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Background: Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP)., Methods: This was a retrospective, case-control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2)., Results: Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment., Conclusions: The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous)., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Sarcina ventriculi is a gram-positive bacterium, able to survive in extreme low pH environment. It's first description dates from 1842, by John Goodsir. Since then, just a few cases have been reported. In veterinary medicine, especially in ruminants, it causes bloating, vomiting, gastric perforation and death of the animal. It is commonly associated with delayed gastric emptying or obstruction to gastric outlet, although it's pathogenicity in humans is not fully understood. We report two cases with identification of the bacteria in gastric specimens stained with hematoxylin-eosin staining, in different clinical settings. The first patient is a young female patient, presenting cardiac arrest and death after gastric perforation and the second patient an adult male presenting with gastric adenocarcinoma, treated with partial gastrectomy followed by adjuvant chemoradiation. In our literature review, we identified forty-five cases reporting Sarcina ventriculi appearance, with a sudden increase since 2010., Competing Interests: Conflict of interest: None, (Copyright © 2021 The Author(s).)

Background: The incidence of adenocarcinoma of the ampulla of Vater has been increasing over the past years. Nevertheless, it is still a rare disease and the prognostic factors predicting long-term survival are not sufficiently clarified. This study aims to evaluate the association between histopathological characteristics and long-term survival of patients with ampullary cancer after curative resection, as well as the efficiency of immunohistochemical expression of CK7, CK20, and CDX2 to distinguish the histopathological (intestinal or pancreaticobiliary) patterns., Methods: Demographic, histopathological data, pTNM stage, and immunohistochemical expression patterns were collected from 65 patients with adenocarcinoma of the ampulla of Vater. Five and 10-year overall and disease-free survival rates after curative resection were determined., Results: Of the 65 patients with ampullary carcinoma, 47 (72%) underwent radical resection. The 5- and 10-year overall survival rate was 46% and 37%, respectively. Our results demonstrate that the main prognostic factors were the presence and number of lymph node metastases, lymph node ratio (LNR), differentiation grade, and lymphovascular invasion. After multivariate analysis, only lymph node ratio ≥ 20% remained an independent prognostic factor of survival (HR: 2.63 95% CI: 1.05-6.61; p = 0.039)., Conclusion: Here, we demonstrated more evidence that the lymph node metastases are associated with poor prognosis in ampullary carcinoma. Particularly, the relation between the number of metastatic lymph nodes and the number of harvested lymph node (LNR) should be considered a major prognostic factor., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: In this study, we describe for the first time a Neurofibromatosis type 1 patient with pancreas divisum, multiple periampullary tumors and germline pathogenic variants in NF1 and CFTR genes., Case Report: A 62-year-old female NF1 patient presented with weakness, choluria, nausea, and diffuse abdominal pain to an emergency room service. Magnetic resonance imaging revealed an abdominal mass involving the periampullary region and pancreas divisum. After surgical resection, three synchronous neoplasms were detected including two ampullary tumors (adenocarcinoma of the major ampulla and a neuroendocrine tumor of the minor ampulla) and a gastrointestinal stromal tumor (GIST). Germline multigene panel testing (MGPT) identified two pathogenic heterozygous germline variants: NF1 c.838del and CFTR c.1210-34TG[12]T[5]., Conclusion: This is the first report of a Neurofibromatosis type 1 patient with pancreas divisum and multiple periampullary tumors harboring pathogenic germline variants in NF1 and CFTR genes. The identification of two germline variants and a developmental anomaly in this patient may explain the unusual and more severe findings and underscores the importance of comprehensive molecular analyses in patients with complex phenotypes., (Copyright © 2020 Gregório, Rosset, Alves, Netto, Machado, Bersch, Osvaldt and Ashton-Prolla.)

Background: Gallstones and alcohol are currently the most frequent aetiologies of acute pancreatitis (AP). The aim of this study is to quantify these aetiologies worldwide, by geographic region and by diagnostic method., Methods: A systematic review of observational studies published from January 2006 to October 2017 was performed. The studies provided objective criteria for establishing the diagnosis and aetiology of AP for at least biliary and alcoholic causes. A random-effects meta-analysis was used to assess the frequency of biliary (ABP), alcoholic (AAP) and idiopathic AP (IAP) worldwide and to perform 6 subgroup analyses: 2 compared diagnostic methods for AP aetiology and the other 4 compared geographic regions., Results: Forty-six studies representing 2,341,007 patients of AP in 36 countries were included. The global estimate of proportion (95% CI) of aetiologies was 42 (39-44)% for ABP, 21 (17-25)% for AAP and 18 (15-22)% for IAP. In studies that used discharge code diagnoses and in those from the US, IAP was the most frequent aetiology. ABP was more frequent in Latin America than in other regions., Conclusion: Gallstones represent the main aetiology of AP globally, and this aetiology is twice as frequent as the second most common aetiology., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Hepatic encephalopathy (HE) represents a brain dysfunction caused by both acute and chronic liver failures, and its severity deeply affects the prognosis of patients with impaired liver function. In its pathophysiology, ammonia levels and glutamatergic system hyperactivity seem to play a pivotal role in the disruption of brain homeostasis. Here, we investigate important outcomes involved in behavioral performance, electroencephalographic patterns, and neurochemical parameters to better characterize the well-accepted animal model of acute liver failure (ALF) induced by subtotal hepatectomy (92% removal of tissue) that produces ALF. This study was divided into three cohorts: (1) rats clinically monitored after hepatectomy every 6 h for 96 h or until death; (2) rats tested in an open-field task (OFT) before and after surgery and had blood, cerebrospinal fluid, and brain tissue collected after the last OFT; and (3) rats that had continuous EEGs recorded before and after surgery for 3 days. The hepatectomized rats presented significant motor behavioral changes accompanied by important abnormalities in classical blood laboratory parameters of ALF, and EEG features suggestive of HE and deep disturbances in the brain glutamatergic system. Using an animal model of ALF induced via subtotal hepatectomy, this work provides a comprehensive and reliable experimental model that increases the opportunity for studying the effects of new treatment strategies to be explored in an unprecedented way. It also presents insights into the pathophysiology of HE in a reproducible model of ALF, which correlates important neurochemical and EEG aspects of the syndrome., (Copyright © 2018 IBRO. Published by Elsevier Ltd. All rights reserved.)

Several biosimilar versions of enoxaparin are already approved and in use globally. Analytical characterization can establish good quality control in manufacturing, but they may not assure similarity in clinical outcomes between biosimilar and branded enoxaparin. This study evaluated the efficacy and safety of biosimilar Cristália versus branded Sanofi enoxaparin in venous thromboembolism (VTE) prevention in patients undergoing major abdominal surgery at risk for VTE. In this randomized, prospective single-blind study, we compared Cristália enoxaparin (Ce), a biosimilar version, versus branded Sanofi enoxaparin (Se; at a dose of 40 mg subcutaneously per day postoperatively from 7 to 10 days) in 243 patients submitted to major abdominal surgery at risk for VTE for VTE prevention. The primary efficacy outcome was occurrence of VTE or death related to VTE. The principal safety outcomes were a combination of major bleeding and clinically relevant non-major bleeding. Bilateral duplex scanning of the legs was performed from days 10 to 14, and follow-ups were performed up to 60 days after surgery. The incidence of VTE was 4.9% in the Cristália group and 1.1% in the Sanofi group (absolute risk difference = 3.80%, 95% confidence interval [CI]: -1.4%-9.0%) yielding noninferiority since the 95% CI does not reach the prespecified value Δ = 20%. Clinically significant bleeding occurred in 9.9% in the Cristália group and in 5.5% in the Sanofi group (n.s. ). In conclusion, this study suggests that 40 mg once daily of Ce, a biosimilar enoxaparin, is as effective and safe as the branded Sanofi enoxaparin in the prophylaxis of VTE in patients submitted to major abdominal surgery at risk for VTE.

Background: Pancreatic adenocarcinoma has a high mortality rate. A prognostic tool is essential for a better risk stratification. The neutrophil/lymphocyte ratio and adaptations and the platelet/lymphocyte ratio seem promising for this purpose., Aim: Evaluate the prognostic value of neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio, analyze the ideal cutoff values and investigate their utility in predicting resectability., Methods: Data were collected of patients with pancreatic adenocarcinoma in Hospital de Clínicas de Porto Alegre between 2003 and 2013. The studied ratios were determined by blood count collected at hospital admission and after two cycles of palliative chemotherapy., Results: Basal neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio did not have prognostic impact in survival (p=0.394, p=0.152, p=0.177 respectively). In subgroup analysis of patients submitted to palliative chemotherapy, neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio determined after two cycles of chemotherapy were prognostic for overall survival (p=0.003, p=0.009, p=0.001 respectively). The ideal cutoff values found were 4,11 for neutrophil/lymphocyte ratio (sensitivity 83%, specificity 75%), 2,8 for derived neutrophil/lymphocyte ratio (sensitivity 87%, specificity 62,5%) and 362 for platelet/lymphocyte ratio (sensitivity 91%, specificity 62,5%), Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were not able to predict resectability (p=0.88; p=0.99; p=0.64 respectively)., Conclusions: Neutrophil/lymphocyte ratio, derived neutrophil/lymphocyte ratio and platelet/lymphocyte ratio are useful as prognostic markers of overall survival in patients with pancreatic adenocarcinoma submitted to palliative chemotherapy. Its use as resectability predictor could not be demonstrated.

Neuroendocrine tumours are a heterogeneous group of diseases with a significant variety of diagnostic tests and treatment modalities. Guidelines were developed by North American and European groups to recommend their best management. However, local particularities and relativisms found worldwide led us to create Brazilian guidelines. Our consensus considered the best feasible strategies in an environment involving more limited resources. We believe that our recommendations may be extended to other countries with similar economic standards.

Acute liver failure is a complex and fatal disease. Cell-based therapies are a promising alternative therapeutic approach for liver failure due to relatively simple technique and lower cost. The use of semipermeable microcapsules has become an interesting tool for evaluating paracrine effects in vivo. In this study, we aimed to assess the paracrine effects of bone marrow mononuclear cells (BMMC) encapsulated in sodium alginate to treat acute liver failure in an animal model of 90% partial hepatectomy (90% PH). Encapsulated BMMC were able to increase 10-day survival without enhancing liver regeneration markers. Gene expression of Il-6 and Il-10 in the remnant liver was markedly reduced at 6 h after 90% PH in animals receiving encapsulated BMMC compared to controls. This difference, however, was neither reflected by changes in the number of CD68+ cells nor by serum levels of IL6. On the other hand, treated animals presented increased caspase activity and gene expression in the liver. Taken together, these results suggest that BMMC regulate immune response and promote apoptosis in the liver after 90% PH by paracrine factors. These changes ultimately may be related to the higher survival observed in treated animals, suggesting that BMMC may be a promising alternative to treat acute liver failure., Competing Interests: The authors have no conflict of interests to declare.

Background/objectives: Epigenetic deregulation may be involved in tumor cell biology, including differentiation, tumor progression, and cell death, and histone acetylation is a major regulatory mechanism of gene transcription. Patterns of global histone modifications have been recently suggested as outcome predictors in cancer patients, but few studies have been conducted on pancreatic ductal adenocarcinomas (PDACs). This study was designed to investigate the predictive value of histone acetylation modifications on PDAC., Materials and Methods: A retrospective clinicopathologic analysis was undertaken in 119 patients diagnosed with PDAC between 2005 and 2011, and immunohistochemistry performed with polyclonal antibodies against H4K12ac, H3K9ac, and H3K18ac. Positive nuclear staining for each histone was measured as the intensity and expression, being classified into low-staining or high-staining groups. Results were analyzed in relation to patients' clinicopathologic parameters., Results: There was a positive relationship between tumor differentiation and H4K12ac high scores (P<0.05) and staining with the 3 markers correlated positively with tumor stage (P<0.01). Univariate analysis showed worse survival in patients with high detection levels of H4K12ac (P=0.038) and H3K18Ac (P=0.033). A backwards Cox proportional hazards model analysis revealed the independent prognostic effect of high H4K12ac and H3K18ac levels (hazard ratios of 1.6 and 1.7, respectively, P<0.05), especially for patients at early stages of disease., Conclusions: We propose that acetylation of H4K12 and H3K18 may be considered valuable prognostic factors for pancreatic cancer, although the mechanism involved needs further investigation. Increasing insights into histone acetylation modifications can ultimately generate new ideas for rational and molecularly based diagnostic and therapeutic approaches.

Objectives: Pancreatic ductal adenocarcinoma (PDAC) is one of the most deadly cancers, and its diagnosis often requires invasive procedures. Deregulated miRNA expression has been described in patients with PDAC. In this study, we analyzed the expression levels of 6 miRNAs (miR-21, -34a, -155, -196a, -200b, and -376a involved in PDAC tumorigenesis) in serum and salivary samples to assess their potential role as circulating diagnostics biomarkers., Methods: Serum and salivary samples were collected from patients with PDAC and healthy controls, and miRNA levels were quantified using qRT-PCR. Twenty-four patients with PDAC and 10 healthy controls were recruited., Results: A significant difference between PDAC and healthy groups was observed for the expression of miR-21 and miR-34a (P < 0.001 and P = 0.001) in serum samples. Both miRNAs accurately discriminated between the 2 groups, with an area under the curve for miR-21 and miR-34a of 0.889 (P = 0.001) and 0.865 (P = 0.002), respectively. In general, the expression of miRNAs between salivary samples did not differ., Conclusions: Serum miR-21 and miR-34a are potentially useful diagnostic biomarkers of PDAC. In addition, our results suggest that these miRNAs are not differentially expressed in saliva, making them unsuitable for use as noninvasive biomarkers for diagnostic purposes.

Objectives: Extracellular purines are a component of the systemic inflammatory response, and their levels are modulated by ectonucleotidases. In addition, nucleotide hydrolysis releases phosphate. We studied serum phosphate levels as a predictor of severity in acute pancreatitis (AP) and their correlation with extracellular purinergic metabolism., Methods: Acute pancreatitis was induced by the retrograde injection of sodium taurocholate. The AP group was compared with animals submitted to a model of sepsis by cecal ligation and puncture. The sham group was submitted to laparotomy and closure. We measured the phosphate and purine levels in serum and the expression of 5'-nucleotidase (CD73) and the adenosine A2a receptor in pancreatic tissue by quantitative real-time polymerase chain reaction., Results: Serum phosphate levels were higher in severe AP and correlated with severity. Severe AP led to increased serum levels of adenosine diphosphate, adenosine monophosphate, and adenosine. In addition, adenosine monophosphate conversion to adenosine in serum was accelerated in the AP groups. We found a positive correlation between serum adenosine and phosphate in the AP groups. The expression levels of CD73 and the adenosine A2a receptor in the pancreas were not altered., Conclusions: Our study suggests that serum phosphate correlates with severity in AP and implicates extracellular purines in the systemic response to severe AP.

Periampullary neoplasms are rapidly progressive tumors with a poor prognosis and high morbidity and mortality rates, which have a negative influence on patient outcomes. Some probiotics and prebiotics have the ability to protect the intestinal barrier and prevent bacterial translocation, infection, and postoperative complications. We evaluated the use of synbiotics in a prospective, double-blind study of patients undergoing surgery for periampullary neoplasms (PNs) and assessed the effect of these agents on nutritional status, postoperative complications, antibiotic use, length of hospital stay, and mortality. Patients were randomized to receive probiotics and prebiotics-synbiotics--group S [Lactobacillus acidophilus 10, 1 × 10(9)CFU, Lactobacillus rhamnosus HS 111, 1 × 10(9) CFU, Lactobacillus casei 10, 1 × 10(9) CFU, Bifidobacterium bifidum, 1 × 10(9)CFU, and fructooligosaccharides (FOS) 100 mg]--or placebo-controls--group C, twice daily, for a total of 14 days. Risk, clinical status, and postoperative complication rates were assessed. Twenty-three patients were allocated to each group. The incidence of postoperative infection was significantly lower in group S (6 of 23 patients, 26.1%) than in group C (16 of 23 patients, 69.6%) (P = 0.00). Duration of antibiotic therapy was also shorter in group S (mean = 9 days vs. 15 days in group C; P = 0.01). Noninfectious complications were less common in group S (6 of 23 vs. 14 of 23 patients in group C; P = 0.03). Mean length of hospital stay was 12 ± 5 days in group S vs. 23 ± 14 days in group C (P = 0.00). No deaths occurred in group S, whereas 6 deaths occurred in group C (P = 0.02). Perioperative administration of synbiotics reduces postoperative mortality and complication rates in patients undergoing surgery for PNs.

TP53 mutation is a common event in many cancers, including pancreatic adenocarcinoma, where it occurs in 50-70 % of cases. In an effort to reactivate mutant p53 protein, several new drugs are being developed, including PRIMA-1 and PRIMA-1(Met)/APR-246 (p53 reactivation and induction of massive apoptosis). PRIMA-1 has been shown to induce apoptosis in tumor cells by reactivating p53 mutants, but its effect in pancreatic cancer remains unclear. Here we investigated the effects of PRIMA-1 on cell viability, cell cycle and expression of p53-regulated proteins in PANC-1 and BxPC-3 (mutant TP53), and CAPAN-2 (wild-type TP53) pancreatic cell lines. Treatment with PRIMA-1 selectively induced apoptosis and cell cycle arrest in p53 mutant cells compared to CAPAN-2 cells. The growth suppressive effect of PRIMA-1 was markedly reduced in p53 mutant cell lines transfected with p53 siRNA, supporting the role of mutant p53 in PRIMA-1 induced cell death. Moreover, treatment with the thiol group donor N-acetylcysteine completely blocked PRIMA-1-induced apoptosis and reinforced the hypothesis that thiol modifications are important for PRIMA-1 biological activity. In combination treatments, PRIMA-1 enhanced the anti-tumor activity of several chemotherapic drugs against pancreatic cancer cells and also exhibited a pronounced synergistic effect in association with the Mdm2 inhibitor Nutlin-3. Taken together, our data indicate that PRIMA-1 induces apoptosis in p53 mutant pancreatic cancer cells by promoting the re-activation of p53 and inducing proapoptotic signaling pathways, providing in vitro evidence for a potential therapeutic approach in pancreatic cancer.

Background: Long-term insulin independence after islet transplantation depends on engraftment of a large number of islets. However, the yield of pancreatic islets from brain-dead donors is negatively affected by the up-regulation of inflammatory mediators. Brain death is also believed to increase tissue factor (TF) expression, contributing to a low rate of engraftment., Methods: We conducted a case-control study to assess brain death-induced inflammatory effects in human pancreas. Seventeen brain-dead patients and 20 control patients undergoing pancreatectomy were studied. Serum tumor necrosis factor (TNF), interleukin (IL) 6, IL-1β, interferon (IFN) γ, and TF were measured using enzyme-linked immunosorbent assay kits. Gene expressions of these cytokines and TF were evaluated by reverse transcriptase quantitative polymerase chain reaction. Protein quantification was performed by immunohistochemistry in paraffin-embedded pancreas sections., Results: Brain-dead patients had higher serum concentrations of TNF and IL-6 and increased TNF protein levels compared to controls. The groups had similar TNF, IL-6, IL-1β, and IFN-γ messenger RNA levels in pancreatic tissue. Reverse transcriptase quantitative polymerase chain reaction revealed TF messenger RNA up-regulation in controls. Immunohistochemical analyses showed that brain-dead patients had increased TNF protein levels compared to controls., Conclusions: Brain death induces inflammation evidenced by the up-regulation of TNF in serum and pancreatic tissue. Blocking the expression of key inflammatory mediators in brain-dead donors should be evaluated as a new approach to improve the outcomes of islet transplantation.

Purpose: To evaluate the influence of the anesthetic regimen on anesthetic recovery, survival, and blood glucose levels following a 90% partial hepatectomy in rats., Methods: Thirty adult male Wistar rats were divided into two groups according to their anesthetic regimens: intraperitoneal ketamine and xylazine or inhaled isoflurane. In order to prevent hypoglycemia, glucose was administered intraperitoneally and glucose (20%) was added to the drinking water., Results: Anesthetic recovery time was longer in the ketamine and xylazine group. The survival rate after 72 hours was lower (log rank=0.0001) in the ketamine and xylazine group (0.0%) than in the isoflurane group (26.7%). The blood glucose after six hours was lower (p=0.017) in the ketamine and xylazine group (63 ± 31.7 mg/dL) than in the isoflurane group (98 ± 21.2 mg/dL). The prolonged anesthesia recovery time associated with ketamine and xylazine decreased the survival rate and blood glucose levels after 90% hepatectomy., Conclusion: Isoflurane anesthesia reduced the recovery time and incidence of hypoglycemia and increased the survival rate in the early hours, providing a therapeutic window that is suitable for experimental studies.

Objective: To evaluate the effects of the use of gadolinium chloride before and after induction of acute pancreatitis with sodium taurocholate 3% in rats., Methods: Wistar rats were divided into five groups: SF--control with saline intra-ductal and IV; GD control with saline intra-ductal and gadolinium chloride IV; TS--with AP control induced by sodium taurocholate 3% and saline IV; GDTS--pre-treatment with GD (24 hours before the induction of AP) and TSGD--treatment with GD (1 hour after the induction of AP). Analysis was made in serum amylase, transaminases and TNF-α; determination of the MPO activity in lung tissue, lung and pancreatic histology., Results: The number of dead animals before the end of the experiment was significantly higher in TSGD (P = 0.046). The scores of pancreatitis and lung damage were higher in the groups that used sodium taurocholate compared to groups with intra-ductal infusion of saline solution. There were no differences in other variables studied when comparing TS, GDTS and TSGD groups., Conclusion: The benefits with the use of gadolinium chloride as a prophylactic and therapeutic drug were not demonstrated.

Objectives: To evaluate the effects of nicotine and cigarette smoke exposure on mice submitted to 7,12-dimethylbenzanthracene (DMBA) model of pancreatic carcinogenesis., Methods: One hundred fourteen male mice were divided into the DMBA-n and DMBA-s groups: the DMBA-n group was given 2 mg/kg per dose of nicotine ([3-(1-methyl-2-pyrrolidinyl)pyridine]) subcutaneously for 45 days, and the DMBA-s group was exposed to 100 mg/m of cigarette smoke. At day 16, 1 mg of DMBA crystals was implanted in the pancreatic head of both groups. Euthanasia was performed in all mice 30 days after the surgery. The specimens were evaluated according to the following criteria: normal ducts, reactive hyperplasia, pancreatic intraepithelial neoplasm 3 (PanIN-3), and carcinoma. For statistical analysis, DMBA-exclusive ([DMBA-e] historical control group) was included., Results: The frequency of PanIN in the 3 groups was almost the same when considering the higher-grade lesions: DMBA-e (16 [66.7%]), DMBA-s (20 [66.7%]), and DMBA-n (12 [44.4%]). Pancreatic adenocarcinoma has a higher frequency in the DMBA-n group (14 [51.9%]) than in the DMBA-e (4 [16.7%]) and DMBA-s (4, 13.3%) groups. The DMBA-s group has the highest score of PanIN-3 (40%). The differences among the groups were statistically significant (P = 0.05, Fisher exact test)., Conclusions: Nicotine but not cigarette smoke promotes pancreatic DMBA carcinogenesis in mice. Pancreatic adenocarcinomas and PanINs have the same phenotypic appearance as those that occur in humans.

Hernias occurring through the foramen of Winslow are extremely rare (accounting for only 8% of all internal hernias and 0.08% of all hernias) and are seldom diagnosed preoperatively. A delay in treatment is responsible for high mortality rates of around 36% to 49%. Successful management requires prompt diagnosis and surgical treatment.

Objective: To study the effects of hyperbaric oxygen therapy on tissue lesions in an experimental model of acute pancreatitis induced by pancreatic duct ligation., Animals: Forty-eight adult female Wistar rats were randomized into two groups (n=24): control group and hyperbaric oxygen therapy group., Intervention: The second group was treated with a two-hour daily session of hyperbaric oxygen therapy at 2.5 ATA started 6 hours after pancreatic duct ligation., Setting: The two groups were divided into 3 subgroups of 8 rats each undergoing euthanasia on days 1, 3, and 7 after the acute pancreatitis induction., Main Outcome Measures: The pancreas was evaluated according to the following histopathologic criteria: edema, hemorrhage, acinar necrosis and leukocyte infiltration., Results: Hyperbaric oxygen therapy was efficient in significantly reducing acinar necrosis on the first day (P=0.049) and the foci of hemorrhage on the seventh day (P=0.050). The edema and leukocyte infiltration did not show the expected reduction., Conclusion: The utilization of a daily session of hyperbaric oxygen therapy at 2.5 ATA is efficient in reducing the hemorrhage and acinar necrosis but is not sufficient to reduce edema and leukocyte infiltration.

Objectives: Call attention of the gastroenterologists and surgeons on the patients with high risk of developing pancreatic carcinoma, and whether or not forms of surveillance and prevention of this disease, which can be applied to daily clinical practice. DATA SURVEY: It was used the database of PubMed (US National Library of Medicine), looked up the publications of recent years for the groups at risk, molecular biological testing and methods of image used in the identification of small tumors of the pancreas., Background: The survival rates of adenocarcinoma of the pancreas remain negligible, even after the significant advances in diagnosis by imaging, treatment and understanding of the molecular biology of this disease. Although embryonic strategies for surveillance and prevention for people with high risk of pancreatic cancer has developed., Conclusions: This review summarizes how to identify people at high risk of developing this disease and what is the state of the art of genetic counseling and screening through techniques of image available.

Purpose: To evaluate the effects of alcohol and caffeine in a pancreatic carcinogenesis mouse model induced by 7,12-dimethylbenzantracene (DMBA), according to the PanIN classification system., Methods: 120 male, Mus musculus, CF-1 mice were divided into four groups. Animals received either water or caffeine or alcohol or alcohol + caffeine in their drinking water. In all animals, 1 mg of DMBA was implanted into the head of the pancreas. After 30 days, euthanasia was performed; excised pancreata were then fixed in formalin, stained with hematoxylin-eosin and categorized as follows: normal ducts, reactive hyperplasia, PanIN-1A, PanIN-1B, PanIN-2, PanIN-3 or adenocarcinoma., Results: PanIN lesions were verified in all groups. Adenocarcinoma was detected in 15% of animals in the caffeine group, 16.6% in the water group, 23.8% in the alcohol + caffeine group and 52.9% in the alcohol group (P<0.05)., Conclusions: The experimental pancreatic carcinogenesis mouse model using DMBA effectively induces PanIN lesions and pancreatic adenocarcinoma. This study verified the association between alcohol use and pancreatic adenocarcinoma; caffeine did not present the same effect.

Background: Pancreatic ductal adenocarcinoma has a poor long-term prognosis. Experimental models are necessary to understand not only its biologic behavior, but also the early pancreatic lesions known as pancreatic intraepithelial neoplasia (PanIN) and to develop new treatments. The aim of this study was to evaluate pancreatic carcinogenesis induced by 7,12-dimethyl-1,2-benzanthracene (DMBA) implantation in mice according to the PanIN classification system., Methods: Ninety male, Mus musculus, CF-1 mice underwent a median laparotomy and 1 mg of DMBA was implanted into the proximal pancreas held in place by a purse-string suture. Mice were killed after 30 and 60 days after which the excised pancreata were fixed in formalin, embedded in paraffin, and stained with hematoxylin-eosin for histologic analysis. The specimens were evaluated blind by 2 pathologists for the presence of the following histology: normal ducts, reactive hyperplasia, PanIN-1A, PanIN-1B, PanIN-2, and PanIN-3, and adenocarcinoma., Results: In the 30-day group, pathologic evaluation showed 4 (17%) reactive hyperplasia, 16 (67%) PanIN lesions, and 4 (17%) adenocarcinomas. In the 60-day group, there were 10 (27%) specimens with reactive hyperplasia, 13 (35%) with PanIN lesions, and 14 (38%) with adenocarcinomas. The difference between groups was statistically significant (P<.05). All pancreata with adenocarcinoma had concomitant PanIN lesions., Conclusions: The DMBA experimental model in mice induces PanIN lesions and ductal adenocarcinoma that have similar histology to that of human pancreatic cancer. This model may be useful for study of pancreatic carcinogenesis, particularly the molecular progression of early pancreatic ductal lesions.

Purpose: To present the authors experience managing anular pancreas and to compare the results found by the authors with the ones found in the literature., Methods: A retrospective review of four patients treated at the Departamento de Cirurgia da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul with anular pancreas. The disease was present in three different ages: one in the neonatal age, one in childhood and two in the adulthood. Gastroduodenal obstructive symptoms were the most common. Abdominal pain was present in adult patients. The diagnostic investigation began with radiological studies such as upper gastrointestinal barium series, upper endoscopy and abdominal computed tomographic scan, although all the diagnoses required surgery for confirmation. The duodenoduodenostomy was the treatment of choice in the pediatric patients, and division of the anulus was carried out in the adults., Results: All patients had symptomatic relief and postoperative recovery. The hospital stay ranged from 9 to 12 days (median 10.5 days). There were no postoperative complications. All patients remain asymptomatic up to now., Conclusion: The rare condition of anular pancreas does not allow a more detailed and comparative study. The results of the authors showed that both gastrointestinal by-pass and division of the pancreas are effective and safe treatments.

Objective: To characterize nuclei from pancreatic adenocarcinoma and nonneoplastic pancreatic tissue by digital karyometry, demonstrating specific nuclear signatures for each of them., Study Design: Of cells from malignant and nonmalignant pancreatic tissue, 1,300 nuclei were assessed by digital karyometry from paraffin blocks stored at the Pathology Service of Hospital de Clinicas de Porto Alegre. A set of 40 features descriptive of the spatial and statistical distribution of nuclear chromatin was computed for each nucleus. Signatures were created for both types of tissue, and a distance metric from "normal" was defined and calculated for them., Results: There were significant differences in 11 features between the 2 groups, allowing the creation of digital signatures., Conclusion: Nuclear chromatin texture signature can offer a specific digital characterization for both pancreatic adenocarcinoma and nonmalignant pancreatic tissue. Several isolated nuclear features serve as markers for the diagnosis of pancreatic adenocarcinoma. The present karyometric study of normal and malignant pancreatic tissue may be of use as a continuing tool to early diagnosis of pancreatic adenocarcinoma as it can be applied to cytologic specimens, also. In the future, studies using this technique should assess the chemopreventive potential of different agents as well as prognosis and treatment options for pancreatic adenocarcinoma.

There are a few prospective studies assessing the severity of acute pancreatitis with exclusive criteria for biliary etiology. In a cohort prospective study, Ranson (biliary etiology), Glasgow-modified, APACHE-II, and APACHE-O prognostic criteria were assessed in 65 patients with acute biliary pancreatitis (ABP). Local complications such as necrosis with fluid peripancreatic collection (3 patients), fluid collection with pancreas enlargement (3 patients), pancreatic fistula (1 patients), and pancreatic pseudocyst (1 patients); and organic failure such as renal (5 patients), hemodynamic (3 patients), and respiratory (3 patients) were found. The prognostic criteria performance, according to parameter number or positive variables evidenced that relative risk (RR) varied from 4.7 to 11.2, sensibility from 33.3% to 83.3%, specificity from 79.2% to 98.1%, positive predictive value from 45.0% to 83.3%, negative predictive value from 86.4% to 95.5%, and accuracy from 78.5% to 89.6%. In isolation, most important parameters correlated to severity included white blood cell count >18,000/mm3, lactate dehydrogenase (LDH) >400 UI/l, 10% drop of the hematocrit, serum calcium <8 mg/dl, increase of urea nitrogen >2 mg/dl, aspartate aminotransferase (AST) >200 mg/dl, LDH >600 UI/l, white blood cell count >15,000/mm3, urea >45 mg/dl, arterial pH < or = 7.33 or > or = 7.49, creatinin < or = 0.6 or > or = 1.4, hematocrit < or = 30 or > or = 45.9, white blood cell count < or = 3,000/mm3 or > or = 14,900/mm3. Ranson, Glasgow-modified, APACHE-II, and APACHE-O acute biliary pancreatitis severity criteria all present good sensibility and excellent specificity.

Squamous cell carcinoma of the esophagus is endemic in Rio Grande do Sul, the most southern state of Brazil, where the incidence reaches 27 out of 100,000 inhabitants per year. Palliative treatments, surgical or nonsurgical, impose lower mortality and lower costs. The choice of the best treatment for each patient depends on the neoplasia staging, and the local involvement of the tracheobronchial tree by tumor characterizes incurability. Computed axial tomography (CAT) is indicated, but remarkable contradictions were found in the literature. We studied 134 patients, diagnosed with esophageal squamous cell carcinoma, who underwent computed tomography and fiberoptic bronchoscopy (gold standard) performed with an uniform technique. An accuracy of 85.1% was obtained when computed tomography was compared with bronchoscopy with regard to impingement, displacement and invasion of trachea and bronchi. In conclusion, there is no statistically significant difference between computed tomography and fiberoptic bronchoscopy in the evaluation of tracheobronchial involvement by squamous cell carcinoma of the esophagus (p < 0.05).

Wandering spleen is seldom seen in everyday situations, and its prevalence is not well defined in the literature. Its causes are not precisely known, and there is controversy over its management. A 34-year-old woman experienced low-intensity abdominal pain associated with a palpable hypogastric mass, which was confirmed by imaging studies to be a wandering spleen. Because of ureteral compression, a surgical approach was decided upon, and videolaparoscopic splenectomy was chosen. This technique, comments about specific technical issues, and other treatment options presented in the literature are discussed. Videolaparoscopic splenectomy has excellent surgical results, both functional and aesthetic.