Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper

BACKGROUND

Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries.

AIM

This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings.

METHODS

Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval.

RESULTS

ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection.

CONCLUSIONS

Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.

Early enteral nutrition with fructooligosaccharides improves prognosis in severe acute pancreatitis

Soluble dietary fiber, notably as an adjunct to early enteral nutrition (EEN), is gaining prominence in clinical therapy. This study evaluates the effect of fructooligosaccharides (FOS), a new soluble dietary fiber, on the prognosis of patients with severe acute pancreatitis (SAP). In a retrospective cohort study at the Third Xiangya Hospital of Central South University from July 2017 to July 2023, 110 SAP patients were analyzed. TPF (enteral nutritional suspension of total protein)-normal and TPF-FOS groups both received standard EEN solutions; the latter additionally received FOS. Outcomes were compared between the groups. The study included 37 patients in the TPF-FOS group and 73 patients in the TPF-normal group. Mortality was 13.50% in the TPF-FOS group and 34.20% in the TPF-normal group (P < 0.05). FOS was identified as an independent protective factor (OR: 0.826, P = 0.041). The TPF-FOS group showed lower rates of intra-abdominal infection and decreased the level of inflammation (P < 0.05). FOS potentially acts as an independent protective factor against death in SAP. Additionally, the supplementation of EEN with FOS may contribute to reducing mortality and improving the prognosis of SAP patients.

Microbial dynamics of acute pancreatitis: integrating culture, sequencing, and bile impact on bacterial populations and gaseous metabolites

Background

Our study examined the composition of the intestinal microflora in a hospitalized patient with AP symptoms treated several months earlier for diverticulitis. The therapeutic intervention necessitated Hartmann's procedure, culminating in colostomy creation.

Aims

Employing a thorough microbiological analysis we attempted to demonstrate whether the microflora isolated from the peripancreatic fluid exhibited a stronger correlation with the contents of the stoma or with the rectal swab. Additionally, we sought to determine the association between later onset of AP and diverticulitis.

Methods

Following clinical materials from the patient in the initial phase of AP were collected: rectal swab, colostomy bag contents (in the publication referred to as stoma content/stool) and peripancreatic fluid. Microbiological analysis was performed, including classic culture methodology, NGS techniques, and genotyping methodologies. Furthermore, the effect of bile on the shift in the population of selected bacterial species was examined.

Results

The NGS technique confirmed greater consistency in bacteria percentage (phyla/family) between stoma content and peripancreatic fluid. In both samples, a clear dominance of the Proteobacteria phyla (over 75%) and the Enterobacteriaceae family was demonstrated. Moreover, NGS verified the presence of the Fusobacteriota phylum and Fusobacteriaceae family only in rectal swabs, which may indicate a link between this type of bacteria and the etiology of diverticulitis. We observed that Escherichia coli 33 isolated from stool exhibited active gaseous metabolite production (mainly hydrogen).

Conclusions

The abundant production of hydrogen may substantially impact enzymatic processes, inducing specific alterations in disulfide bonds and trypsin inactivation. Our investigation alludes to the conceivable active involvement of bile in effecting qualitative and quantitative modifications in the peripancreatic microbiota composition, establishing a correlation between released bile and bacterial generation of gaseous metabolites.

Construction and interpretation of weight-balanced enhanced machine learning models for predicting liver metastasis risk in colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is a major contributor to cancer-related mortality, with liver metastases developing in approximately 25% of affected individuals. The presence of liver metastasis significantly deteriorates the prognosis for patients. The objective of this study is to predict liver metastasis in CRC patients by developing machine learning (ML)-based models, thereby aiding clinicians in the decision-making process for appropriate interventions.

METHODS

Retrospective analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database, and cases with CRC from 2010 to 2015 were extracted to the downstream analysis. Logistic regression (LR), Random Forest (RF), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Categorical Boosting (CatBoost), and LightGBM are applied to develop machine learning (ML) models to predict liver metastasis of CRC patient. To optimize the models, an improved weight-balancing algorithm was employed, enhancing the performance of the classifiers. The six models were tenfold cross-validated, and the optimal model was selected based on a combination of performance metrics. Shapley additive explanation (SHAP) was utilized to interpret the best-performing ML models globally, locally, and interactively. To ensure the model's reliability and generalizability, an external validation cohort of CRC cases from 2018 to 2021, obtained from a separate SEER database, was used for external evaluation.

RESULTS

In total, 50,062 patients with CRC were included in the analysis, with 5604 patients occurring liver metastasis. Among the six models evaluated, the CatBoost model showed excellent performance with the highest AUC of 0.8844. Moreover, the CatBoost model also outperformed the others in terms of recall (0.8060) and F1-score (0.6736). SHAP-based summary and force plots were used to interpret the CatBoost model. The interpretability analysis revealed that elevated carcinoembryonic antigen (CEA) levels, systemic therapy, N and T stages, and chemotherapy performed were the most significant indicators for predicting liver metastasis according to the optimal model. Furthermore, systemic therapy was suggested to increase liver metastasis risk in N0 stage patients, while it appeared to be beneficial in patients with lymph node metastasis. Preoperative radiation therapy was found to be more effective than postoperative radiation therapy. Validation using an external cohort of CRC cases from 2018 to 2021 further confirmed the robustness and stability of the CatBoost model, as its overall performance remained consistent with the internal validation results.

CONCLUSION

Elevated levels of carcinoembryonic antigen (CEA) have been identified as a crucial clinical predictor for liver metastasis in CRC patients. Furthermore, the administration of systemic therapy to patients who do not exhibit lymph node involvement has been found to increase the risk of liver metastasis. In terms of radiation therapy, preoperative radiation appears to be more efficacious in controlling the risk of liver metastasis compared to postoperative radiation. This finding underscores the importance of optimizing treatment strategies based on the specific clinical context and patient characteristics.

Predictive Value of Several Parameters for Severity of Acute Pancreatitis in a Cohort of 172 Patients

Background: The optimal management of patients with acute pancreatitis is directly related to the early detection of the mild, moderate, or severe forms of the disease, which remains a continuous challenge despite the availability of various severity scores. The aim of this study was to identify prognostic factors with the highest predictive value specific to the local patients and elaborate the score to identify the severe cases. Materials and Methods: A retrospective observational cohort study included 172 patients diagnosed with acute pancreatitis. Personal, clinical, laboratory, and imaging factors and their influence on the severity of acute pancreatitis were evaluated. Results: Etiology nonA-nonB (any etiology except unique alcoholic or biliary etiology), presence of diabetes mellitus, the pain Visual Analogue Scale (VAS), White Blood Cells (WBCs), and CRP (C-reactive protein) levels were found to be directly associated with the severity of acute pancreatitis (AP). Prediction scores were calculated to estimate disease severity using the following regression equations: Prediction Acute Pancreatitis Severity (PAPS) score I = 1.237 + 0.144 × nonA-nonB (0 = no, 1 = yes) + 0.001 × WBC1 + 0.027 × VAS0 and PAPS score II = 1.189 + 0.001 × CRP (mg/L) + 0.135 × nonA-nonB etiology (0 = no, 1 = yes) + 0.025 × VAS0 - 0.047 × CA1. The PAPS Score II demonstrated the best performance. At a cut-off value of 1.248, the score had 80% sensitivity, 80.9% specificity, a positive predictive value (PPV) of 28.6%, a negative predictive value (NPV) of 97.7%, and an accuracy of 80.8%. For a cut-off value of 221.5 mg/L, the accuracy of CRP was 81.4% for predicting severe AP. Conclusions: The PAPS score II is an easy-to-use, fast, and affordable score for determining cases of severe disease for patients diagnosed with AP.

Cumulative Incidence of Mortality Associated with Cardiovascular-Kidney-Metabolic (CKM) Syndrome

Key Points

Background

It is imperative to critically evaluate the prognostic implications of cardiovascular–kidney–metabolic (CKM) syndrome staging to inform clinical practice. The primary aims of this study were to define the risk of mortality associated with each CKM syndrome stage and to determine the corresponding restricted mean survival time over a 15-year period.

Methods

This was a longitudinal study of 50,678 community-dwelling US adults aged 20 years and older with baseline data for CKM stage determination participating in the 1999–2018 National Health and Nutrition Examination Survey. CKM stages were defined according to the American Heart Association presidential advisory. Fifteen-year adjusted cumulative incidences of cardiovascular mortality were calculated for each stage from confounder-adjusted survival curves using the G-formula.

Results

Over a median 9.5-year follow-up, 2564 participants experienced cardiovascular death. The 15-year adjusted cumulative incidences of cardiovascular mortality were stage 0, 5.5% (95% confidence interval [CI], 1.8 to 9.3); stage 1, 5.7% (95% CI, 3.2 to 8.2); stage 2, 7.9% (95% CI, 6.8 to 9.1); stage 3, 8.7% (95% CI, 6.7 to 10.8); and stage 4, 15.2% (95% CI, 13.6 to 16.8). The absolute risk difference between CKM stage 4 and stage 0 at 15 years was 9.6% (95% CI, 5.6 to 13.6). The survival difference between CKM stage 0 and stage 4 at 15 years was 8.1 (95% CI, 8.0 to 8.2) months.

Conclusions

Our findings reveal a graded risk of cardiovascular mortality associated with higher CKM syndrome stage.

Artificial intelligence in gynecologic and obstetric emergencies

BACKGROUND

Artificial intelligence (AI) uses a process by which machines perform human-like functions such as automated clinical decisions. This may operate efficiently in gynecologic and obstetric emergencies. We aimed to review the role and applications of AI in gynecologic and obstetric emergencies.

METHODS

A literature search was carried out in November 2023 in PubMed, Cochrane Library and Google Scholar using the keywords combination of "artificial intelligence, gynecology and obstetrics". Relevant articles were selected and read. Reference lists of the selected articles were also searched.

RESULTS

The literature demonstrated the role of AI to improve healthcare in emergency settings in several aspects such as diagnostic imaging, improving predictions in emergencies, and improving planning and resource allocation for emergency services. AI works objectively, overcoming human biases in decision-making. Creating interconnected data registries for AI will likely enhance its performance. Validation research in emergency settings has shown that AI-prediction tools perform more accurately compared with the estimation of risk and outcomes by gynecologists and obstetricians in emergency situations including endometriosis and acute abdominal pain. There was acceptance of AI and its potential benefits. Ethical dilemmas of using AI include data governance, responsibility for errors, and security issues. Providing training on AI to healthcare professionals working in emergency departments is needed.

CONCLUSIONS

Healthcare professionals should educate themselves about the anticipated role of AI in gynecologic and obstetric emergencies, its indications, limitations, and ethical considerations so that they can take steps towards its application in their future practice using defined guidelines.

Adoption of Artificial Intelligence in Rehabilitation: Perceptions, Knowledge, and Challenges Among Healthcare Providers

BACKGROUND/OBJECTIVES

The current literature reveals a gap in understanding how rehabilitation professionals, such as physical and occupational therapists, perceive and prepare to implement artificial intelligence (AI) in their practices. Therefore, we conducted a cross-sectional observational study to assess the perceptions, knowledge, and willingness of rehabilitation healthcare providers to implement AI in practice.

METHODS

This study was conducted in Saudi Arabia, with data collected from 430 physical therapy professionals via an online SurveyMonkey questionnaire between January and March 2024. The survey assessed demographics, AI knowledge and skills, and perceived challenges. Data were analyzed using Statistical Package for the Social Science (SPSS 27) and DATAtab (version 2025), with frequencies, percentages, and nonparametric tests used to examine the relationships between the variables.

RESULTS

The majority of respondents (80.9%) believed that AI would be integrated into physical therapy in future, with 78.6% seeing AI as significantly impacting their work. While 61.4% thought that AI would reduce workload and enhance productivity, only 30% expressed concerns about AI endangering their profession. A lack of formal AI training has commonly been reported, with social media platforms being respondents' primary source of AI knowledge. Despite these challenges, 85.1% expressed an eagerness to learn and use AI. Organizational preparedness was a significant barrier, with 45.6% of respondents reporting that their organizations lacked AI strategies. There were insignificant differences in the mean rank of AI perceptions or knowledge based on the gender, years of experience, and qualification degree of the respondents.

CONCLUSIONS

The results demonstrated a strong interest in AI implementation in physical therapy. The majority of respondents expressed confidence in AI's future utility and readiness to incorporate it into their practice. However, challenges, such as a lack of formal training and organizational preparedness, were identified. Overall, the findings highlight AI's potential to revolutionize physical therapy while underscoring the necessity to address training and readiness to fully realize this potential.

C-reactive protein to serum calcium ratio as a novel biomarker for predicting severity in acute pancreatitis: a retrospective cross-sectional study

Background

Acute pancreatitis (AP) is a prevalent gastrointestinal emergency with a wide spectrum of clinical outcomes, varying from mild cases to severe forms. The early identification of high-risk patients is essential for improving prognosis. However, the predictive and prognostic potential of the C-reactive protein to serum calcium ratio (CCR) in AP has not been investigated. This study aims to explore the association between CCR and disease severity in patients with AP.

Methods

This retrospective cross-sectional study included 476 AP patients. The CCR was calculated from C-reactive protein and serum calcium levels within the first 24 h of admission. Multivariable logistic regression models were used to evaluate the relationship between CCR and AP severity, with restricted cubic spline analysis and receiver operating characteristic (ROC) analysis to assess dose-response and predictive performance, respectively.

Results

Of the 476 patients, 176 (37%) had mild acute pancreatitis (MAP) and 300 (63%) had moderate to severe AP. The CCR distribution had a median value of 17.5, with an interquartile range (IQR) of 3.0 to 60.2. Each unit increase in CCR was associated with a 7% increase in the risk of developing moderate to severe AP (OR: 1.07; 95% CI: 1.06-1.09). In fully adjusted models, this association remained statistically significant. The area under the curve (AUC) for CCR in predicting moderate to severe AP was 86.9%, with a sensitivity of 73.7% and specificity of 89.2%.

Conclusion

The CCR measured within the first 24 h of admission shows promise as a valuable biomarker for predicting the severity of AP. However, further multicenter prospective cohort studies are needed to confirm its clinical utility and investigate its role in improving treatment strategies and patient management.

Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis

OBJECTIVE

Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA.

DESIGN

Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ2 test, Mann-Whitney-U-test and log-rank test for survival.

RESULTS

Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable.

CONCLUSIONS

The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

Clinical risk factors for sarcopenia in acute and chronic pancreatitis

BACKGROUND

Sarcopenia is common in chronic pancreatitis (CP) and has been associated with unfavorable outcomes; however, it is not well studied in acute pancreatitis (AP).

AIMS

To evaluate risk factors for sarcopenia among individuals with AP or CP.

METHODS

A cross sectional analysis was performed among subjects with AP or CP seen in a tertiary care Pancreas Clinic. TeraRecon software was used to calculate the cross-sectional area of skeletal muscle, visceral fat, and subcutaneous fat at the level of the L3 vertebrae. Sarcopenia was classified using sex-specific skeletal muscle index. Univariate and multivariate logistic regressions were performed to assess differences between groups and associations with sarcopenia.

RESULTS

A total of 49 subjects with AP and 54 subjects with CP were included. Sarcopenia was more frequently observed in CP compared to AP (83.3% vs. 46.9%, p < 0.001). The multivariate logistic regression demonstrated CP, male sex, increased age, and decreased subcutaneous fat were independently associated with sarcopenia.

CONCLUSION

Sarcopenia is observed in both CP and AP. In addition to traditional risk factors (including male sex, older age, and decreased subcutaneous fat), CP is independently associated with sarcopenia. Further investigations are necessary to gain deeper insights into sarcopenia pathogenesis, which could inform potential intervention strategies.

Examining inclusivity: the use of AI and diverse populations in health and social care: a systematic review

BACKGROUND

Artificial intelligence (AI)-based systems are being rapidly integrated into the fields of health and social care. Although such systems can substantially improve the provision of care, diverse and marginalized populations are often incorrectly or insufficiently represented within these systems. This review aims to assess the influence of AI on health and social care among these populations, particularly with regard to issues related to inclusivity and regulatory concerns.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six leading databases were searched, and 129 articles were selected for this review in line with predefined eligibility criteria.

RESULTS

This research revealed disparities in AI outcomes, accessibility, and representation among diverse groups due to biased data sources and a lack of representation in training datasets, which can potentially exacerbate inequalities in care delivery for marginalized communities.

CONCLUSION

AI development practices, legal frameworks, and policies must be reformulated to ensure that AI is applied in an equitable manner. A holistic approach must be used to address disparities, enforce effective regulations, safeguard privacy, promote inclusion and equity, and emphasize rigorous validation.

Urgent Endoscopic Biliary Procedures: "Run Like the Wind"?

Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.

β-galactosidase-activated red fluorescent probe assists in the diagnosis of pancreatitis

Acute pancreatitis (AP) is an acute inflammatory disease resulting from abnormal digestion of itself and surrounding organs by pancreatic enzymes caused by a variety of pathogenic factors. When the tissue of a biological organism is afflicted with pancreatitis and experiences swelling, bleeding, and necrotic injuries, the abnormal expression of β-galactosidase (β-Gal) activity becomes one of the main indicators for assisting in the diagnosis of pancreatitis. In this study, a highly specific red fluorescent probe designed for the detection of β-Gal activity has been developed. β-galactoside is used as the enzyme activating group, and the long-wavelength luminescent water-soluble organic molecule NBDOH is used as the luminophore to construct the fluorescent probe NBD-gal. NBD-gal is activated by abnormally overexpressed β-Gal, releasing a strong red fluorescent signal. The new fluorescent probe developed in this study is used to assist in the diagnosis of pancreatitis by detecting abnormal expression of β-Gal activity in vivo. In in vivo imaging experiments, NBD-gal can effectively differentiate between normal nude mice and pancreatitis nude mice. In addition, NBD-gal can be effectively localized in real-time to the pancreas and intestines, which are rich in β-Gal in nude mice. Therefore, NBD-gal exerts great potential in the early diagnosis, treatment, and prevention of biomedical clinical pancreatitis.

Construction and validation of risk prediction models for renal replacement therapy in patients with acute pancreatitis

BACKGROUND

Renal replacement therapy (RRT) plays a crucial role in managing acute pancreatitis (AP). This study aimed to develop and evaluate predictive models for determining the need for RRT among patients with AP in the intensive care unit (ICU).

METHODS

A retrospective selection of patients with AP was made from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version V2.0). The cohort was randomly divided into a training set (447 patients) and a validation set (150 patients). The least absolute shrinkage and selection operator (LASSO) regression cross-validation method was utilized to identify key features for model construction. Using these features, four machine learning (ML) algorithms were developed. The optimal model was visualized and clarified using SHapley Additive exPlanations (SHAP) and presented as a nomogram.

RESULTS

The mean age of the cohort was 59.17 years, with an average Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17.55. Acute kidney injury (AKI) was observed in 52.43% of patients with AP, and 9.05% required RRT. After feature selection, four of 41 clinical factors were ultimately chosen for use in model construction. The Lasso-Logistic Regression (Lasso-LR) model showed a high discriminative ability to predict RRT risk in patients with AP, with an area under the receiver operating characteristic (AUROC) of 0.955 (95% CI 0.924-0.987) in the training set. In the validation set, it maintained its discriminative performance, achieving an AUROC of 0.985 (95% CI 0.970-1.000). Calibration curves indicated an excellent fit in both sets (Brier scores: 0.039 and 0.032, respectively), suggesting high consistency. Decision curve analysis (DCA) highlighted the Lasso-LR model's significant clinical utility in predicting RRT likelihood in patients with AP.

CONCLUSIONS

Developed via the LASSO regression cross-validation method, the Lasso-LR model significantly excels in predicting the requirement for RRT in patients with AP, demonstrating its potential for clinical application.

Sestrin2 balances mitophagy and apoptosis through the PINK1-Parkin pathway to attenuate severe acute pancreatitis

Mitophagy serves as a mitochondrial quality control mechanism to maintain the homeostasis of mitochondria and the intracellular environment. Studies have shown that there is a close relationship between mitophagy and apoptosis. Sestrin2 (Sesn2) is a highly conserved class of stress-inducible proteins that play important roles in reducing oxidative stress damage, inflammation, and apoptosis. However, the potential mechanism of how Sesn2 regulates mitophagy and apoptosis in severe acute pancreatitis (SAP) remains unclear. In the study, RAW264.7 (macrophage cell Line) cellular inflammation model established by lipopolysaccharide (LPS) treatment as well as LPS and CAE-induced SAP mouse model (wild-type and Sen2 Knockout mouse) were used. Our study showed that LPS stimulation significantly increased the level of Sesn2 in RAW264.7 cells, Sesn2 increased mitochondrial membrane potential, decreased inflammation levels, mitochondrial superoxide levels and apoptosis, and also promoted monocyte macrophages toward the M2 anti-inflammatory phenotype, suggesting a protective effect of Sesn2 on mitochondria. Further, Sesn2 increased mitophagy and decreased apoptosis via modulating the PINK1-Parkin signaling. Meanwhile, knockout of Sesn2 exacerbated pancreatic, mitochondrial damage and inflammation in a mouse model of SAP. In addition, the protective effect of Sesn2 against SAP was shown to be associated with mitophagy conducted by the PINK1-Parkin pathway via inhibiting apoptosis. These findings reveal that Sesn2 in balancing mitochondrial autophagy and apoptosis by modulating the PINK1-Parkin signaling may present a new therapeutic strategy for the treatment of SAP.

Roux-en-Y gastric bypass versus duodenal switch in patients with body mass index ≥50 kg/m2: a systematic review and meta-analysis

Currently, there is no consensus on the best bariatric surgery type for patients with body mass index (BMI) ≥50 kg/m2. This systematic review and meta-analysis aimed to compare outcomes of duodenal switch (DS) and Roux-en-Y gastric bypass (RYGB) in terms of weight loss, resolution of obesity-related comorbidities, and complications among patients with a BMI ≥50 kg/m2. A systematic search was conducted across databases including PubMed, Embase, Scopus, and Web of Science to include studies that compared outcomes of DS and RYGB in patients with BMI ≥50 kg/m2. A meta-analysis was carried out, alongside subgroup analyses based on the type of study and duration of follow-up. Twelve articles were included in this study (2678 patients, follow-up: 1-15 years). Patients with DS had 7.31 kg/m2 higher BMI loss (95% CI: 5.59-9.03, P < .001) and 9.9% more total weight loss (95% CI: 4.47-15.28%, P < .001) compared with RYGB. The rate of complications, reoperation, mortality, and remission of comorbidities including diabetes, hypertension, dyslipidemia, and obstructive sleep apnea was not significantly different between DS and RYGB. Rate of malnutrition was 8.3% in the DS group compared with 1.2% in RYGB (OR: 5.53, 95% CI: 1.35-22.44, P = .02). In addition, 5.4% DS patients needed revisional surgery for malnutrition versus none in RYGB (OR: 6.1, 95% CI: 1.03-36.33, P = .05), and 24.6% of DS patients developed gallbladder disease needed cholecystectomy versus 4.5% after RYGB (OR: 6.36, 95% CI: 1.70-23.82, P = .01). DS leads to significantly higher BMI and total weight loss in patients with BMI ≥50 kg/m2 but may be associated with a higher rate of major malnutrition and needed revisional surgery. These should be considered in surgical planning.

Risk factors and a prediction model of severe asparaginase-associated pancreatitis in children

We aimed to investigate whether early clinical indicators were associated with eventual disease severity, and to develop a predictive model for severe asparaginase-associated pancreatitis (AAP). Seventy-five acute lymphoblastic leukaemia (ALL) cases with AAP admitted to Shanghai Children's Medical Center from March 2013 to August 2023 were divided into non-severe (n = 44) and severe (n = 31) groups based on Atlanta diagnostic and AAP grading criteria. We compared essential information, asparaginase(ASP) dosage form, cumulative dose, clinical characteristics and laboratory tests between the groups. Statistically significant indicators were analysed with multifactorial logistic regression to identify independent risk factors for severe AAP. Receiver operating characteristic (ROC) curves assessed the early predictive value of age, C-reactive protein (CRP) and fibrinogen (FIB) levels. In the early stages of AAP onset, significant differences in age, CRP, platelet count, red blood cell distribution width, albumin, calcium, FIB, and D-dimer levels were found between the non-severe and severe AAP groups (p < 0.05). Multifactorial logistic regression identified age (odds ratio [OR] = 1.204, p = 0.035), CRP (OR = 1.334, p = 0.003), and FIB (OR = 0.85, p = 0.008) as independent predictors of severe AAP. ROC analysis showed an area under the curves (AUC) for age was 0.681 (95% CI: 0.557-0.805), CRP was 0.766 (95% CI: 0.653-0.880), FIB was 0.735 (95% CI: 0.612-0.857). Optimal cut-off values for age, CRP, and FIB were 9.46 years, 48.5 mg/L and 1.265 g/L respectively. The combined AUC was 0.916 (95% CI: 0.845-0.986), with 0.903 sensitivity and 0.818 specificity, outperforming individual predictors (p < 0.05). Age, CRP, and FIB levels are good early predictors of severe AAP, and their combination significantly improves predictive accuracy.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

Gene Regulation of Neutrophils Mediated Liver and Lung Injury through NETosis in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal emergencies, often resulting in self-digestion, edema, hemorrhage, and even necrosis of pancreatic tissue. When AP progresses to severe acute pancreatitis (SAP), it often causes multi-organ damage, leading to a high mortality rate. However, the molecular mechanisms underlying SAP-mediated organ damage remain unclear. This study aims to systematically mine SAP data from public databases and combine experimental validation to identify key molecules involved in multi-organ damage caused by SAP. Retrieve transcriptomic data of mice pancreatic tissue for AP, lung and liver tissue for SAP, and corresponding normal tissue from the Gene Expression Omnibus (GEO) database. Conduct gene differential analysis using Limma and DEseq2 methods. Perform enrichment analysis using the clusterProfiler package in R software. Score immune cells and immune status in various organs using single-sample gene set enrichment analysis (ssGSEA). Evaluate mRNA expression levels of core genes using reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Validate serum amylase, TNF-α, IL-1β, and IL-6 levels in peripheral blood using enzyme-linked immunosorbent assay (ELISA), and detect the formation of neutrophil extracellular traps (NETs) in mice pancreatic, liver, and lung tissues using immunofluorescence. Differential analysis reveals that 46 genes exhibit expression dysregulation in mice pancreatic tissue for AP, liver and lung tissue for SAP, as well as peripheral blood in humans. Functional enrichment analysis indicates that these genes are primarily associated with neutrophil-related biological processes. ROC curve analysis indicates that 12 neutrophil-related genes have diagnostic potential for SAP. Immune infiltration analysis reveals high neutrophil infiltration in various organs affected by SAP. Single-cell sequencing analysis shows that these genes are predominantly expressed in neutrophils and macrophages. FPR1, ITGAM, and C5AR1 are identified as key genes involved in the formation of NETs and activation of neutrophils. qPCR and IHC results demonstrate upregulation of FPR1, ITGAM, and C5AR1 expression in pancreatic, liver, and lung tissues of mice with SAP. Immunofluorescence staining shows increased levels of neutrophils and NETs in SAP mice. Inhibition of NETs formation can alleviate the severity of SAP as well as the levels of inflammation in the liver and lung tissues. This study identified key genes involved in the formation of NETs, namely FPR1, ITGAM, and C5AR1, which are upregulated during multi-organ damage in SAP. Inhibition of NETs release effectively reduces the systemic inflammatory response and liver-lung damage in SAP. This research provides new therapeutic targets for the multi-organ damage associated with SAP.

Mesopancreas dissection level 3 for pancreatic head cancer in combined robotic/open pancreatoduodenectomy: a propensity score-matched study

BACKGROUND

Mesopancreas dissection (MPD) level 3 in combined robotic/open pancreatoduodenectomy (CR/OPD) is technique-demanding. This study aims to clarify the feasibility and justification of MPD level 3.

METHODS

Propensity score matching (PSM) analysis was conducted for 208 patients with pancreatic head cancer undergoing CR/OPD with or without MPD level 3. The comparison focused on surgical and oncological outcomes.

RESULTS

After PSM, each group comprised 86 patients. Surgical outcomes were comparable between these two groups, except longer operation time for MPD level 3 (+), median: 10.5 vs. 9.5 h, p = 0.002. MPD level 3 (+) group exhibited higher lymph node yield, median: 20 vs. 17, p < 0.001, and curative (R0) resection rate, 89.5% vs. 69.8%, p = 0.001, compared to MPD level 3 (-) group. Among the entire cohort, no significant survival difference was observed between the MPD Level 3 (+) and (-) groups. Survival outcome for R0 resection after CR/OPD was notably better than those for R2 resection, 5-year survival: 34.0% vs. 0, p = 0.038. However, within the curative (R0) resection cohort, no survival difference was observed between the MPD level 3 (+) and MPD level 3 (-) groups.

CONCLUSION

MPD level 3 in CR/OPD is technically feasible without increasing the surgical risks but takes one hour extra operating time. Incorporation of MPD level 3 does not confer a survival advantage within the curative (R0) resection cohort. The primary focus should continue to be on achieving curative (R0) resection to maximize the survival benefits for pancreatic head cancer.

Onset of pancreatic cancer before and after acute pancreatitis: A multicenter longitudinal cohort study

BACKGROUND

Pancreatic cancer (PC) is a leading cause of cancer mortality, often diagnosed at advanced stages. Acute pancreatitis (AP), particularly idiopathic cases, may serve as an early indicator of PC.

OBJECTIVE

This multicenter cohort study investigated the incidence of PC before and after an AP episode, focusing on idiopathic AP and the role of pseudocysts as potential early markers for PC development.

METHODS

We analyzed data from 2356 AP patients across 25 centers, with a median follow-up of 4.1 years (IQR: 1.6-6.8 years). Patients were categorized into 'PC before AP' and 'PC after AP' groups, and relative risk (RR) and adjusted odds ratios (OR) were calculated for idiopathic AP cases to quantify PC risk.

RESULTS

Among all cases, 69 patients (2.9 %) developed PC: 1.4 % (n = 34) before and 1.5 % (n = 35) after AP. Idiopathic AP cases had a fourfold higher risk of PC (OR = 4.46, [2.25-8.85]). Notably, pseudocysts were five times more prevalent in the PC group (14 %) compared to controls (3 %) (RR = 5.66; p < 0.01), often located at the tumor site. PC developed in 3 % of idiopathic AP cases versus 1.0 % in non-idiopathic cases. The median time to PC diagnosis post-AP was 373 days.

CONCLUSION

Idiopathic AP and pseudocyst formation significantly elevate the risk of PC, particularly within two years. These findings underscore the need for structured follow-up and early screening in idiopathic AP cases to improve PC detection and survival outcomes.

YKL-40 as a risk stratification marker in acute pancreatitis: A prospective study

BACKGROUND/OBJECTIVES

Increased systemic concentrations of YKL-40 are seen in various inflammatory conditions. We explored the relationship between the serum YKL-40 concentrations and subsequent disease severity in patients with acute pancreatitis (AP).

METHODS

Consecutive adults with AP were prospectively enrolled, and classified as having mild, moderate or severe disease. On admission and 48 h later, C-reactive protein (CRP), YKL-40, interleukin-6 and 8 (IL-6, IL-8), and tumor necrosis factor alpha (TNF-α) concentrations were measured. Patients were also classified as those with low (<50 ng/mL, in the range seen in 30 age and sex-matched non-AP subjects), high (≥190 ng/mL, seen in most of the other inflammatory conditions), and intermediate YKL-40 (50-189 ng/mL).

RESULTS

Incidence of mild, moderate and severe AP among the 150 enrolled patients was 80 (53.3 %), 59 (39.3 %), and 11 (7.4 %), respectively. Both on admission and 48 h later, high YKL-40 (vs. intermediate or low) was strongly associated with higher odds of a more severe AP, independently of the concurrent IL-8 and TNF-α concentrations (OR around 3.5-4.0, or higher). On admission, the association was independent also of the concurrent CRP, whereas the association between the later concentrations and the outcome was conditional on CRP - uncertain at low, strong at high CRP. The high YKL-40 - outcome association at both time-points was conditional on concurrent IL-6: uncertain if IL-6 was low, strong if IL-6 was high.

CONCLUSIONS

Serum YKL-40 is a plausible candidate for further evaluation as an early biochemical indicator of subsequent AP severity, particularly if considered jointly with CRP and/or IL-6.

High prevalence of pancreatic steatosis in pancreatic cancer patients: A meta-analysis and systematic review

OBJECTIVE

In the last decade there has been increasing interest in defining pancreatic steatosis (PS) and establishing its association with pancreatic ductal adenocarcinoma (PDAC). However, no consensus guidelines have yet been published on the management of PS. In this systematic review and meta-analysis performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we investigated the association between PS and PDAC.

DESIGN

Medical literature between 2007 and 2023 was reviewed for eligible trials investigating the prevalence of PS in patients with PDAC. Eligible studies reporting on PS, assessed via imaging or histology, were included. The primary objective was to determine the association between PDAC and PS by comparing the prevalence of PS in individuals with- and without PDAC. Secondary, an evaluation was conducted to establish whether the method of assessment correlated with the association of PDAC and PS, and the prevalence of PDAC in individuals with PS. Measures of effect size were determined using odds ratios (ORs) and corresponding 95 % confidence intervals (95 % CI).

RESULTS

The systematic review identified a total of 23 studies, of which seventeen studies examined PS prevalence among PDAC patients and were included in the meta-analysis. Overall, the pooled prevalence of PS in patients with PDAC was 53.6 % (95 % CI 40.9-66.2). No significant difference in PS prevalence was observed across various diagnostic methods or geographical regions. Overall, the pooled OR for PS in patients with PDAC compared to controls was 3.23 (95 % CI 1.86-5.60).

CONCLUSIONS

PDAC patients have a high prevalence of PS, and they are significantly more likely to have PS compared to controls. These findings emphasize the need to prioritize a standardized approach to the diagnosis, follow-up, and treatment of PS, with future studies focusing on identifying patients who would benefit from PDAC surveillance programs.

Neutrophil-to-Lymphocyte Ratio Differentiates Infections from Sterile Inflammation in First Week of Acute Pancreatitis

BACKGROUND

Differentiating infections from sterile inflammation is crucial in early AP management.

AIM

This study aimed to assess the capability of Neutrophil-to-Lymphocyte Ratio (NLR) and procalcitonin to differentiate between sterile inflammation and infections in the first week of AP and to analyze the source, microbiological profile, and impact of infections in AP.

METHODS

Consecutive patients presenting within 5 days of symptom onset were included. Microbiological profiles and serious adverse events (SAEs: in-hospital mortality or discharge in critical state) were analyzed. Blood count obtained at fever onset was used for calculating the NLR. The ability of NLR and procalcitonin to differentiate infections from sterile inflammation in the first week was assessed.

RESULTS

Of 505 AP patients, 150 developed fevers. 48 (32%) had sterile inflammation, while 102 (68%) had infections. Most patients (n = 98, 65.3%) developed fever during the first week of illness (sterile inflammation (n = 43) and infections (n = 55)). NLR demonstrated good accuracy in differentiating infections from sterile inflammation in the first week (AUROC 0.70, p = 0.001), outperforming procalcitonin (AUROC 0.54, p = 0.58). Within infections (n = 102), 44 (43.1%) had infected pancreatic necrosis, 68 (66.7%) had extra-pancreatic infections, and 10 (9.8%) had both. Lower respiratory tract infection was the most common extra-pancreatic infection. Of 54 patients with culture-positive infections, 36 (66.7%) had grown multidrug-resistant (MDR) organisms. Fungal isolates were identified in 5 patients. Patients with infections had higher SAE incidence (21.6% vs. 4.2%, p = 0.007) than those with inflammation. The SAE incidence was higher with MDR infections than those without MDR (37.5% vs. 9.3%, p < 0.01).

CONCLUSIONS

Infections in AP occur early in the course of illness. NLR could serve as a reliable biomarker to distinguish infections from sterile inflammation in the early course of AP, aiding timely management. Patients with MDR infections have higher serious adverse outcomes.

Percutaneous Interventions and Necrosectomy in the Management of Peripancreatic Collections

Acute pancreatitis (AP) is a severe inflammatory condition of the pancreas with significant morbidity and mortality, particularly in its necrotizing form. This review explores the management of peripancreatic collections and in particular necrotizing pancreatitis, focusing on the evolution from traditional open surgical methods to contemporary minimally invasive image-guided techniques. AP can lead to various local complications, including pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Imaging plays a crucial role in diagnosing complications of AP, while treatment approaches have shifted toward a step-up strategy involving percutaneous, endoscopic, and minimally invasive methods. Percutaneous necrosectomy, combining mechanical and chemical debridement, has shown promising results. Mechanical necrosectomy uses devices like baskets and retrieval nets, while chemical necrosectomy adds agents like hydrogen peroxide and streptokinase. Current evidence suggests that the step-up approach, starting with percutaneous drainage or necrosectomy and escalating to endoscopic or surgical interventions, if necessary, improves patient outcomes. The review underscores the need for a multidisciplinary approach in managing complicated AP and highlights ongoing advancements in minimally invasive techniques.

Diagnostic performance of pancreatic fluid aspiration through metagenomic next-generation sequencing for suspected infected pancreatic necrosis

AIMS

This study aimed to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS) with pancreatic fluid aspiration for the detection of infected pancreatic necrosis (IPN).

METHODS

This retrospective observational study included 66 patients with suspected IPN. The participants simultaneously underwent pancreatic fluid aspiration mNGS, and microbial and blood culture. We compared the diagnostic performance of mNGS with that of culture in the detection of pathogens associated with IPN.

RESULTS

Of the 66 patients, 45 (68.2 %) were confirmed to have IPN. Pancreatic fluid aspiration mNGS yielded positive results in 32 of these patients (71.1 %), significantly outperforming microbial culture results (25 patients, 55.6 %; P = 0.039); however, both methods exhibited similar specificity (95.2% vs. 100 %). The results of pancreatic fluid aspiration mNGS and microbial culture matched in 73.3 % (33/45) of patients with IPN. The turnaround time for the mNGS results was significantly shorter than that for the microbial culture method (P < 0.001). In addition, survival analysis demonstrated that a positive mNGS result was not associated with increased mortality (hazard ratio, 0.652; 95 % confidence interval 0.157-2.699, P = 0.555).

CONCLUSIONS

Our study highlights the potential of mNGS for diagnosing IPN, with implications for improving patient care by facilitating early and accurate diagnosis, guiding appropriate interventions, and possibly improving patient outcomes.

Diagnostic accuracy of interleukin-6 as a biomarker for early prediction of severe acute pancreatitis: A systematic review and meta-analysis

Background

Acute pancreatitis (AP) is an inflammatory disease of the pancreas with varying severity. The mortality rate varies from 20% to 40% among severe acute pancreatitis (SAP). Interleukin-6 (IL-6) is a pro- and anti-inflammatory cytokine that involves various infections, inflammations, and systemic disorders. Injury to acinar cells leads to necrosis, releasing proinflammatory cytokines, including IL-6, which peaks earlier. The lack of extensive data regarding the association of IL-6 with AP influences us to do this meta-analysis for early detection and treatment of AP to prevent multiorgan failure.

Methods

We searched the PubMed, Cochrane Library, and Google Scholar databases for relevant articles published from inception to June 2024. We examined the positive and negative likelihood ratios, diagnostic odds ratios, and pooled sensitivity and specificity. We used the QUADAS-2 tool to evaluate the risk of bias.

Results

This meta-analysis included 13 studies involving 1386 patients with AP, of which 343 had SAP and 1043 had mild and moderately severe AP. The positive and negative likelihood ratios were 3.5 (95% CI 2.6 to 4.5) and 0.25 (95% CI 0.16 to 0.40). The diagnostic odds ratio of IL-6 to diagnose SAP is 14 (95% CI: 7 to 27), and the summary receiver operating characteristic curve is 0.85 (95% CI: 0.82-0.88).

Conclusion

Based on the results of this meta-analysis, serum IL-6 is a promising biomarker for diagnosing SAP in the early stage. However, a larger-scale study involving a more extensive population is necessary due to the considerable variation between the studies.

Comparative analysis of readmission rates and outcomes: Sleeve gastrectomy with versus without Nissen fundoplication using a National Database

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure. To study the safety of LSG done with Nissen Fundoplication (NF) in patients affected by obesity and GERD and assess the complication rate. A retrospective cohort study using the Nationwide Readmissions Database from 2016 to 2019. A total of 236111 patients underwent LSG with and without NF. A matched cohort of 1096 without NF and 548 with NF was obtained. The median age of patients was 47 years old. Median length of hospital stay was higher in the LSG with NF group. Median total charge was higher in the LSG with NF group. There was no statistically significant difference in 30-day readmission rates in patients with obesity and GERD who received LSG with NF compared to those who received LSG alone. Complications after both procedures were low, which highlights the safety of both procedures.

Hyperspectral imaging in neurosurgery: a review of systems, computational methods, and clinical applications

Significance

Accurate identification between pathologic (e.g., tumors) and healthy brain tissue is a critical need in neurosurgery. However, conventional surgical adjuncts have significant limitations toward achieving this goal (e.g., image guidance based on pre-operative imaging becomes inaccurate up to 3 cm as surgery proceeds). Hyperspectral imaging (HSI) has emerged as a potential powerful surgical adjunct to enable surgeons to accurately distinguish pathologic from normal tissues.

Aim

We review HSI techniques in neurosurgery; categorize, explain, and summarize their technical and clinical details; and present some promising directions for future work.

Approach

We performed a literature search on HSI methods in neurosurgery focusing on their hardware and implementation details; classification, estimation, and band selection methods; publicly available labeled and unlabeled data; image processing and augmented reality visualization systems; and clinical study conclusions.

Results

We present a detailed review of HSI results in neurosurgery with a discussion of over 25 imaging systems, 45 clinical studies, and 60 computational methods. We first provide a short overview of HSI and the main branches of neurosurgery. Then, we describe in detail the imaging systems, computational methods, and clinical results for HSI using reflectance or fluorescence. Clinical implementations of HSI yield promising results in estimating perfusion and mapping brain function, classifying tumors and healthy tissues (e.g., in fluorescence-guided tumor surgery, detecting infiltrating margins not visible with conventional systems), and detecting epileptogenic regions. Finally, we discuss the advantages and disadvantages of HSI approaches and interesting research directions as a means to encourage future development.

Conclusions

We describe a number of HSI applications across every major branch of neurosurgery. We believe these results demonstrate the potential of HSI as a powerful neurosurgical adjunct as more work continues to enable rapid acquisition with smaller footprints, greater spectral and spatial resolutions, and improved detection.

Systematic Review of Volume and Methodological Quality of Randomized Trials in Acute Pancreatitis

BACKGROUND

This systematic review assessed the volume and methodological quality of randomized controlled trials (RCTs) in relation to management of acute pancreatitis (AP).

MATERIALS AND METHODS

The PubMed, MEDLINE, and CENTRAL databases were systematically searched for RCTs published across 3 time periods: <1996 (P1), 1996-2008 (P2), and >2008 (P3). RCT quality was assessed using the Cochrane Risk of Bias (RoB) 2 tool and sample size recalculation, and for spin (interpretation of nonstatistically significant results as relevant, making the study appear to be positive).

RESULTS

Overall, 263 RCTs with 23,232 patients with AP were included. The average number of RCTs per year increased from 1.4, 6.0, to 10.6 in P1, P2, and P3, respectively. The RoB assessment showed low, some, and high concerns in overall RoB in 21%, 56%, and 24% of all RCTs. Selective reporting bias improved over time. Sample size calculation reporting significantly increased through the 3 time periods (17%, 38%, and 47%; P < 0.001). Spin was identified in 68 RCTs (26% of all RCTs).

CONCLUSION

The quantity and quality of published RCTs relating AP management has increased over time, however significant shortcomings of methodological quality persist. Significant improvements in the conduct and reporting of randomized trials in AP are required to improve the evidence base in this field.

Pancreatic Cystic Lesions in Children: A Comprehensive Scoping Review

OBJECTIVE

Pediatric pancreatic cystic lesions (PPCLs) are uncommon and differ from adult pancreatic cystic lesions. Literature is limited on the etiologies, evaluation, and management of PPCL. A multidisciplinary working group formed to provide a comprehensive description of PPCL and recommend best available evidence-based evaluation and management.

MATERIALS AND METHODS

The PPCL working group performed a scoping review by 2 methods: 1) a targeted literature review to describe PPCL and 2) a systematic literature review for management recommendations for PPCL. The systematic review was completed using a 2-stage sifting approach: title and abstract screening followed by a full text review.

RESULTS

One hundred thirty-one studies were included in the systematic review and an additional 20 were included in the targeted search to complete a comprehensive list of PPCL. Five neoplastic PPCL and 10 nonneoplastic PPCL were identified, and prevalence of different cystic lesions differs widely in adults and children. Recommendations on evaluation and management of PPCL are presented based on best available evidence.

CONCLUSIONS

We present a comprehensive review and evidence-based management recommendations with management algorithms for pediatric pancreatic cystic lesions. Given the rarity of many of these entities, this review also highlights many aspects of PPCL, which are not adequately described in the current literature.

Risk Factors for Acute Pancreatitis Following Intragastric Balloon Insertion: A 7-Year Retrospective Cohort Study

BACKGROUND

Acute pancreatitis (AP) is a rare but serious complication of intragastric balloon (IGB) therapy. Despite the popularity of IGBs for weight loss, the incidence and risk factors of AP post-IGB insertion are not well understood. This study aimed to identify potential predictors and risk factors of AP in IGB patients.

METHODS

A retrospective time-to-event study was conducted over 7 years, encompassing patients who received IGBs between January 2017 and 2024. Cox regression analyses were performed to identify risk factors. The incidence of AP was evaluated as a secondary outcome. Patients were categorized into the AP and non-AP groups at a 1:3 ratio. The Revised Atlanta Classification was used to diagnose AP.

RESULTS

Among 450 patients with IGB, 25 developed AP, yielding an incidence of 5.56%. The Orbera balloon was associated with a lower AP risk (HR 0.29, 95% CI: 0.09-0.96; P = 0.042). The median time to AP onset was 40 days. Higher preprocedural BMI and age > 30 years showed a trend toward reduced AP risk, though not statistically significant.

CONCLUSIONS

AP following IGB insertion is uncommon but may be underreported, with substantial variability in onset time. The Orbera balloon demonstrated a protective effect, highlighting the role of balloon type in AP risk. These findings underscore the importance of balloon selection and the need for further prospective studies to confirm these results and optimize AP risk management in IGB patients.

Significant projected savings with expansion of an emergency department observation protocol for mild acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) significantly contributes to healthcare costs, but not all patients require hospitalization. A novel, validated Emergency Department (ED) pathway for mild AP (MAP) at our tertiary care center reduced hospitalizations and resource utilization, without affecting outcomes.

METHODS

A decision-analytic model was constructed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist and methodologic recommendations by the Second Panel on Cost-Effectiveness in Health and Medicine to predict healthcare costs based on whether an ED discharge protocol for MAP was utilized.

RESULTS

Average savings for one MAP discharged from the ED were $1720.5 compared to the standard of care hospitalization. Assuming that 67.7 % of cases are mild and that there are 288,820 hospitalizations for AP annually, the ED discharge pathway would result in $98.6 million direct healthcare savings.

CONCLUSIONS

Implementation of an evidence-based, protocoled ED pathway for MAP could result in over $100 million in direct healthcare savings.

Six-fold increased risk of acute pancreatitis in alcohol-related liver disease compared to matched comparators: A population-based cohort study

BACKGROUND AND AIMS

Patients with alcohol-related liver disease (ALD) might be at increased risk of acute pancreatitis (AP), but large-scale data are lacking.

METHODS

Population-based cohort study using data from the Swedish National Patient Register on 37,062 patients with ALD from 1969 to 2020. Patients were matched to ≤10 general population comparators (n = 352,931). We used logistic regression to estimate the risk of acute or chronic pancreatitis prior to ALD diagnosis and Cox regression to estimate rates for hospitalization for AP after ALD diagnosis.

RESULTS

Median age at ALD diagnosis was 59 years; 72% were men, and 67% had cirrhosis at baseline. Overall, 7% had experienced pancreatitis before ALD diagnosis, resulting in 9-fold higher odds of pancreatitis compared to comparators. The 10-year cumulative incidence of hospitalization for AP was 2.7% (95%CI = 2.5-2.8) in ALD and 0.6% (95%CI = 0.58-0.63) in comparators, yielding an adjusted HR of 6.3 (95%CI = 5.8-6.9). Younger age, male sex, and diagnoses of alcohol use disorders and chronic obstructive pulmonary disease were independent risk factors for developing AP in ALD. Continued drinking after baseline was associated with a higher risk of AP (adjusted hazard ratio [aHR] 2.6, 95%CI = 2.29-2.85).

CONCLUSIONS

ALD is associated with 9-fold higher odds of prevalent pancreatitis compared to the general population. The hospitalization rate for AP following ALD diagnosis is 6-fold higher. About 10% of patients with ALD have or develop AP, suggesting that assessing history of pancreatitis and its sequelae might be relevant for patients with ALD.

Nucleosome fibre topology guides transcription factor binding to enhancers

Cellular identity requires the concerted action of multiple transcription factors (TFs) bound together to enhancers of cell-type-specific genes. Despite TFs recognizing specific DNA motifs within accessible chromatin, this information is insufficient to explain how TFs select enhancers1. Here we compared four different TF combinations that induce different cell states, analysing TF genome occupancy, chromatin accessibility, nucleosome positioning and 3D genome organization at the nucleosome resolution. We show that motif recognition on mononucleosomes can decipher only the individual binding of TFs. When bound together, TFs act cooperatively or competitively to target nucleosome arrays with defined 3D organization, displaying motifs in particular patterns. In one combination, motif directionality funnels TF combinatorial binding along chromatin loops, before infiltrating laterally to adjacent enhancers. In other combinations, TFs assemble on motif-dense and highly interconnected loop junctions, and subsequently translocate to nearby lineage-specific sites. We propose a guided-search model in which motif grammar on nucleosome fibres acts as signpost elements, directing TF combinatorial binding to enhancers.

Precision oncology: Using cancer genomics for targeted therapy advancements

Cancer genomics plays a crucial role in oncology by enhancing our understanding of how genes drive cancer and facilitating the development of improved treatments. This field meticulously examines various cancers' genetic makeup through various methodologies, leading to groundbreaking discoveries. Innovative tools such as rapid gene sequencing, single-cell studies, spatial gene mapping, epigenetic analysis, liquid biopsies, and computational modeling have significantly progressed the field. These techniques uncover genetic alterations, tumor heterogeneity, and the evolutionary dynamics of cancers. Genetic abnormalities and molecular markers that initiate and propagate distinct cancer types are classified according to tumor type. The integration of precision medicine with cancer genomics emphasizes the significance of utilizing genetic data in treatment decision-making, enabling personalized care and enhancing patient outcomes. Critical topics in cancer genomics encompass tumor diversity, alterations in non-coding DNA, epigenetic modifications, cancer-specific proteins, metabolic changes, and the impact of inherited genes on cancer risk.

Visceral adipose tissue area predicts major adverse kidney events in patients with acute necrotizing pancreatitis

BACKGROUND

Given the previously reported harmful effects of abdominal fat burden on kidney function, we aim to investigate the relationship between major adverse kidney events within 30 days (MAKE30) and abdominal obesity in acute necrotizing pancreatitis (ANP) patients and explore the underlying risk factors.

METHODS

A retrospective cohort study of all patients admitted within 72 h after the first episode of ANP to a tertiary center between June 2015 and June 2019 was conducted. Automatic image analysis software was used to calculate the area of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and skeletal muscle from computed tomography scans at the umbilical level. The potential risk factors of MAKE30 were analyzed by logistic regression.

RESULTS

A total of 208 eligible ANP patients were enrolled, with an incidence of 23% for MAKE30. VAT area was more closely associated with the development of MAKE30, with an area under the ROC curve of 0.69 (cutoff value 200 cm2, 63.8% sensitivity and 66.7% specificity). Multivariate logistic regression analysis demonstrated that VAT area [OR 1.01 (1.01-1.02); p < 0.001] was an independent risk factor in predicting MAKE30. Patients with a VAT area > 200 cm2 had more requirements of renal replacement therapy (32% vs. 12%, P < 0.001), and a significantly higher incidence of other poor clinical outcomes (all p < 0.05).

CONCLUSION

Early assessment of the VAT area may help identify ANP patients at high risk of MAKE30, suggesting that it could be a potential indicator for adverse kidney events.

Artesunate protects against a mouse model of cerulein and lipopolysaccharide‑induced acute pancreatitis by inhibiting TLR4‑dependent autophagy

Severe acute pancreatitis (SAP) is a severe clinical condition associated with high rates of morbidity and mortality. Multiple organ dysfunction syndrome that follows systemic inflammatory response syndrome is the leading cause of SAP‑related death. Since the inflammatory mechanism of SAP remains unclear, there is currently a lack of effective drugs available for its treatment. Therefore, it is important to study effective therapeutic drugs and their molecular mechanisms based on studying the inflammatory mechanism of SAP. In the present study, in vivo, a mouse model of AP induced by cerulein (CR) combined with lipopolysaccharide (LPS) was established to clarify the therapeutic effect of artesunate (AS) in AP mice by observing the gross morphological changes of the pancreas and surrounding tissues, calculating the pancreatic coefficient, and observing the histopathology of the pancreas. The serum amylase activity in AP mice was detected by iodine colorimetry and the superoxide dismutase activity in the pancreas was detected by WST‑1 assay. The levels of proinflammatory cytokines in the serum, the supernatant of pancreatic tissue homogenates and the peritoneal lavage fluid were detected by ELISA assay. The total number of peritoneal macrophages was assessed using the cellular automatic counter, and the expression of proteins related to autophagy, and the TLR4 pathway was detected by immunohistochemistry and western blotting. In vitro, the effect of trypsin (TP) combined with LPS was observed by detecting the release of proinflammatory cytokine levels from macrophages by ELISA assay, and detecting the expression of proteins related to autophagy and the TLR4 pathway by immunofluorescence and western blotting. The present study revealed that AS reduced pancreatic histopathological damage, decreased pancreatic TP and serum amylase activities, increased superoxide dismutase activity, and inhibited pro‑inflammatory cytokine levels in a mouse model of AP induced by cerulein combined with lipopolysaccharide. In vitro, TP combined with LPS was found to synergistically induce pro‑inflammatory cytokine release from mouse macrophages and RAW264.7 cells, while AS could inhibit cytokine release. Furthermore, CR combined with LPS synergistically increased amylase activity in acinar cells, whereas AS decreased amylase activity. Autophagy serves an important role in the release of pro‑inflammatory cytokines. In the present study, it was revealed that the autophagy inhibitor LY294002 suppressed the release of pro‑inflammatory cytokines from macrophages treated with TP combined with LPS, and pro‑inflammatory cytokine release was not further reduced by AS combined with LY294002. Furthermore, AS not only inhibited the expression of important molecules in the Toll‑like receptor 4 (TLR4) signaling pathway, but also inhibited autophagy proteins and reduced the number of autolysosomes in mice with AP and in macrophages. In conclusion, these results suggested that AS may protect against AP in mice via inhibition of TLR4‑dependent autophagy; therefore, AS may be considered a potential therapeutic agent against SAP.

Organoids, tissue slices and organotypic cultures: Advancing our understanding of pancreatic ductal adenocarcinoma through in vitro and ex vivo models

Pancreatic ductal adenocarcinoma (PDAC) has one of the worst prognoses of all common solid cancers. For the large majority of PDAC patients, only systemic therapies with very limited efficacy are indicated. In addition, immunotherapies have not brought the advances seen in other cancer types. Several key characteristics of PDAC contribute to poor treatment outcomes, and in this review, we will discuss how these characteristics are best captured in currently available ex vivo or in vitro model systems. For instance, PDAC is hallmarked by a highly desmoplastic and immune-suppressed tumor microenvironment that impacts disease progression and therapy resistance. Also, large differences in tumor biology exist between and within tumors, complicating treatment decisions. Furthermore, PDAC has a very high propensity for locally invasive and metastatic growth. The use of animal models is often not desirable or feasible and several in vitro and ex vivo model systems have been developed, such as organotypic cocultures and tissue slices, among others. However, the absence of a full host organism impacts the ability of these models to accurately capture the characteristics that contribute to poor outcomes in PDAC. We will discuss the caveats and advantages of these model systems in the context of PDAC's key characteristics and provide recommendations on model choice and the possibilities for optimization. These considerations should be of use to researchers aiming to study PDAC in the in vitro setting.

A systematic review of the relationship between gut microbiota and prevalence of pancreatic diseases

Acute pancreatitis (AP) represents one of the most common gastrointestinal (GI) diseases; it can manifest in varying degrees of severity, sometimes leading to a life-threatening condition for the patient. Pancreatic ductal adenocarcinoma (PDAC), due to its high malignancy and uncertain prognosis, is widely regarded as one of the most fatal diseases. The increasing prevalence of AP and PDAC represents a major burden on public health and the healthcare system worldwide. The aim of this systematic review was to discuss the current state of knowledge regarding the relationship between the gut microbiota and the incidence, prognosis, diagnosis and treatment of AP and PDAC. To identify studies that analyzed the relationship between the gut microbiota and the occurrence/development of pancreatic diseases or PDAC, the online databases PubMed, Scopus and Google Scholar were searched between November 2023 and January 2024. Finally, 14 publications met the inclusion criteria (1. were conducted exclusively in humans and/or animals; 2. original, published in English in peer-reviewed journals after 2019; 3. described the relationship between gut microbiota and the occurrence of AP or PDAC). The collected studies indicated significant changes in the gut microbiota of patients with AP and PDAC. Moreover, they highlighted the presence of a relationship between the gut microbiota and the occurrence, course, treatment efficiency and prognosis of the disease in question. Further research is needed to understand precisely the relationship between the gut microbiota and the occurrence of pancreatic diseases and whether it may be a starting point for the development of modern forms of therapy based on the use of prebiotics and/or diet to restore the normal composition of the intestinal bacteria.

Propofol, Triglycerides, and Acute Pancreatitis: A Multicenter Epidemiologic Analysis

Rationale: Propofol is one of the first-line sedative-hypnotic agents for critically ill adults requiring mechanical ventilation. Although propofol can elevate triglyceride levels, and the latter is a risk factor for pancreatitis, the association between propofol and acute pancreatitis is unclear. Objectives: We sought to determine the clinical impact and potential associations between propofol infusion, hypertriglyceridemia, and acute pancreatitis. Methods: This is an observational multicenter study of adults (⩾18 yr old) who were admitted to an intensive care unit, who required mechanical ventilation and received continuous propofol infusion for at least 24 hours. The primary outcomes were the frequency of hypertriglyceridemia (>400 mg/dl) and acute pancreatitis. Further analyses were done to determine the clinical impact of elevated triglyceride levels (i.e., sedation changes) and risk factors for pancreatitis development. Results: Of 11,828 patients included, 33.2% (n = 3,922) had triglyceride levels measured, of whom 21.7% (n = 851) had hypertriglyceridemia at 4.5 days (SD = 6.8) after propofol initiation. Of those still requiring sedation, 70.4% (n = 576/818) received alternative sedatives after developing hypertriglyceridemia. Pancreatitis occurred in 1.2% of patients (n = 47/3,922) and was more frequent in those with hypertriglyceridemia (3.2%, 27/851; vs. 0.7%, 20/3,071; P < 0.001). After adjustment for potential confounding variables, each 100 mg/dl increase in triglyceride levels was associated with an 11% increase in risk of pancreatitis. Propofol dose was not associated with pancreatitis development. Conclusions: Acute pancreatitis is uncommon in patients receiving propofol infusion, and it occurs over a wide range of triglyceride levels, indicating a multifactorial pathophysiology. Hypertriglyceridemia frequently prompts the use of alternative sedatives. Further study is needed to determine how to best monitor and treat hypertriglyceridemia in critically ill patients receiving propofol infusion.

Development and validation of an explainable machine learning model for mortality prediction among patients with infected pancreatic necrosis

Background

Infected pancreatic necrosis (IPN) represents a severe complication of acute pancreatitis, commonly linked with mortality rates ranging from 15% to 35%. However, the present mortality prediction tools for IPN are limited and lack sufficient sensitivity and specificity. This study aims to develop and validate an explainable machine learning (ML) model for death prediction among patients with IPN.

Methods

We performed a prospective cohort study of 344 patients with IPN consecutively enrolled from a large Chinese tertiary hospital from January 2011 to January 2023. Ten ML models were developed to predict 90-day mortality in these patients. A benchmarking test, involving nested resampling, automatic hyperparameter tuning and random search techniques, was conducted to select the ML model. Sequential forward selection method was employed to select the optimal feature subset from 31 candidate subsets to simplify the model and maximize predictive performance. The final model was internally validated with the 1000 bootstrap method and externally validated using an independent cohort of 132 patients with IPN retrospectively collected from another Chinese tertiary hospital from January 2018 to January 2023. The SHapley Additive exPlanations (SHAP) method was employed to interpret the model in terms of features importance and features effect. The final model constructed with optimal feature subset was deployed as an interactive web-based Shiny app.

Findings

Random survival forest (RSF) model showed the best predictive performance than other 9 ML models (internal validation, C-index = 0.863 [95% CI: 0.854-0.875]; external validation, C-index = 0.857 [95% CI: 0.850-0.865]). Multiple organ failure, Acute Physiology and Chronic Health Examination II (APACHE II) score ≥20, duration of organ failure ≥21 days, bloodstream infection, time from onset to first intervention <30 days, Bedside Index of Severity in Acute Pancreatitis score ≥3, critical acute pancreatitis, age ≥ 50 years, and hemorrhage were 9 most important features associated with mortality. Furthermore, SHAP algorithm revealed insightful nonlinear interactive associations between important predictors and mortality, identifying 9 features pairs with high interaction SHAP value and clinical significance. Two interactive web-based Shiny apps were developed to enhance clinical practicability: https://rsfmodels.shinyapps.io/IPN_app/ for cases where the APACHE II score was available and https://rsfmodels.shinyapps.io/IPNeasy/ for cases where it was not.

Interpretation

An explainable ML model for death prediction among IPN patients was feasible and effective, suggesting its superior potential in guiding clinical management and improving patient outcomes. Two publicly accessible web tools generated for the optimized model facilitated its utility in clinical settings.

Funding

The Natural Science Foundation of Hunan Province (2023JJ30885), Postdoctoral Fellowship Program of CPSF (GZB20230872), The Youth Science Foundation of Xiangya Hospital (2023Q13), The Project Program of National Clinical Research Center for Geriatric Disorders of Xiangya Hospital (2021LNJJ19).

Gender Disparities and Their Impact on the Professional Experiences of Female Neurosurgery Residents in Germany: A Cross-Sectional Survey

BACKGROUND

Despite advancements in gender equality within neurosurgery, the field continues to encounter challenges related to the under-representation of women and reports of gender-based disparities. This study examines the impact of these disparities on the experiences, professional development, and well-being of female neurosurgery residents in Germany, identifying specific challenges within the neurosurgical community.

METHODS

An anonymous, questionnaire-based survey was conducted among female neurosurgery residents from various German training hospitals nationwide, using a quantitative approach. Data were collected from June 2021 to January 2023.

RESULTS

A total of 63 female neurosurgery residents participated, representing about 19% of all female neurosurgery residents in Germany. Seventy percent reported experiencing incidents of discrimination during training, with 39% encountering "sometimes" emotional abuse, 20% physical abuse, and 17% "rarely" experiencing sexual harassment. Eighty-six percent did not report these incidents, primarily due to doubts about reporting effectiveness (24%) and the belief that reporting would not lead to change (24%). Discrimination significantly impacted job satisfaction (56%) and career progression (71%). Additionally, 60% reported frequent frustration, 52% experienced occasional depression, and burnout was common.

CONCLUSIONS

The survey highlights gender disparities affecting female neurosurgery residents in Germany, negatively influencing job satisfaction and career advancement. Tackling gender discrimination and harassment requires a multifaceted approach, and further studies are warranted to assess these methods. The neurosurgical community must ensure a supportive environment by adopting no-tolerance policies against discrimination for all residents, paving the way for a future where professional excellence and patient care are free from gender inequalities.

Markers of Collagen Formation and Degradation in Serum and Pancreatic Fluid Collections in Patients With Acute and Chronic Pancreatitis

OBJECTIVES

Current knowledge on the fibro-inflammatory process underlying chronic pancreatitis originates from animal studies or human studies based on circulating biomarkers. To provide new insight into the underlying fibro-inflammatory processes, we simultaneously assessed fibrosis biomarkers in pancreatic fluid collections and the systemic circulation.

MATERIALS AND METHODS

This prospective observational cross-sectional study included patients with acute and chronic pancreatitis undergoing drainage of pancreatic fluid collections, as well as 20 healthy controls (only serum levels). PRO-C3, PRO-C11 and PRO-C19 (markers of collagen formation), and C3M and C4M (markers of collagen degradation) were evaluated for both compartments (serum and fluid collection).

RESULTS

Forty-three patients were included: 26 with walled-off necrosis and 17 with pseudocyst. Serum levels of all 5 fibrosis biomarkers were elevated in patients as compared to controls (all P < 0.001). PRO-C3 levels were significantly higher in pancreatic fluid vs serum (280.6 vs 20.8 ng/mL, P < 0.001). In contrast, levels of C3M (20.5 vs 13.1 ng/mL, P = 0.003), PRO-C19 (64.9 vs 14.3 nM, P < 0.001), and C4M (55.6 vs 20.4 ng/mL, P < 0.001) were significantly higher in serum vs pancreatic fluid.

CONCLUSIONS

The high serum levels in patients suggest increased overall fibrotic activity in pancreatitis patients as compared to healthy controls. PRO-C3 elicited higher levels in the pancreatic fluid, indicating localized fibrotic activity.