Quality of Life and Psychological Functioning in Children with PFAPA Syndrome

BACKGROUND/OBJECTIVES

This study analyzes the impact of PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) on health-related quality of life (HRQoL) and the psychological functioning of children and adolescents aged 2 to 1 years.

METHODS

A cross-sectional descriptive study was conducted with 62 participants (31 males and 31 females) diagnosed with PFAPA. The Strengths and Difficulties Questionnaire (SDQ) and the Family Impact Module scale of Pediatric Quality of Life Inventory (PedsQL) were used to assess psychological functioning and HRQoL, respectively.

RESULTS

Participants exhibited predominantly low HRQoL, particularly in physical health and emotional functioning. School functioning was also affected. However, social functioning and family relationships showed more favorable scores. A positive correlation was observed between age and emotional symptoms. Family concern was the most significantly impacted aspect.

CONCLUSIONS

PFAPA syndrome has a significant impact on the HRQoL of affected children and adolescents, particularly in physical and emotional aspects. A holistic approach is necessary for disease management, considering not only physical symptoms but also psychosocial and academic factors, as well as the impact on the family.

Histologic Diagnosis of Pancreatic Cystic Lesions with Endoscopic Ultrasound Fine Needle Biopsy and Impact on Management Decisions

PURPOSE

Endoscopic ultrasound with fine needle biopsy (EUS-FNB) has not been well studied in pancreatic cystic lesions (PCLs). This study evaluates the diagnostic performance of EUS-FNB for PCLs and its impact on management decisions.

METHODS

We conducted a single-center, retrospective study of patients who had EUS-FNB between March 2016 and February 2024. We included patients with ≥ 6-month follow-up and excluded those with a solid pancreatic mass. We obtained clinical, radiologic, endoscopic, surgical, laboratory, and pathology data from chart review. We evaluated: (A) diagnostic yield; (B) predictors of diagnostic FNB; (C) diagnostic accuracy compared to surgical histopathology; (D) appropriateness of management decisions; and (E) adverse events. We compared the appropriateness of management decisions between diagnostic and non-diagnostic FNB.

RESULTS

100 subjects underwent EUS-FNB for PCLs (56% microcystic or with mural nodule). FNB yielded a histologic diagnosis in 60% of sampled lesions. Performing 2 or more needle passes was the only significant predictor of a diagnostic FNB (p = 0.02). Compared to surgical histopathology (n = 21), FNB needles highly accurately diagnosed specific cyst types (IPMN = 85.7%, MCN = 90.5%, SCA = 95.2%, NET = 95.2%, SPN = 100%) and malignant PCLs (accuracy = 81.0%; specificity = 100%; sensitivity = 72.7%). There was a 7.2-fold increase of appropriate management decisions when FNB was diagnostic vs. non-diagnostic (p < 0.001). This was due to improvement in surveillance discontinuation for benign cysts and in appropriate surgical resection for malignant PCLs (p < 0.001). Post-FNB pancreatitis occurred in 4% of patients.

CONCLUSION

EUS-FNB accurately diagnoses different PCL types and their degree of neoplasia, leading to more appropriate management decisions. Future prospective studies are needed to confirm these findings.

Evaluation of scoring systems and hematological parameters in the severity stratification of early-phase acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an emergency gastrointestinal disease that requires immediate diagnosis and urgent clinical treatment. An accurate assessment and precise staging of severity are essential in initial intensive therapy.

AIM

To explore the prognostic value of inflammatory markers and several scoring systems [Acute Physiology and Chronic Health Evaluation II, the bedside index of severity in AP (BISAP), Ranson's score, the computed tomography severity index (CTSI) and sequential organ failure assessment] in severity stratification of early-phase AP.

METHODS

A total of 463 patients with AP admitted to our hospital between 1 January 2021 and 30 June 2024 were retrospectively enrolled in this study. Inflammation marker and scoring system levels were calculated and compared between different severity groups. Relationships between severity and several predictors were evaluated using univariate and multivariate logistic regression models. Predictive ability was estimated using receiver operating characteristic curves.

RESULTS

Of the 463 patients, 50 (10.80%) were classified as having severe AP (SAP). The results revealed that the white cell count significantly increased, whereas the prognostic nutritional index measured within 48 hours (PNI48) and calcium (Ca2+) were decreased as the severity of AP increased (P < 0.001). According to multivariate logistic regression, C-reactive protein measured within 48 hours (CRP48), Ca2+ levels, and PNI48 were independent risk factors for predicting SAP. The area under the curve (AUC) values for the CRP48, Ca2+, PNI48, Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, BISAP, CTSI, and Ranson scores for the prediction of SAP were 0.802, 0.736, 0.871, 0.799, 0.783, 0.895, 0.931 and 0.914, respectively. The AUC for the combined CRP48 + Ca2+ + PNI48 model was 0.892. The combination of PNI48 and Ranson achieved an AUC of 0.936.

CONCLUSION

Independent risk factors for developing SAP include CRP48, Ca2+, and PNI48. CTSI, BISAP, and the combination of PNI48 and the Ranson score can act as reliable predictors of SAP.

Prognostic value of the measurement at admission of the inferior vena cava in acute pancreatitis

BACKGROUND

Identifying new early predictive markers for the development of severe forms in acute pancreatitis remains a major challenge. The aim of this study was to evaluate the performance of inferior vena cava (IVC) measurement to predict severe acute pancreatitis.

METHODS

We conducted a single-center retrospective study including patients consecutively hospitalized for acute pancreatitis between 2014 and 2019 who had an abdominal scan within 24 h after admission, before any significant fluid resuscitation. We calculated the ratio of inferior vena cava diameters (IVCR) by dividing the transverse diameter by the anteroposterior. Admission parameters associated with the occurrence of severe acute pancreatitis (persistent organ failure or necrosis infection) were identified by multivariate logistic regression.

RESULTS

Of the 404 included patients, 64 (15.8%) progressed to severe pancreatitis. IVCR in these patients was significantly higher (2.2 ± 0.6 vs. 1.7 ± 0.9, p < .001). In multivariate analysis, IVCR was independently associated with severe pancreatitis (OR = 2.27 95% CI [1.38-3.72], p = .001), as well as visual analog scale, creatinine, albumin, and bicarbonates. The areas under the Receiver Operating Characteristic (ROC) curve of IVCR was 0.67, inferior to systemic inflammatory response syndrome (0.76; p = .03) and Bedside Index for Severe Acute Pancreatitis (BISAP) (0.80; p = .002) in predicting severe acute pancreatitis.

CONCLUSIONS

IVCR is associated with the development of severe acute pancreatitis.

Automated machine learning for early prediction of systemic inflammatory response syndrome in acute pancreatitis

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a frequent and serious complication of acute pancreatitis (AP), often associated with increased mortality. This study aims to leverage automated machine learning (AutoML) algorithms to create a model for the early and precise prediction of SIRS in AP.

METHODS

This study retrospectively analyzed patients diagnosed with AP across multiple centers from January 2017 to December 2021. Data from the First Affiliated Hospital of Soochow University and Changshu Hospital were used for training and internal validation, while testing was conducted with data from the Second Affiliated Hospital. Predictive models were constructed and validated using the least absolute shrinkage and selection operator (LASSO) and AutoML. A nomogram was developed based on multivariable logistic regression (LR) analysis, and the performance of the models was assessed through receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Additionally, the AutoML model's effectiveness and interpretability were assessed through DCA, feature importance, SHapley Additive exPlanation (SHAP) plots, and locally interpretable model-agnostic explanations (LIME).

RESULTS

A total of 1,224 patients were included, with 812 in the training cohort, 200 in validation, and 212 in testing. SIRS occurred in 33.7% of the training cohort, 34.0% in validation, and 22.2% in testing. AutoML models outperformed traditional LR, with the deep learning (DL) model achieving an area under the ROC curve of 0.843 in the training set, and 0.848 and 0.867 in validation and testing, respectively.

CONCLUSION

The AutoML model using the DL algorithm is clinically significant for the early prediction of SIRS in AP.

YouTube and TikTok as sources of information on acute pancreatitis: a content and quality analysis

BACKGROUND

As one of the leading causes of hospitalization and huge medical expenses for gastrointestinal disorders, morbidity and mortality of acute pancreatitis continue to rise globally. Short videos are an important medium for population to achieve information about acute pancreatitis. We aimed to evaluate the content and quality of acute pancreatitis-related videos on TikTok and YouTube.

METHOD

A search was performed on the TikTok and YouTube platforms using the keyword "Acute pancreatitis". The sources of the videos were categorized as academic institutions, national institutions, physicians, healthcare professionals other than physicians, health information websites and others. The Journal of American Medical Association (JAMA), Global Quality Scale (GQS), and modified DISCERN scores were used to assess the quality of the included videos.

RESULT

A total of 75 TikTok videos and 79 YouTube videos were included and analyzed. Regarding modified DISCERN scale, the videos from national institutions scored highest on TikTok (p = 0.020). As for YouTube, healthcare professionals other than physicians had the highest averaged score judged by GQS score and JAMA score (p = 0.016 for JAMA score, p = 0.020 for GQS score). The duration of the videos on TikTok are significantly shorter than that on YouTube (71.5 vs. 361, respectively; p < 0.01). The length of the video was associated with higher JAMA score and DISCERN score (p < 0.01, r = 0.635 and 0.207, respectively).

CONCLUSION

According to TikTok and YouTube, basic information about acute pancreatitis was the main presentation of the videos. We recommend that video producers extend the length of their videos appropriately to flesh out the content, and national institutions, physicians, and healthcare professionals other than physicians are all great resource of getting to know the acute pancreatitis better for viewers.

Risk of and factors influencing the progression from acute to recurrent acute to chronic pancreatitis

OBJECTIVES & AIMS

Acute pancreatitis (AP) recurrence rates range from 11 to 36 % yet accurately predicting recurrent acute pancreatitis (RAP) and its progression to chronic pancreatitis (CP) after an initial episode remains challenging. Thus, this study explored the risk factors contributing to RAP and its progression to CP.

METHODS

This retrospective study included patients with AP from three tertiary medical centers between January 2010 and December 2017. The patients were followed up for up to 60 months. The primary endpoint was the incidence of RAP and CP; risk factors influencing these outcomes were also identified.

RESULTS

Overall, 501 patients were included, of which 164 (32.7 %) experienced RAP, and 71 (14.2 %) progressed to CP. The leading causes of AP were alcohol consumption (43.1 %), gallstones (41.5 %) and hypertriglyceridemia (4.4 %). Multivariate Cox regression analysis revealed that smoking (HR, 4.09; 95 % CI, 2.752-6.078, p < 0.001), and organ failure after 48 h of hospitalization (HR, 3.52; 95 % CI, 1.22-10.19, p < 0.02) were significant risk factors for RAP. Significant risk factors for progression to CP included age over 60 years (HR, 5.29; 95 % CI, 1.25-22.47, p = 0.024), smoking (HR, 2.50; 95 % CI, 1.04-6.01, p = 0.04), alcohol consumption (HR, 8.79; 95 % CI, 2.06-37.43, p = 0.003), computed tomography severity index (CTSI) (HR, 1.22; 95 % CI, 1.04-1.44, p = 0.015), and recurrence of AP (HR, 70.69; 95 % CI, 2.61-1914.86, p = 0.011). In alcohol-induced RAP patients, ≥3 recurrences (HR, 4.18; 95 % CI, 1.75-9.98, p = 0.001) was significant risk factor for progression to CP.

CONCLUSIONS

Alcohol consumption was the predominant cause of AP and RAP. The severity of the initial AP episode was the key determinant for RAP, and RAP was the most significant risk factor for the progression to CP. Therefore, smoking and alcohol cessation are important to prevent the development of recurrent AP and CP during long-term follow-up.

Comparison of Computed Tomography/Magnetic Resonance Imaging Characteristics of Acute Pancreatitis Between Cholecystectomy and Non-cholecystectomy Patients

OBJECTIVE

This study aimed to compare computed tomography (CT)/magnetic resonance imaging (MRI) characteristics of acute pancreatitis (AP) between patients with cholecystectomy and non-cholecystectomy and to validate the effect of prior cholecystectomy on the severity of subsequent pancreatitis.

METHODS

This retrospective study included 384 inpatients with AP at our hospital from January 1, 2020 to December 31, 2023. Based on their history of cholecystectomy, the patients were split into cholecystectomy and non-cholecystectomy groups. propensity score matching was applied, considering age and sex, in a 1:3 ratio. Demographic, clinical, laboratory, and CT/MRI parameters of each group were analyzed.

RESULTS

There were 200 (52.1%) males and 184 (47.9%) females, with a mean age of 53.55 ± 13.86 years (range: 18-98 y). Ninety-six patients were in the cholecystectomy group that had previously undergone cholecystectomy, and 288 in the non-cholecystectomy group. Creatinine and C-reactive protein levels were lower in the patients with cholecystectomy than in patients with non-cholecystectomy (P1 = 0.001, P2 = 0.049). In the prevalence of biliary pancreatitis, the cholecystectomy patients are 27.1%, whereas the non-cholecystectomy patients are 45.8% (P = 0.005). The non-cholecystectomy patients had a significantly higher mean CT/MRI severity index score (3.57 ± 1.72 points) than the cholecystectomy group (3.00 ± 1.58 points; P < 0.001). Regarding local complications, In the groups that underwent cholecystectomy and those that did not, the prevalence of acute peripancreatic fluid collection was 40.4% and 21.9%, respectively. (P < 0.001).

CONCLUSIONS

AP following cholecystectomy exhibits unique imaging characteristics. Cholecystectomy reduces the severity and acute peripancreatic fluid collection rate of subsequent pancreatitis on CT/MRI.

Neutrophil CD64 index: a novel biomarker for risk stratification in acute pancreatitis

Objective

Effective early diagnosis and timely intervention in acute pancreatitis (AP) are essential for improving patient outcomes. This study aims to evaluate the clinical utility of the neutrophil CD64 index (nCD64) in stratifying patients with SAP and assessing mortality risk.

Methods

A total of 302 AP patients were enrolled and divided into a training cohort (n = 226) and a validation cohort (n = 76). Venous blood samples were collected within 24 hours of admission, and the nCD64 index was measured via flow cytometry. Other clinical parameters, including C-reactive protein (CRP) and procalcitonin (PCT), were also recorded. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic value of the nCD64 index and its capacity to predict mortality risk.

Results

ROC curve analysis identified a cutoff value of 1.45 for the nCD64 index. Patients with nCD64 > 1.45 had significantly higher risks of complications, including systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), and death. Over 65% of patients with acute pancreatitis (AP) can be effectively risk-stratified at a low cost, and it has been demonstrated that AP patients with an nCD64 value ≤ 1.45 have an extremely low mortality rate (no mortality in present training and validation cohort). Kaplan-Meier survival analysis revealed a significant survival difference between high-risk (nCD64 > 1.45) and low-risk groups (p < 0.001).

Conclusion

The nCD64 index is an effective tool for early identification of SAP patients, allowing for the classification of over 65% of cases as low-risk for mortality.

Machine learning for modeling and identifying risk factors of pancreatic fistula

BACKGROUND

Pancreatic fistula is the most common complication of pancreatic surgeries that causes more serious conditions, including bleeding due to visceral vessel erosion and peritonitis.

AIM

To develop a machine learning (ML) model for postoperative pancreatic fistula and identify significant risk factors of the complication.

METHODS

A single-center retrospective clinical study was conducted which included 150 patients, who underwent pancreatoduodenectomy. Logistic regression, random forest, and CatBoost were employed for modeling the biochemical leak (symptomless fistula) and fistula grade B/C (clinically significant complication). The performance was estimated by receiver operating characteristic (ROC) area under the curve (AUC) after 5-fold cross-validation (20% testing and 80% training data). The risk factors were evaluated with the most accurate algorithm, based on the parameter "Importance" (Im), and Kendall correlation, P < 0.05.

RESULTS

The CatBoost algorithm was the most accurate with an AUC of 74%-86%. The study provided results of ML-based modeling and algorithm selection for pancreatic fistula prediction and risk factor evaluation. From 14 parameters we selected the main pre- and intraoperative prognostic factors of all the fistulas: Tumor vascular invasion (Im = 24.8%), age (Im = 18.6%), and body mass index (Im = 16.4%), AUC = 74%. The ML model showed that biochemical leak, blood and drain amylase level (Im = 21.6% and 16.4%), and blood leukocytes (Im = 11.2%) were crucial predictors for subsequent fistula B/C, AUC = 86%. Surgical techniques, morphology, and pancreatic duct diameter less than 3 mm were insignificant (Im < 5% and no correlations detected). The results were confirmed by correlation analysis.

CONCLUSION

This study highlights the key predictors of postoperative pancreatic fistula and establishes a robust ML-based model for individualized risk prediction. These findings contribute to the advancement of personalized perioperative care and may guide targeted preventive strategies.

The impact of the novel EUS scope and ultrasonographic system for diagnosis and therapy in patients with pancreatobiliary diseases (videos)

PURPOSE

We evaluated the diagnostic and therapeutic capabilities of endoscopic ultrasonography (EUS) in pancreaticobiliary diseases. We aimed to validate the efficiency of detective flow imaging (DFI), shear wave elastography (SWE), and other advanced imaging techniques.

METHODS

We used new EUS scopes (EG-740 UT and G-580UR) and the latest ultrasound equipment (ARIETTA 850) (Fujifilm Healthcare, Kanagawa, Japan). Diagnostic procedures were performed in 16 cases, including pancreatic cancer and intraductal papillary mucinous neoplasms, and therapeutic procedures in eight cases, involving complex biliary and pancreatic interventions. The utility of SWE in assessing tissue stiffness was quantified by measuring the shear wave velocity (SWV) in pancreatic cancer and autoimmune pancreatitis.

RESULTS

We found no significant difference in SWVs among different pancreatic conditions; however, significant variations were observed in the net percentage of effective SWV. Interventional EUS had a 100% technical and clinical success rate, demonstrating the efficacy of new imaging techniques and equipment in enhancing procedural safety and diagnostic accuracy.

CONCLUSIONS

The integration of advanced EUS imaging technologies, particularly DFI, contrast-enhanced EUS, and SWE, significantly enhances the diagnosis and treatment of pancreaticobiliary diseases.

Managing complicated pancreatitis with more knowledge and a bigger toolbox!

Acute pancreatitis (AP) is a heterogeneous inflammation of the pancreas, most frequently attributable to gallstones or alcohol. AP accounts for an estimated 300 000 patients admitted each year in the USA, and an estimated US$2.6 billion/year in hospitalization costs. Disease severity is classified as mild, moderate, or severe, dependent on the presence or degree of concomitant organ failure. Locally, pancreatitis may be complicated by fluid collections, necrosis, infection, and hemorrhage. Infection of necrotizing pancreatitis (NP) is associated with a doubling of mortality risk. The modern management of AP is evolving. Recent data suggest a shift from normal saline to lactated Ringer's solution, and from aggressive to more judicious volume resuscitation. Similarly, while historical wisdom advocated keeping patients nothing by mouth to 'rest the pancreas', recent data convincingly show fewer complications and reduced mortality with early enteral nutrition, when tolerated by the patient. The use of antibiotics in NP is controversial. Current recommendations suggest reserving antibiotics for cases with highly suspected or confirmed infected necrosis, as well as in patients with biliary pancreatitis complicated by acute cholecystitis or cholangitis. Regarding the management of local complications, control of acute hemorrhage can be attained either endovascularly or via laparotomy. Abdominal compartment syndrome is associated with a mortality risk of 50%-75%. Routine monitoring of intra-abdominal pressure is recommended in patients at high risk. Pancreatic pseudocysts require intervention in symptomatic patients or those with infection or other complications. Endoscopic transmural drainage may be considered as the first step when technically feasible. Necrotizing pancreatitis without suspicion of infection is often managed medically, while the delay, drain, debride approach remains the standard of care for the vast majority of infected pancreatic necrosis. Robotic surgery, in appropriately selected patients, allows for a one-step approach, and merits further study to explore its initially promising results.

A systematic review of the predictive factors for the recurrence of acute pancreatitis

PURPOSE

Acute Pancreatitis (AP) is a prevalent clinical pancreatic disorder characterized by acute inflammation of the pancreas, frequently associated with biliary or alcoholic events. If not treated with cholecystectomy after the first episode, patients may experience a recurrence of AP, with consequent need for emergency surgery and increased risk of death. Analyzing the risk factors that may contribute to the recurrence of Biliary and Alcoholic Pancreatitis (BAP and AAP), future research can be driven toward new solutions for preventing and treating this pancreatic disease.

METHODS

A systematic review was conducted selecting studies from BiomedCentral, PubMed, Scopus and Web of Science by two independent reviewers. Publications were considered only if written in English in the time interval between January 2000 and June 2024 and investigated the risk factors for the recurrence of BAP and AAP. At the end of the selection, a quality assessment phase was conducted using the PROBAST tool.

RESULTS

In this systematic review, 8 articles were selected out of 6.945, involving a total sample of 11.271 patients of which 38.77% developed recurrence episodes. 37.5% of the included studies focus on recurrent acute biliary pancreatitis (RBAP), while 62.5% are dedicated to recurrent acute alcoholic pancreatitis (RAAP). The risk factors for the recurrence of AP showed a clear differentiation between the alcoholic and biliary etiology. Most of the considered studies adopted a retrospective design, characterized by a susceptibility to potential methodological biases. However, the trend indicated a more recent increase in prospective studies, together with a greater focus on identifying and understanding the possible risk factors associated with the recurrence of acute pancreatitis (RAP). This result highlighted the progress in the scientific approach toward a more rigorous and systematic assessment of the causes and dynamics that influence the recurrence of the disease.

CONCLUSION

Studies highlighted the importance of lifestyle factors, clinical complications, and surgical interventions that can impact the risk of biliary or alcoholic recurrent acute pancreatitis. Increased and systematic adoption of artificial intelligence-based tools could significantly impact future knowledge relating to the risks of recurrence and relative possibilities of prevention.

Acute Pancreatitis in Children: It's Not Just a Simple Attack

Acute pancreatitis (AP) in children presents unique challenges distinct from adult manifestations, requiring specialized diagnostic and therapeutic approaches. Compared with adults, pediatric AP has lower mortality rates but still carries significant morbidity and potential long-term complications. This review examines current evidence on pediatric AP, highlighting recent advances in diagnosis, risk stratification, and management strategies. Current diagnostic approaches use serum lipase and amylase testing, along with various imaging modalities that have different diagnostic values. Recent research has identified promising biomarkers for predicting severe AP, including blood urea nitrogen, C-reactive protein, and specific cytokine signals. Emerging evidence suggests a role of gut microbiome dysbiosis in disease pathogenesis, opening new therapeutic possibilities targeting the gut-pancreas axis. Genetic factors, specifically pancreatitis risk genes, influence disease progression to recurrent and chronic pancreatitis. In this review, we summarize the consequences of an isolated AP episode in children. Our review highlights for the first time how AP can lead to significant long-term sequelae, including exocrine/nutritional deficiencies, endocrine pancreatic dysfunction, diabetes, recurrent pain, and decreased quality of life compared with healthy population controls. The goal of this review is to summarize advances in understanding of pediatric AP and to emphasize the importance of early recognition, appropriate risk stratification, and comprehensive follow-up after the first pediatric AP episode, while highlighting areas requiring future research to optimize patient outcomes.

Clinical Value of Circulating Angiopoietin-like Protein 8/Betatrophin Levels in Patients with Acute Pancreatitis

Background and Objectives: Acute pancreatitis (AP) is an inflammatory disorder of the pancreas, with severe cases linked to a higher mortality rate. The prognosis of AP is influenced by factors such as necrosis, secondary infections, and organ failure. Tissue damage in AP is driven by the activation of leukocytes and the release of inflammatory mediators. Angiopoietin-like protein 8 (ANGPTL8), also known as betatrophin, is a recently discovered protein that regulates lipid metabolism. This study aimed to investigate the relationship between ANGPTL8 levels and disease severity in AP patients, and to explore the potential of ANGPTL8 as a biomarker. Materials and Methods: This prospective study included 50 patients diagnosed with AP who were admitted to the Department of Internal Medicine at Dr. Cemil Taşcıoğlu City Hospital between September 2021 and February 2022. Additionally, 39 healthy volunteers who underwent a check-up at the same hospital served as the control group. The Glasgow-Imrie (GI) score was used to assess the severity of pancreatitis. Results: ANGPTL8 levels were found to be significantly lower in the AP group compared to the control group, with a statistically significant correlation between ANGPTL8 levels and the severity of AP (p < 0.05). The cut-off level of ANGPTL8 based on the GI score was determined to be 70.9 ng/L. The GI score for ANGPTL8 was 0.749 (95% CI: 0.606-0.861) (p < 0.001). The overall cut-off value for ANGPTL8 was 179.2 ng/L, with an overall classification rate of 0.936 (95% CI: 0.864-0.977) (p < 0.001). Conclusions: This study demonstrates that ANGPTL8 levels vary between patients with and without AP, with lower levels observed in AP patients. Our research is the first to identify decreased ANGPTL8 levels as an independent predictor of AP severity. ANGPTL8 may play a crucial role in regulating inflammation or metabolic dysfunction in AP. However, further studies are needed to confirm these findings in larger populations and investigate ANGPTL8's mechanistic role in AP. Longitudinal studies could help determine whether ANGPTL8 levels act as a biomarker for disease progression or treatment response, potentially paving the way for targeted therapies to improve outcomes for AP patients.

A qualitative study to explore the patient experience of hypertriglyceridemia-related acute pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG) is a common cause of acute pancreatitis (AP) and can be exacerbated by acquired metabolic conditions or rare inherited disorders (eg, familial chylomicronemia syndrome [FCS]), leading to HTG-induced AP (HTG-AP). HTG-AP is associated with severe abdominal pain typically requiring hospitalization and significantly impacts health-related quality of life (HRQoL).

OBJECTIVE

To understand patients' perspectives on the HRQoL impacts of HTG-AP.

METHODS

Interviews were conducted with adults with severe/very severe HTG and/or FCS, experiencing ≥1 HTG-AP episode in the past 2 years requiring an overnight hospitalization. An interview guide, developed with patient and clinical expert input, explored symptoms, long-term HRQoL impacts, and management of HTG-AP. Participants completed a background questionnaire, the EQ-5D-5L and select items from the PROMIS Profile v1.0-FCS 28 prior to interview. Interview transcripts were analyzed using thematic and content analysis.

RESULTS

Twelve participants completed the study (aged 32-66 years), 3 with genetically confirmed FCS. Participants described a sudden onset of HTG-AP episodes and a gradual recovery following medical intervention (up to several weeks). Participants described substantial symptomatic burden during episodes, including severe abdominal pain, fatigue, gastrointestinal symptoms, fever, and appetite loss. These impacted psychological wellbeing, relationships, and daily activities. Many of the symptoms and impacts on HRQoL (eg, pain, work impacts) persisted between episodes and had long-term effects. Participants reported substantial lifestyle restrictions (eg, dietary) to manage symptoms.

CONCLUSION

HTG-AP has a substantial symptomatic and HRQoL burden during episodes, which can persist postrecovery. Treatments that reduce the incidence of HTG-AP have potential to improve HRQoL.

A nomogram for predicting risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit

AimTo investigate the incidence and risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit.DesignA retrospective study.MethodsFour hundred and one elderly patients (defined as aged ≥60 years) with severe traumatic brain injury who had undergone surgery and were admitted to the intensive care unit were enrolled in this study. We collected data on the incidence of lower extremity deep vein thrombosis and analyzed its influencing factors. Binary logistic regression analysis was employed to assess the associations between these factors and the occurrence of DVT. A nomogram was developed, and calibration curves were utilized to evaluate the model's accuracy. Additionally, a receiver operating characteristic curve was employed to assess the model's clinical discriminatory power.ResultsThe incidence of lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit was 25.69%. The final nomogram included age, intraoperative hypothermia, intraoperative bleeding volume, surgery time, D-dimer level, any organ failure, and body mass index as independent risk factors. The standard curve fit well with the calibrated prediction curve. The area under the receiver operating characteristic curve was 0.976 (95% CI: 0.958-0.994), and the model had good discrimination ability and reliability.ConclusionsThe risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit can be preliminarily assessed via the nomogram prediction model. This information may help guide medical staff in making reasonable decisions regarding the management of deep vein thrombosis prophylaxis.Patient or Public ContributionElderly postoperative patients with severe traumatic brain injury in the intensive care unit participated in the retrospective investigation of this study.

Imaging-based biomarkers in acute pancreatitis: the predictive value of adrenal contrast ratios for intensive care unit admission

BACKGROUND

Early risk stratification is crucial in acute biliary pancreatitis (ABP) to optimize patient management and guide intensive care unit (ICU) admission decisions. Traditional biomarkers and scoring systems have limitations in early severity assessment. This study aimed to evaluate the predictive value of adrenal contrast ratios on contrast-enhanced CT (CECT) as imaging-based biomarkers for ICU admission and prolonged hospitalization in ABP patients.

METHODS

This retrospective study included 288 ABP patients who underwent CECT within 24 h of admission. Adrenal-to-inferior vena cava (IVC) and adrenal-to-spleen contrast ratios were measured from portal venous phase images. The predictive performance of these ratios for ICU admission was assessed using receiver operating characteristic (ROC) analysis, and their correlation with clinical outcomes was evaluated through regression analysis.

RESULTS

ICU-admitted patients had significantly higher adrenal contrast ratios compared to non-ICU patients (adrenal-to-IVC ratio: 1.15 vs. 0.99, p < 0.001; adrenal-to-spleen ratio: 0.97 vs. 0.75, p < 0.001). ROC analysis demonstrated strong predictive accuracy (AUC = 0.74 for adrenal-to-IVC, AUC = 0.81 for adrenal-to-spleen). Additionally, adrenal contrast ratios correlated significantly with prolonged hospital stay (r = 0.49-0.55, p < 0.001).

CONCLUSION

Adrenal contrast ratios serve as promising imaging-based biomarkers for early ICU admission prediction and risk stratification in ABP patients. Their integration into clinical decision-making may enhance early management strategies. Further prospective validation is warranted.

STANDARDIZATION OF THE WHITE TEST IN OPEN LIVER RESECTION: TOWARD NEAR-ZERO CLINICALLY SIGNIFICANT BILE LEAKAGE

BACKGROUND

Biliary fistula is one of the most common complications after liver resection and is associated with significant morbidity and mortality. One of the methods used to evaluate biliary fistulas is the White test, which consists of injecting a lipid emulsion into the bile duct. However, no standard technique for performing the White test has been published.

AIMS

The aim of this study was to standardize the technique for performing the White test in patients undergoing hepatectomies, with and without previous cholecystectomy, and to assess the preliminary results.

METHODS

Patients over 18 years of age who were submitted to open hepatectomy were included in the study. The primary outcome was the rate of biliary fistula. Secondary outcomes were the incidence of acute pancreatitis and overall morbidity, measured by the Clavien-Dindo classification.

RESULTS

The standard technique for the White test was performed on 17 patients. In total, three patients had previous cholecystectomy, and two had low insertion of the cystic duct, requiring cannulation of the hepatocholedochal duct. None of the patients developed clinically significant biliary leaks. Acute pancreatitis did not occur in any patient. One patient developed pneumonia requiring mechanical ventilation (Clavien-Dindo IV). All others had minor or no complications.

CONCLUSIONS

The standardized technique for performing the White test suggests an appropriate strategy to maximize the detection of intraoperative biliary leaks.

Management of acute pancreatitis in the "no man's land"

Acute pancreatitis (AP) is an inflammatory disease that can represent a challenge for clinicians, in fact, the early determination of its severity in the first 72 h is crucial for prognosis, recognizing the etiology and carrying out risk stratification to determine a more specific therapy. No accurate early prognostic scores for disease severity have been published, so the severity of AP often cannot be properly defined in the first few hours of the disease. This initial phase represents a "no man's land", in which there is no certainty in the stratification of the damage, prognosis is difficult to establish, therapy must be started promptly, although there is still no effective medical therapy against pancreatic enzymatic activation. Therefore, it is very difficult at this stage to make the correct decisions to achieve the best outcome for the patient with AP. Literature search was carried out using the PubMed database by entering early management of acute pancreatitis [title] or therapy of acute pancreatitis [title] and selecting the most relevant articles for the diagnosis and therapy of acute pancreatitis in clinical practice. This document provides suggestions on managing the key clinical decisions for patients suffering from AP before disease severity is defined, to achieve the best outcomes for patients with AP.

Maternal and fetal death associated with acute pancreatitis during pregnancy: A case report

BACKGROUND

Acute pancreatitis in pregnancy is a rare but serious condition that can lead to high maternal mortality and fetal loss. Instances of pregnancy complicated by severe acute pancreatitis, particularly with subsequent respiratory and cardiac arrest, are rarely reported.

CASE SUMMARY

We present the case of a 35-year-old woman, at 36 + 5 weeks of gestation, who presented with paroxysmal epigastric pain accompanied by low back pain, nausea, and vomiting. According to the clinical symptoms, B-ultrasound imaging and biochemical indicators, the patient was diagnosed with acute pancreatitis and initially managed conservatively. However, 3 hours after admission, the patient experienced respiratory and cardiac arrest, and the fetus died. In this case, the adverse outcomes occurred due to the lack of aggressive fluid resuscitation and an active surgical intervention.

CONCLUSION

Implementing aggressive fluid resuscitation to sustain tissue perfusion, alongside the proactive evaluation of pharmacological agents that suppress gastric acid secretion and inhibit pancreatic enzyme activity, may be beneficial in mitigating the risk of a severely adverse prognosis. Effective management of acute pancreatitis during pregnancy requires careful timing of surgical intervention, a thorough evaluation of the risks and benefits regarding the continuation or termination of pregnancy, and a focus on safeguarding both maternal and fetal health.

Hotspots and scientometrics in gallbladder cancer surgery research: a bibliometric and visualization analysis (2014-2024)

Background

Gallbladder cancer (GBC) is the most common malignancy of the biliary tract, with significant geographical variations in incidence. The prognosis of GBC is generally poor due to its aggressive nature and late diagnosis. Surgical resection is the only curative treatment, but less than 10% of patients are eligible for radical surgery.

Methods

This study utilized bibliometric analysis and visualization tools to analyze research trends and hotspots in GBC surgery from 2014 to 2024. Data were collected from the Web of Science Core Collection using specific search terms related to GBC and surgical methods. The analysis was performed using tools such as CiteSpace, VOSviewer, and Microsoft Excel to identify key authors, institutions, countries, and research themes.

Results

A total of 479 publications were analyzed, showing a significant increase in research output and citation frequency over the past decade. China and the United States were the leading contributors to GBC surgery research. The analysis revealed six main research clusters, focusing on early diagnosis, surgical techniques, postoperative management, and the application of advanced technologies such as laparoscopic and robotic surgery.

Conclusions

The study highlights the evolution of research priorities in GBC surgery, with a shift towards minimally invasive techniques and comprehensive postoperative management. Future research should emphasize international collaboration and the exploration of emerging technologies to improve patient outcomes.

Robot-assisted hemihepatectomy is superior to laparoscopic hemihepatectomy through dorsal approach: A propensity score-matched study (with videos)

BACKGROUND

Dorsal approach is the potentially effective strategy for minimally invasive liver resection. This study aimed to compare the outcomes between robot-assisted and laparoscopic hemihepatectomy through dorsal approach.

METHODS

We compared the patients who underwent robot-assisted hemihepatectomy (Rob-HH) and who had laparoscopic hemihepatectomy (Lap-HH) through dorsal approach between January 2020 and December 2022. A 1:1 propensity score-matching (PSM) analysis was performed to minimize bias and confounding factors.

RESULTS

Ninety-six patients were included, 41 with Rob-HH and 55 with Lap-HH. Among them, 58 underwent left hemihepatectomy (LHH) and 38 underwent right hemihepatectomy (RHH). Compared with Lap-HH group, patients with Rob-HH had less estimated blood loss (median: 100.0 vs. 300.0 mL, P = 0.016), lower blood transfusion rates (4.9% vs. 29.1%, P= 0.003) and postoperative complication rates (26.8% vs. 54.5%, P = 0.016). These significant differences consistently existed after PSM and in the LHH subgroups. Furthermore, robot-assisted LHH was associated with decreased Pringle duration (45 vs. 60 min, P = 0.047). RHH subgroup analysis showed that compared with Lap-RHH, Rob-RHH was associated with less estimated blood loss (200.0 vs. 400.0 mL, P = 0.013). No significant differences were found in other perioperative outcomes among pre- and post-PSM cohorts, such as Pringle duration, operative time, and hospital stay.

CONCLUSIONS

The dorsal approach was a safe and feasible strategy for hemi-hepatectomy with favorable outcomes under robot-assisted system in reducing intraoperative blood loss, transfusion, and postoperative complications.

Reflux-Related Abnormalities at Distal oesophagus, Gastric Pouch and Anastomotic Site 4 Years After OAGB: Diagnostic Accuracies of Endoscopy Compared to Biopsy and of Symptoms Compared to Both

BACKGROUND

The purpose of the current study is to appraise the diagnostic accuracy of upper endoscopy (UE) vs histopathological assessment of patients after one-anastomosis gastric bypass (OAGB), and the presence/absence of symptoms vs these two diagnostic modalities.

METHODS

Retrospective study of 50 consecutive patients who underwent OAGB during April 2019-April 2020 and consented to participate. Symptoms (symptoms score questionnaire), macroscopic and microscopic data were collected 4 years later to assess distal oesophageal, gastric pouch and anastomotic site changes. Diagnostic accuracies (sensitivity, specificity, positive/negative predictive values) of UE vs biopsy and symptoms vs both were assessed.

RESULTS

Mean age was 48.6 ± 13.3 years; 66% were females. At 4 years, 54% had symptoms (symptom score ≥ 4). There were no dysplasia or cancer among this series. UE abnormalities included non-erosive gastritis (44%) and ulcer/s or erosive gastritis (16% each); histopathology abnormalities included chronic gastritis (80%) and Barrett's oesophagus (14%). For UE compared to biopsy, highest sensitivity (76.5%) was at the level of distal oesophagus and highest specificity (100%) at anastomotic site. Pertaining to symptoms compared to investigative modality, highest sensitivity (81.5%) was in relation to symptoms vs UE, while highest specificity (82.6%) was for symptoms vs biopsy.

CONCLUSIONS

It is generally not recommended that (a) UE be used to forecast biopsy abnormalities or lack thereof, except at the anastomotic site, and (b) symptoms or lack thereof be used to forecast the findings of investigative modalities, except with caution, to forecast UE findings in identifying healthy individuals, or to forecast biopsy findings in identifying diseased individuals. Long-term routine follow-up is needed post-OAGB regardless of whether patients are symptomatic or otherwise to rule in or out possible macroscopic/microscopic pathologies. Further research on UE and biopsy findings post-OAGB and their relationships with each other and with symptoms/lack thereof are required to strengthen the thin evidence base.

Qingyi decoction and its active ingredients ameliorate acute pancreatitis by regulating acinar cells and macrophages via NF-κB/NLRP3/Caspase-1 pathways

BACKGROUND AND PURPOSE

Macrophage infiltration and activation is a critical step during acute pancreatitis (AP). NLRP3 inflammasomes in macrophages plays a critical role in mediating pancreatic inflammatory responses. Qing-Yi Decoction(QYD)has been used for many years in clinical practice of Nankai Hospital combined with traditional Chinese and western medicine treatment of acute pancreatitis. Although QYD has a well-established clinical efficacy, little is known about its bioactive ingredients, how they interact with different therapeutic targets and the pathways to produce anti-inflammatory effects. Here, we elucidate the therapeutic effects of QYD against acute pancreatitis and reveal its mechanism of action.

METHODS

The main components of QYD were identified using UHPLC-Q-Orbitrap MS. Network pharmacology was employed to predict potential therapeutic targets and their mechanisms of action. C57BL/6 mice were randomly divided into control group, model group, low, medium and high dose (6, 12, 24 g/kg) QYD groups, with 10 mice in each group. The therapeutic effect of QYD on cerulein-induced acute pancreatitis. (CER-AP) was evaluated by histopathological score, immunohistochemistry, serum amylase and cytokines detection by ELISA. The protein expressions of MyD88/NF-κB/NLRP3 signaling pathway were detected by Western blotting. Along with molecular docking of key bioactive compounds and targets, RAW264.7 cells stimulated with 1μg/ml LPS is used to screen components with more potent effects on target proteins. AR42 J cells were stimulated with 100 nM dexamethasone (dexa) combined with 10 nM cerulein (CN) as s a cell-culture model of acute pancreatitis. Inhibitory effects of the main chemical composition Wogonoside on NLRP3 inflammasomes were analyzed by qRT-PCR and Western blots.

RESULTS

Using UHPLC-Q-Orbitrap MS, 217 compounds were identified from QYD, including Wogonoside, Catechins, Rhein, etc. A visualization network of QYD-compounds-key targets-pathways-AP show that QYD may modulate PI3K-Akt signaling pathway, NOD-like receptor signaling pathway, MAPK signaling pathway, Ras signaling pathway and Apoptosis signaling pathway by targeting TNF, IL1β, AKT1, TP53 and STAT3 exerting a therapeutic effect on AP. QYD administration effectively mitigated CER-induced cytokine storm, pancreas edema and serum amylase. QYD (12 mg/kg) showed better effect. The protein expression levels of MyD88, NF-κB, NLRP3, Caspase-1 and GSDMD in pancreatic tissue were significantly decreased. Through molecular docking and LPS-RAW264.7 inflammation model, the selected Wogonoside significantly decreased IL-1β mRNA. The expression levels of NLRP3/Caspase-1/GSDMD pathway-related proteins were also decreased on AR42J-AP.

CONCLUSION

The results of network pharmacology indicate that QYD can inhibit AP through multiple pathways and targets. This finding was validated through in vivo tests, which demonstrated that QYD can reduce AP by inhibiting NLRP3 inflammasomes, additionally, it should be noted that 12mg/kg was a relatively superior dose. One of the main chemical compositions Wogonoside regulated NLRP3 inflammasome activation to protect against AP. This study is the first to verify the intrinsic molecular mechanism of QYD in treating AP by combining network pharmacology and animal experiments. The findings can provide evidence for subsequent clinical research and drug development.

A Case of Severe Acute Gallstone Pancreatitis With Black Ascites in a Patient Without Underlying Diseases

In acute pancreatitis, ascitic fluid is typically pale yellow and exudative due to inflammation. We report a rare case of black ascitic fluid associated with gallstone-induced severe acute pancreatitis in a 71-year-old man with no underlying disease. The patient initially presented to a local hospital with acute-onset abdominal pain. Abdominal computed tomography (CT) revealed a common bile duct stone, and he was diagnosed with acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and endoscopic nasobiliary drainage (ENBD) was performed. On the following day, his abdominal pain worsened, and further evaluation revealed elevated pancreatic enzyme levels and peripancreatic inflammatory changes on CT. He was subsequently diagnosed with acute pancreatitis. Despite four days of treatment with fluid resuscitation and antibiotics, his condition deteriorated, and he was transferred to our facility on Day 0. Upon arrival, he was intubated and started on mechanical ventilation due to respiratory failure. Continuous hemodiafiltration (CHDF) was initiated on Day 1 for metabolic acidosis and worsening renal function. On Day 3, abdominal CT revealed newly developed ascites, and paracentesis was performed due to concern for increased intra-abdominal pressure. The ascitic fluid appeared black. Laboratory analysis revealed a mildly elevated total bilirubin level and markedly elevated amylase and lipase levels, consistent with pancreatic ascites. Despite drainage and intensive supportive care, the patient developed multiple organ dysfunction syndrome (MODS), including refractory shock, respiratory failure, and renal insufficiency. He died on Day 5 of hospitalization. This case highlights an extremely rare presentation of pancreatic ascites with black discoloration in the early phase of acute pancreatitis. The black color was most likely due to pancreatic duct disruption and enzyme-mediated hemorrhagic changes. To our knowledge, this is the first reported case of black pancreatic ascites secondary to acute pancreatitis. Awareness of this rare manifestation may aid in the timely recognition and management of similar cases in the future.

Hypertriglyceridemia-Induced and Alcohol-Induced Acute Pancreatitis-A Severity Comparative Study

Background: Alcohol use and hypertriglyceridemia are the second and third common causes of acute pancreatitis after choledocholithiasis. Still, few studies directly compare the severity and outcomes of these two groups, which share pathophysiology pathways. Methods: In our study, we compared the biologic profile, severity according to the Atlanta classification and Balthazar index, intensive care unit admissions, and mortality between patients with hypertriglyceridemia-induced pancreatitis (HTGP) and alcohol-induced acute pancreatitis (AAP). A total of 78 patients were included in this study, 37.17% of which had HTGP, and 62.82% had AAP. Results: HTGP was more severe in terms of the Atlanta revised classification severity assessment (82.76% vs. 46%, p = 0.014), led to more extended hospitalizations (p = 0.024), and resulted in similar serum CRP levels among patients, with a significant difference regarding median serum fibrinogen values (739 vs. 563 mg/dL, p = 0.030) and necrotizing forms (24.13% vs. 10.20%). Hyponatremia was more significant in HTGP patients compared with AAP patients (130 vs. 137 mmol/L, p < 0.000). No differences were found in other inflammation indexes such as NLR (neutrophil count/lymphocyte count), PLR (platelet count/lymphocyte count), MLR (monocyte/lymphocyte count), SII (systemic immune-inflammation index), or SIRI (systemic inflammation response index). Conclusions: The pattern of acute pancreatitis is related to its etiology and may have different grades of severity. In our study, we found that hypertriglyceridemia-induced pancreatitis required twice as many admissions to the intensive care unit and was associated with lower serum sodium levels, and almost twice as many patients with HTGP had moderate or severe forms of acute pancreatitis compared to alcohol-induced pancreatitis cases.

The Effects of Having Surgeon's Hands in Line of Vision During Single-Incision Laparoscopic Surgery: A Feasibility Study

Aim: Single-incision laparoscopic surgery (SILS) provides improved cosmesis compared with multiport laparoscopy. However, it involves hand-clashing and cross-triangulation, making it challenging even for experienced surgeons to adopt in their practice. This study aims to assess the effect of providing an additional view of the surgeon's hands on task performance in SILS. Methods: Surgically naive participants were recruited via volunteer sampling and instructed to perform tasks using a laparoscopic trainer set and a singular triport access device. A head-mounted camera was worn by the participant and angulated inferiorly to provide an additional view of the operators' hands. Both views were displayed on a 90″ monitor. Tasks were performed with and without the additional view in an alternating manner. Attempts were recorded and assessed blindly for duration and success. Chi-squared and Mann-Whitney U tests were applied as required. A P value <.05 was considered significant. Results: A total of 467 attempts were conducted by 30 volunteers. The pass rates were 79.09% and 69.23% for the additional and traditional views, respectively (P = .015). A trend toward shorter durations was seen in attempts using the additional view (P = .128). Males (P = .003) and PC video game players (P = .022) were more likely to pass and mobile video game players were more likely to fail (P = .003). Conclusion: The use of a head-mounted camera to directly visualize surgeon's hands enhances performance in an ex vivo setting. More research is needed to assess clinical impact.

Red Blood Cell Distribution Width-to-Platelet Count Ratio as a Prognostic Marker for Predicting Severity and Various Outcomes in Acute Pancreatitis

INTRODUCTION

The natural course of acute pancreatitis is quite variable, where most patients with mild acute pancreatitis usually follow a self-limiting course, whereas the mortality is quite higher in severe acute pancreatitis. Hence, early prediction of severity is essential for proper triaging. The study aimed to assess the diagnostic accuracy of red blood cell distribution width (RDW)-to-platelet count ratio (RPR) as a prognostic marker in acute pancreatitis.

METHODS

It was a prospective, observational study conducted on consecutive patients with acute pancreatitis. All participants were subjected to routine laboratory investigations and radiological evaluation using transabdominal ultrasound at the time of admission and a contrast-enhanced CT scan after 96 hours. All the parameters, including RPR, and various severity scores, such as the Systemic Inflammatory Response Syndrome (SIRS) score, Ranson score, Bedside Index for Severity in Acute Pancreatitis (BISAP) score, and Modified Marshall score, were compared between patients with mild or moderate to severe acute pancreatitis by using standard statistical tests.

RESULTS

A total of 200 patients diagnosed with acute pancreatitis were enrolled in this study, out of which the most common etiologies of acute pancreatitis were alcohol abuse (88 (44%)) and gallstones (57 (28.5%)). The overall mortality in our patients was seven (3.5%), which occurred only in severe acute pancreatitis. The mean RPR of patients with mild and moderately severe to severe acute pancreatitis were 0.07 ± 0.02 and 0.12 ± 0.09, respectively (p < 0.05), whereas the mean RPR of patients who survived and those who did not were 0.09 ± 0.06 and 0.12 ± 0.05, respectively (p < 0.05).

CONCLUSION

RPR calculated at the time of admission is found to be an independent prognostic marker in acute pancreatitis with the potential to identify individuals at risk for developing severe acute pancreatitis as well as mortality.

Strengthening Discovery and Application of Artificial Intelligence in Anesthesiology: A Report from the Anesthesia Research Council

Interest in the potential applications of artificial intelligence in medicine, anesthesiology, and the world at large has never been higher. The Anesthesia Research Council steering committee formed an anesthesiologist artificial intelligence expert workgroup charged with evaluating the current state of artificial intelligence in anesthesiology, providing examples of future artificial intelligence applications and identifying barriers to artificial intelligence progress. The workgroup's findings are summarized here, starting with a brief introduction to artificial intelligence for clinicians, followed by overviews of current and anticipated artificial intelligence-focused research and applications in anesthesiology. Anesthesiology's progress in artificial intelligence is compared to that of other medical specialties, and barriers to artificial intelligence development and implementation in our specialty are discussed. The workgroup's recommendations address stakeholders in policymaking, research, development, implementation, training, and use of artificial intelligence-based tools for perioperative care.

Knowledge, attitude, and practice of artificial intelligence among doctors and medical students in Saudi Arabia

Background

Artificial intelligence (AI) is advancing rapidly across fields, including healthcare, where it is being adopted for diagnostics and patient management. However, research on Saudi Arabian healthcare professionals' understanding and perceptions of AI remains limited.

Objectives

This study aims to assess the knowledge, attitude, and practices (KAP) regarding AI among medical students, interns, and residents, identifying educational gaps and perceptions of AI's future in medicine.

Methods

A cross-sectional survey was conducted in Riyadh, Saudi Arabia, targeting medical students, interns, and residents. An online questionnaire collected demographic information, as well as participants' knowledge and attitudes towards AI, and their experience with its applications in medicine. Responses were analyzed statistically for any associations.

Results

Of 374 responses, 98.4% were aware of AI, though only 50.5% could identify AI subtypes, and 48.9% understood its medical applications. Formal AI education was lacking for 59.4%, despite 81.8% recognizing AI's importance in diagnosis. Concerns about AI's impact on jobs were noted by 77.8%. While 62.6% had used AI in practice, 66.6% found it beneficial.

Conclusion

High awareness of AI contrasts with gaps in specific knowledge and formal training. Positive attitudes are tempered by job security concerns. Findings suggest the need for a structured AI curriculum in medical education to improve comprehension and application in healthcare.

Serum Trypsin Is a Reliable Biomarker of Pancreas Function

ABSTRACT

Pancreatic diseases pose significant diagnostic and therapeutic challenges necessitating robust biomarkers for accurate diagnosis, management, and monitoring of pancreas function.Pancreas function can be measured with direct (invasive) and indirect tests. However, neither approach allows for continuous disease monitoring to identify disease progression or therapeutic response. We demonstrate literature evidence suggesting that trypsin, an important pancreatic digestive enzyme, holds promise as a continuous biomarker. On one hand, assessment of trypsin concentration in the serum sensitively and specifically detects pancreas inflammation; whereas on the other hand, declining trypsin levels in serum show good correlation with direct pancreatic function tests to identify exocrine pancreatic insufficiency. With this comprehensive review, we aimed to evaluate the existing evidence on the utility of trypsin as a continuous biomarker, spanning from acute to chronic pancreatitis and pancreas function, highlighting its potential in monitoring disease evolution on an individual patient level.

Circulating Biomarkers of Macrophage Activation in Different Stages of Chronic Pancreatitis: A Pilot Study

OBJECTIVES

Activation of type M2 macrophages has been implicated in the pathogenesis of chronic pancreatitis (CP). In a clinical pilot study, we investigated blood-based markers of macrophage activation at different stages of CP.

MATERIALS AND METHODS

We performed a cross-sectional analysis of prospectively collected plasma samples from healthy controls and patients with suspected or definitive CP according to the M-ANNHEIM criteria. Plasma concentrations of soluble CD163 (sCD163), soluble CD206 (sCD206), and monocyte chemoattractant protein-1 (MCP-1) were analyzed using enzyme-linked immunosorbent assays. Group and pairwise comparisons of analytes were performed using regression models and area under the receiver operating curves (AUC-ROC).

RESULTS

In total, 73 subjects with CP (28 suspected CP and 45 definitive CP) and 40 controls were included. Compared to controls, the median plasma concentrations of sCD163 ( P  = 0.019) and sCD206 ( P  = 0.033) were elevated in patients with definitive CP. sCD206 was also elevated in patients with definitive CP ( P  = 0.042) compared to suspected CP. ROC analysis revealed the optimal sCD163 cutpoint to distinguish definitive CP from controls was 1.84 mg/mL (AUC-ROC 0.65; 95% confidence interval [CI], 0.54-0.77). The optimal sCD206 cutpoint to distinguish definitive CP from controls was 0.24 mg/mL (AUC-ROC 0.66; 95% CI, 0.54-0.78). MCP-1 concentrations showed no differences across subgroups.

CONCLUSION

Our study demonstrates that subjects with definitive CP, sampled during a clinically quiescent phase, exhibited increased levels of sCD163 and sCD206. This indicates the presence of activated M2 macrophages in patients with CP at advanced, but not early, clinical stages.

Ethics and trustworthiness of artificial intelligence in Hepato-Pancreato-Biliary surgery: a snapshot of insights from the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) survey

BACKGROUND

Hepato-Pancreato-Biliary (HPB) surgery is a complex specialty and Artificial Intelligence (AI) applications have the potential to improve pre- intra- and postoperative outcomes of HPB surgery. While ethics guidelines have been developed for the use of AI in clinical surgery, the ethical implications and reliability of AI in HPB surgery remain specifically unexplored.

METHODS

An online survey was developed by the Innovation Committee of the E-AHPBA to investigate the current perspectives on the ethical principles and trustworthiness of AI in HPB Surgery among E-AHPBA membership. The survey consisted of 22 questions, based on guidelines outlined by the Artificial Intelligence Surgery Journal Task Force on AI Ethics in clinical surgery and was disseminated via email to all E-AHPBA members.

RESULTS

A total of 84 members of the E-AHPBA participated in the survey. Seventeen out of 22 questions achieved more than 80 % agreement, with nine of those exceeding 90 %. Five questions had agreement levels between 70 % and 80 %.

CONCLUSION

While HPB surgeons are aware of the need to regulate the use of AI devices, robots, and to protect patient data, consensus appears to be heterogeneous regarding AI's role in mitigating gender-related and minority biases, as well as ensuring fairness and equity.

Strengthening Discovery and Application of Artificial Intelligence in Anesthesiology: A Report from the Anesthesia Research Council

Interest in the potential applications of artificial intelligence in medicine, anesthesiology, and the world at large has never been higher. The Anesthesia Research Council steering committee formed an anesthesiologist artificial intelligence expert workgroup charged with evaluating the current state of artificial intelligence in anesthesiology, providing examples of future artificial intelligence applications and identifying barriers to artificial intelligence progress. The workgroup's findings are summarized here, starting with a brief introduction to artificial intelligence for clinicians, followed by overviews of current and anticipated artificial intelligence-focused research and applications in anesthesiology. Anesthesiology's progress in artificial intelligence is compared to that of other medical specialties, and barriers to artificial intelligence development and implementation in our specialty are discussed. The workgroup's recommendations address stakeholders in policymaking, research, development, implementation, training, and use of artificial intelligence-based tools for perioperative care.

The Effect of Epidural Analgesia on In-hospital Outcomes in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis of Randomized Clinical Trials

OBJECTIVES

Acute pancreatitis (AP) can lead to severe complications and high mortality. Previous studies suggest that epidural analgesia (EA) may improve outcomes in AP. This systematic review and meta-analysis aimed to evaluate the efficacy of EA on in-hospital outcomes in AP patients.

METHODS

Electronic databases (PubMed, Medline-Ovid, Scopus, CINAHL, Web of Science) were systematically searched until May 2024 for RCTs comparing EA with other pain strategies in AP patients. Variables were pooled using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Data analysis employed random-effects the Mantel-Haenszel method and I 2 statistic was used for heterogeneity.

RESULTS

Five RCTs with 260 participants were included. Meta-analysis showed no significant differences in in-hospital mortality (RR, 0.69; 95% CI [0.29-1.65]; P  = 0.40), mechanical ventilation (RR, 0.82; 95% CI [0.61-1.10]; P  = 0.19), sepsis (RR, 0.88; 95% CI [0.42-1.86]; P  = 0.74), hospital/ICU stay (WMD, 0.49 days; 95% CI [-1.13 to 2.10]; P  = 0.55), and pain score (WMD, 1.49; 95% CI [-0.42 to 3.40]; P  = 0.13). Opioid requirements were significantly lower, with one study reporting MME of 15 mg/d compared to 52 mg/d in the control group ( P  = 0.001). Heterogeneity was low to moderate for most outcomes but high for pain score ( I2  = 92%). Small number of studies, risk of bias, and sample size limited overall certainity.

CONCLUSIONS

EA did not significantly improve in-hospital outcomes in AP patients. However, findings suggested potential benefits in pain management. High-quality randomized trials are needed to understand the potential benefits of EA in this population.

Learning curve analysis of 100 consecutive robotic liver resections

BACKGROUND

Robotic liver surgery, as part of minimally invasive liver surgery (MILS), offers advantages like enhanced dexterity and stable camera and instrument control. However, the learning curve - particularly the number of cases required for proficiency - remains underexplored. This study analyzes 100 consecutive robotic liver resections performed by a single surgeon to assess the learning curve and outcomes.

PATIENTS AND METHODS

This retrospective analysis reviewed data from the Magdeburg registry of minimally invasive liver surgery (MD-MILS) from June 2013 to July 2024, to identify surgeons who performed at least 100 robotic liver resections. Operation time and Iwate difficulty score were used as indicators of surgical proficiency and learning progression.

RESULTS

One surgeon fulfilled the inclusion criteria of performing 100 robotic liver resections. Of these, 41 (41%) were major and 59 (59%) were minor liver resections. A significant reduction in average operation time was observed across the series, decreasing from an initial average of 450 min to approximately 300 min by the 100th operation. Similarly, the Iwate difficulty score showed a significant upward trend, reflecting the increasing technical challenges of the procedures. The learning curve was divided into four distinct phases: Competency (Cases 1-20), Proficiency (Cases 21-30), Early Mastery (Cases 31-65), and Full Mastery (Cases 66-100), highlighting the progression in skill acquisition and case complexity. Major complications (21%), such as bile leak, bilioma, and pulmonary embolism, were observed during the study period.

CONCLUSION

Over 100 robotic liver resections, significant learning curve progression was evident, with marked improvements in operation time and handling of complex cases. The results suggest that approximately 65 cases are needed for a surgeon experienced in open and laparoscopic liver surgery to achieve consistent proficiency in robotic liver resections. These findings underscore the importance of standardized training protocols to support the learning curve in robotic liver surgery.

Comparison of acute pancreatitis and acute on chronic pancreatitis: a retrospective cohort study

BACKGROUND

Acute on chronic pancreatitis (ACP) shares a similar clinical presentation with acute pancreatitis (AP) and is often diagnosed and treated in the same way. However, these two conditions may have distinct clinical risk profiles and prognoses. There is currently limited evidence available regarding the specific characteristics of ACP.

METHODS

This retrospective cohort study included all adult patients admitted with a diagnosis of AP or ACP between 2017 and 2019 at two tertiary referral centers. The primary outcome was disease severity as defined by the Atlanta classification. Secondary outcomes included the presence of local and systemic complications, organ failure, ICU admission, and mortality. Differences in outcomes between ACP and AP were compared using multivariate logistic regression models, with results presented as odds ratios (ORs).

RESULTS

We included 1163 patients, 90% of whom had AP and 10% had ACP. ACP patients were predominantly male (81 vs. 46%; P  < 0.001), whereas AP patients were older (mean age 62.6 vs. 56.5 years, P  < 0.001). ACP patients had lower amylase and lipase levels ( P  < 0.001). Multivariate analysis showed no difference in the risk of moderate or severe pancreatitis (OR, 1.15; 95% CI, 0.66-1.98; P  = 0.615). ACP patients had a higher risk of local complications (predominantly pseudocysts) (OR, 1.71; 95% CI, 1.00-2.92; P  = 0.049) and a lower risk of organ failure ( P  = 0.019) and ICU admission ( P  = 0.005).

CONCLUSION

Our study confirms previous observations that ACP has a more favorable in-hospital prognosis than AP and extends these findings to a modern European setting.

Comparative Assessment of Outcomes: Abdominal Drain Versus No Abdominal Drain After Left Pancreatectomy-A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement postpancreatectomy.

BACKGROUND

Left pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like postoperative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach.

METHODS

A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and nonrandomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% CIs, and a P value of <0.05 was considered statistically significant.

RESULTS

A total of 13,081 patients underwent drain placement after left pancreatectomy, and 2736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group [relative risk (RR): 0.77, 95% CI: 0.64-0.93, P =0.006]. Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P <0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P =0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P =0.009) were observed in the no-drain group. In addition, a shorter length of hospital stay was noted in this group [mean difference (MD): -1.65, 95% CI: -2.50 to -0.81, P =0.0001].

CONCLUSIONS

Omitting routine drainage after a left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.

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.

Quercetin, a natural flavonoid, protects against hepatic ischemia-reperfusion injury via inhibiting Caspase-8/ASC dependent macrophage pyroptosis

INTRODUCTION

Hepatic ischemia-reperfusion injury (IRI) is an inevitable adverse event following liver surgery, leading to liver damage and potential organ failure. Despite advancements, effective interventions for hepatic IRI remain elusive, posing a significant clinical challenge. The innate immune response significantly contributes to the pathogenesis of hepatic IRI by promoting an inflammatory cytotoxic cycle. We have reported that blocking GSDMD-induced pyroptosis in innate immunity cells protected hepatic IRI from inflammatory injury. However, the search for effective pyroptosis inhibitors continues.

OBJECTIVES

This study aims to evaluate whether quercetin, a natural flavonoid, can inhibit GSDMD-induced pyroptosis and mitigate hepatic IRI.

METHODS

We established the hepatic IRI murine model and cellular pyroptosis model to evaluate the efficacy of quercetin.

RESULTS

Quercetin effectively alleviated hepatic IRI-induced tissue necrosis and inflammation. We found that during hepatic IRI, the cleavage of GSDMD occurred in hepatic macrophages, but not in other non-parenchymal cells. Quercetin inhibited the cleavage of GSDMD in macrophages. Moreover, we found that quercetin blocked the ASC assembly to inhibit the formation of NLRP3 inflammasomes and AIM2 inflammasomes, suppressing macrophage pyroptosis. Co-immunoprecipitation experiments confirmed that quercetin inhibited the interaction between ASC and Caspase-8, which is the mechanism of ASC complex and inflammasome formation. Overexpression of Caspase-8 abolished the anti-pyroptosis effect of quercetin in NLRP3 and AIM2 inflammasome signaling. Furthermore, we found that the hepatoprotective activity of quercetin was reduced in myelocytic GSDMD-deficient mice.

CONCLUSION

Our findings suggest that quercetin has beneficial effects on hepatic IRI. Quercetin could attenuate hepatic IRI and target inhibition of macrophage pyroptosis via blocking Caspase-8/ASC interaction. We recommend that quercetin might serve as a targeted approach for the prevention and personalized treatment of hepatic IRI in perioperative patients.

Redox signaling in the pancreas in health and disease

This review addresses oxidative stress and redox signaling in the pancreas under healthy physiological conditions as well as in acute pancreatitis, chronic pancreatitis, pancreatic cancer, and diabetes. Physiological redox homeodynamics is maintained mainly by NRF2/KEAP1, NF-κB, protein tyrosine phosphatases, peroxisome proliferator-activated receptor-γ coactivator 1α (PGC1α), and normal autophagy. Depletion of reduced glutathione (GSH) in the pancreas is a hallmark of acute pancreatitis and is initially accompanied by disulfide stress, which is characterized by protein cysteinylation without increased glutathione oxidation. A cross talk between oxidative stress, MAPKs, and NF-κB amplifies the inflammatory cascade, with PP2A and PGC1α as key redox regulatory nodes. In acute pancreatitis, nitration of cystathionine-β synthase causes blockade of the transsulfuration pathway leading to increased homocysteine levels, whereas p53 triggers necroptosis in the pancreas through downregulation of sulfiredoxin, PGC1α, and peroxiredoxin 3. Chronic pancreatitis exhibits oxidative distress mediated by NADPH oxidase 1 and/or CYP2E1, which promotes cell death, fibrosis, and inflammation. Oxidative stress cooperates with mutant KRAS to initiate and promote pancreatic adenocarcinoma. Mutant KRAS increases mitochondrial reactive oxygen species (ROS), which trigger acinar-to-ductal metaplasia and progression to pancreatic intraepithelial neoplasia (PanIN). ROS are maintained at a sufficient level to promote cell proliferation, while avoiding cell death or senescence through formation of NADPH and GSH and activation of NRF2, HIF-1/2α, and CREB. Redox signaling also plays a fundamental role in differentiation, proliferation, and insulin secretion of β-cells. However, ROS overproduction promotes β-cell dysfunction and apoptosis in type 1 and type 2 diabetes.

Endoscopic retrograde cholangiopancreatography and endoscopic cystogastrostomy in very young children (aged <5 years): Feasibility, success, and safety

Objectives

Paucity of data and concerns about potential lower effectiveness and more adverse events limit the use of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic cystogastrostomy in younger children even in high-volume centers. We retrospectively analyzed indications, success rates, and adverse events of all the children (<18 years) who underwent ERCP and endoscopic cystogastrostomy between January 2010 to May 2024 at our center.

Methods

Data, including patient demographics, indications for the procedure, technical details, and adverse events, were collected from our prospectively kept database and compared according to age groups (<1 year, 1-5 years, 5-10 years, and 10-18 years).

Results

A total of 286 ERCP (273 therapeutic and 13 diagnostic) and 57 endoscopic cystogastrostomy were performed in 222 (138 boys) and 55 children (32 boys), respectively, during the study period with 20% ERCP procedures in under-five children. In children <5 years, the majority of the ERCPs were for biliary diseases (87%), while pancreatic duct procedures (39.5%) were done in higher numbers in children >5 years. For biliary ERCP, choledochal cyst (15, 33%) was the most common etiology in under-five children and choledocholithiasis (60, 34%) in children >5 years. Cannulation and technical success rates were 95% and 92%, respectively with no significant difference across age groups. Adverse events were noted in 36 (16%) with post-ERCP pancreatitis (8%) being the most common. All adverse events were managed conservatively with no mortality.

Conclusion

ERCP can safely be performed in all children, including those under five with various hepato-pancreato-biliary diseases with high technical success rates.

Fluid Resuscitation in the Treatment of Acute Pancreatitis: Rate and Volume Controversies

The aim of the Research to Practice column is to enhance the research critique abilities of both advanced practice registered nurses and emergency nurses, while also aiding in the translation of research findings into clinical practice. Each column focuses on a specific topic and research study. In this article, we used a scenario of left upper quadrant pain to explore the study by de-Madaria et al., titled "Aggressive or moderate fluid resuscitation in acute pancreatitis".

Evaluation of retinal structural and microvascular changes in patients with acute pancreatitis

BACKGROUND

This study aimed to show the changes in retinal vascular densities and thicknesses in the peripapillary and macular regions in the acute period in patients with acute pancreatitis (AP).

METHODS

This prospective cross-sectional study included 57 eyes of 30 patients with AP and 58 eyes of 30 healthy people. Optical coherence tomography angiography (OCTA) was taken within 24-72 h of AP patients' hospitalization. OCTA was used to evaluate the retinal microvascular structure and retinal thickness.

RESULTS

Peripapillary retinal nerve fiber layer (pp-RNFL) and perifoveolar ganglion cell complex (pef-GCC) thickness in patients with AP were significantly higher than in the healthy control group (p = 0.020 and p = 0.039, respectively). While whole image vessel density (wiVD) and perifoveal vessel density (pefVD) were significantly lower in the deep capillary plexus (DCP), choriocapillaris flow area (CCFA) in the macula were significantly lower in each of the 1 mm and 3 mm radius areas in patients with AP (p = 0.014, p = 0.011; p = 0.011, and p = 0.035 respectively). In the univariable and multivariable linear regression analysis, it was observed that serum lipase and procalcitonin levels affected the thickness of pp-RNFL and pef-GCC (for pp-RNFL, β= 0.001, p = 0.002, β=24.992, p < 0.001, and for pef-GCC, β= 0.001 p = 0.014, β=17.107 p < 0.001 respectively).

CONCLUSIONS

There are significant microvascular and structural changes in the optic nerve and macula in patients with AP. The relationship between these changes and serum lipase and procalcitonin levels was shown. Clinicians should consider ocular involvement in AP patients with high serum lipase and procalcitonin levels.

Minimally invasive adrenalectomy for adrenocortical cancers: A systematic review

Introduction

Adrenocortical cancer (ACC) is a rare malignancy with poor prognosis. Due to the widespread use of imaging, greater proportion of cases are being discovered at an early stage, and it is possible to surgically excise these tumors by minimally invasive (MIS) approaches, including pure laparoscopy and robotic assistance. However, due to the fear of capsular breach, tumor spill, and incomplete removal, open surgery (OS) is still the preferred option for managing ACC. The aim of this review is to compare the two approaches and assess where MIS can be option for the surgical management of ACC.

Methods

This review was performed as per the Preferred Reporting Items for Systematic Reviews statement. Studies comparing OS and MIS approaches for ACC were retrieved from the PubMed, Scopus, and Cochrane databases. The two approaches were compared for tumor characteristics and outcomes.

Results

A total of 22 studies comparing MIS with OS were included in this review. Out of the total 4639 patients, 1411 underwent surgery by MIS and 3228 by OS. Patients operated by MIS had smaller tumors, lower operative time and blood loss with higher positive surgical margin rate, and higher rate of local recurrence. However, the overall survival was comparable between the two approaches.

Conclusions

MIS can be used in localized Stage-I ACC but only at high-volume centers. Stage II ACC may be considered for MIS if there is no evidence of local invasion and the surgery can be performed without capsular perforation and conversion to OS.

Impact of immunosuppression medication management on short-term complications following sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most performed bariatric procedure in the United States due to its favorable safety profile. However, managing patients on chronic immunosuppressive therapy (CIT) during bariatric surgery poses challenges, particularly in balancing surgical outcomes with the risks associated with CIT interruption. This study aims to compare the short-term outcomes of SG in patients who temporarily discontinued CIT versus those who continued it perioperatively.

METHODS

A retrospective review was conducted of 75 patients on CIT who underwent SG at a single academic center between 2008 and 2022. Patients were categorized based on perioperative CIT management: 20 (26.7%) interrupted CIT and 55 (73.3%) continued therapy. Data on patient demographics, CIT indications, operative details, and short-term outcomes, including complications and readmissions, were analyzed.

RESULTS

The most common CIT indication was organ transplantation (61.4%), predominantly in the non-interruption group, while rheumatoid arthritis was the leading indication (50%) among patients who interrupted CIT. Early complications (≤ 30 days) were significantly higher in the non-interruption group (20% vs. 5%, p = 0.031), with bleeding being the most frequent (7 cases), followed by wound infections (4 cases). In contrast, the interruption group experienced only one complication, a wound infection. Weight outcomes were similar between groups, with no significant differences in percentage of total weight loss (%TWL) at 3 or 6 months. Notably, the interruption group had no 30-day readmissions or reoperations, compared to 16.4% and 5.5%, respectively, in the non-interruption group.

CONCLUSIONS

Temporary interruption of CIT in SG patients is associated with lower early complication rates and improved short-term outcomes. These findings highlight the importance of individualized perioperative CIT management and suggest potential benefits of CIT interruption when clinically feasible.

Surgical and functional outcomes of bilateral synchronous adrenalectomy for functional tumors: A cohort study

Introduction

Bilateral synchronous adrenalectomy has the potential for significant surgical and functional morbidity. We reviewed our 15-year experience with bilateral synchronous adrenalectomy to assess the safety, surgical outcomes, morbidity, and impact on health-related quality of life (QoL).

Materials and Methods

In an IRB-approved study, we reviewed our database of patients who underwent bilateral synchronous adrenalectomy for functional tumors between April 2008 and August 2022. Demographic profile, metabolic and radiological parameters, operative details, and complications were recorded. Follow-up was obtained either in-person or telephonically and analyzed for resolution of symptoms, QoL using the WHO-QoL BREF questionnaire, and complications of chronic steroid intake. Data were reported descriptively and compared between laparoscopic and open approaches.

Results

During the study period, 337 adrenalectomies were performed, of which, 51 were bilateral and in 48 patients both the surgeries were performed synchronously. Thirty-three of these 48 patients had bilateral pheochromocytomas and 15 had Cushing's syndrome. Among patients with Cushing's syndrome, three had life-threatening symptoms requiring urgent bilateral surgery. Forty patients underwent transperitoneal laparoscopic surgery and 8 underwent open surgery. There were two intraoperative and 7 post-operative complications. Forty-three patients were available for follow-up. All had resolution of symptoms and body mass index (BMI) changes, and only two patients continued to receive one antihypertensive medication. Episodes of steroid deficiency occurred in 7 patients while steroid excess occurred in 3 patients. QoL was satisfactory in all the patients in all the domains.

Conclusions

Bilateral synchronous adrenalectomy is safe and feasible for functional adrenal tumors. It leads to symptom resolution with amelioration of hypertension and BMI changes with satisfactory overall QoL.