these new principles for the treatment of IPN and herein characterize the recent UCLA experience with management of IPN. A retrospective review of patients with IPN treated at UCLA between 2002 and 2011 was conducted. Mean patient age was 53.4 years. Mean Ranson's score was 3.3 ± 2.3 and average number of concurrent comorbidities 3.2 ± 2.5. All patients were treated with intravenous antibiotics. Thirteen of 18 patients (72.2%) had percutaneous drainage catheters placed (mean 1.1 drains per patient). Two patients were treated with percutaneous drainage alone. Sixteen of 18 (88.9%) eventually underwent surgical débridement. Of the operative patients, mean time from diagnosis to surgery was 28.4 days. The mortality in this group was 16.7 per cent. In conclusion, antibiotics and percutaneous drainage is an acceptable and possibly preferable initial therapeutic strategy for patients with IPN. Delayed operation and early intervention with percutaneous drainage appears to improve mortality for these patients. [ABSTRACT FROM AUTHOR]

Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a severe complication and a challenging problem. The common risk factors are the soft pancreas and small pancreatic duct of the remnant pancreas. Those two risk factors were recognized during surgery. On the other hand, a preoperatively determined risk factor of PF is unclarified. We conducted a retrospective analysis of 203 patients consecutively treated by PD from April 2000 to October 2010. PF was defined according to the criteria of the International Study Group of Pancreatic Fistula. Clinical and pre- and intraoperative data were compared between PF and non-PF patients. The recommended cutoff value of body mass index (BMI) as 20 kg/m² was defined by receiver operating characteristic curve analysis. PF occurred in 53 (26.1%) of 203 patients. In univariate analysis, BMI and soft remnant pancreas were found to be risk factors of PF (P = 0.027, P = 0.005). In multivariate analysis, BMI and soft pancreas were also risk factors of PF (P = 0.040, P = 0.005). Patients with PF had a significantly longer hospital stay than non-PF patients (P = 0.005). High BMI and soft pancreas were significant risk factors for PF. [ABSTRACT FROM AUTHOR]

Background: Transforming growth factor beta (TGFβ) is upregulated in chronic inflammation, where it plays a key role in wound healing and promoting fibrosis. However, little is known about the peripheral effects of TGFβ on nociception. Methods: We tested the in vitro effects of TGFβ1 on the excitability of dorsal root ganglia (DRG) neurons and the function of potassium (K) channels. We also studied the effects of TGFβ1 infusion on pain responses to noxious electrical stimulation in healthy rats as well as the effects of neutralization of TGFβ1 on evoked pain behaviors in a rat model of chronic pancreatitis. Results: Exposure to TGFβ1 in vitro increased sensory neuronal excitability, decreased voltage-gated A-type K+ currents (IA) and downregulated expression of the Kv1.4 (KCNA4) gene. Further TGFβ1 infusion into the naïve rat pancreas in vivo induces hyperalgesia and conversely, neutralization of TGFβ1 attenuates hyperalgesia only in rats with experimental chronic pancreatitis. Paradoxically, TGFβ1 neutralization in naïve rats results in pancreatic hyperalgesia. Conclusions: TGFβ1 is an important and complex modulator of sensory neuronal function in chronic inflammation, providing a link between fibrosis and nociception and is a potentially novel target for the treatment of persistent pain associated with chronic pancreatitis. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess for any trend in management of pancreatic fluid collections (PFCs) and identify impacting factors. The endoscopy and surgical databases were queried for PFC patients. PFCs were categorized as pseudocysts (PP) or complex collections (CC) that included abscess/necrosis. The outcomemeasures were to compare the utilization of surgery and endoscopy from 2004 to 2007 (group I) and from 2008 to 2010 (group II) and identify factors impacting practice patterns. A total of 285 patients were treated: group I included 119 and group II 166. Of 119 group I patients, 29 per cent were treated by surgery and 71 per cent by endoscopy. Of 85 endoscopy patients, 42 per cent were drained by conventional transmural drainage and 58 per cent by endoscopic ultrasound (EUS). Of 166 group II patients, 31 per cent were treated surgically and 69 per cent endoscopically. Of the 115 endoscopy patients, 17 per cent were drained by conventional transmural drainage and 83 per cent by EUS. Compared with group I, all pseudocysts in group II were treated by endoscopy (84% vs 100%, P 5 0.001). There was no difference in the rate of CC treated by endoscopy between both groups (57.7% vs 56.8%, P 5 0.9). PFCs not causing luminal compression (P<0.0001) or measuring <9 cm in size (P<0.0001) were more likely to require EUS. There was a significant trend at our institution in the management of PFCs with all pseudocysts presently being treated only by endoscopy. The ability of EUS to access smaller size PFCs and those not causing luminal compression has significantly expanded the role of endoscopy in PFC management. [ABSTRACT FROM AUTHOR]

We present the case of a 57-year-old patient who initially presented with a constellation of symptoms including intense pruritis, flushing and diarrhoea. Following several months clinical deterioration, the patient was investigated radiologically, where multiple hepatic tumours were identified. Liver biopsy confirmed the presence of a well-differentiated metastatic gastroenteropancreatic endocrine carcinoma with biochemical evidence of serotonin secretion. Over a period of six months, the clinical course of the patient's disease progressed whereby severe hypoglycaemia became the major manifestation. Subsequent biochemical investigations confirmed the diagnosis of an insulinoma. Extensive radiological investigation revealed a solitary primary pancreatic tumour, indicating the presence of a metastatic pancreatic endocrine tumour (PET) secreting both insulin and serotonin. The patient was treated with a chemotherapy regimen consisting of 12 cycles of 5-fluorouracil/oxaliplatin, responding clinically - improved World Health Organization performance score from 3 to 1, biochemically - significantly reduced plasma chromogranin A and cancer antigen 19-9 concentrations and improved liver function tests, and radiologically - reduced pancreatic and hepatic tumour size. This is the first report of a primary PET secreting insulin and serotonin. Due to the association of serotonin-secreting gastroenteropancreatic endocrine tumours (GEP-ETs) with multiple endocrine neoplasia type-1 (MEN1) and biochemical evidence of an insulinoma, MEN1 should also be considered in such cases. The case provides further evidence for the biological heterogeneity of GEP-ETs and the myriad secretory humoral products and resultant clinical syndromes arising from such tumours. [ABSTRACT FROM AUTHOR]

The objective of this study was to identify risk factors for pancreatic fistula (PF) after stapled transection in distal pancreatectomy (DP). Patients undergoing DP using a stapler for transection between 2005 and 2009 were identified from a pancreatic resection database. Variables examined included patient and tumor characteristics, staple size, and the use of mesh reinforcement. Univariate and multivariate regression analyses were performed to identify risk factors for postoperative PF. One hundred forty-nine had stapled transection, and of these, 25 (17%) had mesh reinforcement. The overall morbidity and mortality rates were 28 per cent and less than I per cent; 34 (23%) were diabetic. The rate of clinically significant PF was 14 per cent. On univariate analysis, diabetes (P = 0.04), a firm pancreas (P = 0.03), use of mesh staple line reinforcement (P = 0.02), use of a 4.1-mm staple cartridge (P = 0.01), and blood loss greater than 100 mL (P = 0.01) were associated with higher pancreatic fistula rates. On multivariate analysis, only the presence of diabetes (OR, 4.17; 95% CI, 1.1-15.3; P = 0.03) and the use of a 4.1-mm cartridge (OR, 8.57; 95% CI, 1.2-60.2; P = 0.03) were independently associated with pancreatic fistula formation. Stapled pancreatic transection provides an acceptable PF rate after DP. Diabetes and staple size influence PF rates. In our experience, use of mesh staple line reinforcement did not reduce the incidence of PF after stapled transection. [ABSTRACT FROM AUTHOR]

Background: preoperative assessment of pancreatic masses is still challenging as regards the characterization and assessment of irresectability. The opportunities of modern multidetector computed tomography (MDCT) with image postprocessing can be expected to enhance the diagnostic performance if accurate criteria are elaborated. Purpose: to estimate the accuracy of MDCT and multiplanar image reconstructions with the use of standardized imaging criteria for preoperative evaluation of pancreatic masses with respect to irresectability. Material and Methods: a total of 105 consecutive patients who underwent exploratory laparoscopy or pancreatic resection and had preoperative 3-phase MDCT (4-64 rows) were enrolled retrospectively. First, transverse sections and secondly additional 3Ds were reviewed by two independent blinded observers (O1/O2). Preoperative imaging findings were correlated with intraoperative and histopathologic results. Results: among all 105 patients, 70 malignant pancreatic tumors and 35 benign pancreatic diseases were found (accuracy of 93% for O1 and 91% for O2). For arterial tumor invasion, receiver operator characteristic (ROC) analysis (values averaged from the results of O1 and O2) revealed an area under the curve (AUC) of 0.931 for transverse sections and 0.986 for 3Ds. Regarding irresectability, positive predictive values were 97% (with 3Ds, 97%) for O1/O2; negative predictive values were 84% (with 3Ds, 89%) for O1 and 86% (with 3Ds, 91%) for O2. Conclusion: MDCT with 3Ds was highly accurate for evaluation and assessment of irresectability criteria in patients with pancreatic masses. However, due to the limited specificity regarding arterial tumor infiltration, the indication for surgical exploration should be made generously in case of inconclusive findings. [ABSTRACT FROM AUTHOR]

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic débridement (DPD, n = 13) or transgastric débridement using cyst-gastrostomy (CG, n = 8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to débridement, a lower chance of needing multiple débridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical débridement and to develop pancreatic fistulae compared with patients undergoing DPD. [ABSTRACT FROM AUTHOR]

The author offers views on the 40 years of battling against pancreatic cancer. According to the author, the development of facts, mostly the result of new imaging capabilities, that resulted in progressive understanding of pancreatic diseases. At the same time, however, the incidence of ductal adenocarcinoma escalated. The author believes this is the result of better reporting. The author claims minimally invasive methods, such as laparoscopy, have shifted the options for pancreatic surgery.

The authors sought to develop and test a breath-controlled video game using a digital spirometer that, by providing visual breath biofeedback, could promote awareness of breathing techniques in children with cystic fibrosis (CF). To assess improvement in game performance during hospitalizations for CF exacerbations, the authors conducted a trial on 10 inpatients. Subjects had at least five 15-minute exposures to a breath biofeedback game that challenged them to track a moving target using their breath. Subjects reacted positively to the breath tracking challenge. Repeated-measures analysis of variance of a tracking fidelity statistic showed improvement in eye-breath coordination over 5 sessions (P = .026). It was concluded that an electronic breath game is safe and can improve breath awareness among children with CF. This technology could also contribute to awareness of respiratory symptoms and foster social ties among CF patients. [ABSTRACT FROM AUTHOR]

Pancreatitis-associated protein (PAP)-I and -II, lectin-related secretory proteins, are members of the regenerating gene (Reg) family. Although expression of PAP-I was found in the dorsal root ganglion (DRG) neurons following peripheral nerve injury and cystitis, whether PAP-II could be expressed in DRG neurons in chronic pain models remains unclear. The present study shows an inflammation- and nerve injury-triggered expression of PAP-II in rat DRG neurons. In situ hybridization showed that only a few DRG neurons normally contained PAP-I and -II mRNAs. After peripheral inflammation, PAP-I and -II mRNAs were present in over half of small DRG neurons. Such an elevated expression of PAPI and -II reached the peak level on the second day. Immunostaining showed that the expression of PAP-II was mostly increased in the isolectin B4-positive subset of small DRG neurons after inflammation. Furthermore, the expression of PAP-II was also induced in DRG neurons after peripheral nerve injury. Interestingly, PAP-II expression was shifted from small neurons on day 2 to large DRG neurons that expressed neuropeptide Y during the later post-injury days. These results suggest that PAP-II may play potential roles in the modulation of spinal sensory pathways in pathological pain states. [ABSTRACT FROM AUTHOR]

Pancreatic neuroendocrine tumors (pNETs) are an uncommon pancreatic neoplasm. We reviewed the presentation, management, and outcome of patients with pNETs treated at a single center by a multidisciplinary approach between 2004 and 2008. Over this time period, 154 patients with carcinoid and neuroendocrine tumors were treated, which included 46 patients (30% of total) with pNETs. The most common presentations included abdominal pain (20 of 46 [43%]), systemic symptoms such as hypoglycemia (15 of 46 [33%]), and incidental mass (7 of 46 [15%]). Fourteen patients had functional tumors. At the time of diagnosis, 22 patients (48%) presented without metastases and 24 (52%) had metastatic disease. Median follow up for the entire group was 42 months. All patients with nonmetastatic pNET underwent pancreatic resection with 95 per cent postoperative survival. Overall survival in this group at 3 years was 86 per cent and disease-free survival was 81 per cent. In patients presenting with metastatic pNET, multiple treatment modalities were used, including liver resection or ablation (n = 15), hepatic chemoembolization (n = 17), pancreatic resection (n = 12), and systemic treatments (n = 7). Three-year survival was 70 per cent. Pancreatic resection results in greater than 80 per cent 3-year survival in nonmetastatic pNET. In patients presenting with metastatic pNET, excellent survival rates are also achievable using a multidisciplinary multimodal approach. [ABSTRACT FROM AUTHOR]

Pancreatic fistula is a major cause of morbidity after distal pancreatic resection. When resections are performed with linear stapling devices, the use of bioabsorbable staple line reinforcement has been suggested to decrease the rate of pancreatic fistula. Our objective was to investigate the incidence of pancreatic fistula when using the Gore Seamguard® staple line reinforcement in stapled distal pancreatic resections. A retrospective review of 30 consecutive patients with stapled distal pancreatectomy was conducted. A broad definition of pancreatic fistula was used. Clinicopathologic factors and outcomes were compared between groups. Pancreatic fistula was diagnosed in 11 of 15 patients (73%) and three of 15 patients (20%) in the Seamguard® and non-Seamguard® groups, respectively (P = 0.002). Pancreatic parenchymal transection at the neck of the gland was associated with pancreatic fistula, whereas laparoscopic procedures, splenic preservation, or additional organ resection were not. On multivariate analysis, the association between Seamguard® use and pancreatic fistula was significant (P = 0.005). In conclusion, after introduction of the Gore Seamguard® bioabsorbable staple line reinforcement, we experienced a significant increase in the rate of pancreatic fistula. This experience raises concern about the efficacy of this device in limiting pancreatic fistula after stapled distal pancreatic resection. [ABSTRACT FROM AUTHOR]

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate. [ABSTRACT FROM AUTHOR]

Background: Human faecal elastase-1 (FE-1) is an established biochemical test for the investigation of pancreatic exocrine insufficiency. Conventional extraction methods for FE-1 analysis can give false-positive results with watery stools. This is a major limitation as patients investigated for pancreatic disease commonly produce such stools. We have developed an improved FE-1 test that overcomes water interference by measuring the enzyme in dried faeces. Methods: A novel collection device for FE-1 analysis that involves drying and weighing the stool sample was developed in our laboratory and compared with a conventional wet method, E1 Quick-Prep (Schebo, Biotech AG, Germany). The concentration of faecal FE-1 was determined using a commercially available enzyme-linked immunosorbent assay method (Schebo). Results: FE-1 values obtained using the new dry extraction procedure (mean 1777 mg/g dry stool) were higher when compared with the conventional wet analysis (mean 402 mg/g stool). A 1:2 dilution in water, mimicking a loose stool, was found to affect FE-1 results obtained using the conventional wet extraction procedure. The new dry extraction method gave consistent results when water content was varied in the original stool sample. Conclusion: We have demonstrated that our new device overcomes water interference, allowing results to be obtained from stool samples that would otherwise be unsuitable for FE-1 analysis. [ABSTRACT FROM AUTHOR]

Patients who undergo pancreatic necrosectomy frequently develop complications and often have high mortality rates. These patients are best cared for at specialized centers to minimize morbidity, manage complex complications, and reduce mortality. We present a review of our experience and describe the spectrum of complications encountered in managing of these difficult patients. A registry of patients undergoing pancreatic necrosectomy during a 7-year period was analyzed for preoperative clinical scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II and APACHE IIl scores), patient characteristics related to necrosectomy, and morbidity and mortality. Twenty-nine patients underwent necrosectomy. Indications for surgery were consistent with those previously described. There were 27 complications in 22 patients. Sixteen complications were early (less than 3 weeks after surgery) and 14 were late. The mortality rate was 14 per cent. All deaths were in patients transferred from outside institutions, some after extended time periods. Temporary percutaneous catheter drainage of abscesses before transfer and definitive surgery appeared to reduce mortality in transferred patients. There was a statistically significant correlation between mean maximal preoperative APACHE Ill score, but not APACHE 11 score, and the number of postoperative intensive care unit days (rho = 0.52, P -- 0.004). We describe our experience managing patients with infected pancreatic necrosis that required operative necrosectomy. We found that more severely ill patients (higher APACHE III scores) had longer intensive care unit stays, but the initial severity of their illness did not increase mortality. If patients with infected pancreatic necrosis are referred to specialized centers, preoperative pretransfer percutaneous drainage may serve to temporarily control sepsis. [ABSTRACT FROM AUTHOR]