International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Comparison of Experimental Infection of Normal and Immunosuppressed Chickens with Mycoplasma gallisepticum

Four different models of infection of chickens with Mycoplasma gallisepticum (MG) were evaluated. Normal or immunosuppressed chicks (10 days old) were infected with the MG R_low strain via eye and nasal drops or by direct air sac injection. Bacterial load in the lungs was quantified and air sac and tracheal lesion scores, tracheal mucosal thickness and humoral immune responses were assessed. Serum antibody responses were assessed by use of a serum plate agglutination test. Three days post infection (dpi), all immunosuppressed chicks had developed significant respiratory signs. Chicks infected via air sac injection had significant differences in serum antibody and gross lesion scores at 5 dpi. All chicks had developed pathological changes by 7 dpi. Air sac inoculation of immunosuppressed chicks produced more significant (P ≤0.05) lesions, and these birds had the highest bacterial load in the lungs compared with other groups.

Triptolide induces mitochondrial apoptosis through modulating dual specificity phosphatase 1/mitogen-activated protein kinases cascade in osteosarcoma cells

Due to chemoresistance and metastasis, the overall prognosis of osteosarcoma (OS) has not improved over the last two decades. Exploring novel therapeutic agents that can circumvent theses malignant phenotypes of OS would be essential to improve the survival of OS patients. Triptolide is a unique diterpene triepoxide that possesses potent antitumor activities.However, the effects and mechanism of triptolide on OS cells remain unknown. The effects of triptolide on viability, apoptosis, cell cycle distribution and migratory ability of OS cells were measured using MTT, flow cytometry and wound healing and transwell invasion assays. And an OS tumor xenograft mouse model was produced to further study the in vivo antitumor effects of triptolide. The expression of DUSP1 at the protein and mRNA level in OS cells was detected by western blot and qPCR. We report that triptolide exhibits multidimensional antitumor activities in OS cells, including the induction of apoptosis and G1 phase accumulation, inhibition of cell viability, migration, and invasion. We further demonstrate that triptolide inhibits the expression of dual-specificity protein phosphatase1 (DUSP1) through inhibiting its promoter activity, which causes sustained activation of three subfamilies of mitogen-activated protein kinase (MAPK). And the modulation of DUSP1/MAPK cascade is associated with the apoptosis of OS cells, since the ectopic expression of DUSP1 or the inhibition of MAPK using specific inhibitors can counteract triptolide-induced apoptosis. In addition, triptolide enhances doxorubicin-induced apoptosis. In summary, our study suggests that DUSP1 is an important cellular target of triptolide, and triptolide may be a promising treatment option for OS as a single agent or combined with other chemotherapeutics.

Knockdown of Tripartite Motif Containing 28 suppresses the migration, invasion and epithelial-mesenchymal transition in ovarian carcinoma cells through down-regulation of Wnt/β-catenin signaling pathway

Tripartite motif containing 28 (TRIM28) is a transcriptional corepressor of Kruppel-associated box zinc finger protein, which has been reported to participate in carcinogenesis. Nonetheless, whether TRIM28 plays a role in the metastasis of ovarian carcinoma (OC) is unclear and requires further investigation. In this study, two OC cell lines (A2780 and OVCAR-3) with stable low expression of TRIM28 were established via RNA interference. We found that the migratory and invasive ability of TRIM28-silenced OC cells significantly decreased. The expression and activity of matrix metallopeptidase (MMP)-2 and MMP-9 in these OC cells were inhibited. The TRIM28 shRNA also suppressed the epithelial-mesenchymal transition (EMT) of OC cells as evidenced by the up-regulated E-cadherin and the downregulated Vimentin and N-cadherin. Additionally, the Wnt/β-catenin signaling pathway was suppressed in TRIM28-silenced OC cells: the activity of β-catenin was inhibited, the expression of total and nuclear β-catenin, Axin 2, T-cell factor 1 (TCF1) and lymphoid enhancer binding factor 1 (LEF1) were decreased, whereas the phosphorylation of β-catenin at Ser33/37 was enhanced. Further, re-expression of active β-catenin in TRIM28-silenced OC cells partly restored their metastasis in vitro. Taken together, our study demonstrates a contributory role of TRIM28 in OC metastasis in vitro, suggesting TRIM28 as a novel therapeutic target for this malignant tumor.

[Analysis of risk factors and outcomes for delayed gastric emptying following pancreaticoduodenectomy: a single center experience of 492 cases]

Objective: To evaluate risk factors for delayed gastric emptying(DGE)following pancreaticoduodenectomy(PD). Methods: There were 492 consecutive patients who underwent PD in Pancreas Center, the First Affiliated Hospital with Nanjing Medical University between January 2012 and December 2014 were identified from a prospective database.There were 315 male and 177 female patients with a median age of 60.5 years.Univariate and multivariate analyses were performed to investigate the independent risk factors for clinically relevant DGE(CR-DGE). Results: The overall incidence of DGE was 29.5%, with Grade B and C occurring at 4.3% and 5.9%, respectively.In multivariate analysis, pancreatic duct diameter less than 3 mm(OR=1.888, P=0.042), pylorus-preserving pancreaticoduodenectomy(OR=2.627, P=0.005) and clinically relevant postoperative pancreatic fistula(OR=2.740, P=0.007) were independently associated with CR-DGE.Other main complications such as postoperative pancreatic fistula, pyoperitoneum, intraabdominal infection were also associated with the severity of DGE(χ(2)=21.360, 14.422, 14.378; P=0.011, 0.002, 0.002). DGE patients had a significantly prolonged postoperative length of stay(31(24-41)d vs. 13(11-17)d) and increased medical cost((122 367.5±66 068.3)yuan vs. (78 200.7±27 043.9)yuan)(both P<0.01). Conclusions: Small pancreatic duct, underwent pylorus-preserving pancreaticoduodenectomy and suffered postoperative pancreatic fistula might indicate a high risk of CR-DGE.

[Laparoscopic pancreaticoduodenectomy with a novel artery first and uncinate process first approach through Treitz ligament]

Objective: To explore the clinical effect of a novel artery first and uncinate process first approach for laparoscopic pancreaticoduodenectomy(LPD), emphasizing the left lateral and posterior dissection of uncinate process (UP) via Treitz ligament approach. Methods: From April to November 2016, 18 patients received LPD with a novel approach in Pancreas Center of the First Affiliated Hospital with Nanjing Medical University. All patients were diagnosed as pancreatic head or peri-ampulla tumor, without major vessel invasion nor distant metastasis. For resection, routine caudal view was used in the first step, to dissect the anterior medial border between uncinate process and superior mesenteric vein(SMV). Lymphatic tissues were completely dissected form anterior surface of hepatoduodenal ligament. In the second step, left lateral view with camera from left para-umbilical trocar was used, Treitz ligament was incised, SMA root was exposed. After anticlockwise rotation and retraction of mesentery, the anatomic relationship between SMA trunk, inferior pancreaticoduodenal artery(IPDA), jejunal branch of SMV, and distal part of UP, could be perfectly exposed from left lateral view. SMA was dissected from its root until the position above the uncinate process and duodenum, IPDA was transected, distal part of UP was freed from SMA. In the third step, right lateral view and caudal view were alternatively used; proximal UP mesentery was completely dissected out from SMA root, CA root and posterior surface of hepatoduodenal ligament. Pancreaticoduodenectomy was completed in the forth step after transection of pancreatic neck and common hepatic duct. Results: The SMA root and distal UP were successfully dissected out via Treitz ligament approach in all 18 patients, among them, distal UP was completely excised in 8 patients from left view. Postoperative pathology showed R0 resection rate in 69%. Postoperative complication included intra-abdominal hemorrhage in 1 patient, pancreatic fistula in 7 patients(6 cases with grade A and 1 case with grade B), delayed gastric emptying in 4 patients (2 cases with grade A, 2 cases with grade B). Average postoperative hospital stay was (15.5±6.8)days. Conclusion: The novel artery first and uncinate process first approach through Treitz ligament could help surgeons to completely dissect the full length of meso-pancreas along celiac axis-SMA axis in LPD.

Icariin promotes mouse hair follicle growth by increasing insulin-like growth factor 1 expression in dermal papillary cells

BACKGROUND

Icariin is a major flavonoid isolated from Epimedium spp. leaves (Epimedium Herba), and has multiple pharmacological functions, including anti-angiogenesis, anti-oxidant, anti-inflammatory and immunoprotective effects.

AIM

To investigate whether icariin can stimulate growth of hair follicles in mice and the underlying mechanism.

METHODS

In vitro, the effect of icariin on hair growth was assessed by using a vibrissae hair follicle (VHF) organ-culture model. The proliferation of hair matrix keratinocytes and the expression of insulin-like growth factor (IGF)-1 in follicles were examined by double immunostaining for 5-bromo-2'-deoxyuridine and IGF-1, in the presence or absence of icariin. Dermal papilla cells (DPCs) were cultured and IGF-1 level was measured by reverse transcription-PCR and ELISA after icariin treatment. In vivo, the effect of icariin on hair growth was examined by gavage feeding of icariin to mice whose backs had been depilated, and the conversion of telogen to anagen hair was observed.

RESULTS

Treatment with icariin promoted hair shaft elongation, prolonged the hair cycle growth phase (anagen) in cultured VHFs, and accelerated transition of hair cycle from telogen to anagen phase in the dorsal skin of mice. There was significant proliferation of matrix keratinocytes and an increased level of IGF-1 in cultured VHFs. Moreover, icariin treatment upregulated IGF-1 mRNA expression in DPCs and increased IGF-1 protein content in the conditioned medium of DPCs.

CONCLUSIONS

These results suggest that icariin can promote mouse hair follicle growth via stimulation of IGF-1 expression in DPCs.

Reconstruction with soft tissue free flaps for large defects after the resection of giant facial neurofibroma

Giant facial neurofibroma leads to disfigurement and functional and neurological deficits. Surgical resection is the mainstay of treatment and poses a great challenge to the surgeon with regard to the restoration of the defects arising from tumour resection. The cases of three male and three female patients diagnosed with giant facial neurofibroma, who underwent radical resection and reconstruction with soft tissue free flaps between 2008 and 2015, were analyzed retrospectively. Clinical data including patient sex, age, preoperative embolization of the nutrient artery, volume of blood loss, type and size of flaps used for reconstruction, and complications were recorded. Three of the six patients underwent preoperative embolization of the nutrient artery. The average volume of blood loss was 2850ml. Reconstruction was performed with anterolateral thigh flaps in four patients and latissimus dorsi myocutaneous flaps in two patients. All free flap reconstructions were successful. Partial necrosis of the scalp and wound dehiscence occurred in one patient each. All complications were managed successfully. In conclusion, the soft tissue free flap is a good choice for the coverage of defects after giant facial neurofibroma resection. Multi-disciplinary treatment should be strengthened to minimize the risks of complications, as well as improving quality of life.

Fluctuation Spectroscopy Analysis of Glucose Capped Gold Nanoparticles

In this work, we report the synthesis and biophysical studies carried out on a new kind of biocompatible and very stable gold nanoparticle (GNP) stabilized with glucose through a PEG linker (AuNP-PEG-Glu). The synthetic path was optimized to obtain nanoparticles of controlled sizes. ζ-potential and dynamic light scattering measurements allowed assessment of the nanodimension, dispersity, surface charge, and stability of our GNPs. Confocal microscopy demonstrated qualitatively that glucose molecules are successfully bonded to GNP surfaces. For our study, we selected nanoparticles with diameter in a range that maximizes the internalization efficiency in cells (40 nm). A detailed investigation about the biophysical proprieties of AuNP-PEG-Glu was carried out by means of fluorescence correlation spectroscopy (FCS) and orbital tracking techniques. This work gives new insights about the uptake mechanism of gold nanoparticles capped with glucose molecules.

[The possibility and feasibility of implementation of enhanced recovery after surgery program in pancreatic surgery]

Although the concept of enhanced recovery after surgery(ERAS)had been raised for nearly 20 years, the application of ERAS in pancreatic surgery is still restricted because of great trauma and high incidence of postoperative complications.ERAS have demonstrated significantly accelerated postoperative recovery in pancreatic resections.Large amounts of researches confirmed that using an ERAS protocol in pancreatic surgery could help reduce overall morbidity and shorten postoperative length of hospital stay and reduce in-hospital costs. Systemic standard operating procedure could improve executive ability of the ERAS system, including establishing multi-disciplinary team, making management processes, developing verification regime, guarding against medical risks, increasing patient engagement, setting discharge criteria, improving re-admission system.In conclusion, ERAS can be realized in pancreatic surgery and will get substantial development in future.

Comparison of manganese biodistribution and MR contrast enhancement in rats after intravenous injection of MnDPDP and MnCl2

Purpose: To compare the time course of the MR enhancing properties and biodistri-bution of manganese (Mn) in rats given i.v. Mn dipyridoxyl diphosphate (MnDPDP) or Mn chloride (MnCl2).

Material and Methods: Twenty-four adult rats were injected i.v. with 5 μmol/kg MnDPDP or MnCl2, or with 0.5 ml/kg saline. High resolution T1-weighted MR imaging was performed during early (10 min), mid (2 h) and late (24 h) phases after injection. Mn concentrations in major organs were measured by using an ICP-AES technique, and correlated with MR findings.

Results: Variable degrees of signal enhancement of major organs observed in MR images corresponded with the amount of Mn uptake after injection of MnDPDP or MnCl2. A prominently lower cardiac, pancreatic and hepatic uptake of Mn was seen at 10 min in rats injected with MnDPDP compared with those given MnCl2 and this was reflected in a difference in signal intensity (SI) in the MR images. At 2 h, the Mn content and SI in the major organs were similar with both MnDPDP and MnCl2. An overall Mn clearance was achieved at 24 h without any important organ retention, with kidney excretion of Mn seen only with MnDPDP.

Conclusion: With both MnDPDP and MnCl2, the Mn uptake correlates with the SI enhancement in tissues. The reduced initial cardiac uptake of Mn after MnDPDP treatment compared to MnCl2 may account for the favourable cardiovascular safety of the contrast agent. These data contribute to an understanding of SI enhancement by MnDPDP, and are consistent with other studies showing that at a dose of 5 μmol/kg, MnDPDP can be safely used as a potent MR organ-specific contrast agent.

Leptin changes differentiation fate and induces senescence in chondrogenic progenitor cells

Body weight is a component of the mechanical theory of OA (osteoarthritis) pathogenesis. Obesity was also found to be a risk factor for digital OA involving non-weight-bearing joints, which suggested that metabolism influences the occurrence and progression of OA. The metabolic origin of OA has been partially attributed to the involvement of adipokines, such as leptin, the levels of which are significantly and positively correlated with cartilage degeneration in OA patients. However, the mechanisms by which leptin-induced cartilage degeneration occurs are poorly understood. The discovery of chondrogenic progenitor cells (CPCs) opened up new opportunities for investigation. Investigating the effects of leptin on differentiation and proliferation in CPCs would increase our understanding of the roles played by leptin in the aetiology and development of OA. Here, CPCs were harvested using single-cell sorting from rat cartilage tissues to obtain mesenchymal stem-like cells, which possess clonogenicity, proliferation and stemness. High doses of leptin decreased the ability of the CPCs to migrate, inhibited their chondrogenic potential and increased their osteogenic potential, suggesting that leptin changes differentiation fates in CPCs. High doses of leptin induced cell cycle arrest and senescence in CPCs by activating the p53/p21 pathway and inhibiting the Sirt1 pathway. Inhibiting the Sirt1 pathway accelerated cartilage senescence in knockout (KO) mice. Activating the leptin pathway induced higher Ob-Rb expression and was significantly correlated with cartilage degeneration (lower levels of Coll-2) and tissue senescence (higher levels of p53/p21 and lower levels of Sirt1) in OA patients, suggesting that leptin-induced CPCs senescence contributes to the development of OA. Taken together, our results reveal new links between obesity and cartilage damage that are induced by leptin-mediated effects on cell behaviour and senescence.