Stimulated gastrointestinal hormone release and gallbladder contraction during continuous jejunal feeding in patients with pancreatic pseudocyst is inhibited by octreotide

Review of the impact of antineoplastic therapies on the risk for cholelithiasis and acute cholecystitis

BACKGROUND

Development of cholecystitis in patients with malignancies can potentially disrupt their treatment and alter prognosis. This review aims to identify antineoplastic interventions associated with increased risk of cholecystitis in cancer patients.

METHODS

A comprehensive search strategy was developed to identify articles pertaining to risk factors and complications of cholecystitis in cancer patients. FDA-issued labels of novel antineoplastic drugs released after 2010 were hand-searched to identify more therapies associated with cholecystitis in nonpublished studies.

RESULTS

Of an initial 2,932 articles, 124 were reviewed in the study. Postgastrectomy patients have a high (5-30 %) incidence of gallstone disease, and 1-7 % develop symptomatic disease. One randomized trial addressing the role of cholecystectomy concurrent with gastrectomy is currently underway. Among other risk groups, patients with neuroendocrine tumors treated with somatostatin analogs have a 15 % risk of cholelithiasis, and most are symptomatic. Hepatic artery based therapies carry a risk of cholecystitis (0.02-24 %), although the risk is reduced with selective catheterization. Myelosuppression related to chemotherapeutic agents (0.4 %), bone marrow transplantation, and treatment with novel multikinase inhibitors are associated with high risk of cholecystitis.

CONCLUSIONS

There are several risk factors for gallbladder-related surgical emergencies in patients with advanced malignancies. Incidental cholecystectomy at index operation should be considered in patients planned for gastrectomy, and candidates for regional therapies to the liver or somatostatin analogs. While prophylactic cholecystectomy is currently recommended for patients with cholelithiasis receiving myeloablative therapy, this strategy may have value in patients treated with multikinase inhibitors, immunotherapy, and oncolytic viral therapy based on evolving evidence.

Effect of enteral feeding on gallbladder function in dogs

Nutritional support in critically ill patients is a fundamental principle of patient care. Little is known about gallbladder motility during the interdigestive phase and in response to enteral feeding. The objective of this study was to investigate the effect of enteral feeding on gallbladder function in dogs. The cholagogue meal (Lipofundin infusion) was applied in four anatomical positions (jejunum, duodenojejunal junction, descending duodenum, stomach) in five healthy Beagle dogs. Gallbladder volume (GBV) was monitored by ultrasonography. Lipofundin infusion given through the feeding tube caused a maximal gallbladder contraction of 9.2% (range 3.7-13.9%) in the jejunum, 16.5% (9.1-22.1%) at the duodenojejunal junction and 26.3% (22.8-29.5%) in the descending duodenum. When the cholagogue meal was given through the mouth, it caused a mean 33.8% (28.6-46.5%) maximum gallbladder contraction in the same animals. In conclusion, we can establish that the ultrasound-guided gallbladder emptying method proved to be a useful technique for monitoring the cholagogue effect of Lipofundin meal applied in different anatomical positions of the intestine. The deeper the position of application, the smaller and shorter gallbladder contraction was evoked.

The trophic effect of cholecystokinin on the pancreas declines in rats on total parenteral nutrition

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.

[The clinical relevance of experimental acute pancreatitis models]

The clinical diagnostics and therapeutic standards applied in the routine management of human acute pancreatitis are based on the results of animal experiments and human studies performed in the past several decades. During this time period, a number of experimental acute pancreatitis models have been developed, which allowed us to study the etiopathogenesis of acute pancreatitis, analyzing the local and remote complications of the inflammatory processes and also the preclinical testing of potentially effective drugs and agents. Only animal models are suitable to examine the very early phase of the pathogenetic processes in acute pancreatitis. In recent years, the progress in molecular genetic methods allowed us to create genetically engineered animal models to clarify the role of different mediators in the pathogenetic process. There is no doubt that the results gained from experimental animal studies are of limited value concerning human pancreatitis. Nevertheless, experimental studies seem to be indispensable in the progress of management of human pancreatic disorders.

[Changes in diagnostic and therapeutic standards of acute pancreatitis in clinical practice. Epidemiologic analysis of data from a regional center of internal medicine and surgery]

Epidemiological data analysis of a tertiary (regional) medical and surgical center. Diagnostic and therapeutic standards of patients with acute pancreatitis have changed significantly in the last few decades. Progress in laboratory and imaging diagnostics and achievements in experimental research resulted in a significant modification of the guidelines related to the care of pancreatitic patients. The aim was to analyse and compare the data of patients with acute pancreatitis treated in 1996 (period I) and 2004 (period II) at the Departments of Internal Medicine and Surgery, University of Szeged, to evaluate the concordance with international guidelines during medical and surgical treatment.

RESULTS

The authors analysed the clinical data of 126 and 124 patients, respectively, with acute pancreatitis observed during the two periods. An increase in the incidence of biliary acute pancreatitis, more frequent use of antibiotics, a higher frequency of therapeutic endoscopies (papillotomy and biliary stone extraction), the general application of ultrasonography-guided fine needle aspiration and bacterial culturing in cases of suspected infected necrosis, and higher effectiveness in complex surgical and supportive management of infected necrosis cases were detected in period II.

CONCLUSION

Although most of the achievements suggested in international guidelines on medical/endoscopic and surgical treatment of acute pancreatitis have been implemented during the observation period, no significant changes in the morbidity and mortality data of patients were found.

Effect of parenteral and early intrajejunal nutrition on pancreatic digestive enzyme synthesis, storage and discharge in dog models of acute pancreatitis

AIM: To study the effect of early intrajejunal nutrition on enzyme-protein synthesis and secretion during acute pancreatitis.

METHODS: Fifteen dogs were randomly divided into parenteral nutrition (n = 7) and early intrajejunal nutrition groups (n = 8). An acute pancreatitis model was induced by injecting 5% sodium taurocholate and trypsin into the pancreas via the pancreatic duct. Intrajejunal nutrition was delivered with a catheter via a jejunostomy tube after the model was established for 24 h. On d 1 and 7 and at the beginning of nutritional support, radioactive tracing and electron microscopes were used to evaluate the enzyme-protein synthesis in acinar cells, the subcellular fractionation and the change in zymogen granules after 1.85 × 10⁶ Bq L-³H phenylalanine was infused at 30, 60, 120, and 180 min.

RESULTS: The ³H radioactivity in pancreatic acinar cells reached its peak level at 60 min, and the contents in the early intrajejunal nutrition group were higher than those in the parenteral nutrition group, which were then decreased. The mean number and area of zymogen granules did not show any significant statistical difference in both groups on d 1 or on d 7 (P > 0.05).

CONCLUSION: Early intrajejunal nutrition might be effective in dogs with acute pancreatitis.

A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis

BACKGROUND

After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed.

METHODS

A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays.

RESULTS

A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group.

CONCLUSIONS

The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.

Effect of parenteral and enteral nutrition combined with octreotide on pancreatic exocrine secretion of patients with pancreatic fistula

AIM: To evaluate the effect of parenteral and enteral nutrition combined with octreotide on pancreatic exocrine secretion of the patients with pancreatic fistula.

METHODS: Pancreatic juice, drained directly from the pancreatic fistula, was collected, and the volume, protein, amylase, HCO₃^-, K⁺, Na⁺ and Cl^- were determined on d 1, 4 and 7 before and after 7-d treatment with octreotide, respectively.

RESULTS: No differences in exocrine pancreatic secretion were observed during the enteral and parenteral nutrition period (t = 2.03, P > 0.05); there were significant decreases in pancreatic juice secretion volume, protein, amylase, HCO₃^-, K⁺, Na⁺ and Cl^- after parenteral and enteral nutrition combined with octreotide compared with octreotide pretreatment (t = 4.14, P < 0.05).

CONCLUSION: There is no stimulatory effect on the pancreatic secretion by intrajejunal nutrition and parenteral nutrition. Octreotide is effective on the reduction of pancreatic fistula output.

Parenteral versus early intrajejunal nutrition: Effect on pancreatitic natural course, entero-hormones release and its efficacy on dogs with acute pancreatitis

AIM: To evaluate the effect of early intrajejunal nutrition (EIN) on the natural course, entero-hormone secretion and its efficacy on dogs with acute pancreatitis.

METHODS: An acute pancreatitis model was induced by injecting 1 mL/kg of combined solution (2.5% sodium taurocholate and 8000-10000 BAEE units trypsin/mL) into the pancreas via pancreatic duct. Fifteen dogs were divided into parenteral nutrition (PN) group and EIN group. Two groups were isonitrogenous and isocaloric. EIN was used at postoperative 24 h. Serum glucose, calcium, amylase and lysosomal enzymes were determined before and 1, 4, 7 d after acute pancreatitis was induced. All the dogs were injected 50 uCi ¹²⁵I-BSA 4 h before sacrificed on the 7^th day. The ¹²⁵I-BSA index of the pancreas/muscle, pancreas/blood, and pancreas pathology score (PPS) were determined. The peripheral plasma cholecystokinin (CCK), secretin (SEC) and gastrin were measured by ELISA and RIA, and was quantitative analysis of pancreatic juice and amylase, pancreatolipase and HCO₃^-, Cl^-, Na⁺ and K⁺ performed by an autochemical analyzer at 30, 60, 120 and 180 min after beginning PN or EIN on the first day.

RESULTS: There was no difference between two groups in the contents of serum calcium, amylase and lysosomal enzymes, ¹²⁵I-BSA index of pancreas/muscle and pancreas/blood and PPS. The contents of CCK and gastrin in EIN were higher than those in PN group at 60 and 120 min (P < 0.05). The content of SEC post-infusion of nutrition solution was higher than that of pre-infusion of nutrition solution in both groups, and only at 60 min SEC in EIN group was higher than that in PN group. The content of gastrin in EIN was higher than that in PN group at 120 and 180 min (P < 0.05). The changes of pancreatic juice, amylase, pancreatolipase and HCO₃^-, Cl^-, Na⁺ and K⁺ between two groups did not reach significantly statistical difference (P > 0.05).

CONCLUSION: EIN does not stimulate entero-hormone and pancreatic juice secretion, and enzyme-protein synthesis and release. EIN has no effect on the natural course of acute pancreatitis.

Peroral absorption of octreotide in pigs formulated in delivery systems on the basis of superporous hydrogel polymers

PURPOSE

The aim of this study was to investigate the enhancement of peroral octreotide absorption using delivery systems based on superporous hydrogel (SPH) and SPH composite (SPHC) polymers.

METHODS

Six female pigs (BW of 23.5 kg) were used in this study. SPH-based delivery systems were made of two components: 1) a conveyor system made of SPH and SPHC; 2) a core that contained octreotide. The core was inserted into the conveyor system (core inside, c.i.) or attached to the surface of the conveyor system (core outside, c.o.). Four different peroral formulations were investigated: c.i., c.o., core outside including trimethyl chitosan chloride (c.o.t.), and octreotide only in the absence of any polymer (o.o.). All formulations were placed in enteric-coated gelatin capsules (size 000) and administered perorally. Intravenous administration was used to determine bioavailability (F) values. Blood samples taken from the cannulated jugular vein were analyzed by radioimmunoassay.

RESULTS

Peroral administration of 15 mg o.o. resulted in low F values of 1.0 +/- 0.6% (mean +/- SEM) whereas c.i. and c.o. administrations resulted in remarkably higher F values of 12.7 +/- 3.6% and 8.7 +/- 2.4%, respectively. By the addition of trimethyl chitosan chloride as an extra absorption enhancer to c.o.t., the highest bioavailability (16.1 +/- 3.3%) was achieved.

CONCLUSIONS

These novel delivery systems based on SPH and SPHC polymers are able to increase the peroral bioavailability of octreotide by mechanical fixation and increasing the retention of the dosage form at the absorption site.