Biochemical analysis of pancreatic fluid collections predicts bacterial infection

Total pancreatectomy with intraportal islet autotransplantation for pancreatic malignancies: a literature overview

INTRODUCTION

'Brittle Diabetes' (BD) is a life-threatening metabolic complication after total pancreatectomy (TP). More than 500 Intraportal islet autotransplantation (IAT) have been performed to prevent this complication, with almost 70% insulin independence after 3 years. Even when insulin independence was not achieved, IAT successfully prevented severe hypoglycemia. Currently, preliminary results for oncologic situations are promising, but their oncological outcomes are still a matter of debate.

AREAS COVERED

We performed a bibliographic research of the last 25 years of data. Articles published in English in peer-reviewed journals were retained. In France, auto- and allo-islet transplantation was recently recognized as a valuable treatment for BD by the national health authority. While accepted for benign diseases, the risk of tumor spreading after IAT in oncologic situations is a source of concern.

EXPERT OPINION

Preliminary results of IAT in oncological situations are very encouraging. So far, there is no evidence of tumor dissemination. In our opinion, to overcome BD TP with IAT for resectable pancreatic malignancies in patients with a higher risk of postoperative pancreatic fistula and extended pancreatic cancers can be safely performed. Diagnosis of malignancy should not be considered as an exclusion criterion for IAT.

Association of bacteria in pancreatic fistula fluid with complications after pancreatic surgery

Background

Pancreatic fistula (PF) is a common complication after pancreatic surgery. It is unclear how microbes in PF fluid affect outcomes and which microbes are present after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). The aim of this study was to compare the microbiological spectrum of PF fluid after PD versus DP, and its association with postoperative complications.

Methods

Bacterial strains and antibiotic resistance rates of bacterial swabs obtained from the PF fluid of patients who underwent DP or PD were analysed. Cultured bacteria were classified as Enterobacterales and as ‘other intestinal and non‐intestinal microorganisms’ based on whether they are typically part of the normal human intestinal flora.

Results

A total of 847 patients had a pancreatic resection (PD 600; DP 247) between July 2007 and December 2016. Clinically relevant PF was detected in 131 patients (15·5 per cent). Bacterial swabs were obtained from 108 patients (DP 47; PD 61), of which 19 (17·6 per cent) were sterile. Enterobacterales were detected in 74 per cent of PF fluid swabs after PD, and in 34 per cent after DP. Infected, polymicrobial or multidrug‐resistant PF fluid was more common after PD (rates of 95, 50 and 48 per cent respectively) than after DP (66, 26 and 6 per cent respectively). Patients with higher grade complications (Clavien–Dindo grade IV–V) or grade C PF had more Enterobacterales and multidrug‐resistant Enterobacterales in the PF fluid after DP.

Conclusion

Enterobacterales and multidrug‐resistant bacteria are detected frequently after PD and DP, and are associated with more severe complications and PF in patients undergoing DP.

Quantitative diffusion-weighted magnetic resonance imaging for prediction of early infection in pancreatic collections: Results of a pilot study

BACKGROUND/AIMS

The development of infection in pancreatitis increases the mortality rate up to 32%. Therefore, it is important to identify patients who are at high risk of developing infection, at an early stage. The objectives of the study were (a) to analyze the quantitative parameters of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in infected as well as sterile pancreatic collections (b) to establish "cut-off" values for ADC that can identify infected pancreatic collections.

MATERIALS AND METHODS

Prospective observational study of pancreatitis cases who underwent DW-MRI from August 2018 to July 2019 were enrolled in the study. The collections were analyzed for diffusion restriction. The average of the three ADC values from the wall and center of collection was noted.

RESULTS

Infected collections were seen in 7 and sterile collections observed in 11 cases. The optimal cut-off ADC value to differentiate sterile and infected collection in our study was 1.651 × 10^-3 mm²/s (sensitivity of 81.8%; specificity of 100.0%). ROC curve for mean ADC from the wall showed a significant diagnostic accuracy with AUC: 0.91; 95% CI: 0.77-1.0 (P = 0.004).

CONCLUSION

DW-MRI is a reliable noninvasive technique to differentiate sterile and infected pancreatic collections. ADC values from the periphery of the collection can predict infected pancreatic collections at an early stage. DW-MRI should not be considered as a substitute for aspiration cytology in patients with septic symptoms and absent diffusion restriction on MRI.

Pancreatic cyst fluid harbors a unique microbiome

BACKGROUND

It is clear that specific intestinal bacteria are involved in the development of different premalignant conditions along the gastrointestinal tract. An analysis of the microbial constituents in the context of pancreatic cystic lesions has, however, as yet not been performed. This consideration prompted us to explore whether endoscopically obtained pancreatic cyst fluids (PCF) contain bacterial DNA and to determine the genera of bacteria present in such material.

METHODS

Total DNA was isolated from 69 PCF samples. Bacterial 16S rRNA gene-specific PCR was performed followed by Sanger sequencing and de novo deep sequencing for the V3-V4 variable region of 16S rRNA gene.

RESULTS

We observed that 98.2% of the samples were positive in conventional PCR, and that 100% of selected PCF samples (n = 33) were positive for bacterial microbiota as determined by next generation sequencing (NGS). Comprehensive NGS data analysis of PCF showed the presence of 408 genera of bacteria, of which 17 bacterial genera were uniquely abundant to PCF, when compared to the Human Microbiome Project (HMP) database and 15 bacterial microbiota were uniquely abundant in HMP only. Bacteroides spp., Escherichia/Shigella spp., and Acidaminococcus spp. which were predominant in PCF, while also a substantial Staphylococcus spp. and Fusobacterium spp. component was detected.

CONCLUSION

These results reveal and characterize an apparently specific bacterial ecosystem in pancreatic cyst fluid samples and may reflect the local microbiota in the pancreas. Some taxa with potential deleterious functions are present in the bacterial abundance profiles, suggesting that the unique microbiome in this specific niche may contribute to neoplastic processes in the pancreas. Further studies are needed to explore the intricate relationship between pathophysiological status in the host pancreas and its microbiota.

Non-invasive detection of infection in acute pancreatic and acute necrotic collections with diffusion-weighted magnetic resonance imaging: preliminary findings

PURPOSE

The purpose of this study was to evaluate the contribution of diffusion-weighted magnetic resonance imaging (DW-MRI) to the detection of infection in acute pancreatitis-related collections.

METHODS

A total of 21 DW-MRI, and computed tomography (CT) were performed on 20 patients diagnosed as acute pancreatitis with acute peri-pancreatic fluid or necrotic collections. Collections were classified as infected or sterile according to the culture and follow-up results. Collections with gas bubbles on CT images were considered to be infected. Collections with peripheral bright signals on DW-MRI images were considered to be positive, whereas those without signals were considered to be negative. Apparent diffusion coefficient (ADC) values of the peripheral and central parts of the collections were measured. Student's t test was used to compare the means of ADC values of independent groups.

RESULTS

Apart from one false positive result, the presence of infection was detected by DW-MRI with 95.2% accuracy. The sensitivity and accuracy of DW-MRI were higher than CT for the detection of infection. The ADC values in the central parts of the collections were significantly different between the infected and sterile groups.

CONCLUSION

DW-MRI can be used as a non-invasive technique for the detection of infection in acute pancreatitis-associated collections.

ERCP: the unresolved question of endotracheal intubation

The anesthesia community is still divided as to the appropriate airway management in patients undergoing endoscopic retrograde cholangiopancreatography. Increasingly, gastroenterologists are comfortable with deep sedation (normally propofol) without endotracheal intubation. There are no comprehensive reviews addressing the various pros and cons of an un-intubated airway management. It is hoped that the present review will benefit both anesthesia providers and gastroenterologists. The reasons to avoid routine endotracheal intubation and the approaches for an un-intubated anesthetic management are discussed. The special situations where endotracheal intubation is the preferred approach are mentioned. Many special techniques to manage airway are illustrated.

A Review of Autologous Islet Transplantation

Autologous islet transplantation after total or semitotal pancreatectomy aims to preserve insulin secretory function and prevent the onset of diabetes. The major indication for pancreatectomy is chronic pancreatitis with severe abdominal pain, a benign pancreatic tumor, and trauma. The metabolic outcome of autologous islet transplantation is better than that of allogeneic transplantation and depends on the number of transplanted islets. Achieving islet isolation from a fibrous or damaged pancreas is one of the biggest challenges of autologous islet transplantation; a major complication is portal vein thrombosis after crude islet infusion. However, the incidence of portal vein thrombosis has decreased as islet preparation techniques have improved over time.

The Atlanta Classification of acute pancreatitis revisited

BACKGROUND

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

METHODS

A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.

RESULTS

A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.

CONCLUSION

The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.