Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

Analysis of clinical characteristics of hemorrhagic fever with renal syndrome with acute pancreatitis: a retrospective study

OBJECTIVE

This research aimed to analyze the impact of hemorrhagic fever with renal syndrome (HFRS) with acute pancreatitis (AP) on the severity and prognosis of patients, screen the risk factors of HFRS with AP, and establish a nomogram model.

METHODS

Data were collected from HFRS patients at the First Affiliated Hospital of Dali University and Dali Prefecture People's Hospital (2013-2023). Patients were divided into HFRS with AP (n = 34) and HFRS without AP groups (n = 356). Propensity Score Matching (PSM) and logistic regression analyzed the impact of AP on HFRS severity and short-term prognosis. LASSO-Logistic regression was used to screen risk factors and develop a nomogram model.

RESULTS

After PSM, HFRS patients with AP had higher rates of Continuous Renal Replacement Therapy (CRRT) and/or mechanical ventilation use, , ICU admission, and 30-day mortalitycompared with those without AP (p < 0.05). Further analysis revealed that smoking (OR: 3.702), ferritin (OR: 1.002), white blood cell (OR), fibrinogen (OR: 0.463), and platelet (OR: 0.987) were risk factors for HFRS with AP (p < 0.05). A nomogram model was constructed based on these factors, to predict the risk of HFRS with AP, with an Area Under the Curve (AUC) of 0.90 (95% CI: 0.84-0.95). Additionally, the model calibration curve fit well according to the Hosmer-Lemeshow test (χ2=8.51, p = 0.39).

CONCLUSION

Patients with HFRS with AP exhibit higher disease severity and poorer prognosis. Smoking, elevated ferritin and white blood cell levels, decreased fibrinogen and platelet levels are more susceptible to developing AP.

Exploring the mechanism of intestinal bacterial translocation after severe acute pancreatitis: the role of Toll-like receptor 5

Severe acute pancreatitis (SAP)-induced intestinal bacterial translocation and enterogenic infection are among the leading causes of mortality in patients. However, the mechanisms by which SAP disrupted the intestinal barrier and led to bacterial translocation remained unclear. Therefore, we employed multi-omics analysis including microbiome, metabolome, epigenome, transcriptome, and mass cytometry (CyTOF) to identify potential targets, followed by functional validation using transgenic mice. The integrated multi-omics analysis primarily indicated overgrowth of intestinal flagellated bacteria, upregulation of intestinal Toll-like receptor 5 (TLR5) and acute inflammatory response, and increased infiltration of intestinal high-expressing TLR5 lamina propria dendritic cells (TLR5hi LPDC) after SAP. Subsequently, intestinal flagellin-TLR5 signaling was activated after SAP. Intestinal barrier disruption, bacterial translocation, and helper T cells (Th) differentiation imbalance caused by SAP were alleviated in TLR5 knocked out (Tlr5-/-) or conditionally knocked out on LPDC (Tlr5ΔDC) mice. However, TLR5 conditional knockout on intestinal epithelial cells (Tlr5ΔIEC) failed to improve SAP-induced bacterial translocation. Moreover, depletion of LPDC and regulatory T cells (Treg) ameliorated bacterial translocation after SAP. Our findings identify TLR5 on LPDC as a potential novel target for preventing or treating intestinal bacterial translocation caused by SAP.

Retrospective case control study on the evaluation of the impact of augmented reality in gynecological laparoscopy on patients operated for myomectomy or adenomyomectomy

The objective of this study is to evaluate the safety of using augmented reality (AR) in laparoscopic (adeno)myomectomy, defined as an increase in operating time shorter than 15 min. A total of 17 AR cases underwent laparoscopic myomectomy or adenomyomectomy with the use of AR and 17 controls without AR for the resection of (adeno)myomas. The non-inferiority assumption was defined by an operative overtime not exceeding 15 min, representing 10% of the typical operative time. The 17 AR cases were matched to 17 controls. The criteria used in matching the two groups were the type of lesions, the size and the placement. The mean operative time was 135 ± 39 min for AR cases and 149 ± 62 min for controls. The margin of non-inferiority was expressed as a difference in operative time of 15 min between the case and control groups. The mean difference observed between AR cases and controls was -14 min with 90% CI [-38.3;11.3] and was significantly lower than the non-inferiority margin of 15 min (p = 0.03). This negative time difference means that the operative time is shorter for the AR cases group. Intraoperative data revealed a volume of bleeding ≤200 mL in 82.3% of AR cases and in 75% of controls (p = 0.62). No intra or postoperative complications were reported in the groups. The use of augmented reality in laparoscopic (adeno)myomectomy does not introduce additional constraints for the surgeon. It appears to be safe for the patients, with an absence of additional adverse events and of significantly prolonged operative time.

Pseudotargeted metabolomics profiles potential damage-associated molecular patterns as machine learning predictors for acute pancreatitis

Acute pancreatitis (AP) is a common gastrointestinal disease characterized by pancreatic cell damage and inflammation. Given the early clinical diagnosis and management challenges, exploring novel analytical frameworks from new orientations for interrogating AP is urgent. The release of damage-associated molecular patterns (DAMPs) and their receptor recognition initiate sterile inflammation, serving as key drivers in the development and progression of AP. Thus, this study aimed to delineate the underlying correlations between alterations in the DAMP profile and the AP state. We have developed a new framework combining potential DAMPs profiles obtained from pseudotargeted metabolomics method with machine learning (ML) models for AP prediction. 2-(1-Piperazinyl) pyrimidine chemical labeling was utilized to provide characteristic fragment ions and improve the quantitative sensitivity of targeted metabolites. A total of 49 potential DAMPs were identified and semi-quantified from collected serum samples (n = 84), positive or negative for APs. For modeling obtained datasets with five different ML algorithms, the support vector machine model was chosen as the optimal model to differentiate with high accuracy, achieving an area under the receiver-operating characteristic curve (AUROC) of 0.944. It also showed a strong performance in an external independent validation set (AUROC: 0.907). Moreover, the model was interpreted using the Shapley Additive exPlanations analysis to specify the important features and identify specific free fatty acids as key contributors. Overall, the novel framework enables high accuracy in predicting the presence of AP status. Meanwhile, it underlines the utility of DAMPs in inflammatory diseases and provides reference values for diagnosing in first-line clinics.

Acute pancreatitis after total aortic arch replacement leading to walled-off necrosis: A case report and review of literature

BACKGROUND

Although acute pancreatitis and walled-off necrosis (WON) are rare complications following aortic surgery, they are serious risk factors for postoperative mortality. Considering the poor general condition of the postoperative patient, more effective and less invasive treatments are favorable.

CASE SUMMARY

A 67-year-old man was referred to our hospital for the treatment of WON after acute pancreatitis. He had undergone total aortic arch replacement due to aortic arch aneurysm and coronary artery bypass grafting due to angina pectoris 6 weeks prior in another hospital. On the second postoperative day, laboratory data and computed tomography showed that the patient had developed acute pancreatitis. Although conservative management (antibiotics, hydration, etc.) had helped in relieving the symptoms of acute pancreatitis, peripancreatic fluid collection (PFC) persisted, accompanied by duodenal obstruction and vomiting. Contrast-enhanced computed tomography showed that the heterogeneous enhancement and fluid collection in the pancreatic body and tail had increased, consistent with walled-off WON. We therefore performed endoscopic ultrasound-guided transluminal drainage for the PFC. As a result, the WON resolved gradually, resulting in improved oral intake.

CONCLUSION

Acute pancreatitis is a rare gastrointestinal complication following thoracic and thoracoabdominal aortic aneurysm surgery. To the best of our knowledge, this is the first case of WON after aortic arch surgery treated with endoscopic ultrasound-guided transluminal drainage for PFC.

Design and rationale of the CORE-TIMI 72a and CORE2-TIMI 72b trials of olezarsen in patients with severe hypertriglyceridemia

BACKGROUND

Severe hypertriglyceridemia (HTG), defined as a serum triglyceride (TG) concentration ≥500 mg/dl, is present in approximately 1 in every 100 individuals and carries direct clinical consequences, including pancreatitis, which can be life-threatening. Olezarsen is an investigational antisense oligonucleotide targeted to the mRNA for apolipoprotein C-III (apoC-III), a protein known to impair TG clearance by inhibiting lipoprotein lipase and the hepatic uptake of triglyceride-rich remnants. No dedicated trial has tested olezarsen in patients with severe HTG.

METHODS

In these 2 pivotal phase 3 trials, CORE-TIMI 72a and CORE2-TIMI 72b, patients with severe HTG were randomized in a 2:1 fashion to either olezarsen (80 mg or 50 mg dose) or matching placebo. Patients will be treated for a total of 12 months and evaluated for the primary endpoint of percent change in TGs from baseline to 6 months compared with placebo. Pooled analyses of CORE and CORE2 will also assess olezarsen's effect on acute pancreatitis events and change in hepatic steatosis.

RESULTS

A total of 617 subjects in CORE-TIMI 72a and 446 subjects in CORE2-TIMI 72b were randomized. In these 2 trials, the median age was 54 and 55 years, women made up 24% and 23% of the study population, and the baseline TGs were 836 mg/dl and 749 mg/dl, respectively. A total of 333 subjects, 129 from CORE-TIMI 72a and 204 from CORE2-TIMI 72b, were enrolled in the hepatic MRI substudy.

DISCUSSION

Together, CORE-TIMI 72a and CORE2-TIMI 72b are designed to establish the efficacy and safety of olezarsen in patients with severe HTG.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05079919 and NCT05552326.

Dysfunction of pancreatic exocrine secretion after experimental spinal cord injury

Pancreatic exocrine dysfunction is an underdiagnosed comorbidity in individuals living with spinal cord injury (SCI) who often present cholestasis, acute pancreatitis or high levels of serum pancreatic enzymes. Parasympathetic control of pancreatic exocrine secretion (PES) is mediated in the medullary dorsal vagal complex in part through cholecystokinin (CCK) release. Our previous reports indicate high thoracic (T3-) SCI reduces vagal afferent sensitivity to GI regulatory peptides, like CCK and thyrotropin releasing hormone (TRH). To date, the effects of experimental SCI on PES are unknown. Here we investigated the modulation of PES following T3-SCI in rats. We measured PES volume and amylase concentration in control and T3-SCI rats (3-days or 3-weeks after injury) following: (i) intra-duodenal administration of a mixed-nutrient liquid meal (Ensure® ™) or (ii) central TRH injection (100 pmol) in the dorsal motor nucleus of the vagus. In a separate cohort of overnight-fasted rats, basal serum amylase levels were measured. The baseline volume of PES secretion was lower in 3-week rats destined to receive Ensure® or TRH following T3-SCI surgery compared to control. PES protein concentration was significantly reduced at baseline in 3-week T3-SCI and elevated in 3-day and 3-week T3-SCI rats postprandially but only elevated in 3-day rats following TRH microinjection. Serum amylase activity levels were elevated in 3-day T3-SCI rats and remained at similar levels post 3-weeks T3-SCI. Our data suggest that vagally-mediated regulation of multiple visceral organs is disrupted in the days and weeks following experimental SCI.

Artificial intelligence in gastrointestinal surgery: A minireview of predictive models and clinical applications

BACKGROUND

Artificial intelligence (AI) is playing an increasingly significant role in predicting outcomes of gastrointestinal (GI) surgeries, improving preoperative risk assessment and post-surgical decision-making. AI models, particularly those based on machine learning, have demonstrated potential in predicting surgical complications and recovery trajectories.

AIM

To evaluate the role of AI in predicting outcomes for GI surgeries, focusing on its efficacy in enhancing surgical planning, predicting complications, and optimizing post-operative care.

METHODS

A systematic review of studies published up to March 2025 was conducted across databases such as PubMed, Scopus, and Web of Science. Studies were included if they utilized AI models for predicting surgical outcomes, including morbidity, mortality, and recovery. Data were extracted on the AI techniques, performance metrics, and clinical applicability.

RESULTS

Machine learning models demonstrated significantly better performance than logistic regression models, with an area under the curve difference of 0.07 (95%CI: 0.04–0.09; P < 0.001). Models focusing on variables such as patient demographics, nutritional status, and surgical specifics have shown improved accuracy. AI’s ability to integrate multifaceted data sources, such as imaging and genomics, contributes to its superior predictive power. AI has improved the early detection of gastric cancer, achieving 95% sensitivity in real-world settings.

CONCLUSION

AI has the potential to transform GI surgical practices by offering more accurate and personalized predictions of surgical outcomes. However, challenges related to data quality, model transparency, and clinical integration remain.

Outcome prediction for cholangiocarcinoma prognosis: Embracing the machine learning era

We read with great interest the study by Huang et al. Cholangiocarcinoma (CC) is the second most common type of primary liver tumor worldwide. Although surgical resection remains the primary treatment for this disease, almost 50% of patients experience relapse within 2 years after surgery, which negatively affects their prognosis. Key predictors can be used to identify several factors (e.g., tumor size, tumor location, tumor stage, nerve invasion, the presence of intravascular emboli) and their correlations with long-term survival and the risk of postoperative morbidity. In recent years, artificial intelligence (AI) has become a new tool for prognostic assessment through the integration of multiple clinical, surgical, and imaging parameters. However, a crucial question has arisen: Are we ready to trust AI with respect to clinical decisions? The study by Huang et al demonstrated that AI can predict preoperative textbook outcomes in patients with CC and highlighted the precision of machine learning algorithms using useful prognostic factors. This letter to the editor aimed to explore the challenges and potential impact of AI and machine learning in the prognostic assessment of patients with CC.

Rectal diclofenac versus indomethacin for prevention of post-ERCP pancreatitis (DIPPP): a multicentre, double-blind, randomised, controlled trial

BACKGROUND

Recent meta-analyses suggested diclofenac may be superior to indomethacin in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The aim of our study was to compare the efficacy of 100 mg rectal indomethacin versus diclofenac on PEP incidences.

DESIGN

This multicentre, double-blinded, randomised controlled trial was conducted in nine tertiary centres in China. Patients with low and high risk for PEP and native papilla were randomly allocated (1:1) to receive 100 mg diclofenac or 100 mg indomethacin rectally before ERCP. The primary outcome was the occurrence of PEP defined by the Cotton consensus. The intention-to-treat principle was conducted for the analysis.

RESULTS

The trial was terminated early for futility after the predetermined first interim analysis. Between June 2023 and May 2024, 1204 patients were randomised into the diclofenac group (n=600) or indomethacin group (n=604). Baseline characteristics were balanced. The primary outcome occurred in 53 patients (8.8%) of 600 patients allocated to the diclofenac group and 37 patients (6.1%) of 604 patients allocated to the indomethacin group (relative risk 1.44; 95% CI 0.96 to 2.16, p=0.074). PEP occurred in 35 (14.2%) of 247 high-risk patients in the diclofenac group and 26 (9.8%) of 266 high-risk patients in the indomethacin group (p=0.124). PEP incidences were also comparable in low-risk patients between the two groups (18/353 (5.1%) vs 11/338 (3.3%), p=0.227). Other ERCP-related complications did not differ between the two groups.

CONCLUSION

Pre-procedure 100 mg rectal diclofenac was not superior to the same dose of rectal indomethacin regarding preventing PEP. These findings supported current clinical practice guidelines of 100 mg indomethacin or diclofenac for PEP prophylaxis in patients without contraindications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05947461).

Left Hepatectomy Enlarged to Segment 1 with Total Vascular Exclusion of the Liver Preserving the Caval Flow with Temporary Portacaval Shunt and Hypothermic Oxygenated Portal Perfusion on Machine for Metastatic Recurrence of a Pleural Chondrosarcoma

BACKGROUND

Total vascular exclusion (TVE) of the liver preserving the caval flow with portal hypothermic perfusion and temporary portacaval shunt (PCS) is a validated technique for tumors invading the hepatic veins (HV) close to their confluence with the inferior vena cava (IVC). It prevents the risk of haemorrhage, gas embolism and avoids the haemodynamic consequences of clamping the IVC and veno-venous bypass. No published cases have reported using hypothermic oxygenated perfusion machine.

PATIENTS AND METHODS

The patient was a 58-year-old woman presenting a recurrent metastatic pleural chondrosarcoma, with a pleural metastasis and several intra-abdominal metastases, including a lesion localized in segment 1 close to the hilar plate and invading the left HV near its abutment in the IVC. A left hepatectomy enlarged to segment 1 was performed under TVE preserving the caval flow with in situ hypothermic portal perfusion of the liver using perfusion machine.

RESULTS

PV clamping lasted 57 min, and 2 l of preservative solution were perfused. The maximum pressure in the PV was 10 mmHg and oxygen flow was regulated at 2 L/min. The resection was complete and margins were negative. Liver temperature was monitored at 5-6 °C. Postoperative follow-up was favourable, with hospital discharge at 16 days after surgery.

DISCUSSION

The use of hypothermic oxygenated perfusion machine is therefore possible in this technique. In parallel with the results obtained in liver transplantation on marginal grafts, it could probably reduce ischemia-reperfusion injury of the remnant parenchyma compared with static cold storage and improve post-operative outcome.

MRI and CT radiomics for the diagnosis of acute pancreatitis

Purpose

To evaluate the single and combined diagnostic performances of CT and MRI radiomics for diagnosis of acute pancreatitis (AP).

Materials and methods

We prospectively enrolled 78 patients (mean age 55.7 ± 17 years, 48.7 % male) diagnosed with AP between 2020 and 2022. Patients underwent contrast-enhanced CT (CECT) within 48-72 h of symptoms and MRI ≤ 24 h after CECT. The entire pancreas was manually segmented tridimensionally by two operators on portal venous phase (PVP) CECT images, T2-weighted imaging (WI) MR sequence and non-enhanced and PVP T1-WI MR sequences. A matched control group (n = 77) with normal pancreas was used. Dataset was randomly split into training and test, and various machine learning algorithms were compared. Receiver operating curve analysis was performed.

Results

The T2WI model exhibited significantly better diagnostic performance than CECT and non-enhanced and venous T1WI, with sensitivity, specificity and AUC of 73.3 % (95 % CI: 71.5-74.7), 80.1 % (78.2-83.2), and 0.834 (0.819-0.844) for T2WI (p = 0.001), 74.4 % (71.5-76.4), 58.7 % (56.3-61.1), and 0.654 (0.630-0.677) for non-enhanced T1WI, 62.1 % (60.1-64.2), 78.7 % (77.1-81), and 0.787 (0.771-0.810) for venous T1WI, and 66.4 % (64.8-50.9), 48.4 % (46-50.9), and 0.610 (0.586-0.626) for CECT, respectively.The combination of T2WI with CECT enhanced diagnostic performance compared to T2WI, achieving sensitivity, specificity and AUC of 81.4 % (80-80.3), 78.1 % (75.9-80.2), and 0.911 (0.902-0.920) (p = 0.001).

Conclusion

The MRI radiomics outperformed the CT radiomics model to detect diagnosis of AP and the combination of MRI with CECT showed better performance than single models. The translation of radiomics into clinical practice may improve detection of AP, particularly MRI radiomics.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

Reduced pancreatic fistula rates and comprehensive cost analysis of robotic versus open pancreaticoduodenectomy

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has emerged as a promising surgical approach for the treatment of periampullary neoplasms, offering the potential benefits of minimally invasive surgery. However, the impact of RPD on clinically relevant pancreatic fistula (CR-PF) rates and overall costs compared to open pancreaticoduodenectomy (OPD) remains unclear, limiting its widespread adoption.

METHODS

This retrospective cohort study was conducted at a high-volume Japanese referral center from 2017 to 2023. A total of 193 patients diagnosed with periampullary neoplasms underwent either RPD (n = 81) or OPD (n = 112). To account for potential selection bias, propensity score matching (PSM) was used to balance patient demographics and clinical characteristics, resulting in two well-matched groups of 60 patients each. Perioperative outcomes, CR-PF rates, and a comprehensive cost analysis were evaluated.

RESULTS

RPD resulted in a significantly lower rate of CR-PF (10%) compared to OPD (33.3%) (p = 0.003). Additionally, patients who underwent RPD experienced shorter hospital stays (15 days) compared to those in the OPD group (22.5 days) (p < 0.001). Despite longer operative times for RPD (633 vs. 395 min; p < 0.001), total hospital costs were comparable between the two groups. The higher operative costs associated with RPD were offset by reduced postoperative complications and shorter hospitalization.

CONCLUSIONS

RPD offers significant clinical advantages, including lower CR-PF rates and reduced hospital stays, without increasing overall hospital costs compared to OPD. These findings support the feasibility and potential benefits of adopting RPD for the management of periampullary neoplasms in clinical practice.

Necrosectomy and its timing in relation to clinical outcomes of EUS-guided treatment of walled-off pancreatic necrosis: a multicenter study

BACKGROUND AND AIMS

EUS-guided transmural drainage with on-demand endoscopic necrosectomy (EN) is increasingly used to manage walled-off necrosis (WON). It has not been fully elucidated how EN and its timing are correlated with treatment outcomes compared with the drainage-based approach.

METHODS

Within a multi-institutional cohort of 423 patients with pancreatic fluid collections, including 227 patients with WON, 153 patients were identified who received the step-up treatment after the initial EUS-guided drainage of symptomatic WON; this included 102 EN patients and 51 non-EN (drainage) patients. Using the competing-risks multivariable proportional hazards regression model with adjustment for potential confounders, we calculated subdistribution hazard ratios (SHRs) for clinical treatment success (WON resolution) according to use of EN and its timing.

RESULTS

Compared with drainage alone, the EN-based treatment was associated with a shorter time to clinical success with a multivariable SHR of 1.66 (95% confidence interval, 1.12-2.46). Despite a higher risk of procedure-related bleeding in the EN group, there were no differences in the rates of severe adverse events (7.8% vs 5.9% in the EN and non-EN groups, respectively) or mortality (6.9% vs 9.8%). In the EN-treated patients, the timing of EN was not statistically significantly associated with the time to clinical success (Ptrend = .34).

CONCLUSIONS

Among patients receiving EUS-guided treatment of symptomatic WON, the use of EN in addition to drainage procedures was associated with earlier disease resolution. Further research is desired to determine the optimal timing of initiating EN considering a risk-benefit balance and cost-effectiveness.

Futility of plasmapheresis, insulin in normoglycaemic individuals, or heparin in the treatment of hypertriglyceridaemia-induced acute pancreatitis

There is a well-established link between the severity of hypertriglyceridaemia and acute pancreatitis and long-term triglyceride-lowering therapies known to prevent episodes of acute pancreatitis. Therefore, it has been assumed, without firm evidence, that rapid lowering of plasma triglycerides would be an effective strategy for reducing the clinical severity of acute pancreatitis and improving health outcomes. Therapies, such as intravenous heparin, intravenous insulin in normoglycaemic individuals (with glucose to prevent hypoglycaemia), and plasmapheresis, continue to be widely used as therapeutic interventions to rapidly reduce serum triglyceride concentration. These therapies are all associated with a risk of adverse reactions, require increased resources, and increase health-care costs. Randomised controlled clinical trials of these therapies have generally shown more rapid reductions in plasma triglycerides than conventional supportive care with the patient made nil by mouth. However, these three therapies alone or in combination, have failed to show effectiveness in improving substantial health benefit outcome measures. While we recognise the theoretical basis for rapidly reducing plasma triglycerides in hypertriglyceridaemia-induced pancreatitis-based on our review of studies using heparin, insulin, plasmapheresis, or a combination of these-these strategies overall do not reduce complications associated with acute pancreatitis or the rapidity of disease resolution. Therefore, we do not advocate the use of triglyceride-lowering therapies at this time, pending more convincing evidence.

Comparison of different scoring systems for predicting 28-day mortality in critically ill patients with acute pancreatitis: a retrospective cohort study

BACKGROUND

This study compared eight scoring systems for predicting 28-day and 1-year all-cause mortality in critically ill patients with acute pancreatitis (AP).

METHODS

Data from the Medical Information Mart for Intensive Care IV were used to conduct a comparative analysis of several predictive scoring systems. Predictive performance for 28-day and 1-year mortality was assessed using receiver operating characteristic (ROC) curves (area under the curve [AUC]), restricted cubic splines (RCS) for nonlinearity testing, and multivariable logistic regression for independent predictor analysis.

RESULTS

A total of 694 patients were included (28-day mortality: 15.56%; 1-year mortality: 24.78%). Acute Physiology Score III (APSIII) demonstrated the highest accuracy for 28-day mortality (AUC: 0.847, 95% confidence interval (CI): 0.808-0.886), followed by Bedside Index for Severity in Acute Pancreatitis (BISAP) (AUC: 0.835, 95% CI: 0.794-0.875). Linear relationships between scores and 28-day mortality were confirmed (all p for nonlinear > 0.05). Multivariable regression identified APSIII and BISAP as independent 28-day mortality predictors. For 1-year mortality, APSIII, BISAP, and Simplified Acute Physiology Score II (SAPS II) were independent predictors.

CONCLUSIONS

Both APSIII and BISAP were identified as independent predictors of 28-day mortality, while APSIII, BISAP, and SAPSII were associated with 1-year mortality. Among them, APSIII showed the best overall discriminative ability for both short- and long-term outcomes. However, BISAP remains an attractive alternative for its simplicity and comparable performance.

Diagnostic and prognostic value of miR-146b-5p in acute pancreatitis

OBJECTIVE

MicroRNAs hold great potential as biomarkers for assessing the progression of acute pancreatitis (AP). This study aimed to explore the value of miR-146b-5p in the diagnosis and prognosis of AP patients.

METHODS

110 AP patients were included and divided into 40 severe AP (SAP) patients and 70 non-SAP patients based on disease severity. Serum miR-146b-5p levels were measured using RT-qPCR. The diagnostic value of miR-146b-5p was evaluated utilizing ROC curves. Pearson correlation coefficient was employed to analyze the correlations between APACHEII, BISAP, and MCTSI scores and miR-146b-5p levels. The AP cell model was constructed by treating AR42J cells with deoxycholic acid (DCA), the proliferative capacity of cells was measured with CCK-8, apoptosis was measured by flow cytometry, and IL-6 and IL-8 protein levels were analyzed by ELISA.

RESULTS

Serum miR-146b-5p levels were decreased in SAP and unfavorable patients. Serum miR-146b-5p was able to effectively differentiate between SAP and non-SAP patients, and also effectively differentiate between unfavorable and favorable patients. MiR-146b-5p levels were significantly negatively correlated with APACHEII score (r=-0.6676), BISAP score (r=-0.5696), and MCTSI score (r=-0.5857). Furthermore, in the AP cell model, miR-146b-5p expression was down-regulated, proliferative capacity was diminished, apoptosis was increased, and IL-6 and IL-8 levels were elevated, but overexpression of miR-146b-5p partially reversed these changes.

CONCLUSION

miR-146b-5p expression is down-regulated in the serum of SAP patients and cells, and it has a good diagnostic effect. It may be a potential biomarker and therapeutic target for AP.

Adult patient with enteric intussusception in the emergency department

Acute abdominal pain in adults is a quite common presentation to emergency departments (EDs) with a broad differential diagnosis. Intussusception in adults is rare, so a high index of suspicion is required to consider it as a differential diagnosis. The most common site of an adult's intussusception is the small bowel, most commonly due to a well-defined lesion resulting in a lead point. CT abdominal scan is the definitive investigation of choice, leading to prompt diagnosis and early definitive surgical treatment.We present a case of a woman in her 30s, with a previous laparoscopic partial gastrectomy, who presented to our ED with acute onset of abdominal pain associated with dry retching. Her abdominopelvic CT scan showed small bowel obstruction due to enteric intussusception. She underwent an urgent exploratory laparotomy with manual reduction of the intussusception with no adverse immediate postoperative outcomes due to early diagnosis and management.

Nonlinear association between estimated plasma volume status and acute kidney injury in acute pancreatitis patients

BACKGROUND

Acute pancreatitis (AP), a severe pancreatic inflammatory condition, with a mortality rate reaching up to 40%. Recently, AP shows a steadily elevating prevalence, which causes the greater number of hospital admissions, imposing the substantial economic burden. Acute kidney injury (AKI) complicates take up approximately 15% of AP cases, with an associated mortality rate of 74.7%-81%.

AIM

To evaluate the efficacy of estimated plasma volume status (ePVS) in forecasting AKI in patients with AP.

METHODS

In this retrospective cohort study, AP cases were recruited from the First College of Clinical Medical Science of China Three Gorges University between January 2019 and October 2023. Electronic medical records were adopted for data extraction, including demographic data and clinical characteristics. The association between ePVS and AKI was analyzed using multivariate logistic regression models, with potential confounders being adjusted. Nonlinear relationship was examined with smooth curve fitting, and infection points were calculated. Further analyses were performed on stratified subgroups and interaction tests were conducted.

RESULTS

Among the 1508 AP patients, 251 (16.6%) developed AKI. ePVS was calculated using Duarte (D-ePVS) and Kaplan-Hakim (KH-ePVS) formulas. After adjusting for covariates, the AKI risk exhibited 46% [odds ratio (OR) = 1.46, 95% confidence interval (CI): 0.96-2.24] and 11% (OR = 1.11, 95%CI: 0.72-1.72) increases in the low tertile (T1) of D-ePVS and KH-ePVS, respectively, and 101% (OR = 2.01, 95%CI: 1.31-3.05) and 51% (OR = 1.51, 95%CI: 1.00-2.29) increases in the high tertile (T3) relative to the reference tertile (T2). Nonlinear curve fitting revealed a U-shaped association of D-ePVS with AKI and a J-shaped association for KH-ePVS, with inflection points at 4.3 dL/g and -2.8%, respectively. Significant interactions were not observed in age, gender, hypertension, diabetes mellitus, sequential organ failure assessment score, or AP severity (all P for interaction > 0.05).

CONCLUSION

Our results indicated that ePVS demonstrated the nonlinear association with AKI incidence in AP patients. A U-shaped curve was observed with an inflection point at 4.3 dL/g for the Duarte formula, and a J-shaped curve at -2.8% for the Kaplan-Hakim formula.

Retinal microvasculature alteration in patients with acute pancreatitis: an observational OCTA study

OBJECTIVE

To evaluate changes in retinal layer thickness and microvascular density in pancreatitis patients using optical coherence tomography angiography (OCTA).

METHODS

The study involved 16 pancreatitis patients and 16 healthy controls. Each participant underwent a superficial OCTA scan, with images divided into nine subregions to compare macular retinal thickness (RT) and superficial vascular density (SVD) between groups.

RESULTS

Pancreatitis patients exhibited reduced retinal thickness in specific macular areas, including inner, full, and outer layers (p < 0.05). Additionally, decreased superficial vascular density was noted in inner superior (IS), outer superior (OS), inner nasal (IN), and outer nasal (ON) regions (p < 0.05). ROC curve analysis showed high diagnostic accuracy for full-layer inner superior, outer superior, and outer inferior thickness with areas under the curve of 0.9429, 0.9233, and 0.9990, respectively.

CONCLUSIONS

Pancreatitis is associated with macular retinal thinning and decreased superficial vascular density, offering potential for improved diagnostic imaging.

Endoscopic management of infected necrotizing pancreatitis: Advancing through standardization

Infected necrotizing pancreatitis (INP) remains a life-threatening complication of acute pancreatitis. Despite advancements such as endoscopic ultrasound (EUS)-guided drainage, lumen-apposing metal stents, and protocolized step-up strategies, the clinical practice remains heterogeneous, with variability in endoscopic strategies, procedural timing, device selection, and adjunctive techniques contributing to inconsistent outcomes. This review synthesizes current evidence to contribute to a structured framework integrating multidisciplinary team decision-making, advanced imaging (three-dimensional reconstruction, contrast-enhanced computed tomography/magnetic resonance imaging), EUS assessment, and biomarker-driven risk stratification (C-reactive protein, procalcitonin) to optimize patient selection, intervention timing, and complication management. Key standardization components include endoscopic assessment and procedural strategies, optimal timing of intervention, personalized approaches for complex pancreatic collections, and techniques to reduce the number of endoscopic debridements and mitigate complications. This work aims to enhance clinical outcomes, minimize practice heterogeneity, and establish a foundation for future research and guideline development in endoscopic management of INP.

Quantitative Evaluation of Acute Pancreatitis Based on Dual-Energy Computed Tomography

OBJECTIVE

To evaluate the value of dual-energy computed tomography (DECT) parameters for the quantitative diagnosis of acute pancreatitis (AP) and classification of its severity.

METHODS

Patients with AP underwent a plain CT scan and three contrast-enhanced DECT scans. We analyzed the group differences in iodine concentration (IC) and slope of the spectral Hounsfield unit curve (λHU) of the 3-phase enhanced scans (arterial, venous, and delayed phases).

RESULTS

The study included 60 AP patients (38 males and 22 females; mean age: 47.43±13.47 y). On the basis of the CT severity index (CTSI), the patients were divided into 2 groups: group A (mild AP, n=26) and group B (moderate/severe AP, n=34). IC and λHU in the arterial and venous phases were all significantly higher in group A than in group B (P<0.001) and could effectively differentiate the 2 groups. The areas under the curve were 0.753 (95% CI: 0.624-0.855), 0.799 (95% CI: 0.676-0.892), 0.774 (95% CI: 0.647-0.872), and 0.842 (95% CI: 0.724-0.923) for IC at arterial and venous phases and λHU at arterial and venous phases, respectively. These parameters decreased with the increase of CTSI, showing significant negative correlations, with r were -0.512 (95% CI: -0.678 to -0.297), -0.492 (95% CI: -0.663 to -0.272), -0.552 (95% CI: -0.707 to -0.346), -0.569 (95% CI: -0.719 to -0.368) for IC at arterial and venous phases and λHU at arterial and venous phases, respectively (P<0.001).

CONCLUSIONS

DECT imaging can quantitatively analyze AP, and the IC and λHU can be used to distinguish mild and severe cases, adding functional information to the CT morphology to determine the severity and prognosis of the disease.

Ultrasound-guided endoscopic drainage for the management of pancreatic pseudocysts: A case report

BACKGROUND

The treatment strategy for pancreatic pseudocysts (PPC) is comprehensive and warrants multidisciplinary participation. However, at present, the treatment concepts for PPC are inconsistent. Moreover, the timing of interventional therapy is unclear, and complication management is insufficient. Therefore, the development of a multidisciplinary expert consensus on PPC is warranted. At present, endoscopic treatment is recommended for managing PPC in American Society for Gastrointestinal Endoscopy guideline and Chinese Consensus guidelines.

CASE SUMMARY

In this study, we present a rare case of PPC identified by endoscopy and imaging examination, and successfully managed by endoscopic and percutaneous drainage. In detail, an obese patient with a history of recurrent pancreatitis presents an irregular, elliptical cystic low-density shadow in the pancreatic region. Endoscopic ultrasound combined with double knife incision technique was used to endoscopic drainage, resulting in a favorable prognosis.

CONCLUSION

Ultrasound-guided endoscopic drainage for the management of PPC may provide additional insights to current clinical guidelines.

Etiological treatment of gallstone acute pancreatitis

Gallstone pancreatitis is the leading cause of acute pancreatitis, accounting for more than 40% of cases. Etiological treatment is a critical issue in acute biliary pancreatitis as it helps reduce the risk of recurrence. Patients who have experienced a complicated form of biliary disease are at high risk for recurrent episodes, and the severity of these new episodes can be unpredictable. In recent years, the role and timing of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP), which are the main therapeutic interventions in the etiological treatment, have been considerably clarified. This review aims to detail the different aspects of the etiological treatment of acute biliary pancreatitis. Currently, it is established that cholecystectomy should be performed early during the initial hospitalization in cases of non-severe acute pancreatitis. However, the optimal timing of this procedure in severe acute pancreatitis remains a subject of debate. Emergency ERCP is no longer indicated for acute biliary pancreatitis, except in cases of associated acute cholangitis. ERCP can be useful for the management of persistent bile duct stones. Finally, the role of interval sphincterotomy in frail or elderly patients or to reduce the risk of recurrence in those awaiting cholecystectomy in cases of severe acute pancreatitis remains to be fully established.

Dome vs tapered tip sphincterotomes in endoscopic retrograde cholangiopancreatography: A pilot study on cannulation success and postprocedural pancreatitis

BACKGROUND

Despite advancements, endoscopic retrograde cholangiopancreatography (ERCP) poses challenges, including the risk of post-ERCP pancreatitis and difficulty of biliary cannulation.

AIM

To compare dome and tapered tip sphincterotomes, focusing on their efficacy in achieving successful biliary cannulation and reducing the incidence of post-ERCP pancreatitis.

METHODS

In this prospective, single-blind, randomized pilot study conducted at Inha University Hospital, 85 patients undergoing ERCP were equally divided into dome and tapered tip sphincterotome groups. The co-primary outcomes were the success rate of selective biliary cannulation and incidence of post-ERCP pancreatitis. The secondary outcomes included biliary cannulation time, number of unintended pancreatic duct access events, and total procedure time.

RESULTS

The success rates of selective biliary cannulation were 74.4% and 85.7% in the dome and tapered tip groups, respectively, with no significant difference (P = 0.20). Similarly, the incidence of post-ERCP pancreatitis did not differ significantly between the groups (5 cases in the tapered tip group vs 6 in the dome tip group, P = 0.72). However, difficult cannulation was significantly more common in the dome tip group than in the tapered tip group (P = 0.05). Selective biliary cannulation time emerged as a significant predictor of post-ERCP pancreatitis (multivariate odds ratio = 9.33, 95% confidence interval: 1.31-66.44, P = 0.03).

CONCLUSION

This study indicated that the sphincterotome tip type does not markedly affect biliary cannulation success or post-ERCP pancreatitis rates. However, cannulation duration is a key risk factor for post-ERCP pancreatitis. These findings provide preliminary insights that highlight the importance of refining ERCP practices, including sphincterotome selection, while underscoring the need for larger multicenter studies to improve procedure time and patient safety.

Artificial intelligence and the impact of multiomics on the reporting of case reports

The integration of artificial intelligence (AI) and multiomics has transformed clinical and life sciences, enabling precision medicine and redefining disease understanding. Scientific publications grew significantly from 2.1 million in 2012 to 3.3 million in 2022, with AI research tripling during this period. Multiomics fields, including genomics and proteomics, also advanced, exemplified by the Human Proteome Project achieving a 90% complete blueprint by 2021. This growth highlights opportunities and challenges in integrating AI and multiomics into clinical reporting. A review of studies and case reports was conducted to evaluate AI and multiomics integration. Key areas analyzed included diagnostic accuracy, predictive modeling, and personalized treatment approaches driven by AI tools. Case examples were studied to assess impacts on clinical decision-making. AI and multiomics enhanced data integration, predictive insights, and treatment personalization. Fields like radiomics, genomics, and proteomics improved diagnostics and guided therapy. For instance, the "AI radiomics, genomics, oncopathomics, and surgomics project" combined radiomics and genomics for surgical decision-making, enabling preoperative, intraoperative, and postoperative interventions. AI applications in case reports predicted conditions like postoperative delirium and monitored cancer progression using genomic and imaging data. AI and multiomics enable standardized data analysis, dynamic updates, and predictive modeling in case reports. Traditional reports often lack objectivity, but AI enhances reproducibility and decision-making by processing large datasets. Challenges include data standardization, biases, and ethical concerns. Overcoming these barriers is vital for optimizing AI applications and advancing personalized medicine. AI and multiomics integration is revolutionizing clinical research and practice. Standardizing data reporting and addressing challenges in ethics and data quality will unlock their full potential. Emphasizing collaboration and transparency is essential for leveraging these tools to improve patient care and scientific communication.

The glycocalyx: a key target for treatment of severe acute pancreatitis-associated multiple organ dysfunction syndrome

The endothelial glycocalyx is a dynamic brush-like layer composed of proteoglycans and glycosaminoglycans, including heparan sulfate (HS) and hyaluronic acid (HA), and is an important regulator of vascular homeostasis. Its structure (thickness ranges from 20 to 6450 nm in different species) not only provides a charge-selective barrier but also serves to anchor mechanosensors such as the glypican-1 (GPC-1)/caveolin-1 (CAV-1) complex and buffers shear stress. In severe acute pancreatitis (SAP), inflammatory factors promote the expression of matrix metalloproteinases (MMPs) and heparinases, which degrade syndecan-1 (SDC-1) and HS, while oxidative stress disrupts HA-CD44 binding, leading to increased capillary leakage and neutrophil adhesion. This degradation process occurs before the onset of multiple organ dysfunction syndrome (MODS), highlighting the potential of the glycocalyx as an early biomarker. More importantly, the regeneration of glycocalyx through endothelial cell synthesis of glycosaminoglycans (GAGs) and shear stress-driven SDC recycling provides therapeutic prospects. This review redefines the pathophysiology of severe acute pancreatitis-associated multiple organ dysfunction (SAP-MODS) by exploring the glycocalyx's central mechanistic role and proposes stabilizing glycocalyx structure as a potential strategy to prevent microcirculatory failure.

Network pharmacology analysis reveals that coumestrol targets ZYX to inhibit ferroptosis and alleviate acute pancreatitis

AIM

The therapeutic effect of CMS on acute pancreatitis (AP) and the mechanism of targeting Zyxin (ZYX) to regulate ferroptosis in acinar cells.

METHODS

To assess the therapeutic effects of CMS in AP, we established caerulein-induced AP and caerulein plus LPS-induced SAP mouse models. Subsequently, weighted gene co-expression network analysis (WGCNA) and network pharmacology analysis were used to investigate the mechanism and target of CMS in the treatment of AP. Molecular docking and cell biology techniques were used to explore the molecular mechanisms by which CMS mitigated ferroptosis in AP animal and cell models.

RESULTS

CMS could alleviate the pathological damage of AP and SAP, inhibit ferroptosis and reduce inflammatory response. ZYX was an important target for CMS in the treatment of AP, and CMS could specifically bind to ZYX, down-regulate ZYX expression, and reduce TGF-β/SMAD pathway activity, thereby inhibiting acinar cell ferroptosis and improving pancreatic injury in AP. And we found that ZYX overexpression counteracted the inhibitory effects of CMS on TGF-β/Smad signaling and ferroptosis processes.

CONCLUSION

These results suggested that coumestrol targeting ZYX regulated the TGF-β/SMAD pathway, inhibited ferroptosis in acinar cells, and alleviated AP. Our research provided new drugs and targets for the treatment of AP.

Gender Disparities in Career Longevity Among Surgeons and Physicians: A Decade-Long Analysis

INTRODUCTION

Physician and surgeon retirement patterns are influenced by gender, specialty, and practice settings, impacting workforce composition and equity. We hypothesize that male surgeons have longer career durations and are less likely to retire than their female counterparts, with differences across specialties.

METHODS

Data from the Center for Medicare & Medicaid Services National Downloadable Database (2014-2024) were analyzed to determine career duration and retirement status among physicians and surgeons across various subspecialties. Career duration was defined as the most recent year a physician appeared in the database minus their graduation year; retirement was defined as the year their National Provider Identifier number was no longer present. Univariable and multivariable logistic regression analyzed demographic variables, practice settings, and trends, with an interaction analysis assessing the odds of retirement by specialty and gender.

RESULTS

Among 280,727 physicians, retirement rates were 33.8% for females and 33.7% for males (P = 0.69). Female physicians had shorter careers than males (30 [25-36] versus 35 [28-42] years, P < 0.001). Among surgeons, fewer females were retired (29.6% versus 32.6%, P < 0.001), but males had longer careers (41 [34-47] versus 30 [24 - 38] years, P < 0.001). Male surgeons were more likely to remain in the workforce in 2024 (odds ratio 1.5, confidence interval 1.34-1.60). Female cardiac, general, orthopedic, urologic, and plastic surgeons had lower odds of remaining in the work force compared to male general surgeons.

CONCLUSIONS

Male surgeons exhibit longer careers and greater workforce retention than females. Gender disparities across surgical specialties emphasize the need to support female surgeons' career longevity and address workforce inequities.

Risk factors for peripancreatic and pancreatic infection of acute pancreatitis and the development of a clinical prediction model

Infected necrotizing pancreatitis (INP) is a serious complication that can increase the length of hospital stay and the cost of treatment, and is the leading cause of death in patients with acute pancreatitis (AP). This article aimed to predict the possibility of pancreatic and peripancreatic infections by early clinical indicators of AP and construct a clinical prediction model. We retrospectively studied consecutive patients admitted to the Nankai Hospital for moderate severe AP and severe AP, which developed within 2 weeks. Logistic regression was used to evaluate potential factors that could lead to INP and to develop clinical prediction model. Persistent organ failure, pancreatic necrosis area, and procalcitonin account were risk factors for INP. A prediction model was constructed based on the risk factors. The results showed that the model had good predictive performance. We developed a clinical prediction model with good predictive results that can be helpful for clinicians to identify and prevent the development of INP at an early stage.

ALIF vs. posterior fusion for lumbar degenerative disease: comparable efficacy but elevated risk of severe complications-a systematic review and meta-analysis

BACKGROUND

Over the past years, there has been an upward trend in the total number of spinal fusion procedures worldwide. There are many different strategies to perform the lumbar fusion, each with some advantages. Hospital charges for lumbar spinal surgeries also have increased significantly, with great variation in the costs and recommendations of different surgical procedures. There has also been a trend increase in the rate of the use of interbody fusion implants compared to that of traditional decompression surgery, even though the former is known to incur higher costs. Access through the anterior route gained many followers after studies on sagittal balance, and its indication has also increased worldwide. However, this technique presents different patterns of complications from those observed in traditional posterior approaches.

OBJECTIVES

This study aims to determine the safety and efficacy of surgery in managing patients with symptomatic lumbar degenerative diseases by comparing the effectiveness of posterior and anterior approach techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative complication data.

METHODS

A systematic search of multiple online databases was conducted up to August 2024 to identify randomized controlled trials (RCTs) and other high-quality retrospective studies comparing outcomes of anterior lumbar interbody fusion (ALIF) versus posterior fusion techniques (PLF, PLIF, TLIF) in the treatment of degenerative lumbar diseases. The primary outcomes assessed included the Oswestry Disability Index, Visual Analogue Scale, and overall clinical improvement. Secondary outcomes encompassed complications such as mortality, infections, gastrointestinal complications, deep vein thrombosis (DVT), surgical site infections, and the need for blood transfusions, as well as length of hospital stay and operative duration. Pooled effect estimates were calculated and presented as mean differences (MD) with 95% confidence intervals (CI) at the two-year follow-up.

RESULTS

Regarding VAS and ODI, anterior and posterior approaches were similar in analyzing five RCTs. Including retrospective studies, we also found that the length of hospital stay and duration of surgery were comparable between the two approaches. Anterior approaches had a lower rate of patients requiring blood transfusions OR 0,69[0.60,0,80]. Anterior approaches showed higher rates of mortality (0,21%) OR1,33[1.10,1.62], deep vein thrombosis (0,65%) 1.73 [1.35, 2.20], and gastrointestinal complications (4,9%) OR 2.19 [1.73, 2.78].

CONCLUSION

Clinical outcomes measured by VAS and ODI were comparable between anterior and posterior approaches, demonstrating similar efficacy in treating lumbar degenerative diseases. However, the safety profiles varied significantly. Anterior approaches carried higher rates of severe complications, including mortality, DVT, and gastrointestinal events, while posterior techniques were linked to increased blood transfusion needs. Given the elevated risk of severe complications with ALIF, posterior approaches should be prioritized as the first-line option for lumbar degenerative disease.

Total bilirubin-to-albumin ratio and short- and long-term all-cause mortality in acute pancreatitis: Evidence from the MIMIC-IV database

BACKGROUND

The Total Bilirubin-to-Albumin Ratio (TBAR) is widely recognized and applied as a biomarker in the prognostic evaluation of various diseases. However, its role in predicting survival outcomes in patients with acute pancreatitis (AP) remains underexplored. This study aims to investigate the association between TBAR levels and mortality rates in AP patients, thereby providing a novel prognostic indicator for clinical use.

METHODS

This study investigates the association between TBAR and mortality in AP patients. We stratified patient data using X-tile software to analyze intergroup differences. Risk factors significantly associated with mortality were identified through univariate and multivariate regression analyses. Kaplan-Meier (KM) analysis evaluated TBAR's impact on survival, while Receiver Operating Characteristic (ROC) analysis assessed its predictive accuracy, sensitivity, and Area Under the Curve (AUC) for mortality. To ensure robustness, we used Restricted Cubic Spline (RCS) modeling to explore non-linear relationships and performed subgroup analyses to verify the consistency of the TBAR mortality association across patient subgroups.

RESULT

This study included 477 patients. Using X-tile software, we set the optimal TBAR cutoff at 1.33 based on 28-day mortality. Patients were categorized into high-risk (TBAR ≥ 1.33) and low-risk (TBAR < 1.33) groups. Elevated TBAR significantly correlated with increased mortality at multiple time points (7, 14, 21, 28, 90, and 365 days; P < 0.05). KM analysis confirmed lower survival rates in the high-risk group at all time points (P < 0.05). ROC analysis showed TBAR's predictive accuracy for mortality was comparable to the SOFA score and superior to other indicators. RCS modeling revealed a linear TBAR mortality relationship. Subgroup analyses showed no significant interactions between TBAR and most subgroups.

CONCLUSION

The TBAR is strongly correlated with short-term and long-term mortality in patients with acute pancreatitis.

Cardiovascular comorbidities predict mortality in acute pancreatitis

BACKGROUND

The in-hospital mortality of acute pancreatitis (AP) is determined by severity of AP, but also significantly impacted by patients' comorbidities. Therefore, we aimed to examine the association between comorbid risk-profiles and survival in hospitalized patients admitted with AP.

METHODS

We utilized the German nationwide inpatient statistics to identify all AP patient-cases (ICD code K85) admitted to hospitals in Germany between 2005 and 2019. Hospitalization cases for AP were stratified by survival, and risk factors for in-hospital mortality were examined.

RESULTS

In total, 797,364 hospitalization-cases of patients admitted due to AP (median age 56.0 [IQR 44.0-71.0] years, 39.2 % females) were treated in Germany 2005-2019. Of these, 22,022 (2.8 %) patients died during hospitalization. AP survivors were younger (56.0 [44.0-71.0] vs. 76.0 [64.0-84.0], P < 0.001), more often males (61.0 % vs. 54.1 %, P < 0.001), and were less often afflicted by cardiovascular risk factors and diseases than non-survivors. Cardiovascular diseases (OR 2.08 (95 %CI 2.02-2.15), P < 0.001) and raising number of cardiovascular diseases (OR 1.48 (95 %CI 1.45-1.50), P < 0.001) were independently associated with increasing mortality. In particular, heart failure (OR 2.16 [95 %CI 2.09-2.24], P < 0.001), peripheral artery disease (OR 1.25 [1.15-1.35], P < 0.001), atrial fibrillation/flutter (OR 1.61 [95 %CI 1.55-1.66], P < 0.001), myocardial infarction (OR 4.71 [95 %CI 4.28-5.18], P < 0.001), pulmonary embolism (OR 12.19 [95 %CI 10.91-13.62], P < 0.001), and stroke (OR 7.21 [95 %CI 6.42-8.11], P < 0.001) were independently associated with in-hospital mortality.

CONCLUSIONS

Between 2005 and 2019, the in-hospital mortality among hospitalized AP patients was 2.8 % in Germany. Presence of cardiovascular diseases was associated with significantly reduced survival in AP patients.

Endoscopic ultrasound-guided choledochoduodenostomy results in fewer complications than percutaneous drainage following failed ERCP in malignant distal biliary obstruction

Percutaneous transhepatic biliary drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD), including choledochoduodenostomy (EUS-CDS), are alternative methods for biliary drainage in patients with distal malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Data on long-term outcomes, adverse events (AEs), and quality of life (QoL) after EUS-CDS and PTBD are limited. Therefore, we created a registry to evaluate the outcomes of both drainage procedures.Patients with distal MBO who underwent EUS-CDS or PTBD after unsuccessful ERCP were included in this multicenter investigator-initiated prospective registry over an 18-month inclusion period. Primary end points were procedure-related AEs and mortality within 90 days post-procedure. Secondary end points included technical and clinical success, reinterventions, hospital stay, and QoL.55 patients were included, with 12 patients undergoing PTBD (technical success 100%) and 43 patients EUS-CDS (technical success 97.7%). Prior to ERCP, 7/12 patients in the PTBD group and 12/43 patients in the EUS-CDS group opted for best supportive care. The 90-day mortality rate was 66.7% in the PTBD group and 20.9% in the EUS-CDS group (P = 0.005). Furthermore, 11/12 patients (91.7%) in the PTBD group and 19/43 (44.2%) in the EUS-CDS group developed one or more AEs (P = 0.004). The median post-procedural hospital stay was 4 days (interquartile range [IQR] 2-6) in the PTBD group vs. 1 day (IQR 1-2) in the EUS-CDS group (P = 0.001).When both modalities were available and technically feasible, gastroenterologists preferred EUS-CDS over PTBD. EUS-CDS seems to be associated with lower mortality and AE rates, shorter hospital admission, and fewer reinterventions, but a randomized controlled trial should confirm these observations.

Acute pancreatitis experimental models, advantages and disadvantages

Acute pancreatitis represents a severe health problem, not only because of the number of people affected but also because of the severity of its clinical presentation that can eventually lead to the death of patients. The study of the disease is complex, and we lack optimized models that can approach the clinical presentation in patients, in addition to the significant vulnerability of the organ itself. In the present work, we undertook the task of reviewing and analyzing the experimental methods most currently used for the induction of acute pancreatitis, emphasizing the advantages and disadvantages of each model and their delimitation based on experimental objectives. We aimed to provide an actual and quick-access guide for researchers interested in experimental acute pancreatitis.

A risk nomogram for 30-day mortality in Chinese patients with acute pancreatitis using LASSO-logistic regression

This study proposed to explore the 30-day mortality risk factors in patients with acute pancreatitis (AP) and construct a prognosis nomogram based on the Least absolute shrinkage and selection operator (LASSO) logistic regression. A retrospective study on 965 adult AP patients started from January 2017 and December 2019 was conducted. Feature selection is carried out by using LASSO regression, and the model was established through logistic regression (P < 0.05). The area under the receiver operating characteristic curve (AUC), calibration curves, bootstrap and decision curve analysis (DCA) were utilized for evaluating the performance of the nomogram. A sum of 965 eligible patients were participated, of whom 922 were assigned into a survival group and 43 in a non-survival group. Six independent predictors were identified as the most valuable characteristics in AP patients, including age, activated partial thromboplastin time (APTT), direct bilirubin (DBIL), lactate dehydrogenase (LDH), total protein (TP) and blood urea nitrogen (UREA). The AUC of the nomogram was 0.862 (0.806-0.918). The DCA curve indicates that this nomogram possesses good clinical application value. The nomogram we constructed demonstrates a strong capability in predicting the 30-day mortality of AP patients.

Imaging Pearls and Pitfalls Following Common and Rare Bariatric Procedures

Bariatric surgery is an effective approach to management of morbid obesity. Given its increasing popularity worldwide, post-operative imaging of patients following bariatric surgery is frequently encountered in clinical practice. In this article we review the physiological principles, normal post-operative anatomy, and imaging appearance of common bariatric procedures (Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and laparoscopic adjustable gastric banding) as well as less common bariatric procedures (including intragastric balloon and biliopancreatic diversion with duodenal switch). Technical considerations and imaging pearls for identifying perioperative and late complications following bariatric procedures will be illustrated through fluoroscopic upper GI studies and computed tomography case examples. Familiarity with expected anatomy and imaging appearances following bariatric procedures allows the radiologist to play a key role in early identification and management of postoperative complications.

The Efficacy and Safety of Endoscopic Ultrasound-Guided Retroperitoneal Fluid Collection Drainage with Novel Electrocautery-Enhanced Lumen-Apposing Metal Stents (with Video)

Background/Aims

Various lumen-apposing metal stents (LAMS) have been used for the endoscopic ultrasound-guided transmural drainage (EUS-TD) of postoperative pancreatic fluid collections (POPFC) and peripancreatic fluid collections (PFC). In this study, we aimed to assess the efficacy and safety of novel electrocautery-enhanced LAMSs (Hot-Plumber with Z-EUS IT) with different inter-flange lengths (13 to 33 mm) for managing POPFC and PFC.

Methods

We reviewed the interventional EUS database of Asan Medical Center to identify consecutive patients with POPFC or PFC who underwent EUS-TD with the novel LAMSs between April 2023 and December 2023. Technical success, clinical success, and adverse events were evaluated.

Results

Ten patients (5 with POPFCs and 5 with PFCs) were included in the analysis. The technical and clinical success rates were 100% and 90%, respectively. The LAMS was placed using either the freehand technique (n=5) or the over-the-guide wire technique (n=5). One patient successfully underwent endoscopic necrosectomy for walled-off necrosis through a novel LAMS. Two patients experienced adverse events (one stent migration and one infection). The LAMS was removed in 7 out of 10 patients after resolution of the fluid collection at a median of 61 days (interquartile range, 31 to 69 days) post-LAMS placement.

Conclusions

EUS-TD using the novel LAMS for POPFC and PFC demonstrated high efficacy and an acceptable safety profile. This novel LAMS represents a viable option when selecting stents for EUS-guided drainage of the POPFC and PFC.

Retrospective analysis of surgical pancreatic necrosectomy outcomes in patients with and without obesity

BACKGROUND

Acute necrotizing pancreatitis is associated with high morbidity and mortality. This study aims to compare surgical necrosectomy outcomes in acute necrotizing pancreatitis between patients with and without obesity.

METHODS

A retrospective chart review was performed for all patients who underwent surgical necrosectomy via a minimally invasive approach or an open approach over a 10-year period at a large US healthcare system. Patients were divided into 2 groups: those with obesity (body mass index ≥30 kg/m2) and those without obesity (body mass index <30 kg/m2). The primary end point was the incidence of early complications or postoperative death within 30 and 90 days. The secondary end point was the incidence of long-term complications.

RESULTS

In total, 80 patients were included with 36 (45%) with obesity, and 44 (55%) without obesity. A total of 52 patients (65%) had an open approach and 28 (35%) had an minimally invasive approach. The average age was 54.79 ± 15.25 years, and the median follow-up time was 83.5 days (interquartile range, 40.25-149.75 days). The median body mass index of the patient group with obesity was 34.55 kg/m2 (interquartile range, 31.55-40.61), and that for the patient group without obesity was 25.97 kg/m2 (interquartile range, 23.22-28.35 kg/m2) (P ≤ .0001). Days from admission to surgical intervention was longer in obese patients but it was not statistically significant (44.50 [interquartile range, 12-88] vs 27 [interquartile range, 15-42.5], P = .831). 30 and 90-day complication rates and mortality were similar between the groups.

CONCLUSION

Operative outcomes of pancreatic necrosectomy in patients with obesity appears to be comparable with patients without obesity. Surgical pancreatic necrosectomy can be performed safely, effectively, and in a similar time frame regardless of the presence of obesity.

Partial quadrate lobectomy improves early outcomes of laparoscopic Kasai surgery in type III biliary atresia

Objective

To evaluate the early efficacy and safety of partial quadrate lobectomy during laparoscopic Kasai surgery for type III biliary atresia.

Methods

This retrospective study included 25 children diagnosed with type III biliary atresia, who underwent laparoscopic Kasai surgery between February 2018 and July 2022. Patients were divided into two groups: one with partial quadrate lobectomy and the other without. Data collected included age, gender, weight, incidence of cholangitis before and after surgery, one-year native liver survival, intraoperative blood loss, surgery duration, and jaundice clearance at 6 and 12 months. Follow-up results were compared between the groups.

Results

The partial quadrate lobectomy group (14 patients) had a mean weight of 5.50 kg and average age of 66.79 days, while the control group (11 patients) had a similar weight (5.50 kg) and a mean age of 71.09 days. Weight comparison showed no significant difference (5.50 kg vs. 5.50 kg, P = 0.427). One-year postoperative native liver survival was 9/14 in the partial quadrate lobectomy group vs. 6/11 in the control group (P = 0.654).Intraoperative blood loss was similar between groups (P > 0.05), but the shorter operative time (301 vs. 347 min) associated with partial quadrate lobe resection may reduce anesthesia-related risks in infants, particularly given their limited physiological reserve. The reduced cholangitis rate (29% vs. 73%) aligns with prior reports suggesting that improved hilar exposure facilitates more precise dissection of fibrotic remnants, potentially minimizing postoperative bile stasis and infection. Jaundice clearance (defined as TBIL <20 μmol/L) was achieved in 8/14 (57.1%) of the partial quadrate lobectomy group vs. 3/11 (27.3%) in the control group at 6 months (P = 0.025), and 10/14 (71.4%) vs. 4/11 (36.4%) at 12 months (P = 0.031). The lower TBIL levels (5.11 vs. 9.67 mg/dl) at 6 months suggest enhanced bile drainage efficacy, which is critical for delaying or avoiding liver transplantation in this population.

Conclusion

Partial quadrate lobectomy during laparoscopic Kasai surgery reduces operation time, lowers cholangitis incidence, and improves jaundice clearance rates without increasing intraoperative blood loss or adversely affecting one-year native liver survival. It is a safe and feasible adjunct to improve early postoperative outcomes.

Beyond the Basics: Recommended Approach to Severe Acute Pancreatitis Management in the Critical Care Setting

Acute Pancreatitis (AP) poses a significant healthcare burden globally. While most cases present with a mild course, approximately one-fifth progress to severe forms characterized by severe pancreatitis and systemic complications, leading to a mortality rate of up to 40%. Effective management of severe acute pancreatitis necessitates a multidisciplinary approach involving gastroenterologists, interventional radiologists, intensive care teams, and surgeons. The advances in treatment modalities, including early hydration, nutrition, and pain control, have led to a decrease in the morbidity and long-term complications associated with severe acute pancreatitis down to 20%. In this review, we focus on the management challenges and outcomes associated with the difficult condition of severe acute pancreatitis.

Computed tomography-based conventional imaging features and texture analysis characteristics of chemotherapy drug-related acute pancreatitis

Purpose

Chemotherapy drug-related acute pancreatitis (CDRAP) is a rare adverse event that poses significant challenges to clinicians. This study aimed to describe plain computed tomography (CT)- and contrast-enhanced computed tomography (CECT)-based conventional imaging features and texture analysis characteristics of CDRAP.

Methods

A total of 62 patients with initial clinical and/or biochemical evidence of pancreatitis and 34 patients with normal pancreatic manifestations who underwent CT during chemotherapy were retrospectively included. The diagnosis of CDRAP was established based on clinical, imaging, and biochemical findings. Conventional imaging features, texture analysis characteristics, clinical and biochemical parameters, other complications, chemotherapy drugs, and patient outcomes related to CDRAP were recorded.

Results

A total of 20 (32.26%) patients who were clinically diagnosed with CDRAP had normal pancreatic morphology on CT, while 42 (67.74%) patients presented with changes indicative of acute pancreatitis. The CT findings of 62 CDRAP cases were as follows: diffuse (n = 19) or focal (n = 21) pancreatic enlargement, diffuse (n = 12) or focal (n = 4) heterogeneous enhancement, peripancreatic stranding (n = 20), acute peripancreatic fluid collection (n = 10), and pseudocyst (n = 2). A total of 17 texture features were identified to differentiate CDRAP from normal pancreatic manifestations.

Conclusion

CDRAP mainly manifested as interstitial edematous pancreatitis with/without normal pancreatic morphology on CT. Imaging texture analysis may serve as a potential biomarker for its detection. By combining conventional imaging features with texture analysis characteristics, there is potential to assist radiologists and clinicians in the identification of CDRAP, thereby improving the quality of life for cancer patients.

Influencing factor analysis and clinical efficacy of early intervention in severe acute pancreatitis with persistent organ failure

This study aims to analyze the risk factors requiring early intervention in severe acute pancreatitis (SAP) patients with persistent organ failure and evaluate the clinical outcomes following treatment. This was a retrospective observational study. Inverse probability treatment weighting using propensity score methods was employed to balance baseline characteristics. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with early intervention. Smooth curve fitting was applied to explore potential relationships between variables and intervention timing. Threshold effect analysis was conducted to identify the optimal inflection point in nonlinear relationship. A total of 310 patients were included in this study. Compared to the standard treatment group (n = 162), the early intervention group (n = 148) had a higher proportion of multiple organ failure (77.1% vs. 63.6%, P = 0.021) and higher mortality (27.7% vs. 16.0%, P = 0.013), but early intervention was not significantly associated with adverse outcome (OR 1.52, 95% CI 0.71-3.26, P = 0.283). Risk factors associated with early intervention included computed tomography severity index, SOFA score, intra-abdominal pressure (IAP), and remifentanil equivalents. Among these, the SOFA score showed a negative linear relationship with intervention timing, while distinct threshold effects were observed between IAP, remifentanil equivalents, and intervention timing. One week after intervention, most patients showed improved organ function, along with reduced requirements for sedation and analgesia, as well as decreased C-reactive protein level levels and IAP (all P < 0.05). SAP patients requiring early intervention tended to have higher disease severity. Although early intervention can improve short-term organ function, reduce IAP, and lower analgesic requirements, its impact on reducing mortality remains uncertain.

Effect of proton pump inhibitors on occlusion of lumen-apposing metal stents and rate of endoscopic necrosectomies: a Europe-wide multicenter cohort study

BACKGROUND

 Lumen-apposing metal stents (LAMS) are widely used to drain walled-off necrosis (WON). LAMS occlusion is a significant clinical problem and identification of risk factors for LAMS occlusion could contribute to novel preventive strategies. A previous study suggested contradictory effects of proton pump inhibitors (PPIs) on occlusion and necrosectomy rates.

METHODS

 We conducted a Europe-wide multicenter retrospective cohort study assessing WONs drained by LAMS. The primary aims were to assess the strength of association between PPI intake and LAMS occlusion and necrosectomy rates, respectively. The secondary aim was to assess the strength of association between PPI intake and other LAMS-associated complications. Multiple mixed-effects models were used to control for possible confounding covariates.

RESULTS

 893 patients with 967 LAMS from 17 centers were included. After excluding incomplete datasets and patients who took PPIs intermittently, 768 LAMS remained. The overall occlusion rate was 28.0 %. Most occlusions occurred within 10 days. Most patients received PPIs continuously (n = 577 vs. no intake n = 191). In patients who did not use PPIs continuously, lower rates of LAMS occlusion (odds ratio [OR] 0.61, P = 0.04) and necrosectomies (incidence rate ratio 0.8, P = 0.006) were observed. A post hoc analysis exhibited a dose- and compound-dependent effect of PPI intake on necrosectomy rate. No increase in other complications in the non-PPI group, such as bleeding events (OR 1.14) were observed.

CONCLUSION

 PPI intake was associated with higher rates of LAMS occlusion and necrosectomy.