Machine Learning-Guided Fluid Resuscitation for Acute Pancreatitis Improves Outcomes

INTRODUCTION

Ariel Dynamic Acute Pancreatitis Tracker (ADAPT) is an artificial intelligence tool using mathematical algorithms to predict severity and manage fluid resuscitation needs based on the physiologic parameters of individual patients. Our aim was to assess whether adherence to ADAPT fluid recommendations vs standard management impacted clinical outcomes in a large prospective cohort.

METHODS

We analyzed patients consecutively admitted to the Los Angeles General Medical Center between June 2015 and November 2022 whose course was richly characterized by capturing more than 100 clinical variables. We inputted these data into the ADAPT system to generate resuscitation fluid recommendations and compared with the actual fluid resuscitation within the first 24 hours from presentation. The primary outcome was the difference in organ failure in those who were over-resuscitated (>500 mL) vs adequately resuscitated (within 500 mL) with respect to the ADAPT fluid recommendation. Additional outcomes included intensive care unit admission, systemic inflammatory response syndrome (SIRS) at 48 hours, local complications, and pancreatitis severity.

RESULTS

Among the 1,083 patients evaluated using ADAPT, 700 were over-resuscitated, 196 were adequately resuscitated, and 187 were under-resuscitated. Adjusting for pancreatitis etiology, gender, and SIRS at admission, over-resuscitation was associated with increased respiratory failure (odd ratio [OR] 2.73, 95% confidence interval [CI] 1.06-7.03) as well as intensive care unit admission (OR 2.40, 1.41-4.11), more than 48 hours of hospital length of stay (OR 1.87, 95% CI 1.19-2.94), SIRS at 48 hours (OR 1.73, 95% CI 1.08-2.77), and local pancreatitis complications (OR 2.93, 95% CI 1.23-6.96).

DISCUSSION

Adherence to ADAPT fluid recommendations reduces respiratory failure and other adverse outcomes compared with conventional fluid resuscitation strategies for acute pancreatitis. This validation study demonstrates the potential role of dynamic machine learning tools in acute pancreatitis management.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.

Pancreatectomies with vein resection: Two large institutions' experience of East and West

BACKGROUND

The effectiveness and preferred reconstruction methods of pancreatectomy associated with vein resection (PAVR) for pancreatic cancer, especially for the extensive portal vein/superior mesenteric vein (PV/SMV) resections (more than 4 cm), are still subjects of debate. The aim of this study is to evaluate the safety and feasibility of PAVR by analyzing data from two large institutions from different regions.

METHODS

From 2008 to 2018, we identified consecutive series of patients with pancreatic cancer who underwent PAVR at Karolinska University Hospital (KUH), Sweden, and Cancer Institute Hospital, Japanese Foundation of Cancer Research (JFCR), Japan. Both institutions adopted the artery-first approach to enhance surgical precision. This study compared the short- and long-term outcomes, vein resection types, and reconstruction methods between the two centers.

RESULTS

A total of 506 patients who underwent PAVR were identified, 211 patients were from KUH and 295 patients were from JFCR. A higher incidence of total pancreatectomy was identified at KUH (24.6 % vs 0.3 %). There were no significant differences in intraoperative estimated blood loss (KUH: 630 ml, JFCR: 600 ml), severe complications rate (8.5 %, 5.1 %), and mortality (2.4 %, 0.7 %). Primary end-to-end anastomosis was primarily performed even if the length of PV/SMV resection was 5 cm or more and achieved successfully with acceptable patency (No thrombus rate: overall cases, 98.0 %; 5 cm or more, 93.5 %).

CONCLUSIONS

We report favorable outcomes of PAVR for pancreatic cancer from two high-volume centers in the east and west. Primary end-to-end anastomosis was safe and feasible even if the length of PV/SMV resection was 5 cm or more.

Bee Pollen Phytochemicals and Nutrients as Unequaled Pool of Epigenetic Regulators: Implications for Age-Related Diseases

Bee pollen is characterized by an exceptional diversity and abundance of micronutrients and bioactive phytochemicals. This richness remains very sparsely investigated, but accumulating evidence strongly supports a promising future for bee pollen in human nutrition and medicine. Epigenetic regulation is among the most compelling biomedical topics that remain completely untapped in bee pollen and bee derivative research. In our current research, we identified numerous ubiquitous compounds that are consistently present in this matrix, regardless of its botanical and geographical origins, and that have been well studied and documented as epigenetic regulators in recent years. Given the relative newness of both bee pollen biomedical research and epigenetic studies within nutritional, pharmaceutical, and medical sciences, this review aims to bridge these valuable fields and advance related experimental investigations. To the best of our knowledge, this is the first work that has aimed to comprehensively investigate the epigenetic modulatory potential of bee pollen compounds. Our findings have also unveiled several intriguing phenomena, such as a dual effect of the same compound depending on the cellular context or the effect of some compounds on the cross-generational heritability of epigenetic traits. Although experimental studies of epigenetic regulation by bee pollen as a whole or by its extract are still lacking, our current study clearly indicates that this research avenue is very promising and worth further investigations. We hope that our current work constitutes a foundational cornerstone of future investigations for this avenue of research.

Telling Ghost Stories Around a Bonfire-A Literature Review of Acute Bleeding Secondary to Pancreatitis

Bleeding is a rare but serious complication of pancreatitis, significantly increasing morbidity and mortality. It can arise from various sources, including erosion of blood vessels by inflammatory processes, formation of pseudoaneurysms, and gastrointestinal bleeding. Early diagnosis and timely intervention are crucial for patient survival. Imaging modalities such as computed tomography and angiography are essential for identifying the bleeding source, where endoscopy may help in detecting and treating intraluminal hemorrhage. Management strategies for patients with extraluminal bleeding may involve angioembolization or surgical intervention, depending on the severity and location of the bleeding. While advances in diagnostic and therapeutic techniques have improved outcomes, bleeding in pancreatitis remains a challenging clinical problem requiring a multidisciplinary approach. This review aims to focus its attention specifically on the bleeding complications of pancreatitis.

Host Index and Gallbladder Cancer: An Emerging Prognostic Biomarker

BACKGROUND AND OBJECTIVES

There is emerging evidence that host related variables predict outcomes in various cancers. The Host index (H-index) incorporates various host-related, blood-derived biomarkers (immunological and nutritional parameters) as a single mathematical formula. The aim of this study was to evaluate outcomes using the H-index as a prognostic marker in gallbladder cancer (GBC) patients undergoing curative resection.

METHODS

Retrospective cohort study of surgically treated GBCs at a tertiary cancer centre from January 2010 to May 2023 was performed. Patients who had received neoadjuvant therapy, metastatic (M1) disease at time of surgical exploration and incidental GBCs were excluded. Baseline neutrophil, lymphocyte, monocyte and platelet counts, hemoglobin and albumin levels were recorded. H-index was computed and analysed.

RESULTS

241 curatively resected GBC patients were included. The H-index was inversely associated with disease free survival (DFS), both on univariate (79.7 vs. 61.4% for H-index  3.4 respectively; p = 0.046) and multivariate analysis (Hazard ratio [HR] for recurrence: 1.954 [95% C.I.: 1.366-2.796]; p = < 0.001). Using the maximally distributed rank statistics, a cut-off of 1.31 showed a significant difference in 3-year DFS (86.2 vs. 68.4% for H-index  1.31 respectively; HR: 2.21 [95% CI: 1.16-4.21]; p = 0.013) but not overall survival (OS) (p = 0.269).

CONCLUSION

A higher H-index predicted for worse DFS in curatively resected GBC patients. This shows host related variables do play a role in influencing outcomes in GBC. However, larger prospective studies are required to further strengthen this finding.

SUMMARY

Host-related, blood derived biomarkers can influence outcomes in various solid tumours. A higher baseline Host index (H-index) value which incorporates various blood-derived biomarkers, predicted for worse disease-free survival in curatively resected gallbladder cancers.

[Evidence for the extent and oncological benefit of lymphadenectomy for pancreatic cancer]

Pancreatic cancer is usually diagnosed at a late stage and is characterized by early systemic metastases, which can also be present in the form of micrometastases that are not primarily visible. Lymphatic metastases in pancreatic cancer are common. The extent of lymph node removal (lymphadenectomy, LAD) in pancreatic cancer is defined in the guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) and according to currently available data has more diagnostic and prognostic relevance than therapeutic relevance; however, within the framework of modern multimodal treatment algorithms, radical surgery is the most relevant of all components of multimodal treatment with LAD playing an important role. According to current data, extended LAD without technical necessity in the surgery of the primary tumor brings no advantages for the patients but numerous limitations in the quality of life and should therefore not be performed as the standard. Important aspects of LAD for pancreatic cancer are the lymph node ratio, extended vs. standard LAD and innovations in LAD in the field of interaortocaval lymph nodes and the so-called triangle operation.

3D modeling to predict vascular involvement in resectable pancreatic adenocarcinoma

Background

Current management of patients with borderline resectable pancreatic adenocarcinoma (BR-PDAC) depends on the degree of involvement of the major arterial and venous structures. The aim of this study was to evaluate 3D segmentation and printing to predict tumor size and vascular involvement of BR-PDAC to improve pre-operative planning of vascular resection and better select patients for neoadjuvant therapy.

Methods

We retrospectively evaluated 16 patients with BR-PDAC near vascular structures who underwent pancreatoduodenectomy (PD) with or without vascular resection between 2015 and 2021. The pre-operative computed tomography (CT) images were processed by segmentation with 3D reconstruction and printed as 3D models. Two radiologists specialized in pancreatic imaging and two pancreatic surgeons blindly and independently analyzed the pre-operative CT scans and 3D models using a defined checklist. Their evaluations were compared to the pre-operative 2D-CT reports utilized for patient management. A positive delta was defined by the 3D analysis resulting in greater accuracy in predicting vascular involvement as proven intraoperatively or histopathologically.

Results

Fourteen PD, one total pancreatectomy, and one exploratory laparotomy were performed. Ten patients had a positive delta concerning vascular involvement of the superior mesenteric or portal vein. Tumor extension was also more accurately evaluated by 3D modeling than by 2D-CT (p < 0.05).

Conclusions

Our pilot study demonstrates that 3D segmentation can provide additional information for choosing the best treatment strategy and surgical plain in patients with BR-PDAC. Especially for upcoming mini-invasive techniques like laparoscopic and robotic resections, better pre-operative planning is essential to allow safety and prevent vascular injury.

The therapeutic potential of vitamins A, C, and D in pancreatic cancer

The pancreatic ductal adenocarcinoma (PDAC) is among the deadliest tumor diseases worldwide. While treatment options have generally become more diverse, little progress has been made in the treatment of PDAC and the median survival time for patients with locally advanced PDAC is between 8.7 and 13.7 months despite treatment. The aim of this review was to explore the therapeutic potential of complementing standard therapy with natural or synthetic forms of vitamins A, C, and D. The therapeutic use of vitamins A, C, and D could be a promising addition to the treatment of PDAC. For all three vitamins and their derivatives, tumor cell-specific cytotoxicity and growth inhibition against PDAC cells has been demonstrated in vitro and in preclinical animal models. While the antitumor effect of vitamin C is probably mainly due to its pro-oxidative effect in supraphysiological concentrations, vitamin A and vitamin D exert their effect by activating nuclear receptors and influencing gene transcription. In addition, there is increasing evidence that vitamin A and vitamin D influence the tumor stroma, making the tumor tissue more accessible to other therapeutic agents. Based on these promising findings, there is a high urgency to investigate vitamins A, C, and D in a clinical context as a supplement to standard therapy in PDAC. Further studies are needed to better understand the exact mechanism of action of the individual compounds and to develop the best possible treatment regimen. This could contribute to the long-awaited progress in the treatment of this highly lethal tumor entity.

Unveiling the Emerging Role of Xanthine Oxidase in Acute Pancreatitis: Beyond Reactive Oxygen Species

Acute pancreatitis (AP) is a potentially fatal acute digestive disease that is widespread globally. Although significant progress has been made in the previous decade, the study of mechanisms and therapeutic strategies is still far from being completed. Xanthine oxidase (XO) is an enzyme that catalyzes hypoxanthine and xanthine to produce urate and is accompanied by the generation of reactive oxygen species (ROS) in purine catabolism. Considerable preclinical and clinical studies have been conducted over many decades to investigate the role of XO in the pathogenesis of AP and its potential targeting therapeutic value. There is no doubt that the ROS generated by irreversibly activated XO participates in the local pancreas and multiple organ failure during AP. However, the optimal timing and doses for therapeutic interventions targeting XO in animal studies and the clinic, as well as the additional molecular mechanisms through which XO contributes to disease onset and progression, including metabolic regulation, remain to be elucidated. This review summarized the benefits and contradictions of using XO inhibitors in animal models, offered mechanisms other than ROS, and discussed the difficulties faced in clinical trials. We hope to provide a perspective on the future worthwhile basic and clinical research on XO by analyzing its chemical and biological characteristics, as well as the progress of its regulatory mechanisms in AP.

CT Angiography Assessment of Dorsal Pancreatic Artery and Intrapancreatic Arcade Anatomy: Impact on Whipple Surgery Outcomes

BACKGROUND/OBJECTIVES

The aim was to investigate the association between variations in the dorsal pancreatic artery (DPA) and intrapancreatic arcade anatomy with Whipple procedure outcomes and postoperative complications.

METHODS

This retrospective study was conducted with 362 patients who underwent a Whipple procedure at the Department of Gastroenterological Surgery of Adana City Training and Research Hospital between January 2018 and April 2024. All data collected from medical records were compared and statistically analyzed according to the patients' survival status and arcade subtypes.

RESULTS

After excluding cases that did not meet the study criteria, a total of 284 patients were included in the study. DPA was visualized in 55.98% (159/284) of patients, while the intrapancreatic arcade was observed in 25% (71/284). The most common origin of the DPA was the splenic artery in 69.2% (n = 110) of patients, followed by the superior mesenteric artery in 17.6% (n = 28). The frequency of intrapancreatic arcade anatomy variations was as follows: type 1: 28.2% (n = 20), type 2: 49.3% (n = 35) and type 3: 22.5% (n = 16). Arcade type 4 anatomy was not detected. Postoperative pancreatic fistula (POPF) complication was found to be statistically significantly higher in patients with type 3 anatomy (p = 0.042). The 90-day mortality and long-term mortality rates did not differ among the groups based on the variations in both DPA and intrapancreatic arcade anatomy types.

CONCLUSIONS

Patients with intrapancreatic arcade type 3 anatomy had a higher risk of POPF complications. Determination of preoperative arcade type by computed tomography (CT) angiography may help to predict the risk of POPF.

Active-Targeted ICG for Surgical Navigation and Fluorescence-Guided Laparoscopic Photothermal Ablation in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy, but there is limited improvement in its treatment. Near-infrared fluorescence (NIRF) imaging could potentially address the clinical challenges of PDAC. Indocyanine green (ICG) has been widely used in clinical practice; however, its short half-life and lack of active targeting greatly limit its application in pancreatic surgery. In this study, the active targeting peptide KTLLPTP (which actively recognizes PDAC cell surface overexpression Plectin-1) was modified to the ICG to create the novel contrast agent ICG-PTP, which actively targets PDAC cells. It was successfully applied to the NIRF imaging of the PDAC orthotopic mice model, achieving an improved tumor signal background ratio (T/N ratio) of 4.28, compared to 2.34 in the free ICG group. Next, Fluorescence-guided excision of subcutaneous/orthotopic PDAC using ICG-PTP was performed, accurately identifying the tumor margin and significantly facilitating resection efficiency. Finally, PDAC metastases were identified, and interventional photothermal ablation (iPTA) was performed under fluorescence laparoscope guidance. ICG-PTP exhibits good biosafety and clinical transitional potential. Thus, they can provide surgeons with efficient real-time tumor information and offer new treatment strategies for metastases. Accordingly, modification of probes for clinical use and adaptation studies of current equipment are the current focus.

Neoadjuvant Chemotherapy Can Effectively Avoid Unnecessary Extended Resection for Gastric Cancer with Clinical Evidence of Duodenum or Pancreas Head Involvement

Purpose: This study aims to compare the efficacy of two treatment strategies for gastric cancer with clinical evidence of pancreatic head or duodenal involvement: gastrectomy combined with pancreaticoduodenectomy (GPD) and neoadjuvant chemotherapy followed by surgery (NCS). Methods: A retrospective analysis of patient data from January 2012 to January 2022 was conducted to evaluate the outcomes of these two treatment strategies. Results: The study included 284 patients, comprising 78 in the GPD group and 206 in the NCS group. In the NCS group, 119 patients required extended pancreaticoduodenectomy, a significantly smaller proportion compared to the GPD group (p < 0.001). The NCS group successfully avoided unnecessary extended pancreaticoduodenectomy. In contrast, 15 patients in the GPD group underwent surgery despite postoperative pathological confirmation of no pancreatic head or duodenal involvement (p < 0.001). The incidence of Clavien-Dindo grade ≥ IIIb complications was significantly greater in the GPD group than in the NCS group (10.3% vs. 3.3%, p = 0.034). Overall survival was significantly longer in the NCS group, with a median of 25 months compared to 20 months in the GPD group (p = 0.0005). Multivariate Cox regression analysis revealed that tumor diameter ≥7 cm and N3 stage were independent adverse prognostic factors. Conclusion: Neoadjuvant chemotherapy is recommended for patients with gastric cancer presenting clinical evidence of pancreatic head or duodenal involvement. This approach reduces unnecessary extended surgeries, lowers complication rates, and improves overall survival.

Early prediction of post-pancreatectomy acute pancreatitis after pancreaticoduodenectomy based on serum C-reactive protein

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is an early acute inflammatory process of the pancreatic remnant that is associated with a series of downstream pancreas-specific complications. This study aimed to investigate the relationship between postoperative serum C-reactive protein (CRP) levels and the occurrence of PPAP after pancreaticoduodenectomy (PD).

METHODS

Consecutive patients who underwent PD between January 1, 2020, and May 31, 2022, were retrospectively analyzed. PPAP was defined according to the International Study Group for Pancreatic Surgery (ISGPS) definitions. A Sankey diagram incorporating Fistula Risk Score (FRS), serum amylase levels, and serum CRP levels was further performed for the early iterative risk stratification of PPAP.

RESULTS

A total of 601 patients were included in the analysis. Postoperative serum hyperamylasemia (POH) was observed in 268 patients (44.6 %), of whom 136 (16.7 %) developed PPAP after PD. Patients with serum CRP >100 mg/L on postoperative day (POD) 2 had a significantly higher incidence of PPAP (27.2 % vs. 2.3 %, p < 0.001). The highest Youden index was achieved with the cut-off value of 100 mg/L, with the area under the curve (AUC) value of 0.754 for predicting PPAP (sensitivity 91.8 %, specificity 59.0 %). Multivariate analysis revealed that body mass index (BMI) ≥24 (OR 2.09), estimated blood loss >200 mL (OR 1.70), and elevated serum CRP levels (OR 13.01) were independent risk factors for PPAP. Notably, patients with both POH and elevated serum CRP levels on POD 2 were classified as the high-risk group, exhibiting a remarkably high PPAP rate of 41.8 %.

CONCLUSIONS

Serum CRP levels on POD 2 are strongly associated with the development of PPAP after PD. This finding has the potential to enable tailored postoperative management and pave the way for the anti-inflammation strategies targeting the early postoperative period.

Characterization of Pancreatic Infections in Patients with Severe Acute Pancreatitis: A Retrospective Study from 2019 to 2023

Objective

This study investigated the distribution and changes in pancreatic infections among patients with acute pancreatitis (AP) from 2019 to 2023, while exploring the impact of multidrug-resistant bacterial infections on the prognosis of patients with poor outcomes.

Methods

This study included patients diagnosed with SAP between 2019 and 2023 and collected the demographic and clinical characteristics of all participants. Based on routine clinical microbiological culture results, the distribution and drug resistance of pathogens associated with pancreatic infections were analyzed. Multivariable logistic regression was used to evaluate the association between multidrug-resistant organism (MDRO) infection and poor prognosis.

Results

A total of 1586 pancreatic fluid specimens were analyzed and collected from 843 patients diagnosed with AP. The positive rate of the culture results was 81% (1280/1586), with the predominant pathogens identified as Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Acinetobacter baumannii complex. Of the 843 patients, 756 met the criteria, and the proportion of MDROs in pancreatic infections was 87.57% (662/756). Multivariate logistic regression analysis revealed that septic shock, acute kidney injury, and tracheostomy were associated with a poor prognosis, whereas ICU length of stay, infected pancreatic necrosis, and tracheostomy were associated with multidrug-resistant bacterial infections in patients with severe or critical AP.

Conclusion

The proportion of MDRO infections in patients with severe or critical AP was notably high, primarily involving multidrug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Septic shock, acute kidney injury, and tracheostomy have been identified as independent risk factors of poor prognosis in patients with severe or critical AP.

Nanotherapeutics-mediated restoration of pancreatic homeostasis and intestinal barrier for the treatment of severe acute pancreatitis

Severe acute pancreatitis (SAP) is an inflammatory disease of the pancreas accompanied with intestinal injury, and effective therapeutic modalities are still highly lacking. Herein, a facile and effective nanotherapeutics (pHA@IBNCs) is developed to alleviate pancreatic inflammation and restore intestinal barrier for SAP treatment. Epigallocatechin gallate (EGCG, an anti-oxidant), interleukin-22 (IL-22, an anti-inflammatory and epithelial barrier-protecting cytokine), and bovine serum albumin (a framework protein), are assembled via non-covalent interactions to form nanocomplexes (IBNCs). Then, phenylboronic acid-modified hyaluronic acid (pHA) is synthesized and coated onto IBNCs via formation of the reversible boronate ester bonds to obtain pHA@IBNCs. Upon intravenous injection, pHA@IBNCs could efficiently accumulate at the lesion sites of sodium taurocholate (STC)-induced SAP mice, based on their prolonged blood circulation time and pHA-mediated targeting of activated intestinal epithelial cells and macrophages. Inside the inflammatory microenvironment, over-produced reactive oxygen species (ROS) trigger the shedding of the pHA layer and release of the drug payloads. Thereby, EGCG cooperates with IL-22 to attenuate pancreatitis and restore the intestinal barrier by scavenging ROS, suppressing pro-inflammatory cytokines secretion, and promoting the repair of intestinal epithelia. Such a nano-therapeutic approach targeting multiple pathological events may serve as a promising paradigm for the effective management of SAP.

Case report: A successful case of targeted immunotherapy for locally advanced pancreatic cancer under non-surgical conditions

Introduction

Locally advanced pancreatic cancer (LAPC) is a borderline unresectable malignancy that presents significant treatment challenges. The management of LAPC remains a complex issue, particularly in patients who are not eligible for surgical resection.

Case

Here, we report the case of a 60-year-old woman diagnosed with LAPC through pathological biopsy who subsequently underwent targeted immunotherapy following the failure of a gemcitabine, oxaliplatin, and S-1 (G&S) chemotherapy regimen.

Intervention

Based on next-generation sequencing (NGS), the patient's treatment regimen was adjusted to include albumin-bound paclitaxel and capecitabine chemotherapy, along with the PD-1 inhibitor camrelizumab (200 mg/cycle) for six cycles. Throughout the treatment period, the patient consistently declined surgical intervention. Imaging studies, including an upper abdominal computed tomography (CT), revealed the formation of a calcified layer surrounding the cancerous tissue in the pancreatic head. Remarkably, the patient has shown stable disease and no evidence of metastasis since the initiation of targeted immunotherapy.

Conclusion

This case highlights the potential of targeted immunotherapy for the treatment of LAPC, particularly in non-surgical patients. A personalized approach guided by NGS, combined with immunotherapy, is an effective alternative to traditional treatment strategies for managing this challenging malignancy.

Characteristics of gut microbiota profiles in Asian elephants (Elephas maximus) with gastrointestinal disorders

Colic and diarrhea are common gastrointestinal (GI) disorders in captive Asian elephants, which can severely impact health and lead to mortality. Gut dysbiosis, indicated by alterations in gut microbiome composition, can be observed in individuals with GI disorders. However, changes in gut microbial profiles of elephants with GI disorders have never been investigated. Thus, this study aimed to elucidate the profiles of gut microbiota in captive elephants with different GI symptoms. Fecal samples were collected from eighteen elephants in Chiang Mai, Thailand, including seven healthy individuals, seven with impaction colic, and four with diarrhea. The samples were subjected to DNA extraction and amplification targeting the V3-V4 region of 16S rRNA gene for next-generation sequencing analysis. Elephants with GI symptoms exhibited a decreased microbial stability, as characterized by a significant reduction in microbiota diversity within individual guts and notable differences in microbial community composition when compared with healthy elephants. These changes included a decrease in the relative abundance of specific bacterial taxa, in elephants with GI symptoms such as a reduction in genera Rubrobacter, Rokubacteria, UBA1819, Nitrospira, and MND1. Conversely, an increase in genera Lysinibacillus, Bacteroidetes_BD2-2, and the family Marinifilaceae was observed when, compared with the healthy group. Variations in taxa of gut microbiota among elephants with GI disorders indicated diverse microbial characteristics associated with different GI symptoms. This study suggests that exploring gut microbiota dynamics in elephant health and GI disorders can lead to a better understanding of food and water management for maintaining a healthy gut and ensuring the longevity of the elephants.

A Retrospective Study of Laparoscopic Distal Gastrectomy Guided by Carbon Nanoparticle Suspension Injection Lymphography for Gastric Cancer

BACKGROUND

The use of lymph node (LN) tracers can help obtain a complete dissection of the LNs and increase the detection rate of metastatic LNs. Carbon nanoparticle suspension injection (CNSI) has become increasingly used in radical gastrectomy procedures. This study is designed to evaluate the quality of LN dissection in gastric cancer patients with laparoscopic distal gastrectomy under the guidance of CNSI lymphography.

METHOD

This was a retrospective cohort study including patients with a pathological biopsy diagnosis of resectable gastric cancer who underwent laparoscopic distal gastrectomy. Data was focused on patients at [Renji Hospital of Shanghai Jiaotong University] from July 2023 to January 2024. Patients were divided into the CNSI group and control group after 1:1 propensity score matching analysis. The median number of LNs harvested was compared between groups. Perioperative status and any complications that arose within 30 days were also analyzed.

RESULT

After 1:1 propensity matching analysis, there were 49 patients each in the CNSI group and control group. The median number of harvested LNs was larger in the CNSI group than the control group (P = 0.01). A significant difference between 2 groups was observed in surgery time (P = 0.008). The morbidity of any short-term postoperative complications within 30 days after surgery revealed a similar outcome (P > 0.05).

DISCUSSION

CNSI-guided laparoscopic distal gastrectomy is less time-consuming and harvests more LNs. For laparoscopic distal gastrectomy, CNSI-guided lymphography can be an excellent adjuvant.

[Hemorrhage after pancreaticoduodenectomy]

OBJECTIVE

To analyze the incidence, clinical manifestations and treatment of post-pancreaticoduodenectomy hemorrhage in patients with pancreaticoduodenal tumors.

MATERIAL AND METHODS

There were 362 pancreaticoduodeneectomies for ductal adenocarcinoma of the pancreatic head and pancreatoduodenal tumors in 2016-2023. Post-pancreatectomy hemorrhage (PPH) occurred in 52 (14.4%) patients. Delayed post-pancreatectomy hemorrhage followed postoperative pancreatitis, pancreatic fistula or non-drained fluid collections. Bleeding was diagnosed considering clinical manifestations with verification through contrast-enhanced CT.

RESULTS

Emergency re-laparotomy was required in 15 (28.8%) patients with unstable hemodynamics; 9 (60%) people died. Thirty-seven patients with stable hemodynamics underwent emergency contrast-enhanced CT and subsequent endovascular hemostasis. Bleeding was stopped in 31 patients (89.2%). Endovascular hemostasis was ineffective in 1 patient who underwent re-laparotomy. We found no the cause of bleeding in 3 patients, and there was no hemorrhage recurrence. Six (18.7%) people died. The overall mortality among patients with PPH was 28.8% (15 out of 52 postoperative patients).

CONCLUSION

PPH follows postoperative pancreatitis, pancreatic fistula or non-drained fluid collection. In case of stable hemodynamics, endovascular hemostasis is preferable for this complication.

Moment-Consistent Contrastive CycleGAN for Cross-Domain Pancreatic Image Segmentation

CT and MR are currently the most common imaging techniques for pancreatic cancer diagnosis. Accurate segmentation of the pancreas in CT and MR images can provide significant help in the diagnosis and treatment of pancreatic cancer. Traditional supervised segmentation methods require a large number of labeled CT and MR training data, which is usually time-consuming and laborious. Meanwhile, due to domain shift, traditional segmentation networks are difficult to be deployed on different imaging modality datasets. Cross-domain segmentation can utilize labeled source domain data to assist unlabeled target domains in solving the above problems. In this paper, a cross-domain pancreas segmentation algorithm is proposed based on Moment-Consistent Contrastive Cycle Generative Adversarial Networks (MC-CCycleGAN). MC-CCycleGAN is a style transfer network, in which the encoder of its generator is used to extract features from real images and style transfer images, constrain feature extraction through a contrastive loss, and fully extract structural features of input images during style transfer while eliminate redundant style features. The multi-order central moments of the pancreas are proposed to describe its anatomy in high dimensions and a contrastive loss is also proposed to constrain the moment consistency, so as to maintain consistency of the pancreatic structure and shape before and after style transfer. Multi-teacher knowledge distillation framework is proposed to transfer the knowledge from multiple teachers to a single student, so as to improve the robustness and performance of the student network. The experimental results have demonstrated the superiority of our framework over state-of-the-art domain adaptation methods.

Development and validation of a prognostic model for cachexia in postoperative gastric cancer patients with low nutritional risk: a dual-center retrospective cohort study

BACKGROUND

Gastric cancer can lead to excessive catabolism in patients. After undergoing gastric surgery, patients may experience additional unintended weight loss, resulting in severe malnutrition and potentially cachexia.

METHODS

We selected and incorporated patients from two centers. Cohort 1 (n = 1393) served as the development cohort, while cohort 2 (n = 501) was designated as an external validation cohort. Within cohort 1, 70% of the patients were utilized for model training, with the remaining 30% reserved for internal validation. The training set initially underwent univariate logistic regression, followed by multivariate logistic regression. The factors ultimately incorporated were used to construct the model and create nomograms. The discriminative ability was assessed using ROC curves in all three datasets, calibration curves were used to evaluate consistency, and decision curves analysis was performed to assess the clinical application value.

RESULTS

The model incorporated 12 factors, specifically: age (OR = 1.07), preoperative BMI (OR = 0.89), surgery type (Total Gastrectomy (TG), OR = 1.83), chemotherapy (yes, OR = 1.52), stage (III, OR = 1.40), anastomotic obstruction (yes, OR = 6.85), Postsurgical Gastroparesis Syndrome (PGS) (yes, OR = 2.27), albumin (OR = 0.95), hemoglobin (OR = 0.98), triglycerides (OR = 0.36), CRP (OR = 1.07), and Neutrophil to Lymphocyte Ratio (NLR) (OR = 1.05). The model demonstrated robust performance in ROC with AUC values of 0.805 in the training set, 0.767 in the validation set, and 0.795 in Cohort 2. Calibration curves in all three datasets exhibited a high degree of concordance between actual and predicted probabilities. Decision curve analysis (DCA) indicated that the model holds substantial clinical utility across all three datasets.

CONCLUSIONS

We have developed a predictive model for cachexia in patients undergoing gastric cancer surgery. This model enables healthcare professionals to accurately estimate the risk of cachexia in postoperative patients with nutritional deficits, allowing for timely nutritional interventions to enhance patient quality of life and prognosis.

Effect of carbon nanoparticle suspension injection versus indocyanine green tracer in guiding lymph node dissection during radical gastrectomy (FUTURE-01): a randomized clinical trial

BACKGROUND

Carbon nanoparticle suspension injection (CNSI) and indocyanine green (ICG) have both been applied intraoperatively to facilitate lymphatic mapping and postoperatively to sort lymph nodes (LNs) in gastric cancer patients. However, no study has compared the two tracers in gastric cancer patients.

MATERIALS AND METHODS

This prospective randomized controlled trial was conducted from January 2022 to March 2023. Patients with potentially resectable gastric cancer (cT1-4a N0/+ M0) were randomized to the CNSI or ICG group.

RESULTS

This study enrolled 96 patients. Ninety patients were in the modified intention-to-treat population, including 46 patients [32 males and 14 females; mean (SD) age, 57.4 (9.4) years] in the CNSI group and 44 patients [31 males and 13 females; mean (SD) age, 60.8 (8.8) years] in the ICG group. The mean (SD) number of retrieved LNs was 69.8 (21.9) and 53.6 (17.2) in the CNSI and ICG groups, respectively ( P <0.001). The mean (SD) number of retrieved micro-LNs was 19.9 (13.3) and 11.6 (9.9) in the CNSI and ICG groups, respectively ( P =0.001). The mean (SD) number of metastatic LNs was 8.1 (11.9) and 5.2 (9.2) in the CNSI and ICG groups, respectively ( P =0.19).

CONCLUSIONS

Compared with ICG, CNSI can increase the number of LNs detected, especially micro-LNs. Both tracers have high diagnostic value for detecting metastatic LNs. CNSI-guided lymphography may be a superior method for improving the accuracy of LN dissection.

Dual-energy CT in differentiating benign gallbladder wall thickening from wall thickening type of gallbladder cancer

OBJECTIVE

To evaluate the performance of dual-energy computed tomography (DECT) in differentiating non-acute benign from malignant gallbladder wall thickening (GBWT).

METHODS

This prospective study comprised consecutive adults with GBWT who underwent late arterial phase (LAP) and portal venous phase (PVP) DECT between January 2022 and May 2023. The final diagnosis was based on histopathology or 3-6 months follow-up imaging. DECT images in LAP and PVP were assessed independently by two radiologists. The demographic, qualitative, and quantitative parameters were compared between two groups Multivariate logistic regression was performed to determine the association between the aforementioned factors and malignant GBWT.

RESULTS

Seventy-five patients (mean age 56 ± 12.8 years, 46 females) were included. Forty-two patients had benign, and 33 had malignant GBWT. In the overall group, female gender (p = 0.018), lymphadenopathy (p = 0.011), and omental nodules (p = 0.044) were significantly associated with malignant GBWT. None of the DECT features differed significantly between benign and malignant GBWT in overall group. In the xanthogranulomatous cholecystitis (XGC, n = 9) vs. gallbladder cancer (GBC) (n = 33) subgroup, mean attenuation value at 140 keV LAP VMI was significantly associated with malignant GBWT [p = 0.023, area under curve 0.759 (95%CI 0.599-0.919)].

CONCLUSION

DECT-generated quantitative parameters do not add value in differentiating non-acute benign from malignant GBWT. However, DECT may have a role in differentiating XGC from GBC in a selected subgroup of patients. Further, larger studies may be necessary to confirm these findings.

CLINICAL RELEVANCE STATEMENT

In patients with non-acute gallbladder wall thickening in whom there is suspicion of xanthogranulomatous cholecystitis (XGC), DECT findings may allow differentiation of XGC from wall thickening type of gallbladder cancer.

KEY POINTS

Differentiation of benign and malignant gallbladder wall thickening (GBWT) at CT is challenging. Quantitative dual energy CT (DECT) features do not provide additional value in differentiating benign and malignant GBWT. DECT may be helpful in a subgroup of patients to differentiate xanthogranulomatous cholecystitis from gallbladder cancer.

The proinflammatory status, based on preoperative interleukin-6, predicts postpancreatectomy acute pancreatitis and associated postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND AND AIM

Early predictors of morbidity after pancreaticoduodenectomy (PD) can guide tailored postoperative management. Preoperative inflammatory data in patients who underwent PD remained poorly studied in investigating the clinical significance of predicting postpancreatectomy acute pancreatitis (PPAP) and PPAP-associated postoperative pancreatic fistula (POPF).

METHODS

The clinical data of 467 patients receiving PD between January 2020 and December 2022 were retrospectively reviewed. Preoperative inflammatory data were stratified according to PPAP, and independent risk factors were analyzed. Multivariate logistic regression and subgroup analyses were conducted to compare risk factors of PPAP-associated POPF and non-PPAP-associated POPF.

RESULTS

PPAP occurred in 17.6% of patients. The incidence of other complications increased following PPAP. Among the preoperative inflammatory factors, only interleukin-6 (IL-6) increased (P < 0.001), leading to a higher incidence of PPAP and POPF (P < 0.001; P = 0.002). The area under the curve of IL-6 in predicting PPAP was 0.71 (0.65-0.77; P < 0.001). Abnormal preoperative IL-6 levels (odds ratio [OR]: 5.01; P < 0.001), soft pancreatic texture (OR: 2.15; P = 0.007), and pathology (OR: 2.03; P = 0.012) were independent risk factors for PPAP. The subgroup analysis showed that increased IL-6 (OR: 1.01; P = 0.006) and soft pancreatic texture (OR: 2.05; P = 0.033) resulted in a higher risk of PPAP-associated POPF, while increased IL-8 (OR: 1.01; P = 0.007), older age (OR: 1.05; P = 0.008), and higher body mass index (OR: 1.12; P = 0.021) correlated with non-PPAP-associated POPF.

CONCLUSION

PPAP is common after PD; a high preoperative IL-6 level can predict its occurrence, in addition to associated POPF, which could be due to a preoperative proinflammatory status.

Exosome applications for the diagnosis and treatment of pancreatic ductal adenocarcinoma: An update (Review)

Pancreatic ductal adenocarcinoma (PDAC) is a malignant neoplasm that typically manifests with subtle clinical manifestations in its early stages and frequently eludes diagnosis until the advanced phases of the disease. The limited therapeutic options available for PDAC significantly contribute to its high mortality rate, highlighting the urgent need for novel biomarkers capable of effectively identifying early clinical manifestations and facilitating precise diagnosis. The pivotal role of cellular exosomes in both the pathogenesis and therapeutic interventions for PDAC has been underscored. Furthermore, researchers have acknowledged the potential of exosomes as targeted drug carriers against regulatory cells in treating PDAC. The present article aims to provide a comprehensive review encompassing recent advancements in utilizing exosomes for elucidating mechanisms underlying disease development, patterns of metastasis, diagnostic techniques and treatment strategies associated with PDAC.

Essential Elements in Synoptic Operative Reports for Hepato-Pancreato-Biliary Cancer Surgery: An HPB/CGSO Training Program Survey

BACKGROUND

Synoptic operative reports (SORs) are checklists or templates that contain standardized elements of an operation. These elements are associated with standardized inclusion of critical elements of the operative report that translate into numerous potential benefits. Whereas SORs for melanoma, breast, and colorectal cancer surgery have already been widely implemented, similar templates for hepato-pancreato-biliary (HPB) cancer surgery are currently lacking.

METHODS

An anonymous voluntary online survey was distributed to HPB attendings and fellows at HPB and complex general surgical oncology (CGSO) fellowship programs.

RESULTS

The 54 participants in this study comprised 31 (57%) HPB surgery attendings, 15 (28%) HPB surgery fellows, and 8 (15%) CGSO fellows. Notably, only six (11%) participants reported consistent use of an HPB SOR. The most commonly reported barriers to SOR uptake were the "lack of a readily available template" (55%) and the "lack of consensus/guidelines" (49%). Despite these limiting factors, a majority of respondents indicated a strong willingness to use a standardized and readily available HPB SOR (mean, 4.13/5 ± 1.23). This interest did not differ between attendings and fellows (p = 0.52) or between the participants stratified by surgical experience (p = 0.58). Finally, the participants were provided a comprehensive list of possible elements to incorporate into a standardized pancreatic and hepatobiliary SOR. After the exclusion of elements with less than 75% agreement, the pancreatic SORs included 17 (57%) of 30 possible elements, and the hepatobiliary SORs included 19 (76%) of 25 possible elements.

CONCLUSION

Broad consensus on several elements of the HPB SOR suggests that uptake should be accelerated in HPB surgery.

Evolving Dynamics of Colorectal Cancer in High Socio-Demographic Regions

BACKGROUND

Colorectal cancer (CRC) poses a significant global health challenge, with evolving demographic trends emphasizing the need for accurate forecasting models. Existing forecasting models lack comprehensive coverage. By integrating machine learning algorithms, this study aims to provide more accurate and precise predictions, filling critical gaps in understanding CRC incidence, death, and disability-adjusted life year (DALY) rate trends, especially in high socio-demographic index (SDI) regions. Specific emphasis is placed on exploring age-, sex-, and country-specific variations in CRC trends.

MATERIALS AND METHODS

An ensemble forecasting algorithm integrating Simple Linear Regression, Exponential Smoothing, and Autoregressive Integrated Moving Average, capable of handling a short time series was developed and validated, utilizing a dataset encompassing age-, sex-, and country-specific CRC incidence, mortality, and DALY rates.

RESULTS

Our forecasting models reveal rising trends in CRC burden in the 15-49 years age group (young-onset) and decreasing trends in CRC burden in the 50-74 years age group (late-onset) in high SDI regions with sex-specific variations in incidence, mortality, and DALY rates. Some inflection points for demographic shifts in CRC disease burden, particularly death rates, were identified as early as within the next 5 years. We predict a shift in CRC burden towards females, particularly in older adults.

CONCLUSION

A novel multifactor model was developed for comparing the incidence, mortality, and DALY rates of young- and late-onset CRC in high SDI regions. The rising incidence of young-onset CRC in high SDI regions underscores the need for proactive health strategies. By refining predictive models, adjusting screening guidelines to target younger, high-risk populations, and investing in public awareness and research, we can facilitate early detection and improve outcomes. This study addresses a significant gap in CRC forecasting and provides a robust framework for anticipating demographic shifts in CRC burden, making it an indispensable tool for healthcare planning.

The short-term outcomes of laparoscopic enucleation of pancreatic tumors with exposing the Wirsung duct

BACKGROUND

It is widely believed that the prerequisite for safely performing enucleation is that the distance between the tumor and the main pancreatic duct (MPD) is at least 2-3 mm. However, enucleating a deep pancreatic tumor adjacent to the MPD remains challenging, particularly when exposure or repair of the MPD is necessary. This study reported our initial experience with this procedure and demonstrated the feasibility and safety of the MPD exposure or repair.

METHODS

Patients who underwent laparoscopic enucleation (LapEN) with exposing the MPD from January 2017 to August 2023 were collected and analyzed in this retrospective cohort study. Data from procedures of laparoscopic middle pancreatectomy (LMP) and LapEN for superficial tumors were collected for comparative analyses.

RESULTS

A total of 26 patients were enrolled, 27 tumors were enucleated. Tumor located in the pancreatic head and neck (n = 20), and the body (n = 7). The mean tumor size, operating time, and blood loss were 2.3 cm, 163 min, and 63 ml, respectively. MPD injuries occurred in 8 cases due to the need for complete tumor resection, which were repaired or reconstructed using 6-0 PDS-II with or not inserting a plastic stent. 10 cases (38.5%) developed surgical-related complications, seven (26.9%) were classified as Clavien-Dindo grade I, and three (11.5%) were Clavien-Dindo grade IIIa. Biochemical leakage occurred in 16 cases (61.5%), clinically relevant pancreatic fistula (CR-POPF) occurred in 10 cases (38.5%). Two patients (7.7%) experienced post-pancreatectomy hemorrhage. Further analyses indicated LapEN with MPD exposure had a longer operating time and higher incidence of CR-POPF compared to LapEN for superficial tumors, but a shorter operating time and less blood loss compared to LMP (P < 0.05).

CONCLUSION

Laparoscopic enucleation with exposing the MPD is feasible and safe with the support of precise preoperative assessments, meticulous intraoperative dissection, well familiarity with the anatomy of the MPD, and excellent surgical skills.

Quality of care in hepatocellular carcinoma-A critical review

There is significant variation in HCC management across different centers with poor adherence to evidence-based clinical practice guidelines as assessed in prior studies. In Australia, quality indicators (QIs) have recently been proposed by a multidisciplinary group of experts to help provide a framework to assess and monitor the quality of HCC care. In this review, we discuss the many areas where real-world practice deviates from evidence-based medicine, the role that QI sets play in addressing this gap, and the similarities and differences between Australian QIs and other leading treatment guidelines and QI sets from around the world. We focus on the utility of QI sets to identify opportunities for targeted improvement in the real-world clinical environment. We conclude with a discussion about the formation of a national clinical quality registry as a long-term measure to facilitate continual improvements in patient care within and across sites in order to optimize patient outcomes.

The impact of chronic obstructive pulmonary disease on risk for complications after pancreatoduodenectomy - a single centre cohort study

BACKGROUND

The association between chronic obstructive pulmonary disease (COPD) and risk for postoperative complications after pancreatic surgery has not been clarified. The aim of this study was to investigate if COPD is associated with increased risk for postoperative complications after pancreatoduodenectomy.

METHODS

All patients aged ≥18 years undergoing pancreatoduodenectomy from 2008 to 2019 at a high-volume tertiary centre for pancreatic cancer surgery were included. COPD was defined as an established diagnosis according to the International Statistical Classification of Diseases. The primary outcome was Clavien-Dindo-score (CD)≥ IIIa.

RESULTS

Out of 1009 available patients, 57 (5.6 %) had a diagnosis of COPD. There was no association between COPD and CD≥ IIIa (25.5 % vs. 29.8 % p-value 0.471). COPD was associated with an increased risk for postoperative pancreatic fistula (POPF) (odds ratio [OR] 3.06, 95 % confidence interval 1.62-5.89; p < 0.001). The 12 months mortality rate was higher among patients with COPD compared to patients without COPD, although not statistically significant (28.07 % vs., 18.17 %, p-value = 0.063).

CONCLUSION

COPD was associated with increased risk for POPF. These results imply that among patients deemed fit enough to undergo surgery, COPD should be thoroughly evaluated in the risk stratification.

Comparative transcriptomic analysis uncovers molecular heterogeneity in hepatobiliary cancers

Hepatobiliary cancers (HBCs) pose a major global health challenge, with a lack of effective targeted biomarkers. Due to their complex anatomical locations, shared risk factors, and the limitations of targeted therapies, generalized treatment strategies are often used for gallbladder cancer (GBC), hepatocellular carcinoma (HCC), and intrahepatic cholangiocarcinoma (ICC). This study aimed to identify specific transcriptomic signatures in GBC, HCC, and ICC. The transcriptomic data analysis revealed distinct expression profiles, highlighting complex molecular heterogeneity within these cancers, even within the same organ system. Functional annotation revealed distinct biological pathways associated with each type of HBCs. GBC was linked to cell cycle regulation, HCC was associated with immune system modulation, and ICC was involved in metabolic dysregulation, particularly lipid metabolism. Gene co-expression network (GCN) and protein-protein interaction (PPI) network analyses identified potential key genes, such as MAPK3 and ERBB2 in GBC, AC069287.1 and ACTN2 in HCC, and TRPC1 and BACE1 in ICC. The FOX family of transcription factors (TFs) was conserved across all three cancer types. To further explore the relationship between Epithelial-Mesenchymal Transition (EMT) and the identified hub genes and TFs, an EMT score analysis was conducted. This analysis revealed distinct phenotypic characteristics in each cancer type, with TFs identified in GBC and ICC showing a stronger correlation with EMT compared to those in HCC. External validation using The Cancer Genome Atlas (TCGA) databases confirmed the expression of candidate genes, underscoring their potential as therapeutic targets. These findings provide valuable insights into the molecular heterogeneity and complexity of HBCs, opening new avenues for personalized therapeutic interventions.

An update on pancreatic cancer imaging, staging, and use of the PACT-UK radiology template pre- and post-neoadjuvant treatment

Pancreatic ductal adenocarcinoma continues to have a poor prognosis, although recent advances in neoadjuvant treatments (NATs) have provided some hope. Imaging assessment of suspected tumours can be challenging and requires a specific approach, with pancreas protocol CT being the primary imaging modality for staging with other modalities used as problem-solving tools to facilitate appropriate management. Imaging assessment post NAT can be particularly difficult due to a current lack of robust radiological criteria to predict response and differentiate treatment induced fibrosis/inflammation from residual tumour. This review aims to provide an update of pancreatic ductal adenocarcinoma with particular focus on three points: tumour staging pre- and post-NAT including vascular assessment, structured reporting with introduction of the PAncreatic Cancer reporting Template-UK (PACT-UK) radiology template, and the potential future role of artificial intelligence in the diagnosis and staging of pancreatic cancer.

Italian survey about intraperitoneal drain use in distal pancreatectomy

Intraperitoneal prophylactic drain (IPD) use in distal pancreatectomy (DP) is still controversial. A survey was carried out through the Italian community of pancreatic surgeons using institutional emails, Twitter, and Facebook accounts of the Italian Association for the Study of the Pancreas (AISP) and the Italian Association of Hepato-biliary-pancreatic Surgery (AICEP). The survey was structured to learn surgeons' practice in using IPD through questions and one clinical vignette. Respondents were asked to report their regrets for omission and commission regarding the IPD use for the clinical scenario, eliciting a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were built to identify respondents' attitudes. One hundred six surgeons completed the survey. Sixty-three (59.4%) respondents confirmed using at least 1 drain, while 43 (40.6%) placed 2 IPDs. Only 13 respondents (12.3%) declared a change in IPD strategy in patients at high risk of clinically relevant postoperative pancreatic fistula (CR-POPF), while 9 (9.4%) respondents changed their strategy in low-risk POPF situations. Thirty-five (35.5%) respondents declared they would remove the IPD within the third postoperative day (POD) in the absence of CR-POPF suspicion. The median omission regret, which proved to be the wrong decision, was 80 (50-100, IQR). The median regret due to the commission of IPD, which turned out to be useless, was 2.5 (1-20, IQR). The CR-POPF probability threshold at which drainage omission was the less regrettable choice was 7% (1-35, IQR). The threshold to perceive drain omission as the least regrettable choice was higher in female surgeons (P < 0.001), in surgeons who modulated the strategies based on the risk of CR-POPF, and in high volume centers (p = 0.039). The threshold was lower in surgeons who performed minimally invasive distal pancreatectomy (P < 0.001), adopted a closed system (P < 0.001), placed two IPDs (P < 0.001), or perceived the IPD as important to prevent reintervention (p = 0.047). Drain management after DP remains very heterogeneous among surgeons. The regret model suggested that IPD omission could be performed in low-risk patients (7% of CR-POPF), leading to low regret in the case of the wrong decision, making it an acceptable clinical decision.

Acute pancreatitis in intraductal papillary mucinous neoplasm: Associations with epithelial subtype, degree of dysplasia, and risk of recurrence

BACKGROUND

Acute pancreatitis is an uncommon presentation of intraductal papillary mucinous neoplasm; however, it is considered a worrisome feature in current guidelines and can be an indication for surgery. There is controversy regarding its association with malignancy, and there is little information regarding the recurrence of pancreatitis after surgical resection.

METHODS

We retrospectively reviewed patients who underwent resection for intraductal papillary mucinous neoplasm at a single institution between January 1990 and December 2023. Patients with and without acute pancreatitis as part of the clinical presentation were compared.

RESULTS

A total of 812 patients were reviewed. Of these, 156 patients (19.2%) had intraductal papillary mucinous neoplasms associated with acute pancreatitis, and in 92% of them pancreatitis was the symptom leading to the diagnosis. Half of the patients had a single episode of pancreatitis (n = 77, 49.4%), and 42 (26.9%) had had 3 or more episodes before diagnosis. Acute pancreatitis was significantly associated with high-grade dysplasia (odds ratio 2.07) but had a lower likelihood of invasive cancer (odds ratio 0.62). It was also significantly associated with main duct and mixed duct-type intraductal papillary mucinous neoplasm (odds ratio 1.97) and intestinal epithelial subtype (odds ratio 2.28). Median follow-up for all patients was 61 months, and the likelihood of recurrent pancreatitis after surgical resection was 9% (14 patients), whereas pancreatitis after resection in patients without prior history occurred in only 0.9% (6 patients, P < .001).

CONCLUSIONS

Almost 1 in 5 patients undergoing resection for intraductal papillary mucinous neoplasm have a history of acute pancreatitis and are twice as likely to have high-grade dysplasia, supporting its categorization as a worrisome feature. Recurrence of pancreatitis after resection was 9%.

Impact of diabetes mellitus on postoperative complications in patients undergoing pancreatic surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols decrease postoperative complications, but data on their effect on diabetic patients undergoing pancreatectomy are scarce. This study assessed whether diabetes mellitus (DM) was a morbidity predictor after pancreatectomy within an ERAS program.

METHODS

A cross-sectional study including all patients who underwent pancreatectomy (2012-2022) and followed an ERAS pathway was performed. Multivariable analysis was used to determine whether DM was a morbidity predictor. Association between ERAS compliance and morbidity rate was assessed.

RESULTS

A total of 558 patients were included (266 women, median age 66, median body-mass index 25). Most patients underwent open pancreatoduodenectomy (n=369, 66%). In diabetic patients with overall ERAS compliance≤60 %, morbidity was 38/40 (95%), whereas in diabetic patients with overall ERAS compliance>60 %, it decreased to 37/50 (74%, p=0.008). DM was not found as an independent complication predictor (OR 0.7, 95%CI 0.4-1.2, p=0.186), while body-mass index>25 kg/m2 and preoperative biliary stenting were preoperative morbidity predictors (OR 1.1, 95%CI 1.0-1.1, p=0.049; OR 1.7, 95%CI 1.0-2.5, p=0.044).

CONCLUSION

This study showed that DM was not associated with postoperative complications after pancreatectomy within an ERAS program. It highlighted the importance of a good ERAS compliance to decrease the risk of postoperative complications in DM patients.

Minimally invasive versus open lateral pancreaticojejunostomy in patients with painful chronic pancreatitis: systematic review

BACKGROUND

Patients with painful chronic pancreatitis combined with a dilated main pancreatic duct and a normal size pancreatic head are treated according to guidelines by lateral pancreaticojejunostomy (LPJ). This systematic review compared outcomes of minimally invasive LPJ and open LPJ.

METHODS

From 1 January 2000 until 13 November 2023, series reporting on minimally invasive LPJ and open LPJ in patients with symptomatic chronic pancreatitis were included. This study was structured in accordance with the PRISMA guidelines. The primary outcome was intraoperative and postoperative complications. Secondary outcomes included long-term clinical outcomes.

RESULTS

Overall, 19 retrospective studies were included. Morbidity rate ranged from 0% to 57% after minimally invasive LPJ versus 4% to 68% after open LPJ (median: 25, i.q.r.: 23). Length of hospital stay ranged from 5 to 7 days after minimally invasive LPJ and from 6 to 16 days after open LPJ. The rate of pain relief ranged from 62% to 91% after open LPJ (median: 78.5, i.q.r.: 23) and from 71% to 100% (median: 82.5, i.q.r.: 12.5) after minimally invasive LPJ respectively. New-onset endocrine insufficiency ranged from 21% to 22% in minimally invasive LPJ and 19% to 26% after open LPJ. New-onset exocrine insufficiency was shown in 11% to 27% in minimally invasive LPJ versus 8% to 26% after open LPJ. Weight gain ranged from 60% to 100% (median: 97, i.q.r.: 23) after minimally invasive LPJ.

DISCUSSION

This systematic review suggested that minimally invasive LPJ can be performed safely in selected patients with symptomatic chronic pancreatitis. Phase 2 randomized trials should assess potential short-term benefits such as postoperative pain and length of hospital stay after minimally invasive LPJ.

Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group

Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.

NGF-mediated crosstalk: unraveling the influence of metabolic deregulation on the interplay between neural and pancreatic cancer cells and its impact on patient outcomes

Neural invasion is one of the most common routes of invasion in pancreatic cancer and it is responsible for the high rate of tumor recurrence after surgery and the pain generation associated with pancreatic cancer. Several molecules implicated in neural invasion are also responsible for pain onset including NGF belonging to the family of neutrophins. NGF released by cancer cells can sensitize sensory nerves which in turn results in severe pain. NGF receptors, TrkA and P75NTR, are expressed on both PDAC cells and nerves, strongly suggesting their role in neural invasion. The crosstalk between the nervous system and cancer cells has emerged as an important regulator of pancreatic cancer and its microenvironment. Nerve cells influence the pancreatic tumor microenvironment and these interactions are important for cancer metabolism reprogramming and tumor progression. In this review, we summarized the current knowledge on the interaction between nerves and pancreatic cancer cells and its impact on cancer metabolism.

Metabolic syndrome and acute pancreatitis: Current status and future prospects

Rising incidence of a complicated disorder with a multifarious etiology is acute pancreatitis. Growing numbers of cases of acute pancreatitis are linked to obesity, hyperlipidemia, hyperglycemia, hypertension, and other metabolic diseases. Trends driven by better living standards and unhealthy lifestyle choices both in China and abroad. Furthermore common diagnosis for many patients is metabolic syndrome. Predicting the adverse effect of metabolic syndrome on the severity and prognosis of acute pancreatitis is a main focus of present clinical research. Our next studies seek to investigate the fundamental causes of this link and create preventative plans meant to lower the incidence of pancreatitis linked to metabolic syndrome and enhance the prognosis.

Plasticity and Tumor Microenvironment in Pancreatic Cancer: Genetic, Metabolic, and Immune Perspectives

Cancer has long been believed to be a genetic disease caused by the accumulation of mutations in key genes involved in cellular processes. However, recent advances in sequencing technology have demonstrated that cells with cancer driver mutations are also present in normal tissues in response to aging, environmental damage, and chronic inflammation, suggesting that not only intrinsic factors within cancer cells, but also environmental alterations are important key factors in cancer development and progression. Pancreatic cancer tissue is mostly comprised of stromal cells and immune cells. The desmoplasmic microenvironment characteristic of pancreatic cancer is hypoxic and hypotrophic. Pancreatic cancer cells may adapt to this environment by rewiring their metabolism through epigenomic changes, enhancing intrinsic plasticity, creating an acidic and immunosuppressive tumor microenvironment, and inducing noncancerous cells to become tumor-promoting. In addition, pancreatic cancer has often metastasized to local and distant sites by the time of diagnosis, suggesting that a similar mechanism is operating from the precancerous stage. Here, we review key recent findings on how pancreatic cancers acquire plasticity, undergo metabolic reprogramming, and promote immunosuppressive microenvironment formation during their evolution. Furthermore, we present the following two signaling pathways that we have identified: one based on the small G-protein ARF6 driven by KRAS/TP53 mutations, and the other based on the RNA-binding protein Arid5a mediated by inflammatory cytokines, which promote both metabolic reprogramming and immune evasion in pancreatic cancer. Finally, the striking diversity among pancreatic cancers in the relative importance of mutational burden and the tumor microenvironment, their clinical relevance, and the potential for novel therapeutic strategies will be discussed.

Epidermal Growth Factor Receptor (EGFR) and SMAD4 negatively correlated in the progression of gallbladder cancer in Eastern Indian patients

BACKGROUND AND INTRODUCTION

Two and half percent of the Indian population suffer from gallbladder cancer (GBC). The primary factors that lead GBC are associated with mutation of several protooncogenes such as EGFR, ERBB2, Myc, and CCND1 along with dysregulation of several tumor suppressor genes such as SMAD4 and CDKN2A. Bacterial infection caused by S.typhi and H.pylori are also hypothesized to be potential factors driving GBC.

AIMS

This study aims to investigate the molecular mechanisms driving the progression of gallbladder adenocarcinoma in Eastern Indian patients. We specifically focussed on analyzing the mutational status of the KRAS gene, examining the amplification of the ERBB2/Her2-neu gene, and evaluating the expression patterns of six dysregulated genes (CCND1, MYC, EGFR, ERBB2/Her2-neu, CDKN2A, SMAD4). Additionally, we assessed the expression status of TGF-beta, the association between bacterial infections (S. Typhi and H. pylori) and GBC, and the impact of single nucleotide polymorphisms in ERBB2/Her2-neu and CCND1 genes within this population.

METHODS

Sixty-seven samples from GBC-diagnosed patients, 26 other unrelated GBC samples for validation cohort, and 68 gallstone tissue samples were collected for this study. Genomic DNA from normal as well as tumor tissues were isolated, exon 2 and exon 3 of KRAS gene were amplified along, DNA sequenced and analyzed. KRAS codon 12 mutation was detected by allele specific PCR (ASPCR) method. Amplification of UreC A (coding for urease subunit α), VacA (coding for Vacuolating cytotoxin A) and CagA genes (coding for cytotoxin-associated gene A) in H.pylori were amplified using PCR. Similarly, FlicC (coding for flagellin gene C) in S.typhi was amplified using PCR. The ERBB2/Her2-neu SNP I655V, and CCND1 SNP A870G were analyzed using PCR followed by RFLP. Expression studies of CCND1, Myc, CDKN2A, ERBB2/Her2-neu, EGFR, and SMAD4 genes were measured in GBC tumor tissues by sybr green quantitative RT PCR.

RESULTS

The oncogenes (EGFR and ERBB2/Her2-neu) were statistically significantly overexpressed and the tumor suppressor gene (SMAD4) downregulated in our GBC tumor patient samples. The EGFR and SMAD4 genes were negatively correlated (r = -0.01) in GBC patients and the data is statistically significant and validated through IHC technique. A significant downregulation of TGF-beta had also been observed. Lower frequency (i.e. 11.5%) of KRAS mutation in GBC tumor was observed.

CONCLUSIONS

EGFR and SMAD4 expression were found to be negatively correlated in GBC tissue samples. ERBB2 overexpression/amplification was observed in 30% of the GBC samples. We also found a low percentage of GBC samples to show KRAS codon 12 mutation in Indian GBC patient population, as had been previously documented in pancreatic cancers.

Hemodynamic Assessment Using SPY Laser Fluorescence Imaging During Pancreatoduodenectomy with Common Hepatic Artery Resection

BACKGROUND

Pancreatectomies combined with arterial resection can be indicated for pancreatic cancer. In a pancreatectomy with arterial resection, intraoperative confirmation of blood flow through reconstructed vessels is crucial. This study highlights the usefulness of SPY laser fluorescence imaging during a pancreatoduodenectomy with common hepatic artery resection (PD-CHAR).

PATIENT AND METHODS

A 55-year-old man with borderline resectable pancreatic head cancer underwent a PD-CHAR. After confirming tumor resectability, reconstruction of the CHA to the proper hepatic artery was performed. Subsequently, the superior mesenteric vein was reconstructed.

RESULTS

SPY laser fluorescence imaging demonstrated arterial blood perfusion to the liver through the reconstructed hepatic artery, followed by perfusion from the portal vein. The operation lasted 493 min, with an estimated blood loss of 400 mL. The postoperative course was uneventful with good arterial blood flow.

CONCLUSION

The SPY Portable Handheld Imager could be valuable for visualizing blood flow in reconstructed vessels and assessing tissue perfusion during a pancreatectomy combined with vascular reconstruction.

Sociodemographic Factors and Utilization of Pediatric Oncology Satellite Clinics in Ontario, Canada

Importance

Pediatric cancer care services in high-income nations are mainly centralized in metropolitan cities. To allow treatments closer to home, patients across Ontario, Canada, a geographically large province, are offered decentralized care via satellite clinics; however, it is unclear whether the utilization of these pediatric oncology satellite clinics differs by area-level sociodemographic factors.

Objective

To examine whether sociodemographic factors, such as area-level income and rurality, are independently associated with the odds of satellite clinic visit and the hazards of time to first visit among pediatric oncology patients receiving cancer treatment.

Design, Setting, and Participants

This is a retrospective population-based cohort study of patients aged 0 to 17 years with cancer living in a satellite catchment area in Ontario, Canada (from 2015 to 2022, with follow-up through 2023). The Pediatric Oncology Group of Ontario Networked Information System cancer registry (containing age, sex, diagnosis type, and year information) was linked to satellite, OpenStreetMap, and postal-code databases to ascertain rural or urban dwelling, neighborhood-based income, and driving time saved.

Exposures

Age, sex, rural or urban dwelling, and neighborhood-level income quintiles.

Main Outcomes and Measures

The primary outcomes were the odds of satellite clinic attendance within 1 year of diagnosis and the hazards of first clinic visit after starting systemic therapy, derived from multivariable logistic and Cox proportional hazards models, respectively.

Results

Among the 1280 eligible patients (median [IQR] age, 7.0 [3.0-13.0] years; 753 male [58.8%]), 844 (65.9%) visited a satellite clinic within 1 year of diagnosis with a median (IQR) of 39 (14-67) days to first visit. Driving time saved (>60 minutes) was the factor most associated with satellite use, followed by diagnostic type (with patients with central nervous system tumors least likely to visit). Rural (vs urban) patients had significantly lower odds of satellite visit within a year of diagnosis (odds ratio, 0.48; 95% CI, 0.31-0.74; P = .001) and lower instantaneous likelihood of visiting after start of treatment (hazard ratio, 0.65; 95% CI, 0.53-0.81; P < .001). Living in a lower-income (vs middle-income) area was also associated with significantly lower utilization (odds ratio, 0.53; 95% CI, 0.35-0.80; P = .009; hazard ratio, 0.73; 95% CI, 0.60-0.89; P = .002).

Conclusions and Relevance

This population-based study of pediatric oncology patients found that satellite clinics, despite being designed to reduce transportation and financial burdens, were disproportionately underutilized by patients living in rural and lower-income areas. Monitoring area-level social determinants of health can help inform interventions to improve timely and equitable access to childhood cancer care closer to home.

Intraoperative liquid biopsy as a tool for detecting R1 resection during pancreatoduodenectomy in patients with pancreatic carcinoma: the CETUPANC trial (part II)

INTRODUCTION

A positive surgical margin (R1 resection) is a relevant risk factor for local recurrence in patients with pancreatic ductal adenocarcinoma of the pancreas (PDAC). An intraoperative liquid biopsy (ILB) based on tumor cell mobilization could help to detect R1 resection intraoperatively.

OBJECTIVE

To evaluate the potential role of the intraoperative circulating tumor cells (CTCs) and cluster mobilization on the R0/R1 detection.

METHODS

Sixty-three patients with resectable PDAC of the head of the pancreas were prospective enrolled under the CETUPANC trial. Open pancreaticoduodenectomy (PD) was done in all patients. Intraoperative CTCs and clusters were determined during PD.

RESULTS

The overall rate of R1 resection was 34.9% (22/63 patients). Multivariate analysis showed that factors associated with R1 resection (AUC=0.920) were the presence of undifferentiated G3 tumor (P=0.017), microscopic vascular invasion (P=0.016), and the intraoperative increase of both free CTCs and clusters in portal vein determination from the beginning to the end of the surgery (P=0.002 and P=0.005, respectively). A specific logistic regression model, including delta end to baseline CTCs and cluster mobilization to achieve a combined cut-off to detect R1 detection was calculated (AUC=0.799). The obtained R1-index based on ILB had 84% of sensitivity and 68% of specificity to detect R1 resection.

CONCLUSIONS

The ILB based on the intraoperative mobilization of CTCs and clusters from the beginning to the end of the PD was a predictive factor to detect R1 resection in patients with PDAC.

Exploring definitions of graft pancreatitis following pancreas transplantation: A scoping review

Despite the clinical relevance of graft pancreatitis (GP) after pancreas transplantation (PT), a universally accepted definition is lacking. Aim of this scoping review was to provide a systematic overview of GP definitions reported in the literature. MEDLINE, Web of Science and Embase were searched for relevant articles. Prospective/retrospective studies reporting a GP definition were included. The included series (n = 20) used four main criteria (clinical, biochemical, radiological and pathological) to define GP. Overall, 9 studies defined GP using a single criterion (n = 8 biochemical, n = 1 pathological), 7 series using two criteria (n = 3 clinical + biochemical, n = 3 biochemical + radiological, n = 1 clinical + radiological), 3 series using three criteria (n = 3 clinical + biochemical + radiological), and 1 series using four criteria. Overall, 20 definitions of GP were found. GP rate was reported by 19 series and ranged between 0% and 87%. This scoping review confirms that a universally accepted definition of GP is absent, and there is no consensus on the criteria on which it should be grounded. Future research should focus on developing a validated definition of GP.

Gallbladder Cancer

Gallbladder cancer is the most common biliary tract malignancy, often detected incidentally post-cholecystectomy or at an advanced stage, historically linked to a poor prognosis. Advances in minimally invasive surgery and systemic therapies have improved outcomes. Global incidence varies, with risk factors including gender, age, gallbladder disease history, and polyp size influencing malignancy risks. Management involves cross-sectional imaging, staging laparoscopy in select cases, and radical cholecystectomy with lymphadenectomy and adjuvant therapy, though its use is limited. Trials are ongoing assessing the role of neoadjuvant therapy. Prognosis depends on the tumor stage, with early detection crucial for long-term survival.

Clinical significance of peripheral blood DDR1 and CtBP gene methylation detection in patients with acute pancreatitis

To investigate the clinical value of methylation levels of peripheral blood DDR1 and CtBP genes in evaluating the severity of acute pancreatitis (AP). Collect 90 blood samples from AP patients and healthy volunteers, and test methylation levels of SPINK1, STAT3, KIT, CFTR, DDR1, CtBP1, CtBP2 genes by bisulfite amplicon sequencing (BSAS). The gene methylation and clinical predictors of SAP early prediction were determined by univariate and multifactorial analysis, respectively. (1) The methylation level of CtBP1 gene and MCTSI score were independent predictors of SAP, with AUC values of 0.723 and 0.8895, respectively. (2) The methylation levels of DDR1, CtBP2, CFTR and SPINK1 genes were statistically significant in HC group vs AP group, HC group vs MAP group, and HC group vs SAP group. (3) The combined detection of CtBP1 gene methylation level and MCTSI score predicted the sensitivity, specificity, AUC, and 95%CI of SAP were 0.750, 0.957, 0.902, and 0.816-0.989, respectively. (1) The methylation level of CtBP1 gene in peripheral blood is an independent risk factor for predicting SAP and is a potentially good predictor of SAP, and the combined testing with the MCTSI score does not further significantly improve the early predictive value for SAP. (2) The methylation levels of DDR1, SPINK1, CtBP2, and CFTR genes were potential indicators for recognizing AP.