Infection prevention in necrotizing pancreatitis: an old challenge with new perspectives

Necrotizing pancreatitis still remains a life-threatening disease despite several improvements in diagnosis, prevention and treatment. In recent years, some important questions have been answered such as the need for early intensive medical treatment rather than early surgery, but others are still strongly debated. The aim of this paper is to present an up-to-date assessment of current challenges in the management of necrotizing pancreatitis in order to prevent infection.

[Intermediate resection and distal pancreatectomy for benign neoplasms of the pancreas: comparison of postoperative complications and costs]

The middle pancreatic resection for benign pathology of the pancreas has been proposed as an advantageous alternative to the distal pancreatectomy, even though the risk of complications is greater. The purpose of the present study is to compare the cost and intra and perioperative impact for the 2 procedures. All patients with benign neoplasia of the body and tail of the pancreas operated on from 1990-1999 were selected from our computer archives, 21 patients underwent an intermediate resection and 64 a distal pancreatectomy. Operative time, units transfused, perioperative complications, post-operative stay and cost were compared. Statistical analysis revealed that the 2 operations are not significantly different in the intra-operative period. Comparing serious complications, the percentage of pancreatic fistulas (33% vs. 11%; P < 0.03) and average hospital stay (21.2 +/- 11.7 days vs. 15.5 +/- 7.1 days; p = 0.009) are greater for the middle than distal resection, respectively. In cases with post-operative complications the hospital stay is even more significant (middle 31.8 +/- 10.3 days vs. 19.1 +/- 7.6 days; p = 0.0002). The economic margin of residual costs, calculated by using the difference of DRG (no 192) and average post-operative costs, is similar for the 2 procedures in cases with normal post-operative courses, (intermediate Euro 2890.02; distal Euro 3181.9), while in cases with complications (DRG no 191), the difference increases (intermediate Euro 8670.11; distal Euro 12788.94). The middle pancreatic resection in respect to the distal pancreatectomy presents a greater technical difficulty when you take into account the longer post-operative course, the increased difficulty in treating complications and the increased costs.

The structure of duplications on human acrocentric chromosome short arms derived by the analysis of 15p

We report the molecular analysis of a 130-kb DNA region containing a junction between beta and non-beta satellite DNA from chromosome 15p. The genomic region is characterized by beta satellite blocks intermingled with variants of the D4Z4 repeat, and duplicons from 4q24 and 4q35. Besides the p-arm of acrocentric chromosomes, the duplicons showed a wide genomespread involving pericentromeric, sub-telomeric, and interstitial regions. In this regard, the paralogous sequences were characterized by a high similarity index (96%), thus indicating a recent transposition during the evolution. The acrocentrics differedwith regard to the location of the 4q24 paralogous region, since it mapped on the p-arm of chromosomes 13-15 and 21, but only on 22q11.2. Conversely, the 4q35 duplication marked the p-arm of all the acrocentrics. In different individuals, the short arm of acrocentric chromosomes revealed a great variability of sequence representation and location at p11 and/or p13 for both the 4q24 and 4q35 duplications. The studied genomic region from chromosome 15p, of which a contig of approximately 200 kb has been derived, could lead to more detailed investigations into the sequence organization and possible biological function of chromosome regions that are located close to the rDNA array.

Lactobacillus plantarum reduces infection of pancreatic necrosis in experimental acute pancreatitis

BACKGROUND

Infection is the commonest cause of death in acute pancreatitis. Early reduction of commensal flora (particularly Lactobacillus species) and, at the same time, overgrowth of Enterobacteriaceae, especially Escherichia coli, have recently been described during acute pancreatitis. Lactobacillus plantarum has been shown to be effective in reducing the egress of endotoxin and microbial translocation in several experimental models such as chemically induced hepatitis and ulcerative colitis.

AIM

The aim of the study was to determine whether L. plantarum 299v (Lp 299v) is capable of effectively reducing microbial translocation in experimental pancreatitis.

METHODS

Acute pancreatitis was induced by isolation and ligation of the biliopancreatic duct in Lewis rats weighing 250-350 g. The animals were divided into 3 groups: group A, sham operation; group B, induction of pancreatitis and no further treatment, and group C, induction of pancreatitis + daily administration by gavage of a 5-ml/day suspension of Lp 299v at 0.5-1.0 x 10(9) bacteria/ml for 8 days, 4 days before and 4 days after induction of pancreatitis. All animals were sacrificed after 96 h. Histological studies and microbiological analyses were performed.

RESULTS

At sacrifice, 40/55 animals showed signs of severe pancreatitis. Since acute pancreatitis was the specific disease investigated, only these animals were subjected to further study. In group B, we found pathogenic micro-organisms in the mesenteric lymph nodes in 14/20 animals and in the pancreatic tissue in 10/20. The bacterial flora consisted predominantly of E. coli, Enterococcus faecalis, Pseudomonas and Proteus species. In contrast, when the animals were kept under an 'umbrella' of Lp 299v, growth of E. faecalis or E. coli were detected only in 4/20 mesenteric lymph node cultures and in 3/20 pancreatic tissue cultures.

CONCLUSIONS

Lp 299v is effective in reducing microbial translocation in experimental pancreatitis. Treatment with probiotic bacteria seems to be a promising alternative to antibiotic therapy.

IS-741 (Ishihara Sangyo)

IS-741 is a phospholipase A2 (PLA2) inhibitor under development by Ishihara Sangyo Kaisha and Sumitomo as a potential treatment for pancreatitis 1187575]. Sumitomo is developing the drug in phase II trials for acute pancreatitis 13990261. In an animal model, IS-741 has been shown to prevent pancreatitis-associated lung injury following endotoxemia [337503].

Clinicopathological features and treatment of intraductal papillary mucinous tumour of the pancreas

BACKGROUND

The surgical strategy in patients with a pancreatic intraductal papillary mucinous tumour (IPMT) is still controversial. In this study the pathological findings in a series of patients were used to rationalize surgical choice.

METHODS

Fifty-one patients with IPMT were observed between 1988 and 1998 and treated by pancreatic resection. Factors evaluated included symptoms, tumour site, type of operation, histological findings and resection margins, tumour stage, follow-up and survival.

RESULTS

Pancreaticoduodenectomy was the most frequent surgical treatment (33 patients; 65 per cent), followed by left pancreatectomy (ten), total pancreatectomy (five) and middle pancreatectomy (three). Histological assessment revealed the tumour to be an adenoma in 13 patients (25 per cent), a borderline tumour in ten (20 per cent) and a carcinoma in 28 (55 per cent), 19 of which were invasive. Mild to moderate dysplasia was present at the resection margin in 20 specimens (41 per cent), and carcinoma in one. Local recurrence was observed in four patients (8 per cent), all of whom underwent a second resection. The 3-year actuarial survival rate for benign and malignant disease was 94 and 69 per cent respectively (P = 0.03).

CONCLUSION

These results suggest that resection should be the treatment for IPMT. Management of the resection margin could be crucial in avoiding tumour recurrence.

[Gabexate mesilate vs gabexate mesilate combined with octreotide in the prevention of postoperative complications of pancreatic surgery: preliminary results]

To date, gabexate mesilate, a synthetic protease inhibitor, has been used in the prophylaxis and treatment of acute pancreatitis, but has yet to be tested in preventing the postoperative complications of pancreatic surgery. For this purpose we planned a pilot study based on two treatment groups, each numbering 25 patients, submitted to high-risk pancreatic resection. In the first group, all patients received a continuous infusion of gabexate mesilate 1 g/day up to postoperative day 4; the second group of patients received the same treatment plus octreotide 0.1 mg every 8 hours for 5 days after surgery. All patients were followed until discharge with clinical and instrumental investigations to detect the onset of postoperative complications. The overall incidences of an uneventful course were 40% (10/25) and 32% (8/25), respectively. We found 12 complications closely related to pancreatic surgery in the former and 8 in the latter group. In the combined treatment group therefore we observe a 33% reduction in the incidence of related abdominal complications (12 vs 8). This favourable trend, however, needs to be confirmed in a larger multicentre trial.

[Does locoregional chemotherapy improve survival in patients with non-resectable pancreatic carcinoma? Results of an open controlled study]

About 90% of patients suffering from pancreatic carcinoma are diagnosed with disease that is not amenable to surgical intervention due to local infiltration or the presence of hepatic metastases. Palliative intra-arterial chemotherapy was developed to improve the response in these patients by increasing the antiblastic dose and minimizing the side effects. The aim of this study is to evaluate the efficacy of this treatment comparison to a control group. From December 1994 to February 1997, 135 patients with ductal carcinoma, in whom 68 were stage III and 67 stage IV, with a median age of 63.3 years (range 38.4-79), were enrolled in an open study. Sixty four patients were subjected to a median of 3.5 cycles, according to intra-arterial FLEC protocol. Four patients had a partial response (6.3%), 27 enjoyed a stabilization of their disease (42.2%) and 13 showed disease progression (20.3%). The toxicity was mild. The overall survival was 8.3 months, better in the treated group (9.6 months) in respect to the control one (7.1 months), although this was not statistically significant. The treatment reported here, therefore, does not seem to change the prognosis of patients affected by no resectable pancreatic carcinoma, but it may demonstrate good tolerability and minimal toxicity.

Pancreatic tumours: molecular pathways implicated in ductal cancer are involved in ampullary but not in exocrine nonductal or endocrine tumorigenesis

Alterations of K- ras, p53, p16 and DPC4/Smad4 characterize pancreatic ductal cancer (PDC). Reports of inactivation of these latter two genes in pancreatic endocrine tumours (PET) suggest that common molecular pathways are involved in the tumorigenesis of pancreatic exocrine and endocrine epithelia. We characterized 112 primary pancreatic tumours for alterations in p16 and DPC4 and immunohistochemical expression of DPC4. The cases included 34 PDC, 10 intraductal papillary-mucinous tumours (IPMT), 6 acinar carcinomas (PAC), 5 solid-pseudopapillary tumours (SPT), 16 ampulla of Vater cancers (AVC) and 41 PET. All tumours were also presently or previously analysed for K- ras and p53 mutations and allelic loss at 9p, 17p and 18q. Alterations in K- ras, p53, p16 and DPC4 were found in 82%, 53%, 38% and 9% of PDC, respectively and in 47%, 60%, 25% and 6% of AVC. Alterations in these genes were virtually absent in PET, PAC or SPT, while in IPMT only K- ras mutations were present (30%). Positive immunostaining confirmed the absence of DPC4 alterations in all IPMT, SPT, PAC and PET, while 47% of PDC and 38% of AVC were immunonegative. These data suggest that pancreatic exocrine and endocrine tumourigenesis involves different genetic targets and that among exocrine pancreatic neoplasms, only ductal and ampullary cancers share common molecular events.

Alcohol intake, cigarette smoking, and body mass index in patients with alcohol-associated pancreatitis

The differential diagnosis between acute and chronic alcohol-associated pancreatitis is often difficult or impossible at onset of the disease. A study was conducted to determine possible relationships between patients suffering from a first episode of acute alcoholic pancreatitis and patients with unequivocal chronic alcoholic pancreatitis, comparing age, drinking and smoking habits, and body mass index (BMI). Two groups of men were considered. The first group consisted of 67 patients with a diagnosis of acute alcohol-associated pancreatitis in the absence of other potential pathogenic factors; in this group, 48 of the 56 patients surviving the acute attack were submitted to imaging studies for a median period of 9 years. The second group consisted of 396 patients with chronic alcoholic pancreatitis with a median follow-up period of 12 years. The variables that differed significantly in the two groups were BMI (p < 0.009) and number of smokers (p < 0.001). Logistic regression analysis selected only BMI with an odds ratio of 1.19 (95% CI, 1.07-1.33; p < 0.00015) in favor of acute alcoholic pancreatitis. In male patients, from an epidemiologic standpoint, only smoking habits and BMI are significant differences at clinical onset between the two types of pancreatitis.

[Clinical evolution of chronic pancreatitis and quality of life]

Nowadays the availability of reliable, efficacious methods of assessing the outcome of chronic pancreatitis is mandatory, especially in view of the several new procedures developed to relieve the symptoms of the disease. Together with the traditional evaluation of postoperative morbidity and mortality and the assessment of exo/endocrine function in patient follow-up, we currently consider the patient's perception of his or her health status as a priority. This information is obtained by administering quality of life questionnaires along with reliable physical and psychometric evaluation.

Molecular structure and evolution of DNA sequences located at the alpha satellite boundary of chromosome 20

We have isolated and characterised one PAC clone (dJ233C1) containing a linkage between alphoid and non-alphoid DNA. The non-alphoid DNA was found to map at the pericentromeric region of chromosome 20, both on p and q sides, and to contain homologies with one contig (ctg176, Sanger Centre), also located in the same chromosome region. At variance with the chromosome specificity shown by the majority of non-alphoid DNA, a subset of alphoid repeats derived from the PAC yielded FISH hybridisation signals located at the centromeric region of several human chromosomes, belonging to three different suprachromosomal families. The evolutionary conservation of this boundary region was investigated by comparative FISH experiments on chromosomes from great apes. The non-alphoid DNA was found to have undergone events of expansion and transposition to different pericentromeric regions of great apes chromosomes. Alphoid sequences revealed a very wide distribution of FISH signals in the great apes. The pattern was substantially discordant with the data available in the literature, which is essentially derived from the central alphoid subset. These results add further support to the emerging opinion that the pericentromeric regions are high plastics, and that the alpha satellite junctions do not share the evolutionary history with the main subsets.

Surgical treatment of pancreatic metastases from renal cell carcinomas

Pancreatic metastases from a renal cell carcinoma are rare and may occur long after manifestation of the primary disease. Resection of the metastases should be regarded as the best treatment. In our center, owing to the slow evolution of these secondaries, we perform resections capable of limiting the destruction of the pancreatic parenchyma as far as possible. The use of 'atypical' resections of the pancreas is characterized by a higher incidence of postoperative complications, particularly fistulas. Despite this, we believe that adjusted resection is to be advocated because of the possibility of additional remote secondaries, the shorter duration of surgery, the preservation of the glandular parenchyma and intact adjacent organs, such as duodenum, stomach, and spleen, and the fact that there have been no reports on local recurrences.

Alcohol, smoking and papillomavirus infection as risk factors for esophageal squamous-cell papilloma and esophageal squamous-cell carcinoma in Italy

Esophageal papilloma, an infrequent benign tumor, and esophageal squamous-cell carcinoma sometimes appear to be associated with human papillomavirus (HPV) infection, HPV being implicated in anogenital carcinogenesis. Our aim was to assess whether there is any epidemiological difference in terms of risk factors for papilloma and cancer. From 1989 to 1996, a total of 12,011 patients (53% male, median age 52.7 years) were submitted to esophagogastroduodenoscopy by our Digestive Endoscopy Service. The genome of HPV was sought by PCR using 2 different primer sets. Of the total, 42 subjects (0.35%), 50% male with a mean age of 45.1 years, were suffering from esophageal squamous-cell papilloma and 45 (0.37%), 91% male with a mean age of 63.0 years, from esophageal squamous-cell carcinoma. Of these patients, only 2 with papilloma were HPV(+). Compared with the general endoscopic population, patients with papilloma do not present significantly different characteristics (even in terms of frequency of esophagitis and hiatal hernia). Those with carcinoma differ significantly both from the general endoscopic population and from those with papilloma in that they are more often male (p < 0. 0001), older (p < 0.0001) and drinkers (p < 0.0001); they differ significantly only from the general population, but not from the papilloma patients, in smoking habits. Papilloma appears to be neither a lesion involving a risk of development into a malignancy nor a marker for any such risk. Environmental factors, such as alcohol and smoking, appear to play a decisive role in esophageal carcinogenesis in northern Italy.

Alcohol, smoking and papillomavirus infection as risk factors for esophageal squamous-cell papilloma and esophageal squamous-cell carcinoma in Italy

Esophageal papilloma, an infrequent benign tumor, and esophageal squamous-cell carcinoma sometimes appear to be associated with human papillomavirus (HPV) infection, HPV being implicated in anogenital carcinogenesis. Our aim was to assess whether there is any epidemiological difference in terms of risk factors for papilloma and cancer. From 1989 to 1996, a total of 12,011 patients (53% male, median age 52.7 years) were submitted to esophagogastroduodenoscopy by our Digestive Endoscopy Service. The genome of HPV was sought by PCR using 2 different primer sets. Of the total, 42 subjects (0.35%), 50% male with a mean age of 45.1 years, were suffering from esophageal squamous-cell papilloma and 45 (0.37%), 91% male with a mean age of 63.0 years, from esophageal squamous-cell carcinoma. Of these patients, only 2 with papilloma were HPV(+). Compared with the general endoscopic population, patients with papilloma do not present significantly different characteristics (even in terms of frequency of esophagitis and hiatal hernia). Those with carcinoma differ significantly both from the general endoscopic population and from those with papilloma in that they are more often male (p < 0. 0001), older (p < 0.0001) and drinkers (p < 0.0001); they differ significantly only from the general population, but not from the papilloma patients, in smoking habits. Papilloma appears to be neither a lesion involving a risk of development into a malignancy nor a marker for any such risk. Environmental factors, such as alcohol and smoking, appear to play a decisive role in esophageal carcinogenesis in northern Italy.

Assessment and treatment of severe pancreatitis. Protease inhibitor

From the theoretical point of view, antiproteolytic therapy would seem to be the rationale for acute pancreatitis management. Unfortunately, clinical human trials studying the role of antiproteases in the treatment of acute pancreatitis differ in several respects in terms of their basic design. As a consequence, any form of homogeneous analysis of the reported data as a whole is impossible. Considering the data emerging from a meta-analysis of five trials a rational use of antiproteases may result in a reduction of complications requiring surgery and of patient management costs only in selected cases, meaning by that severe and necrotic forms. As regards presumptive applications, over 400 patients were prospectively tested versus placebo in a double-blind trial with the aim of preventing acute pancreatitis after ERCP. The complication incidence was significantly lower among the pretreated patients; anyway, also in this field of protease inhibitor clinical application it is necessary to identify the patients with the greatest risk to develop post-ERCP acute pancreatitis. In conclusion, antiproteases can still play a role when given prophylactically or when used in the very early phases of the disease; moreover a 'multiple drugs approach' (including, for example, suitable antibiotics) seems to represent nowadays the most modern and rational treatment of acute pancreatitis.

Alcohol, smoking and papillomavirus infection as risk factors for esophageal squamous-cell papilloma and esophageal squamous-cell carcinoma in Italy

Esophageal papilloma, an infrequent benign tumor, and esophageal squamous-cell carcinoma sometimes appear to be associated with human papillomavirus (HPV) infection, HPV being implicated in anogenital carcinogenesis. Our aim was to assess whether there is any epidemiological difference in terms of risk factors for papilloma and cancer. From 1989 to 1996, a total of 12,011 patients (53% male, median age 52.7 years) were submitted to esophagogastroduodenoscopy by our Digestive Endoscopy Service. The genome of HPV was sought by PCR using 2 different primer sets. Of the total, 42 subjects (0.35%), 50% male with a mean age of 45.1 years, were suffering from esophageal squamous-cell papilloma and 45 (0.37%), 91% male with a mean age of 63.0 years, from esophageal squamous-cell carcinoma. Of these patients, only 2 with papilloma were HPV(+). Compared with the general endoscopic population, patients with papilloma do not present significantly different characteristics (even in terms of frequency of esophagitis and hiatal hernia). Those with carcinoma differ significantly both from the general endoscopic population and from those with papilloma in that they are more often male (p < 0. 0001), older (p < 0.0001) and drinkers (p < 0.0001); they differ significantly only from the general population, but not from the papilloma patients, in smoking habits. Papilloma appears to be neither a lesion involving a risk of development into a malignancy nor a marker for any such risk. Environmental factors, such as alcohol and smoking, appear to play a decisive role in esophageal carcinogenesis in northern Italy.

Need for a standard report and future directions in pancreatic resections for cancer

The ability to compare treatment results is essential for the proper evaluation of treatment protocols. Especially in the case of exocrine pancreatic cancer different classifications and documentation systems hinder the comparison between institutions and do not allow multicenter analysis across the world. This might explain the vastly different results of similar therapeutical trials and studies. In the classifications used at present, the features included, as well as terminology and description, vary greatly. First attempts to stage pancreatic malignancies according to UICC criteria were mentioned in the 1987 edition. These rules were predominantly based on the suggestions of the AJCC Cancer of the Pancreas Task Force of 1981 and have since not been changed. In Japan a different staging system has emerged and was first published by the Japanese Pancreatic Society (JPS) in 1986: General Rules for Surgical and Pathological Studies on Cancer of the Pancreas. The major difference between the two classifications concerns the evaluation of local tumor growth and the extent of lymph node involvement. Unfortunately most attempts to 'restage' Western patients postoperatively according to the JPS criteria, or vice versa, in order to compare treatment results have not added to a clearer understanding. Much in contrary, the results were frequently confusing since not comparable data were nevertheless retrospectively compared. Thus, a uniform standard report is needed, leading to prospective data acquisition and biometric analysis of outcome. The report should serve as a standard format for worldwide data acquisition and documentation and thereby become the common language to describe diagnosis, treatment, pathology and outcome of pancreatic cancer patients undergoing surgical therapy. It should enable: (1) inter-institutional data exchange from different staging systems; (2) comparisons between institutions on an international basis; (3) quality management in clinical practice and studies, and (4) reliable insight into tumor biology and differences in growth patterns.

Intraductal papillary mucinous tumors of the pancreas. Verona University Pancreatic Team

METHODS

Literature is thoroughly reviewed and compared to our own experience.

RESULTS

Clinical history data do not appear to be useful in differentiating between benign and malignant cases. Usually IPMT patients are older than individuals suffering from chronic obstructive pancreatitis and tend to drink and smoke less. Malignant forms of IPMT are more frequently associated with diabetes, and pain seems to be more frequent in benign cases, although these findings are not confirmed in all reports. Also, laboratory tests are of little use, whereas imaging findings currently enable us to reach a correct diagnosis in about 70% of cases without differentiating in a reliable and definitive way the benign or malignant nature of the neoplasm. The WHO classification appears to be related to the different prognosis. Surgery, whenever possible, is the gold standard treatment.

CONCLUSION

IPMT are a recent established clinical entity embracing a spectrum of lesions ranging from benign to malignant infiltrating cases. The only recognized radical treatment is surgery. Despite diagnostic capacity based on clinical presentation and imaging techniques has becoming increasingly refined we are still incapable of identifying the different degree of malignancy preoperatively, if any. The lengthy mean survival after resection confirm the high potential cure rate of IPMT of the pancreas.