1
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Hooks G, Lu H, Eaton A, Trikudanathan G, Downs E, Freeman ML, Schwarzenberg SJ, Pruett TL, Chinnakotla S, Ramanathan K, Beilman GJ, Bellin MD. Addressing long-term mortality risk in patients undergoing total pancreatectomy with islet autotransplant (TPIAT): causes of death and risk factors. HPB (Oxford) 2024; 26:664-673. [PMID: 38368218 PMCID: PMC11070297 DOI: 10.1016/j.hpb.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplant (TPIAT) can improve quality of life for individuals with pancreatitis but creates health risks including diabetes, exocrine insufficiency, altered intestinal anatomy and function, and asplenia. METHODS We studied survival and causes of death for 693 patients who underwent TPIAT between 2001 and 2020, using the National Death Index with medical records to ascertain survival after TPIAT, causes of mortality, and risk factors for death. We used Kaplan Meier curves to examine overall survival, and Cox regression and competing-risks methods to determine pre-TPIAT factors associated with all-cause and cause-specific post-TPIAT mortality. RESULTS Mean age at TPIAT was 33.6 years (SD = 15.1). Overall survival was 93.1% (95% CI 91.2, 95.1%) 5 years after surgery, 85.2% (95% CI 82.0, 88.6%) at 10 years, and 76.2% (95% CI 70.8, 82.3%) at 15 years. Fifty-three of 89 deaths were possibly related to TPIAT; causes included chronic gastrointestinal complications, malnutrition, diabetes, liver failure, and infection/sepsis. In multivariable models, younger age, longer disease duration, and more recent TPIAT were associated with lower mortality. CONCLUSIONS For patients undergoing TPIAT to treat painful pancreatitis, careful long-term management of comorbidities introduced by TPIAT may reduce risk for common causes of mortality.
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Affiliation(s)
- Gregory Hooks
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Han Lu
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Eaton
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Guru Trikudanathan
- Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Elissa Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Martin L Freeman
- Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Karthik Ramanathan
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Melena D Bellin
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA.
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2
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Ciofoaia V, Chen W, Tarek BW, Gay M, Shivapurkar N, Smith JP. The Role of a Cholecystokinin Receptor Antagonist in the Management of Chronic Pancreatitis: A Phase 1 Trial. Pharmaceutics 2024; 16:611. [PMID: 38794273 PMCID: PMC11125239 DOI: 10.3390/pharmaceutics16050611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic pancreatitis (CP) is a rare but debilitating condition with an 8-fold increased risk of developing pancreatic cancer. In addition to the symptoms that come from the loss of endocrine and exocrine function in CP, the management of chronic pain is problematic. We previously showed that the CCK-receptor antagonist called proglumide could decrease inflammation, acinar-ductal metaplasia, and fibrosis in murine models of CP. We hypothesized that proglumide would be safe and diminish pain caused by CP. A Phase 1 open-labeled safety study was performed in subjects with clinical and radiographic evidence of CP with moderate to severe pain. After a 4-week observation period, the subjects were treated with proglumide in 400 mg capsules three times daily (1200 mg per day) by mouth for 12 weeks, and then subjects returned for a safety visit 4 weeks after the discontinuation of the study medication. The results of three pain surveys (Numeric Rating Scale, COMPAT-SF, and NIH PROMIS) showed that the patients had significantly less pain after 12 weeks of proglumide compared to the pre-treatment observation phase. Of the eight subjects in this study, two experienced nausea and diarrhea with proglumide. These side effects resolved in one subject with doses reduced to 800 mg per day. No abnormalities were noted in the blood chemistries. A blood microRNA blood biomarker panel that corresponded to pancreatic inflammation and fibrosis showed significant improvement. We conclude that proglumide is safe and well tolerated in most subjects with CP at a dose of 1200 mg per day. Furthermore, proglumide therapy may have a beneficial effect by decreasing pain associated with CP.
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Affiliation(s)
- Victor Ciofoaia
- Departments of Gastroenterology and Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA; (V.C.); (B.W.T.)
| | - Wenqiang Chen
- Department of Medicine, Georgetown University, Washington, DC 20007, USA; (W.C.); (M.G.); (N.S.)
| | - Bakain W. Tarek
- Departments of Gastroenterology and Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA; (V.C.); (B.W.T.)
| | - Martha Gay
- Department of Medicine, Georgetown University, Washington, DC 20007, USA; (W.C.); (M.G.); (N.S.)
| | - Narayan Shivapurkar
- Department of Medicine, Georgetown University, Washington, DC 20007, USA; (W.C.); (M.G.); (N.S.)
| | - Jill P. Smith
- Department of Medicine, Georgetown University, Washington, DC 20007, USA; (W.C.); (M.G.); (N.S.)
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3
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Olson CG, Karime C, Chirila R. 34-Year-Old Man With Sudden Epigastric Abdominal Pain. Mayo Clin Proc 2024; 99:649-654. [PMID: 38323944 DOI: 10.1016/j.mayocp.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 02/08/2024]
Affiliation(s)
- Caroline G Olson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Christian Karime
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Razvan Chirila
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Jacksonville, FL
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4
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Cammarata F, Rovati L, Fontana P, Gambitta P, Armellino A, Aseni P. Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review. Diagnostics (Basel) 2023; 13:3256. [PMID: 37892077 PMCID: PMC10606009 DOI: 10.3390/diagnostics13203256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/24/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.
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Affiliation(s)
- Francesco Cammarata
- Department of General Surgery, Ospedale Luigi Sacco, Università degli Studi di Milano, 20157 Milan, Italy;
| | - Lucrezia Rovati
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Paola Fontana
- Department of Gastroenterology, ASST Ovest Milanese, 20025 Legnano, Italy; (P.F.); (P.G.)
| | - Pietro Gambitta
- Department of Gastroenterology, ASST Ovest Milanese, 20025 Legnano, Italy; (P.F.); (P.G.)
| | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, 23807 Lecco, Italy;
| | - Paolo Aseni
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
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5
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Liou GY, Fleming Martinez AK, Döppler HR, Bastea LI, Storz P. Inflammatory and alternatively activated macrophages independently induce metaplasia but cooperatively drive pancreatic precancerous lesion growth. iScience 2023; 26:106820. [PMID: 37250781 PMCID: PMC10212997 DOI: 10.1016/j.isci.2023.106820] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/16/2023] [Accepted: 05/02/2023] [Indexed: 05/31/2023] Open
Abstract
The innate immune system has a key role in pancreatic cancer initiation, but the specific contribution of different macrophage populations is still ill-defined. While inflammatory (M1) macrophages have been shown to drive acinar-to-ductal metaplasia (ADM), a cancer initiating event, alternatively activated (M2) macrophages have been attributed to lesion growth and fibrosis. Here, we determined cytokines and chemokines secreted by both macrophage subtypes. Then, we analyzed their role in ADM initiation and lesion growth, finding that while M1 secrete TNF, CCL5, and IL-6 to drive ADM, M2 induce this dedifferentiation process via CCL2, but the effects are not additive. This is because CCL2 induces ADM by generating ROS and upregulating EGFR signaling, thus using the same mechanism as cytokines from inflammatory macrophages. Therefore, while effects on ADM are not additive between macrophage polarization types, both act synergistically on the growth of low-grade lesions by activating different MAPK pathways.
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Affiliation(s)
- Geou-Yarh Liou
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
- Department of Biological Sciences, Center for Cancer Research & Therapeutic Development, Clark Atlanta University, Atlanta, GA 30314, USA
| | | | - Heike R. Döppler
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Ligia I. Bastea
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Peter Storz
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224, USA
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6
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Kempeneers MA, Issa Y, Bruno MJ, van Santvoort HC, Besselink MG, Boermeester MA, Dijkgraaf MG. Cost-effectiveness of Early Surgery Versus Endoscopy-first Approach for Painful Chronic Pancreatitis in the ESCAPE Trial. Ann Surg 2023; 277:e878-e884. [PMID: 35129523 DOI: 10.1097/sla.0000000000005240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Economic evaluation of early surgery compared to the endoscopy-first approach in CP. BACKGROUND In patients with painful CP and a dilated main pancreatic duct, early surgery, as compared with an endoscopy-first approach, leads to more pain reduction with fewer interventions. However, it is unknown if early surgery is more cost-effective than the endoscopy-first approach. METHODS The multicenter Dutch ESCAPE trial randomized patients with CP and a dilated main pancreatic duct between early surgery (surgery within 6 weeks) or the endoscopy-first approach in 30 centers (April 2011-September 2016). Healthcare utilization was prospectively recorded up to 18 months after randomization. Unit costs of resources were determined, and cost-effectiveness and cost-utility analyses were performed from societal and healthcare perspectives. Primary outcomes were the costs per unit decrease on the Izbicki pain score and per gained quality-adjusted life-year. RESULTS In total, 88 patients were included in the analysis, with 44 patients randomized to each group. Total costs were lower in the early surgery group but did not reach statistical significance (mean difference €-4,815 (95% bias-corrected and accelerated confidence interval €-13,113 to €3411; P = 0.25). Early surgery had a probability percentage of 88.4% of being more cost-effective than the endoscopy-first approach at a willingness-to-pay threshold of €0 per day per unit decrease on the Izbicki pain score. The probability percentage per additional gained quality-adjusted life-year was 75.7% at a willingness-to-pay threshold of €50,000. CONCLUSION In patients with painful CP and a dilated main pancreatic duct, early surgery was more cost-effective than the endoscopy-first approach.
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Affiliation(s)
- Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yama Issa
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, the Netherlands
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7
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Takuma K, Okano N, Ito K, Ujita W, Iwata S, Mizutani S, Nakagawa H, Watanabe K, Yamada Y, Kimura Y, Yoshimoto K, Iwasaki S, Hara S, Kishimoto Y, Igarashi Y, Matsuda T, Amemiya K. Focal pancreatic ductal change induced by 10-Fr S-type plastic stent in chronic pancreatitis. J Gastroenterol Hepatol 2023; 38:112-118. [PMID: 36334302 DOI: 10.1111/jgh.16052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/25/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND AIM Stent-induced ductal change (SIDC) is a complication of endoscopic pancreatic stenting (EPS) in patients with chronic pancreatitis (CP). However, the evaluation of SIDC associated with S-type pancreatic plastic stent (PS) and large-caliber PS, such as 10 Fr, is limited. This study aimed to analyze the SIDC of the main pancreatic duct (MPD) associated with 10-Fr S-type PS in patients with CP. METHODS Between January 2008 and December 2021, 132 patients with CP in whom a 10-Fr S-type PS had been installed by EPS were retrospectively reviewed. The SIDC incidence rate was examined, and the clinical features of patients with and without SIDC were investigated, including the outcomes for detected SIDC. RESULTS Stent-induced ductal change during EPS was confirmed in 41 patients (31.1%) of 132 patients at a site coincident with the PS tip or distal flap in the MPD. All patients were asymptomatic during the development of SIDC. Morphological changes in the MPD were detected as elevated (75.6%) or bearing stricture changes (24.4%). A total of 90.2% of SIDC developed after the first 10-Fr PS installation. No significant differences were noted between the patients with and without SIDC. The outcomes of continued PS installment for SIDC showed persistence and secondary change. CONCLUSIONS Stent-induced ductal change-associated 10-Fr PS installation was performed in just under one-third of the patients, indicating a substantial incidence rate and a possible development of SIDC from early stages onwards. More emphasis should be placed on SIDC as the complication.
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Affiliation(s)
- Kensuke Takuma
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Naoki Okano
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ken Ito
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Wataru Ujita
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Shuntaro Iwata
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Saori Mizutani
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroki Nakagawa
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Koji Watanabe
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuto Yamada
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yusuke Kimura
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Yoshimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Susumu Iwasaki
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Seiichi Hara
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yui Kishimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kazuki Amemiya
- Department of Surgical Pathology, Toho University Omori Medical Center, Tokyo, Japan
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8
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Thermodynamic Sensitivity of Blood Plasma Components in Patients Afflicted with Skin, Breast and Pancreatic Forms of Cancer. Cancers (Basel) 2022; 14:cancers14246147. [PMID: 36551631 PMCID: PMC9776601 DOI: 10.3390/cancers14246147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
According to the World Health Organization's 2018 Global Cancer Survey, cancer is the second leading cause of death. From this survey, the third most common is breast cancer, the fifth is melanoma malignum and pancreatic adenocarcinoma ranks twentieth. Undoubtedly, the early diagnosis and monitoring of these tumors and related research is important for aspects of patient care. The aim of our present review was to explain an impressive methodology that is deemed suitable in reference to studying blood sample deviations in the case of solid tumors. Essentially, we compared the heat denaturation responses of blood plasma components through differential scanning calorimetry (DSC). In the control, between five and seven separable components can be detected, in which the primary component was albumin, while in the case of tumorous patients, the peaks of immunoglobulins were dominant. Moreover, the shape of the plasma DSC curves changed with a shift in the higher temperature ranges; thus, their pattern can be used as a suitable marker of direct immunological responses. The further development of the analysis of DSC curves raises the possibility of the early diagnosis of a potential tumor, the monitoring of diseases, or testing the efficacy of the therapy from a single drop of blood.
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9
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Vertiprakhov VG, Ovchinnikova NV. The activity of trypsin in the pancreatic juice and blood of poultry increases simultaneously in the postprandial period. Front Physiol 2022; 13:874664. [PMID: 36388123 PMCID: PMC9641294 DOI: 10.3389/fphys.2022.874664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/13/2022] [Indexed: 10/21/2023] Open
Abstract
Modern literature data indicate that the role of trypsin goes far beyond its digestive function. Once in the blood, trypsin is involved as part of the kallikrein-kinin system in the regulation of blood pressure, regulates pancreatic function by activating PAR receptors, and influences inflammation and immunity in the cell. The interaction of trypsin in the intestine and serum in the living healthy organism has been insufficiently studied. On the basis of our own studies and literature data, we concluded that after overnight fasting the increase of trypsin activity in pancreatic juice and blood serum in the postprandial period occurs in parallel, which determines not only digestion of food protein but also the level of metabolism. Consequently, determining the optimal amount of crude protein in the diet during the morning meal is a paramount task for physiologists.
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Affiliation(s)
| | - Natalya V. Ovchinnikova
- Timiryazev Russian State Agrarian University Moscow Agrarian Academy, Moscow, Russia
- Physiology of Motivation Laboratory, Anokhin Research Institute of Normal Physiology, Moscow, Russia
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10
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Coluzzi M, Naziruddin B, Kumano K, Saracino G, Testa G, Beecherl E, Onaca N. Spleen-preserving total pancreatectomy and islet autotransplantation with complete preservation of the splenic arterial and venous supply does not impact islet yield and function. Am J Surg 2022; 224:1295-1300. [PMID: 35781373 DOI: 10.1016/j.amjsurg.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Standard total pancreatectomy and islet autotransplantation (TPIAT) for chronic pancreatitis includes splenectomy, but TPIAT can be performed without splenectomy by full preservation of the blood supply to the spleen. METHODS We compared the metabolic and clinical outcomes of patients who underwent TPIAT at our center between 2015 and 2021 with or without splenectomy. A total of 89 patients were included in the study, and 17 of them underwent spleen-preserving total pancreatectomy (SPTP). RESULTS The two study groups had similar demographic and metabolic parameters. Short-term morbidity and long-term outcomes were similar. The operative time was significantly shorter with splenectomy: a median of 9.91 h (interquartile range [IQR] 8.89-10.83) compared to 10.78 h (IQR 10.2-11.6) for SPTP (P = 0.021). There was no difference between the groups in postoperative morbidity. Metabolic outcomes at 1 year were better in the SPTP group compared to the splenectomy group, with a median daily insulin requirement of 7 units (IQR 4-12) vs 15 units (IQR 7-26; P = 0.049) and a median C-peptide at 1 year of 0.65 (IQR 0.40-1.26) vs 1.00 (IQR 0.80-1.90; P = 0.63). The reduction in morphine milligram equivalents per day over time was significantly better in the SPTP group (P < 0.001), as was the decrease in pain score (P < 0.001). CONCLUSION TPIAT with full arterial and venous preservation of the spleen had no adverse impact on islet yield or function. TPIAT can be safely and effectively performed with preservation of the spleen and the entire splenic artery and vein. The spleen should be preserved when feasible in every TPIAT surgery.
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Affiliation(s)
- Mariagrazia Coluzzi
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA; Unit of General and Emergency Surgery, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Bashoo Naziruddin
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Kenjiro Kumano
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Ernest Beecherl
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas Onaca
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA; LifeGift, Fort Worth, TX, USA
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11
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Liu Y, Yin XY, Wang D, Dong ZQ, Hao L, Chen C, Wang T, Zhang D, Ma JY, Yang HY, Li J, Zhang LL, Bi YW, Zhang Y, Xin L, Chen H, Zhang QS, Xie T, Lu GT, Li ZS, Liao Z, Hu LH. Risk factor analysis and nomogram development for steatorrhea in idiopathic chronic pancreatitis. J Dig Dis 2022; 23:331-340. [PMID: 35703114 DOI: 10.1111/1751-2980.13102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Steatorrhea, a sign of severe pancreatic exocrine insufficiency (PEI), is related to consequences caused by pancreatitis. This study aimed to identify predictors and to construct a nomogram for steatorrhea in idiopathic chronic pancreatitis (ICP). METHODS ICP patients admitted to our hospital from January 2000 to December 2013 were enrolled in this retrospective-prospective cohort study and randomly assigned to the training and validation cohorts. The cumulative rate of steatorrhea was calculated. A Cox proportional hazard regression model was used to identify predictors for steatorrhea and construct the nomogram. Internal and external validation of the nomogram was then performed. RESULTS There were 1633 ICP patients enrolled, with a median follow-up duration of 9.8 years and 20.8% (339/1633) of patients developed steatorrhea following onset of ICP. Steatorrhea was observed in 93, 115, and 133 patients at 1, 3, and 5 years following diagnosis of CP, with a cumulative rate of 6.5% (95% confidence interval [CI] 5.1%-7.9%), 8.0% (95% CI 6.2%-9.8%), and 9.3% (95% CI 6.6%-12.0%), respectively. Male sex (hazard ratio [HR] 2.479, P < 0.001), diabetes mellitus at/before diagnosis of ICP (HR 2.274, P = 0.003), and aged less than 18 years at onset of ICP (HR 0.095, P < 0.001) were identified risk factors for steatorrhea. Initial manifestations were associated with development of steatorrhea. The nomogram was proven to have good concordance indexes. CONCLUSIONS We identified predictors and developed a nomogram for predicting steatorrhea in ICP. It was recommended that high-risk populations be followed up closely, which might contribute to the early diagnosis and treatment of PEI.
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Affiliation(s)
- Yu Liu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Xiao Yi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhi Qi Dong
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Hao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Cui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Di Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jia Yi Ma
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Huai Yu Yang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Juan Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ling Ling Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ya Wei Bi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yuan Zhang
- Department of Ophthalmology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lei Xin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Qi Sheng Zhang
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Xie
- Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China
| | - Guo Tao Lu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
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12
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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13
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Mou Y, Song Y, Chen HY, Wang X, Huang W, Liu XB, Ke NW. Which Surgeries Are the Best Choice for Chronic Pancreatitis: A Network Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 8:798867. [PMID: 35187048 PMCID: PMC8850358 DOI: 10.3389/fsurg.2021.798867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundSurgery is an effective choice for the treatment of chronic pancreatitis (CP). However, there is no clear consensus regarding the best choice among the surgical procedures. The aim of this study is to conduct a network meta-analysis of randomized controlled trials comparing treatment outcomes to provide high-quality evidences regarding which is the best surgery for CP.MethodsA systematic search of the PubMed (MEDLINE), SCIE, EMBASE, CENTRAL, and CDSR databases were performed to identify studies comparing surgeries for CP from the beginning of the databases to May 2020. Pain relief and mortality were the primary outcomes of interest.ResultsTen studies including a total of 680 patients were identified for inclusion. PPPD had a better postoperative short-term pain relief and quality of life (QOL), but a worse pancreatic exocrine function deficiency and high morbidity. Berne had a significant postoperative long-term pain relief and mortality with a lower risk of pancreatic exocrine function deficiency.ConclusionThe main surgical procedures including the PPPD, Beger procedure, Frey modification and Berne modification can efficaciously treat CP. The Berne modification may be first choice with better efficacy and less complications in pancreatic function, but the impact of postoperative QOL cannot be ignored. Furthermore, when the CP patients have a mass in the pancreatic head which cannot be distinguished from pancreatic cancer, the only legitimate choice should be PPPD or classical pancreaticoduodenectomy.
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Affiliation(s)
- Yu Mou
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Song
- Geriatrics Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hong-Yu Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Neng-Wen Ke
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14
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Inciarte DJ, Ramon D. Diseases of the Pancreas. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Petrik ML, Freeman ML, Trikudanathan G. Multidisciplinary Care for Adults With Chronic Pancreatitis: Incorporating Psychological Therapies to Optimize Outcomes. Pancreas 2022; 51:4-12. [PMID: 35195589 DOI: 10.1097/mpa.0000000000001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
ABSTRACT Chronic pancreatitis (CP) is associated with a high disease burden, extensive negative impact on quality of life, increased rates of depression and anxiety, and significant health care utilization and expenditures. Pain is a hallmark feature of CP, present in up to 90% of patients with this condition, and can lead to high rates of disability, hospitalization, and opioid medication use. Current perspectives on the management of CP have evolved to advocate a multidisciplinary approach which offers new pathways for helping patients manage symptoms. Psychologists play an important role in a multidisciplinary team effort by applying scientifically based psychological principles and techniques to improve pain and adaptation to chronic illness. This review will detail the fundamentals of delivering psychological interventions for adults with CP managed in an outpatient setting. Recommendations for integrating psychological care in multidisciplinary management of CP will be offered. Future directions for psychological care in CP multidisciplinary teams are also discussed.
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Affiliation(s)
- Megan L Petrik
- From the Division of General Internal Medicine, Department of Medicine
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
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16
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Ashraf H, Colombo JP, Marcucci V, Rhoton J, Olowoyo O. A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management. Cureus 2021; 13:e19764. [PMID: 34938639 PMCID: PMC8684888 DOI: 10.7759/cureus.19764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/05/2022] Open
Abstract
An inflammatory process involving the pancreas, known as pancreatitis, can be categorized as either acute or chronic and may present in one of many ways. The clinical manifestations of acute pancreatitis are generally limited to epigastric or right upper quadrant pain, while manifestations of chronic pancreatitis are broader and may include abdominal pain in tandem with signs and symptoms of pancreatic endocrine and exocrine insufficiency. An understanding of the initial insult, proper classification, and prognosis are all factors that are of paramount importance as it pertains to managing patients who are afflicted with this disease. Our review delves into the depths of pancreatitis by exploring the embryology and anatomy of the pancreas, the pathophysiology and etiology of acute and chronic pancreatitis, and the medical and surgical management of acute and chronic pancreatitis.
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Affiliation(s)
- Hamza Ashraf
- Medical Education, St. Peter's University Hospital, New Brunswick, USA
| | - John Paul Colombo
- Medical Research, St. Peter's University Hospital, New Brunswick, USA.,Medical Research, St. George's University School of Medicine, True Blue, GRD
| | | | - Jonathan Rhoton
- Surgery, Hackensack University Medical Center, Hackensack, USA
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17
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Toldi V, Kassay N, Szabó A. Missense PNLIP mutations impeding pancreatic lipase secretion cause protein misfolding and endoplasmic reticulum stress. Pancreatology 2021; 21:1317-1325. [PMID: 34373204 DOI: 10.1016/j.pan.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE Mutation-induced misfolding of digestive enzymes has been shown to cause chronic pancreatitis. Recently, heterozygous pancreatic lipase (PNLIP) mutations leading to reduced secretion were identified. The aim of the present study was to investigate whether PNLIP mutants with a secretion defect result in endoplasmic reticulum (ER) stress in cell culture models. METHODS We introduced the coding DNA for wild-type and A174P, G233E, C254R and V454F mutant PNLIP into two mammalian cell lines and carried out functional assays to assess PNLIP expression, secretion and ER stress. RESULTS We found that wild-type PNLIP was readily secreted from the investigated cell lines. In contrast, none of the lipase mutants were detectable in the conditioned media. PNLIP variants accumulated in the cells as intracellular protein aggregates probably due to misfolding in the ER. Consistent with this notion, PNLIP mutants induced ER stress, as indicated by increased mRNA levels of spliced X-box Binding Protein 1 (XBP1) and the ER chaperone Immunoglobulin Binding Protein (BiP). CONCLUSION The results indicate that PNLIP mutations associated with a lipase secretion defect cause ER stress and thereby may increase the risk for chronic pancreatitis.
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Affiliation(s)
- Vanda Toldi
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Doctoral School of Molecular, Cell and Immune Biology, University of Debrecen, Debrecen, Hungary
| | - Norbert Kassay
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - András Szabó
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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18
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Viggers R, Jensen MH, Laursen HVB, Drewes AM, Vestergaard P, Olesen SS. Glucose-Lowering Therapy in Patients With Postpancreatitis Diabetes Mellitus: A Nationwide Population-Based Cohort Study. Diabetes Care 2021; 44:2045-2052. [PMID: 34362812 DOI: 10.2337/dc21-0333] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Postpancreatitis diabetes mellitus (PPDM) is a type of secondary diabetes that requires special considerations for management. The main objective was to examine prescription patterns of glucose-lowering therapy among adults with PPDM compared with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS In a Danish nationwide population-based cohort study, we identified all individuals with adult-onset diabetes in the period 2000-2018 and categorized them as having type 1 diabetes, type 2 diabetes, or PPDM. We ascertained diabetes incidence rates, clinical and demographic characteristics, and classifications and prescription patterns of glucose-lowering therapy and compared these parameters across diabetes subgroups. RESULTS Among 398,456 adults with new-onset diabetes, 5,879 (1.5%) had PPDM, 9,252 (2.3%) type 1 diabetes, and the remaining type 2 diabetes (96.2%). The incidence rate of PPDM was 7.9 (95% CI 7.7-8.1) per 100,000 person-years versus 12.5 (95% CI 12.2-12.7) for type 1 diabetes (incidence rate ratio 0.6 [95% CI 0.6-0.7]; P < 0.001). A sizeable proportion of patients with PPDM were classified as having type 2 diabetes (44.9%) and prescribed sulfonylureas (25.2%) and incretin-based therapies (18.0%) that can potentially be harmful in PPDM. In contrast, 35.0% of patients never received biguanides, which are associated with a survival benefit in PPDM. Increased insulin requirements were observed for patients with PPDM compared with type 2 diabetes (hazard ratio 3.10 [95% CI 2.96-3.23]; P < 0.001) in particular for PPDM associated with chronic pancreatitis (hazard ratio 4.30 [95% CI 4.01-4.56]; P < 0.001). CONCLUSIONS PPDM is a common type of secondary diabetes in adults but is often misclassified and treated as type 2 diabetes, although PPDM requires special considerations for management.
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Affiliation(s)
- Rikke Viggers
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark .,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Hasselstrøm Jensen
- Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Henrik Vitus Bering Laursen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology and Hepatology, Mech-Sense and Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
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19
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Srivoleti P, Yang AL, Jin DX, Banks PA, McNabb-Baltar J. Does Provider Type Affect Bone Health Surveillance in Chronic Pancreatitis? Dig Dis Sci 2021; 66:2235-2239. [PMID: 32816216 DOI: 10.1007/s10620-020-06542-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/06/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bone density screening (DEXA) and vitamin D serum assay (Vit-D) are recommended in chronic pancreatitis, but adherence by providers is unknown. AIMS Assess DEXA/Vit-D testing according to provider type. METHODS A retrospective cohort study of chronic pancreatitis patients followed in a tertiary hospital (August 2017-2018) was conducted. Provider type was primary care (PCP), gastroenterologist, and pancreas specialist. Chi-square test and multivariable analysis were conducted to assess the relation between provider type and DEXA/Vit-D testing. Subset analyses were performed among patients with fecal elastase < 200 mcg/g. RESULTS A total of 478 charts were reviewed, and 256 (53.6%) met diagnosis of chronic pancreatitis; 184 (71.9%) definite, 45 (17.6%) probable, and 27 (10.6%) borderline chronic pancreatitis. DEXA was tested in 112/256 (43%) patients; 16/57(28%) patients followed by PCP, 11/38 (28.9%) by gastroenterologists, and 85/161(52.2%) by pancreas specialists (p = 0.001). Vit-D was tested in 210/256 (82.0%) patients; 42/57(73.7%) followed by PCP, 29/38 (76.3%) by gastroenterologists, and 139/161(86.3%) by pancreas specialists (p = 0.06). Multivariate analysis assessing DEXA/Vit-D testing showed pancreas specialists were more likely to test compared to PCP (DEXA: OR 3.70, CI 1.77-7.74, p = 0.001. Vit-D: OR 3.24, CI 1.43-7.38, p = 0.005), but gastroenterologists were not. In patients with low fecal elastase, pancreas specialists were more likely to test DEXA (pancreas specialists: 62.1%, PCP: 40.0%, Gastroenterologists: 11.1%, p = 0.01) and all patients received Vit-D testing. CONCLUSIONS Chronic pancreatitis patients often do not receive optimal preventive care. Pancreas specialists were more likely to perform DEXA and Vit-D testing compared to PCP and gastroenterologists. More physician education is needed.
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Affiliation(s)
- Padmavathi Srivoleti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Allison L Yang
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine College, New York, NY, USA
| | - David X Jin
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter A Banks
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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20
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Endoscopic versus Surgical Intervention for Painful Obstructive Chronic Pancreatitis: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10122636. [PMID: 34203858 PMCID: PMC8232696 DOI: 10.3390/jcm10122636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/21/2022] Open
Abstract
There is limited evidence on the standard care for painful obstructive chronic pancreatitis (CP), while comparisons of endoscopic and surgical modes for pain relief have yielded conflicting results from small sample sizes. We aimed to obtain a clear picture of the matter by a meta-analysis of these results. We searched the Pubmed, Embase, and Cochrane Library databases to identify studies comparing endoscopic and surgical treatments for painful obstructive CP. Pooled effects were calculated by the random effect model. Primary outcomes were overall pain relief (complete and partial), and secondary outcomes were complete and partial pain relief, complication rate, hospitalization duration, and endocrine insufficiency. Seven studies with 570 patients were included in the final analysis. Surgical drainage was associated with superior overall pain relief [OR 0.33, 95% CI 0.23–0.47, p < 0.001, I2 = 4%] and lesser incidence of endocrine insufficiency [OR 2.10, 95% CI 1.20–3.67, p = 0.01, I2 = 0%], but no significant difference in the subgroup of complete [OR 0.57, 95% CI 0.32–1.01, p = 0.054, I2 = 0%] or partial [OR 0.67, 95% CI 0.37–1.22, p = 0.19, I2 = 0%] pain relief, complication rates [OR 1.00, 95% CI 0.41–2.46, p = 0.99, I2 = 49%], and hospital stay [OR −0.54, 95% CI −1.23–0.15, p = 0.13, I2 = 87%] was found. Surgery is associated with significantly better overall pain relief and lesser endocrine insufficiency in patients with painful obstructive CP. However, considering the invasiveness of surgery, no significant differences in complete or partial pain relief, and heterogeneity of a few parameters between two groups, endoscopic drainage may be firstly performed and surgical drainage may be considered when endoscopic drainage fails.
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21
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Persistent Anemia in the Setting of a Rare Pancreatic Pseudoaneurysm. Case Rep Gastrointest Med 2021; 2021:5550005. [PMID: 34035967 PMCID: PMC8116162 DOI: 10.1155/2021/5550005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction. Pancreatic pseudoaneurysm is a rare but potentially fatal complication that can follow pancreatitis. While early detection is critical to preventing poor long-term outcomes, clinical features vary significantly. Most often, abdominal pain is the presenting complaint, but this can be complicated as classic symptoms of pancreatitis also present with abdominal pain. Herein, we present a patient with an acute on chronic gastrointestinal bleed that was finally attributed to a pancreatic pseudoaneurysm. Case Presentation. The patient was a 56-year-old male with a past medical history significant for epilepsy, alcohol abuse, and hypertension who presented as a transfer from an outside facility for a gastrointestinal bleed. Prior to presentation, the patient reported rectal bleeding over the prior 1.5 months but had not sought care until bleeding increased along with increased abdominal pain. The patient's hemoglobin was 6.3 at presentation of the outside facility and received a total of four units of packed red blood cells (PRBCs) prior to arrival. After arrival, persistent bleeding was noted, and an additional 2 units of PRBCs were transfused. A computed tomography angiography (CTA) of the abdomen was obtained to identify the source for embolization. This, however, revealed a 4 × 4 × 3.5 cm intrinsically dense or enhanced mass of the pancreatic head. Discussion. Pancreatic pseudoaneurysm is a rare but potentially fatal complication that can follow pancreatitis. In chronic pancreatitis patients who underwent imaging incidence is estimated to be up to 10%. Treatment is difficult, and coil embolization is often used, though this can lead to splenectomy due to splenic ischemia. Stent grafts can be used in the surrounding arteries to maintain the integrity of viscera but carry risk of stent-related thrombosis. Further research is needed on the optimal management of this potentially lethal complication of pancreatitis.
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22
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Mendieta PJO, Sagae VMT, Ribeiro IB, de Moura DTH, Scatimburgo MVCV, Hirsch BS, Rocha RSDP, Visconti TADC, Sánchez-Luna SA, Bernardo WM, de Moura EGH. Pain relief in chronic pancreatitis: endoscopic or surgical treatment? a systematic review with meta-analysis. Surg Endosc 2021; 35:4085-4094. [PMID: 33948714 DOI: 10.1007/s00464-021-08515-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Pain is one of the consequences of chronic pancreatitis (CP) that has the greatest impact on the quality of life of patients. Endoscopic and surgical interventions, by producing a decrease in intraductal pancreatic pressure, can provide pain relief. This is the first systematic review that includes only randomized clinical trials (RTCs) comparing outcomes in the short-term (less than 2 years) and long-term (more than 2 years) between these two types of interventions. MATERIAL AND METHODS A comprehensive search of multiple electronic databases to identify RTCs comparing short and long-term pain relief, procedural complications, and days of hospitalization between endoscopic and surgical interventions was performed following the PRISMA guidelines. RESULTS Three RCTs evaluating a total of 199 patients (99 in the endoscopy group and 100 in the surgery group) were included in this study. Surgical interventions provided complete pain relief, with statistical difference, in the long-term (16,4% vs 35.7%; RD 0.19; 95% CI 0.03-0.35; p = 0.02; I2 = 0%), without significant difference in short-term (17.5% vs 31.2%; RD 0.14; 95% CI -0.01-0.28; p = 0.07; I2 = 0%) when compared to endoscopy. There was no statistical difference in short-term (17.5% vs 28.1%; RD 0.11; 95% CI -0.04-0.25; p = 0.15; I2 = 0%) and long-term (34% vs 41.1%; RD 0.07; 95% CI -0.10-0.24; p = 0.42; I2 0%) in partial relief of pain between both interventions. In the short-term, both complications (34.9% vs 29.7%; RD 0.05; 95% CI -0.10-0.21; p = 0.50; I2 = 48%) and days of hospitalization (MD -1.02; 95% CI -2.61-0.58; p = 0.21; I2 = 0%) showed no significant differences. CONCLUSION Surgical interventions showed superior results when compared to endoscopy in terms of complete long-term pain relief. The number of complications and length of hospitalization in both groups were similar.
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Affiliation(s)
- Pastor Joaquín Ortiz Mendieta
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Vitor Massaro Takamatsu Sagae
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Igor Braga Ribeiro
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Maria Vitória Cury Vieira Scatimburgo
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Salomao Hirsch
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rodrigo Silva de Paula Rocha
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Thiago Arantes de Carvalho Visconti
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Sergio A Sánchez-Luna
- Center for Advanced Endoscopy, Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham, Birmingham,, Alabama, USA
| | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Sanjeevi R, Jamwal KD, Dhar Chowdhury S, Ramadass B, Gayathri R, Dutta AK, Joseph Joseph A, Ramakrishna BS, Chacko A. Assessment of small intestinal bacterial overgrowth in chronic pancreatitis patients using jejunal aspirate culture and glucose hydrogen breath test. Scand J Gastroenterol 2021; 56:588-593. [PMID: 33730978 DOI: 10.1080/00365521.2021.1900383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A subset of chronic pancreatitis patients respond poorly to pancreatic enzyme replacement therapy. Small intestinal bacterial overgrowth (SIBO) is considered to be one of the major reasons for this poor response. Previous studies have reported a wide range of prevalence of SIBO in patients with chronic pancreatitis. We aimed to assess the prevalence of SIBO in chronic pancreatitis using quantitative jejunal aspirate culture and glucose hydrogen breath test (GHBT). The sensitivity and specificity of GHBT for the diagnosis of SIBO in chronic pancreatitis were also estimated. METHODS Newly diagnosed chronic pancreatitis patients were recruited into the study. A detailed history and relevant laboratory tests were done. All patients underwent an endoscopy and jejunal fluid aspiration for bacterial cultures and GHBT to detect SIBO. The results of GHBT were compared with jejunal fluid aspirate culture. RESULTS The jejunal aspirate culture was positive in 18/48 (37.5%) patients while the GHBT showed that 14/48 (29%) patients had SIBO. The sensitivity, specificity, positive and negative predictive value of GHBT in our study was 44.4, 80, 57.14 and 70.59%, respectively. CONCLUSIONS SIBO is not uncommon in chronic pancreatitis patients. One-third of our study population had SIBO. GHBT has low sensitivity but had high specificity in the diagnosis of SIBO in chronic pancreatitis.
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Affiliation(s)
| | | | | | | | - R Gayathri
- Christian Medical College, Vellore, India
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24
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Swentek L, Chung D, Ichii H. Antioxidant Therapy in Pancreatitis. Antioxidants (Basel) 2021; 10:657. [PMID: 33922756 PMCID: PMC8144986 DOI: 10.3390/antiox10050657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis is pathologic inflammation of the pancreas characterized by acinar cell destruction and oxidative stress. Repeated pancreatic insults can result in the development of chronic pancreatitis, characterized by irreversible fibrosis of the pancreas and many secondary sequelae, ultimately leading to the loss of this important organ. We review acute pancreatitis, chronic pancreatitis, and pancreatitis-related complications. We take a close look at the pathophysiology with a focus on oxidative stress and how it contributes to the complications of the disease. We also take a deep dive into the evolution and current status of advanced therapies for management including dietary modification, antioxidant supplementation, and nuclear factor erythroid-2-related factor 2-Kelch-like ECH-associated protein 1(Nrf2-keap1) pathway activation. In addition, we discuss the surgeries aimed at managing pain and preventing further endocrine dysfunction, such as total pancreatectomy with islet auto-transplantation.
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Affiliation(s)
| | | | - Hirohito Ichii
- Department of Surgery, University of California, Irvine, CA 92868, USA; (L.S.); (D.C.)
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25
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Abstract
Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.
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26
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Inciarte DJ, Ramon D. Diseases of the Pancreas. Fam Med 2021. [DOI: 10.1007/978-1-4939-0779-3_175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Short- and long-term surgical outcomes of total pancreatectomy with islet autotransplantation: A comparative analysis of surgical technique and intraoperative heparin dosing to optimize outcomes. Pancreatology 2021; 21:291-298. [PMID: 33268025 DOI: 10.1016/j.pan.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total pancreatectomy with islet autotransplantation (TP-IAT) is an uncommon surgical procedure with unique perioperative management. We evaluated the short- and long-term morbidity and mortality of TP-IAT to optimize surgical technique and heparin dosing during islet autotransplantation. METHODS Eighty patients with chronic pancreatitis undergoing TP-IAT were reviewed. Primary outcome was to evaluate morbidity and mortality based on operative technique: classic (resection of antrum) vs pylorus-preserving. Secondary outcome was to evaluate the effect of heparin dosing (<60 vs ≥ 60 units/kg) during islet autotransplantation on postoperative hemorrhage and portal vein thrombosis (PVT) rates. RESULTS There was no 90-day mortality, and median length of stay was 9 days. All patients underwent an open operation with 53 (66%) pylorus-preserving resections. The 30-day morbidity rate was 39%, with no difference between operative technique (p = 0.82). The median dose was different for each heparin group (<60: 52 units/kg vs ≥ 60: 66 units/kg, p < 0.0001). No difference was observed in postoperative hemorrhage rates between heparin groups (<60: 9% vs ≥ 60: 9%, p = 0.97), with no known incidence of PVT. Median follow-up was 36 months (IQR, 14-71). Morbidity >30 days after TP-IAT was 43% with a higher rate in the pylorus-preserving group (55% vs 15%, p < 0.0001), mainly attributed to marginal ulcer formation (15% vs 0%, p = 0.03). CONCLUSIONS A classic TP-IAT technique should be universally adopted to achieve optimal outcomes, particularly to prevent the formation of marginal ulcers. When considering PVT versus postoperative hemorrhage risk, a lower heparin dose nearing 50 units/kg is optimal. These findings highlight potential areas for future improvement.
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Assessment of Weight Loss and Gastrointestinal Symptoms Suggestive of Exocrine Pancreatic Dysfunction After Acute Pancreatitis. Clin Transl Gastroenterol 2020; 11:e00283. [PMID: 33464001 PMCID: PMC7743841 DOI: 10.14309/ctg.0000000000000283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Studies evaluating the natural history of exocrine pancreatic dysfunction (EPD) after acute pancreatitis (AP) are sparse. This study aims to assess incidence and predictors of weight loss and gastrointestinal (GI) symptoms suggestive of EPD 12 months after an AP episode. METHODS Patients enrolled in the Pancreatitis-associated Risk of Organ Failure Study at the time of an AP episode were included. Weight and GI symptom data were prospectively collected by self-report at enrollment and at 3- and 12-month (windows 2-7 and 8-20) telephone follow-ups. Multivariable logistic regression was used to assess factors associated with ≥10% total body weight loss (EPD surrogate) at 12 months. A generalized estimating equation was used to measure each factor's population effect (in pounds) over 12 months after AP. RESULTS Follow-up at 12 months in 186 patients (median age = 54 years, 46% men, 45% biliary, 65% first AP attack) revealed weight loss ≥10% from baseline, occurring in 44 patients (24%). Risk of weight loss increased with higher baseline body mass index, previous diagnosis of diabetes mellitus, and worsening AP severity (all P < 0.010). GI symptoms were reported in 13/31 (42%) patients at 12 months. AP severity was independently associated with ≥10% weight loss at 12 months. Over 12 months, men lost more weight than women (average 9.5 lbs); patients with severe AP lost, on average, 14 lbs. DISCUSSION Weight loss after AP occurs in one-quarter of patients and is associated with AP severity. EPD incidence after AP is likely underappreciated. Further work is needed to assess EPD and potential for pancreatic enzyme supplementation.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the role of endoscopic ultrasound (EUS) in the diagnosis and treatment of chronic pancreatitis (CP). RECENT FINDINGS EUS has evolved and become invaluable in diagnosing early CP with the use of elastography and contrast enhancement. Lumen-apposing metal stents have allowed for easier transmural drainage and necrosectomy for pancreatic pseudocyst and walled of necrosis. EUS-guided pancreatic duct drainage is being utilized for pancreatic duct complications including stenosis, stones, and duct disruptions that are not amendable to endoscopic retrograde cholangiopancreatography. EUS is an effective tool that assists with the diagnosis and treatment of CP. The technology continues to evolve allowing for diagnosis of CP in earlier stages, which enables more effective therapy. The development of new EUS-guided tools and techniques has improved the treatment of complications from CP.
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A new ultrasound score for the assessment and follow-up of chronic pancreatitis: The 'Gemelli USCP score'. Dig Liver Dis 2020; 52:644-650. [PMID: 32273171 DOI: 10.1016/j.dld.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/31/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ultrasound (US) is frequently the first line imaging technique used in patients with abdominal pain and clinical suspicion of chronic pancreatitis (CP), but its role in the diagnosis and follow-up of CP is still controversial. AIMS We aimed to develop a dedicated score for the US staging of CP and to evaluate the agreement of this score with standard imaging techniques. METHODS Ninety consecutive patients with a diagnosis of CP referred to the pancreatic outpatient clinic of A. Gemelli Hospital between June and September 2018 were recruited in the study. Patients underwent pancreatic US to evaluate different morphological parameters to develop an US based score system, called the Gemelli UltraSound Chronic Pancreatitis (USCP) score. RESULTS The Gemelli USCP score significantly increased according to the Cambridge score for both mean value (p<0.0001) and each parameter evaluated (p<0.0001). Moreover, we found a significant correlation between the score and laboratory parameters related to pancreatic exocrine insufficiency such as vitamin D, B9, and B12 deficiency and fecal elastase values (p<0.0001). CONCLUSIONS The development of a dedicated US score could be useful in the follow up of patients with CP as alternative non-invasive technique to standard radiological imaging.
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31
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Ahmed A, Deep A, Kothari DJ, Sheth SG. Bone disease in chronic pancreatitis. World J Clin Cases 2020; 8:1574-1579. [PMID: 32432135 PMCID: PMC7211537 DOI: 10.12998/wjcc.v8.i9.1574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 04/18/2020] [Indexed: 02/05/2023] Open
Abstract
Bone disease (osteopenia or osteoporosis) is a highly prevalent condition in society and presents a tremendous, preventable public health burden. Screening procedures, such as, dual-energy X-ray absorptiometry scans, have allowed early identification and intervention to improve bone health, and reduce the risk of osteoporotic fractures, which carry significant morbidity and mortality. The association of bone disease has been recognized in several diseases of the gastrointestinal tract, resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac disease. Increasingly, the risk of bone disease has been recognized in patients with chronic pancreatitis (CP), who share similar risk factors as patients with other high gastrointestinal disorders. As a result, there have been a number of studies examining the prevalence and risks of bone disease and fractures in patients with CP. This review aims to summarize the recent literature and current recommendations related to bone disease in CP.
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Affiliation(s)
- Awais Ahmed
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Aman Deep
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
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Barkin JA, Barkin JS. Chronic Pancreatitis and Bone Disease. J Clin Densitom 2020; 23:237-243. [PMID: 31558406 DOI: 10.1016/j.jocd.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022]
Abstract
Patients with chronic pancreatitis (CP) may have a higher prevalence of osteoporosis than the general population thereby increasing the risk of bone fracture. The pathophysiology of bone disease in CP is multifactorial. Their risk factors for secondary osteoporosis include increasing age, low body mass index from sitophobia, maldigestion due to exocrine pancreatic insufficiency (EPI) with resulting low vitamin D, as well as smoking and alcohol abuse. An obvious association of bone disease with CP is from EPI with maldigestion of fat-soluble vitamins including vitamin-D, which has a significant role in the process of bone formation. Vitamin-D deficiency may be higher in CP patients vs controls, and it is especially so in CP patients with EPI. Screening for CP-associated osteopathy, including osteopenia and osteoporosis, should be initiated early in the course of CP, as the overall prevalence of bone disease is approximately two-thirds of CP patients. Our initial approach in the treatment of osteoporosis should include correction of maldigestion resulting from EPI with use of pancreatic enzyme replacement therapy (PERT). PERT, which is the treatment for EPI is associated with improvement in Dual energy X-ray absorptiometry (DXA) values and vitamin-D levels compared to those who are not treated. This should improve, in addition to body mass index, vitamin-D deficiency and calcium absorption as well as improve overall nutritional status. Osteopathy is common in CP patients, has significant associated morbidity, should be screened for regularly, and corrected with fat soluble vitamin supplementation and PERT to prevent clinical sequelae. In this article, we review the epidemiology, pathophysiology, and treatment of bone disease in patients with CP.
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Affiliation(s)
- Jodie A Barkin
- University of Miami, Leonard M. Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL USA.
| | - Jamie S Barkin
- University of Miami, Leonard M. Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL USA
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33
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Issa Y, Kempeneers MA, Bruno MJ, Fockens P, Poley JW, Ahmed Ali U, Bollen TL, Busch OR, Dejong CH, van Duijvendijk P, van Dullemen HM, van Eijck CH, van Goor H, Hadithi M, Haveman JW, Keulemans Y, Nieuwenhuijs VB, Poen AC, Rauws EA, Tan AC, Thijs W, Timmer R, Witteman BJ, Besselink MG, van Hooft JE, van Santvoort HC, Dijkgraaf MG, Boermeester MA. Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis: The ESCAPE Randomized Clinical Trial. JAMA 2020; 323:237-247. [PMID: 31961419 PMCID: PMC6990680 DOI: 10.1001/jama.2019.20967] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. OBJECTIVE To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. INTERVENTIONS There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. MAIN OUTCOMES AND MEASURES The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. RESULTS Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. CONCLUSIONS AND RELEVANCE Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN45877994.
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Affiliation(s)
- Yama Issa
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marinus A. Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Usama Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cees H. Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Hendrik M. van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Casper H. van Eijck
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Jan-Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland Hospital, Sittard/Heerlen, the Netherlands
| | | | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | - Erik A. Rauws
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Adriaan C. Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhemina Hospital, Nijmegen, the Netherlands
| | - Willem Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Ben J. Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel G. Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Hines OJ. Tracing the Evidence to Address Painful Chronic Pancreatitis With Surgery. JAMA 2020; 323:219-220. [PMID: 31961398 DOI: 10.1001/jama.2019.19988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- O Joe Hines
- David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles
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35
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Exocrine Pancreatic Insufficiency and Nutritional Complications. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. RECENT FINDINGS Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.
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Affiliation(s)
- Kaveh Sharzehi
- Division of Gastroenterology & Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
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37
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Abstract
Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine, resulting in malabsorption. Clinical manifestations of EPI are often nonspecific and can lead to lack of timely recognition and diagnosis. Central to this clinical dilemma is the lack of highly accurate or specific testing which leads to misdiagnosis and suboptimal treatment. Identification of high-risk patients is key in the diagnosis of EPI and this includes patients with pancreatic parenchyma disorders such as chronic pancreatitis, pancreatic malignancy, cystic fibrosis, and those undergoing pancreatic resection for benign and malignant disease. Less recognized are the number of additional conditions which may also have EPI as a consequence. Owing to an increase in morbidity and impaired quality of life associated with this condition, goals of treatment have been aimed at repleting exocrine enzyme deficiency by oral pancreatic enzyme replacement therapy (PERT). The basis of PERT is to provide activated digestive enzymes to the small bowel during the prandial period, mainly, leading to sufficient absorption of fat and fat-soluble vitamins. The benefits of PERT have been shown to go beyond the improvement in signs and symptoms associated with EPI and include decreasing prevalence of osteopathy and improving survival outcomes in subsets of patients with this condition. However, despite the overall benefits in treatment, the diagnosis and management of EPI are suboptimal. Current literature suggests patients at high risk of developing EPI are not tested and those who are diagnosed are not treated with adequate dosages. In this review, we highlight patients who are at high risk for the development of EPI, analyze consequences and treatment of this disorder, review rationale for enzyme replacement therapy, and examine current evidence for treatment optimization.
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Affiliation(s)
- Yaseen Perbtani
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
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38
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CT- and MRI-Based Assessment of Body Composition and Pancreatic Fibrosis Reveals High Incidence of Clinically Significant Metabolic Changes That Affect the Quality of Life and Treatment Outcomes of Patients with Chronic Pancreatitis and Pancreatic Cancer. ACTA ACUST UNITED AC 2019; 55:medicina55100649. [PMID: 31569661 PMCID: PMC6843405 DOI: 10.3390/medicina55100649] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022]
Abstract
Background and Objectives: Both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) may lead to cachexia, sarcopenia, and osteoporosis due to different mechanisms. Neither patient gender, age, nor body weight are good predictors of these metabolic changes having a significant negative impact on the quality of life (QOL) and treatment outcomes. The aim of this study was to evaluate radiological changes in body composition and to compare them with manifestations of exocrine and endocrine pancreatic insufficiency, body mass, and QOL among patients with CP and PDAC. Materials and Methods: Prospectively collected data of 100 patients with diagnosed CP or PDAC were used for analysis. All patients underwent dual-energy X-ray absorptiometry (DXA), computed tomography (CT), and magnetic resonance imaging (MRI). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) was used to assess QOL. Diabetes and changes in fecal elastase-1 were also assessed. Results: There was no significant difference in skeletal muscle mass (SMM) among patients with CP and PDAC (p = 0.85). Significantly more underweight patients had low SMM (p = 0.002). Patients with CP had more pronounced pancreatic fibrosis (PF) (p < 0.001). Data showed a significant relationship between a high degree of PF and occurrence of diabetes (p = 0.006) and low fecal elastase-1 levels (p = 0.013). A statistically significant lower QOL was determined in patients with PF ≥ 50% and in the CP group. Conclusions: Sarcopenia and osteoporosis/osteopenia are highly prevalent among patients with chronic pancreatitis and pancreatic cancer, and CT- and MRI-based assessment of body composition and pancreatic fibrosis could be a potentially useful tool for routine detection of these significant metabolic changes.
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Drewes AM, Kempeneers MA, Andersen DK, Arendt-Nielsen L, Besselink MG, Boermeester MA, Bouwense S, Bruno M, Freeman M, Gress TM, van Hooft JE, Morlion B, Olesen SS, van Santvoort H, Singh V, Windsor J. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343-1351. [PMID: 31129569 PMCID: PMC6691929 DOI: 10.1136/gutjnl-2019-318742] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnessota Medical School, Minneapolis, Minnesota, USA
| | - Thomas M Gress
- Department of Gastroenterology, Philipps University & University Hospital of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Roberts KM, Golian P, Nahikian-Nelms M, Hinton A, Madril P, Basch K, Conwell D, Hart PA. Does the Healthy Eating Index and Mediterranean Diet Score Identify the Nutritional Adequacy of Dietary Patterns in Chronic Pancreatitis? Dig Dis Sci 2019; 64:2318-2326. [PMID: 30798461 DOI: 10.1007/s10620-019-05536-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic pancreatitis (CP) is a progressive, irreversible disease characterized by maldigestion and frequently accompanied by epigastric pain, exocrine insufficiency, and/or endocrine insufficiency. There is limited information about the dietary patterns in CP from which to guide medical nutrition therapy recommendations. METHODS Study design was a cross-sectional, case-control study comparing subjects with CP (n = 52) to healthy controls (n = 48). Vioscreen™ food frequency questionnaire was used to assess the dietary pattern and nutrient intake in both groups. Dietary quality scores (the Healthy Eating Index, Mediterranean Diet score), and daily energy, macronutrient, and micronutrient intake levels were compared between groups. ANALYSIS Two sample t tests and Wilcoxon rank sum tests were used to evaluate differences in continuous variables, and Chi-squared tests were used for categorical variables. RESULTS CP was associated with a lower body mass index (BMI) (24 vs. 31 mg/kg2; p < 0.001), lower HEI (57 vs. 65; p = 0.002), and aMED scores (29 vs. 32; p = 0.043) compared to healthy controls. Subjects with CP in the highest BMI quartile had the highest median aMED score compared to those in the lowest BMI quartile. There were no differences in kilocalories, macronutrients, or fat-soluble vitamin intake between groups, with the exception that vitamin K intake was lower in the CP group. CONCLUSIONS The overall quality of dietary intake is lower in subjects with CP compared to controls when assessed by two independent nutritional measurement tools. Further research is needed to examine contributing factors, such as food insecurity and coexisting endocrine or exocrine insufficiency, to dietary patterns in patients with CP from which to guide evidence-based recommendations for medical nutritional therapy.
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Affiliation(s)
- Kristen M Roberts
- Ohio State University, 453 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Paige Golian
- Ohio State University, 453 West 10th Avenue, Columbus, OH, 43210, USA
| | | | - Alice Hinton
- Ohio State University, 1841 Neil Ave., Columbus, OH, 43210, USA
| | - Peter Madril
- Ohio State University, 453 West 10th Avenue, Columbus, OH, 43210, USA
| | - Kathleen Basch
- Ohio State University, 453 West 10th Avenue, Columbus, OH, 43210, USA
| | - Darwin Conwell
- Ohio State University, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Phil A Hart
- Ohio State University, 410 West 10th Avenue, Columbus, OH, 43210, USA
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Pereira R, Eslick G, Cox M. Endoscopic Ultrasound for Routine Assessment in Idiopathic Acute Pancreatitis. J Gastrointest Surg 2019; 23:1694-1700. [PMID: 31197695 DOI: 10.1007/s11605-019-04272-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is one of the most common general acute surgical presentations. Current recommendations are that idiopathic acute pancreatitis (IAP) should account for no more than 20% of AP cases. Some studies suggest gallbladder microlithiasis is the aetiology in up to 75% of IAP patients. Endoscopic ultrasound (EUS) has been reported to be effective in the detection of microlithiasis and choledocholithiasis as well as pancreatic parenchymal, ductal and ampullary disorders. The aims of this study were to evaluate the usefulness of EUS in establishing aetiology in IAP patients and to assess if there is a role for EUS in the selection criteria for laparoscopic cholecystectomy to treat a potential biliary cause in IAP patients. METHODS A systematic review following PRISMA guideline was performed to gather data on patients with IAP undergoing EUS for further investigation. Three databases (MEDLINE, PubMed, and EMBASE) were searched to 28 July 2018. RESULTS Our systematic review included 28 studies, comprising 1850 patients with an initial diagnosis of IAP prior to having EUS. Diagnosis of a potential aetiology or associated pancreatic pathology was established in 1095 (62%, p < 0.001) of cases. A biliary aetiology (microlithiasis or choledocholithiasis) was found in 37%. Chronic pancreatitis and associated pancreatic findings (dilated pancreatic duct, pancreatic duct stricture or stone) were found in 21%. Pancreatic neoplasms were found in 6%. Of the patients who had identifiable biliary pathology on EUS that proceeded to cholecystectomy, 2% had a recurrence of AP during a mean follow-up period of 20.5 months. CONCLUSIONS There is a likely role for the routine use of EUS in the assessment of patients with IAP. The routine use of EUS may decrease the proportion of cases with a diagnosis of IAP. EUS may provide better selection criteria for laparoscopic cholecystectomy in patients with an initial diagnosis of IAP.
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Affiliation(s)
- Ryan Pereira
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia.,Department of Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Guy Eslick
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia
| | - Michael Cox
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia. .,Department of Surgery, Nepean Hospital, Sydney, NSW, Australia.
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Small Intestinal Bacterial Overgrowth Is Common in Chronic Pancreatitis and Associates With Diabetes, Chronic Pancreatitis Severity, Low Zinc Levels, and Opiate Use. Am J Gastroenterol 2019; 114:1163-1171. [PMID: 31008737 PMCID: PMC6610753 DOI: 10.14309/ajg.0000000000000200] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Small intestinal bacterial overgrowth (SIBO) is often present in patients with chronic pancreatitis (CP) with persistent steatorrhea, despite pancreatic enzyme replacement therapy. Overall prevalence of SIBO, diagnosed by glucose breath test (GBT), varies between 0% and 40% but 0%-21% in those without upper gastrointestinal (GI) surgery. We investigated the prevalence and nonsurgical independent predictors of SIBO in CP without upper GI surgery. METHODS Two hundred seventy-three patients ≥18 years old had a presumptive diagnosis of CP and a GBT between 1989 and 2017. We defined CP by Mayo score (0-16) ≥4 and a positive GBT for SIBO by Rome consensus criteria and retrospectively collected data for 5 a priori variables (age, opiates, alcohol use, diabetes mellitus (DM), gastroparesis) and 41 investigational variables (demographics, GI symptoms, comorbidities, CP etiologies and cofactors, CP symptom duration, Mayo score and nondiabetes components, and biochemical variables). RESULTS Ninety-eight of 273 patients had definite CP and 40.8% had SIBO. Five of 46 variables predicted SIBO: opiates, P = 0.005; DM, P = 0.04; total Mayo score, P < 0.05; zinc, P = 0.005; and albumin, P < 0.05). Multivariable analysis of 3 noncorrelated variables identified zinc level (odds ratio = 0.0001; P = 0.03) as the sole independent predictor of SIBO (model C-statistic = 0.89; P < 0.001). DISCUSSION SIBO, diagnosed by GBT, occurs in 40.8% of patients with CP without upper GI surgery. In patients with CP, markers of more severe CP (low zinc level, DM and increased Mayo score) and opiate use should raise clinical suspicion for SIBO, particularly in patients with persistent steatorrhea or weight loss despite pancreatic enzyme replacement therapy.
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44
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Layer P, Kashirskaya N, Gubergrits N. Contribution of pancreatic enzyme replacement therapy to survival and quality of life in patients with pancreatic exocrine insufficiency. World J Gastroenterol 2019; 25:2430-2441. [PMID: 31171887 PMCID: PMC6543241 DOI: 10.3748/wjg.v25.i20.2430] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/02/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
The objective of this study was to analyze the current evidence for the use of pancreatic enzyme replacement therapy (PERT) in affecting survival and quality of life in patients with pancreatic exocrine insufficiency (PEI). Systematic searches of the literature were performed using the PubMed database. Articles were selected for inclusion if they reported findings from trials assessing the effects of PERT on quality of life, survival, malabsorption, growth parameters (such as height, body weight and body mass index), or gastrointestinal symptoms (such as abdominal pain, stool consistency and flatulence). PERT improved PEI-related malabsorption and weight maintenance in patients with cystic fibrosis, chronic pancreatitis, pancreatic cancer, and post-surgical states. In patients with chronic pancreatitis, PERT improved PEI-related symptoms and quality of life measures. Several small retrospective studies have also suggested that PERT may have a positive impact on survival, but long-term studies assessing this effect were not identified. PERT is effective for treating malnutrition and supporting weight maintenance, and it is associated with improved quality of life and possibly with enhanced survival in patients with PEI. However, there is evidence that not all patients with PEI receive adequate PERT. Future work should aim to assess the long-term effects of PERT on the survival of patients with PEI.
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Affiliation(s)
- Peter Layer
- Department of Internal Medicine, Israelitic Hospital, Hamburg 22297, Germany
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis group), Federal State Budgetary Institution “Research Centre for Medical Genetics”, Moscow 115522, Russia
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman 83001, Ukraine
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45
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Khatkov IE, Maev IV, Abdulkhakov SR, Alekseenko SA, Alikhanov RB, Bakulin IG, Bakulina NV, Baranovskiy AY, Beloborodova EV, Belousova EA, Voskanyan SE, Vinokurova LV, Grinevich VB, Darvin VV, Dubtsova EA, Dyuzheva TG, Egorov VI, Efanov MG, Izrailov RE, Korobka VL, Kotiv BN, Kokhanenko NY, Kucheryavyy YA, Livzan MA, Lyadov VK, Nikolskaya KA, Osipenko MF, Pasechnikov VD, Plotnikova EY, Sablin OA, Simanenkov VI, Tsvirkun VV, Tsukanov VV, Shabunin AV, Bordin DS. Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment. TERAPEVT ARKH 2019; 90:13-26. [PMID: 30701935 DOI: 10.26442/terarkh201890813-26] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment was prepared on the initiative of the Russian "Pancreatic Club" on the Delphi method. His goal was to clarify and consolidate the opinions of specialists on the most relevant issues of diagnosis and treatment of exo- and endocrine insufficiency after surgical interventions on the pancreas. An interdisciplinary approach is provided by the participation of leading gastroenterologists and surgeons.
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Affiliation(s)
- I E Khatkov
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia.,A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - I V Maev
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - S R Abdulkhakov
- Kazan State Medical University, Ministry of Health of Russia, Kazan, Russia
| | - S A Alekseenko
- The Far Eastern State Medical University, Ministry of Health of Russia, Khabarovsk, Russia
| | - R B Alikhanov
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - I G Bakulin
- I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint-Petersburg, Russia
| | - N V Bakulina
- I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint-Petersburg, Russia
| | | | - E V Beloborodova
- Siberian State Medical University, Ministry of Health of Russia, Tomsk, Russia
| | - E A Belousova
- M.F. Vladimirskiy Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - S E Voskanyan
- A.I. Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - L V Vinokurova
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - V B Grinevich
- S.M. Kirov Military Medical Academy, Ministry of Defence of Russia, Saint-Petersburg, Russia
| | - V V Darvin
- Medical Institute of Surgut State University, Surgut, Russia
| | - E A Dubtsova
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - T G Dyuzheva
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russia
| | - V I Egorov
- City Clinical Hospital named after the Bakhrushin Brothers, Moscow, Russia
| | - M G Efanov
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - R E Izrailov
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - V L Korobka
- Rostov State Medical University, Ministry of Health of Russia, Rostov-on-Don, Russia
| | - B N Kotiv
- S.M. Kirov Military Medical Academy, Ministry of Defence of Russia, Saint-Petersburg, Russia
| | - N Yu Kokhanenko
- Saint-Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russia
| | - Yu A Kucheryavyy
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - M A Livzan
- Omsk State Medical University, Ministry of Health of Russia, Omsk, Russia
| | - V K Lyadov
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia, Moscow, Russia
| | - K A Nikolskaya
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - M F Osipenko
- Novosibirsk State Medical University, Ministry of Health of Russia, Novosibirsk, Russia
| | - V D Pasechnikov
- Stavropol State Medical University, Ministry of Health of Russia, Stavropol, Russia
| | - E Yu Plotnikova
- Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo, Russia
| | - O A Sablin
- A.M. Nikiforov All-Russian Center for Emergency and Radiation Medicine, Russian Ministry for Emergency Situations, Saint-Petersburg, Russia
| | - V I Simanenkov
- I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint-Petersburg, Russia
| | - V V Tsvirkun
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - V V Tsukanov
- Krasnoyarsk Scientific Center of Siberian Branch in Russian Academy of Sciences, Krasnoyarsk, Russia
| | - A V Shabunin
- S.P. Botkin City Hospital, Moscow Healthcare Department, Moscow, Russia
| | - D S Bordin
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia.,Tver State Medical University, Ministry of Health of Russia, Tver, Russia
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Resman B, Rahelić D, Gajdoš Kljusurić J, Martinis I. Food composition database reliability in calculations of diet offers. J Food Compost Anal 2019. [DOI: 10.1016/j.jfca.2019.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Sabir S, Akash MSH, Fiayyaz F, Saleem U, Mehmood MH, Rehman K. Role of cadmium and arsenic as endocrine disruptors in the metabolism of carbohydrates: Inserting the association into perspectives. Biomed Pharmacother 2019; 114:108802. [PMID: 30921704 DOI: 10.1016/j.biopha.2019.108802] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 12/11/2022] Open
Abstract
Endocrine disrupting chemicals (EDCs) have widespread environmental distribution originated from both natural and anthropogenic sources. From the last few decades, their contamination has been raised dramatically owing to continuous discharge in sewage and untreated industrial effluents. They have rapidly gained a considerable attention due to their critical role in the development of multiple endocrine-related disorders notably diabetes mellitus (DM). Cadmium and arsenic, among the most hazardous EDCs, are not only widely spread in our environment, but they are also found to be associated with wide range of health hazards. After entering into the human body, they are preferably accumulated in the liver, kidney and pancreas where they exhibit deleterious effects on carbohydrate metabolism pathways notably glycolysis, glucogenesis and gluconeogenesis through the modification and impairment of relevant key enzymes activity. Impairment of hepatic glucose homeostasis plays a crucial role in the pathogenesis of DM. Along with compromised function of pancreas and muscles, diminished liver and kidney functions also contribute considerably to increase the blood glucose level. These metals have potential to bring conformational changes in these enzymes and make them inactive. Additionally, these metals also disturb the hormonal balance, such as insulin, glucocorticoids and catecholamines; by damaging pancreas and adrenal gland, respectively. Moreover, these metals also enhance the production of reactive oxygen species and depress the anti-oxidative defense mechanism with subsequent disruption of multiple organs. In this article, we have briefly highlighted the impact of arsenic and cadmium on the metabolism of carbohydrates and the enzymes that are involved in carbohydrate metabolism and glucose homeostasis.
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Affiliation(s)
- Shakila Sabir
- Department of Pharmaceutical Chemistry, Government College University Faisalabad, Pakistan; Department of Pharmacology, Government College University Faisalabad, Pakistan
| | | | - Fareeha Fiayyaz
- Department of Pharmaceutical Chemistry, Government College University Faisalabad, Pakistan; Department of Microbiology, Government College University Faisalabad, Pakistan
| | - Uzma Saleem
- Department of Pharmacology, Government College University Faisalabad, Pakistan
| | | | - Kanwal Rehman
- Institute of Pharmacy, Physiology and Pharmacy, University of Agriculture, Faisalabad, Pakistan.
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48
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Kwon CI, Cho JH, Choi SH, Ko KH, Tirkes T, Gromski MA, Lehman GA. Recent advances in the diagnosis and management of chronic pancreatitis. Korean J Intern Med 2019; 34:242-260. [PMID: 30840807 PMCID: PMC6406102 DOI: 10.3904/kjim.2019.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis is a chronic condition characterized by pancreatic inflammation that causes fibrosis and the destruction of exocrine and endocrine tissues. Chronic pancreatitis is a progressive disease, and no physiological treatment is available to reverse its course. However, with advances in medical technology, the existing diagnostic and treatment methods for chronic pancreatitis are evolving. Managing patients with chronic pancreatitis is challenging and necessitates a multidisciplinary approach. In this review, we discuss the recent advances in the diagnosis and management of chronic pancreatitis and introduce future alternative modalities.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Hoon Choi
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Temel Tirkes
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
OBJECTIVES Patients with chronic pancreatitis (CP) are at increased risk of low bone mineral density (BMD), although the prevalence of low BMD in patients with CP in the United States is lacking. We aimed to determine the prevalence of low BMD and identify potential risk factors, including hypogonadism and use of opioid medications, in subjects with CP in the United States. METHODS This was a prospective, observational study. Subjects with CP underwent dual-energy x-ray absorptiometry scan. Blood was assayed for vitamin D, sex hormones, and a metabolic panel. History was obtained for fractures, menopause, hypogonadal symptoms, and opioid medication doses. Low BMD was defined by both World Health Organization and the International Society for Clinical Densitometry criteria. RESULTS Depending on criteria used, 37% to 55% of our cohort had low BMD. Subjects with low and normal BMD had similar vitamin D levels. Hypogonadism was present in 27% of nonmenopausal subjects and was associated with reduced lumbar spine BMD in subjects 30 years or older. CONCLUSIONS Patients with CP are at increased risk of low BMD, which is likely multifactorial. Hypogonadism, possibly related to opioid pain medications, may be an independent risk factor for low BMD in CP.
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50
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Abstract
Chronic pancreatitis (CP) may remain undiagnosed for years until patients exhibit manifestations, such as pain and exocrine or endocrine insufficiency. Some patients with CP develop serious complications, such as malignancy or peripancreatic fluid collections. Considering CP in at-risk patients such as those with a long-standing history of alcohol or tobacco use is key to establishing the diagnosis. Management involves reducing and eliminating exposures, dietary modification, treatment of pancreatic insufficiency, assessing for complications, and surveillance for neoplasia. The management of CP is often multidisciplinary involving medical, endoscopic, and surgical options for therapy.
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Affiliation(s)
- Vaishali Patel
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Road, Northeast, Building B, Suite 1200, Atlanta, GA 30322, USA
| | - Field Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University Hospital, Children's Healthcare of Atlanta, Emory University School of Medicine, 1365 Clifton Road, Northeast, Building B, Suite 1200, Atlanta, GA 30322, USA.
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