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Yuan J, Xiu D. Effects of early enteral nutrition on pancreatic fistula and long-term prognosis after distal pancreatectomy or enucleation of pancreatic tumours in a major academic university hospital in China: protocol for a single-centre randomised controlled trial. BMJ Open 2023; 13:e068469. [PMID: 37562933 PMCID: PMC10423769 DOI: 10.1136/bmjopen-2022-068469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 07/07/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) remains one of the main complications following pancreatic resection. Despite pancreatic fistula having a low postoperative mortality rate, the readmission and intervention rates in patients with pancreatic fistula are still considerable. Although there are several studies on pancreatic fistula development after pancreaticoduodenectomy, there are only a few studies on the feeding protocols applied after distal pancreatectomy or enucleation of pancreatic tumours. We designed this trial to test the hypothesis that early feeding does not increase the incidence of POPF and positively influences the long-term prognosis in patients who undergo distal pancreatectomy or enucleation of pancreatic tumours. METHODS AND ANALYSIS This is a prospective randomised controlled trial that will be conducted in a single centre. A total of 106 patients undergoing distal pancreatectomy or enucleation of pancreatic tumours will be recruited after providing informed consent. They will be randomly assigned to either an early or late feeding group. The early feeding group will begin enteral nutrition on postoperative day (POD) 3, and the late feeding group will begin enteral nutrition on POD7. The primary outcome is the incidence of POPF. The secondary outcomes include the length of postoperative hospital stay, postoperative complications, and indicators of long-term prognosis. ETHICS AND DISSEMINATION Peking University Third Hospital Medical Science Research Ethics Committee approved the study (M2021395). Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice. TRIAL REGISTRATION NUMBER ChiCTR2100053978.
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Affiliation(s)
- Jingya Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, Beijing, China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, Beijing, China
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Zhang XM, Zhou YQ, Wan YP, Li HJ, Chen ZQ, Song AQ, Tang ML, Xu R, Cai W. The association between parenteral nutrition and pancreatic injury in adult patients: a retrospective observational study. Nutr Metab (Lond) 2022; 19:73. [PMID: 36316774 PMCID: PMC9624056 DOI: 10.1186/s12986-022-00706-z] [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: 03/08/2022] [Accepted: 10/09/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Patients on parenteral nutrition (PN) are at high risk of both liver and pancreatic injury. More efforts were focused on liver, however, limited data is available to evaluate the effects of PN on pancreas. Thus, we performed a retrospective observational study to evaluate the association between PN and pancreatic injury in Chinese adult patients. METHODS Adult patients (18-80 years), who received PN for a week or longer, and with repeated measurements of pancreatic enzymes, were included in the analysis. Pancreatic injury was confirmed by serum level of pancreatic amylase (P-AMYwas 53 U/L or higher) or lipase (LP was 63 U/L or higher), which were evaluated at baseline and following every week during PN duration. Age, sex, body weight, height, diagnosis of diseases, history of diseases, surgery, white blood cell, c-reactive protein, liver and renal function, fasting blood glucose, lipid profile, and daily energy supplied by PN and enteral nutrition were abstracted from medical records. RESULTS A total number of 190 adult patients (125 men, 65 women) were included in the study. The average age and BMI were 61.8 ± 13.0 years and 21.7±3.3 kg/m2, while medium serum level of P-AMY and LP were 29.0 U/L (quartile range: 18.0, 47.0) and 33.0 U/L (quartile range: 19.0, 58.0), respectively at baseline. The median duration of PN was 15 days (quartile range: 11.0, 21.0). The prevalence of pancreatic injury was 42.1% (80/190) while it was 28.4% (54/190), 43.3% (77/178), 47.8% (44/92) after one-, two-, and three-week or longer PN adminstration. The proportion of daily energy supplement by PN (OR = 3.77, 95%CI: 1.87, 7.61) and history of infection were positively (OR = 3.00, 95%CI: 1.23, 7.36), while disease history for diabetes mellitus (OR = 0.38, 95%CI: 0.15, 0.98) and cancer (OR = 0.46, 95%CI: 0.23, 0.95), were negetively associated with pancreatic injury. Total bile acids were associated with the increment of P-AMY (beta = 0.98, 95%CI: 0.39, 1.56) and LP (beta = 2.55, 95%CI: 0.98, 4.12) by multi-variate linear regression. CONCLUSION PN was associated with pancreatic injury, as demonstrated by the increase of both serum P-AMY and LP.
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Affiliation(s)
- Xiao-min Zhang
- grid.16821.3c0000 0004 0368 8293Department of Pediatric Surgery, School of Medicine, Xin Hua Hospital, Shanghai Jiao Tong University, 200092 Shanghai, China ,grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Yi-quan Zhou
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Yan-ping Wan
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Hao-jie Li
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Zhi-qi Chen
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - An-qi Song
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Mo-lian Tang
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Renying Xu
- grid.16821.3c0000 0004 0368 8293Department of Clinical Nutrition, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 200127 Shanghai, China
| | - Wei Cai
- grid.16821.3c0000 0004 0368 8293Department of Pediatric Surgery, School of Medicine, Xin Hua Hospital, Shanghai Jiao Tong University, 200092 Shanghai, China ,grid.412987.10000 0004 0630 1330Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China ,grid.16821.3c0000 0004 0368 8293Shanghai Institute of Pediatric Research, No. 1665, Kong Jiang Road, 200092 Shanghai, China
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Effects of Fasting and Administration of Octreotide Acetate and Ulinastatin on Clinical Outcomes of Pancreatic Fistula after Pancreatoduodenectomy. Int Surg 2022. [DOI: 10.9738/intsurg-d-21-00022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: Postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is the most serious complication of these surgical procedures; therefore, we examine the effectiveness of fasting, and administration of octreotide acetate and ulinastatin as a method of prevention. Summary of Background Data : Although various drug therapies and surgical techniques have been used for the treatment of POPF, no decisive treatment for POPF exists. Methods: The clinical course of 30 patients who developed POPF was retrospectively evaluated and compared between no dietary intake (n=18), octreotide acetate (n=8), and ulinastatin (n=8) using an overlapping design. Patients were allocated to either the dietary intake or fasting (no dietary intake) group, and those in the no dietary intake group were further divided into the octreotide acetate or ulinastatin group. Results: Length of hospitalization was longer for the no dietary intake group than for the dietary intake group (p=0.002). When considering only grade B or C POPF cases, the no dietary intake group had a longer length of hospitalization and a higher white blood cell count on day 7 after the diagnosis of POPF than the dietary intake group (p<0.05). The white blood cell count was also higher in the octreotide acetate group than in the ulinastatin group (p=0.021). The length of hospitalization was shorter in the ulinastatin group than in the octreotide acetate group (p=0.025). Conclusions: The use of no dietary intake, octreotide acetate, and ulinastatin do not seem to contribute to the clinical course of patients with POPF after pancreatoduodenectomy.
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Bolia R, Bhat NK, Kaushal G. Conservative management of pancreatic ascites: The role of nasojejunal feeding. Pancreatology 2021; 21:1555-1556. [PMID: 34602366 DOI: 10.1016/j.pan.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/30/2021] [Accepted: 09/24/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Rishi Bolia
- Division of Pediatric Gastroenterology, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Nowneet Kumar Bhat
- Division of Pediatric Gastroenterology, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
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Fujii T, Yamada S, Murotani K, Okamura Y, Ishigure K, Kanda M, Takeda S, Morita S, Nakao A, Kodera Y. Oral Food Intake Versus Fasting on Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Multi-Institutional Randomized Controlled Trial. Medicine (Baltimore) 2015; 94:e2398. [PMID: 26717392 PMCID: PMC5291633 DOI: 10.1097/md.0000000000002398] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The usefulness of enteral nutrition via a nasointestinal tube for patients who develop postoperative pancreatic fistula (POPF) after miscellaneous pancreatectomy procedures has been reported. However, no clear evidence regarding whether oral intake is beneficial or harmful during management of POPF after distal pancreatectomy (DP) is currently available.To investigate the effects of oral food intake on the healing process of POPF after DP.Multi-institutional randomized controlled trial in Nagoya University Hospital and 4 affiliated hospitals.Patients who developed POPF were randomly assigned to the dietary intake (DI) group (n = 15) or the fasted group (no dietary intake [NDI] group) (n = 15). The primary endpoint was the length of drain placement.No significant differences were found in the length of drain placement between the DI and NDI groups (12 [6-58] and 12 [7-112] days, respectively; P = 0.786). POPF progressed to a clinically relevant status (grade B/C) in 5 patients in the DI group and 4 patients in the NDI group (P = 0.690). POPF-related intra-abdominal hemorrhage was found in 1 patient in the NDI group but in no patients in the DI group (P = 0.309). There were no significant differences in POPF-related intra-abdominal hemorrhage, the incidence of other complications, or the length of the postoperative hospital stay between the 2 groups.Food intake did not aggravate POPF and did not prolong drain placement or hospital stay after DP. There may be no need to avoid oral DI in patients with POPF.
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Affiliation(s)
- Tsutomu Fujii
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan (TF, SY, YO, MK, AN, YK); Center for Clinical Research, Aichi Medical University, Nagakute, Japan (KM); Department of Surgery, Konan Kosei Hospital, Konan, Japan (KI); Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (ST); Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan (SM); and Department of Surgery, Nagoya Central Hospital, Nagoya, Japan (AN)
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Fujii T, Nakao A, Murotani K, Okamura Y, Ishigure K, Hatsuno T, Sakai M, Yamada S, Kanda M, Sugimoto H, Nomoto S, Takeda S, Morita S, Kodera Y. Influence of Food Intake on the Healing Process of Postoperative Pancreatic Fistula After Pancreatoduodenectomy: A Multi-institutional Randomized Controlled Trial. Ann Surg Oncol 2015; 22:3905-12. [PMID: 25777090 DOI: 10.1245/s10434-015-4496-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND The usefulness of enteral nutrition via a nasointestinal tube for patients who develop postoperative pancreatic fistula (POPF) after miscellaneous pancreatectomy procedures has been reported. However, no clear evidence regarding whether oral intake is possible during management of POPF after pancreatoduodenectomy (PD) is currently available. We investigated the effects of oral food intake on the healing process of POPF after PD by a multi-institutional randomized controlled trial. METHODS Patients who developed POPF were randomly assigned to the dietary intake (DI) group (n = 30) or the fasted group [no dietary intake (NDI) group] (n = 29). The primary endpoint was the length of drain placement. RESULTS No significant differences were found in the length of drain placement between the DI and NDI groups [27 (7-80) vs. 26 (7-70) days, respectively; p = .8858]. POPF progressed to a clinically relevant status (grade B/C) in 20 patients in the DI group and 19 patients in the NDI group (p = .9257). POPF-related intra-abdominal hemorrhage was found in 2 patients in the NDI group, but in no patients in the DI group (p = .1434). There were no significant differences in POPF-related intra-abdominal hemorrhage, the incidence of other complications, or the length of the postoperative hospital stay between the 2 groups. CONCLUSION Food intake did not aggravate POPF and did not prolong the length of drain placement or hospital stay after PD. There may be no need to avoid oral dietary intake in patients with POPF.
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Affiliation(s)
- Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Akimasa Nakao
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | - Kenta Murotani
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Yukiyasu Okamura
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Tsuyoshi Hatsuno
- Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Mitsuru Sakai
- Department of Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Sugimoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuji Nomoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shin Takeda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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Bordejé Laguna L, Lorencio Cárdenas C, Acosta Escribano J. [Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): severe acute pancreatitis]. Med Intensiva 2012; 35 Suppl 1:33-7. [PMID: 22309750 DOI: 10.1016/s0210-5691(11)70007-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Severe acute pancreatitis (SAP) causes local and systemic complications leading to high catabolic, hypermetabolic and hyperdynamic stress states with marked morbidity and mortality. In the last decade, nutritional support has become a key element in the treatment of SAP. Thus, specialized nutrition is indicated from admission, with enteral nutrition being preferred to parenteral nutrition. Enteral nutrition should be initiated early using infusion through the jejunum beyond the ligament of Treitz to minimize pancreatic stress. There are no specific studies that establish the type of diet to be used but experts recommend the use of polymeric diets. Parenteral nutrition, without a specific formula, is indicated in patients with SAP who are intolerant to enteral nutrition or when the clinical signs of pancreatitis are exacerbated or aggravated by enteral nutrition. Even so, a minimal level of enteral infusion should be maintained to preserve the trophic effect of the intestinal mucosa. In the last few years, several studies of the administration of immunomodulatory diets in patients with SAP have been carried out to demonstrate their effects on the course of the disease. However, there are few clear recommendations on the prognostic benefits of pharmaconutrient enriched diets in these patients. There is substantial scientific evidence suggesting that the only clear indication for pharmaconutrition in patients with SAP is parenteral glutamine administration, which is recommended by all clinical guidelines with distinct grades of evidence.
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Bassi C, Malleo G. Pancreas: Postoperative pancreatic fistula: use of enteral nutrition. Nat Rev Gastroenterol Hepatol 2011; 8:427-8. [PMID: 21727937 DOI: 10.1038/nrgastro.2011.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J. Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology 2011; 141:157-63, 163.e1. [PMID: 21439962 DOI: 10.1053/j.gastro.2011.03.040] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 02/15/2011] [Accepted: 03/08/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Postoperative pancreatic fistula is the most common and potentially life-threatening complication after pancreatic surgery. Although nutritional support is a key component of conservative therapy in such cases, there have been no well-designed clinical trials substantiating the superiority of either total parenteral nutrition or enteral nutrition. This study was conducted to compare the efficacy and safety of both routes of nutritional intervention. METHODS A randomized clinical trial was conducted in a tertiary surgical center of pancreatic and gastrointestinal surgery. Seventy-eight patients with postoperative pancreatic fistula were treated conservatively and randomly assigned to groups receiving for 30 days either enteral nutrition or total parenteral nutrition. The primary end point was the 30-day fistula closure rate. RESULTS After 30 days, closure rates in patients receiving enteral and parenteral nutrition were 60% (24 of 40) and 37% (14 of 38), respectively (P=.043). The odds ratio for the probability that fistula closes on enteral nutrition compared to total parenteral nutrition was 2.571 (95% confidence interval [CI]: 1.031-6.411). Median time to closure was 27 days (95% CI: 21-33) for enteral nutrition, and no median time was reached in total parenteral nutrition (P=.047). A logistic regression analysis identified only 2 factors significantly associated with fistula closure, ie, enteral nutrition (odds ratio=6.136; 95% CI: 1.204-41.623; P=.043) and initial fistula output of ≤200 mL/day (odds ratio=12.701; 95% CI: 9.102-47.241; P<.001). CONCLUSIONS Enteral nutrition is associated with significantly higher closure rates and shorter time to closure of postoperative pancreatic fistula.
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Affiliation(s)
- Stanislaw Klek
- 1st Department of Surgery, Jagiellonian University Medical College, Krakow, Poland.
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Wu XM, Liao YW, Ji KQ, Li GF, Zang B. The trophic effect of cholecystokinin on the pancreas declines in rats on total parenteral nutrition. J Anim Physiol Anim Nutr (Berl) 2011; 96:214-9. [PMID: 21438927 DOI: 10.1111/j.1439-0396.2011.01140.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Total parenteral nutrition (TPN) results in atrophy of the pancreas, while cholecystokinin (CCK) can significantly stimulate the exocrine pancreas in rodents. This study was designed to examine whether CCK may improve the atrophy of the pancreas in rats on TPN treatment. Forty-eight Sprague-Dawley rats were divided into orally fed and TPN groups and were infused with CCK at a dose of 5 μg/kg/h or the CCK-receptor antagonist devazepide at a dose of 200 μg/kg/h for 10 days. Infusion of CCK caused hypercholecystokininemia (hyperCCKemia) and decreased the atrophy of the pancreas resulting from TPN. The hyperplastic response to CCK in orally fed rats was decreased in the rats given TPN. Devazepide did not influence the pancreatic variables. This study further confirmed that CCK stimulates the exocrine pancreas and decreases the atrophy of the exocrine pancreas resulting from TPN. Our present findings suggest that the trophic effect of CCK on the exocrine pancreas declines in TPN.
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Affiliation(s)
- X-M Wu
- Intensive Care Unit, Shengjing Hospital, China Medical University, Shenyang, Liaoning Province, China.
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