Painless form of chronic pancreatitis - multicentre study

BACKGROUND

The painless form of chronic pancreatitis is one of the rarer forms of the disease. While 80% to 90% of all chronic pancreatitis cases have abdominal pain as their clinical symptom, a smaller proportion of persons with chronic pancreatitis do not report typical pain. This form of the disease is often associated with exocrine and endocrine pancreatic insufficiency and weight loss, but the absence of pain symptoms may initially lead to misdiagnosis.

METHODS

In a cohort of 257 people with chronic pancreatitis, the painless form was diagnosed in 30 individuals (11.6%), with an average age of 56 years and a predominance of men (71.4%). Thirty-eight percent were non-smokers and 47.6% of patients smoked up to 10 cigarettes per day. Alcohol intake of less than 40 g per day was reported by 61.9% of subjects. A quarter were moderately overweight, with a mean BMI of 26.5. Newly diagnosed diabetes mellitus had 25.7% of the subjects.

RESULTS

A frequent finding was the demonstration of morphological changes, with calcifications found in 85,7% and dilatation of the pancreatic duct greater than 6.0 mm in 66%. A surprising finding was the presence of metabolic syndrome in 42.8% and the most frequent finding was the demonstration of decreased external pancreatic secretion (90%).

CONCLUSION

Painless chronic pancreatitis is usually treated conservatively. We demonstrate a subset of 28 patients with painless chronic pancreatitis treated surgically. Most frequent indications were benign stenosis of the intrapancreatic bile duct and stenosis of the pancreatic duct. Although approximately 1 in 10 people with chronic pancreatitis present with a painless form of it, so that the form of the disease is described as rare, this does not change the fact that management of these people is still not optimal.

Skin manifestations of pancreatic diseases

Although symptoms of pancreatic diseases such as pancreatitis, acute and chronic and, carcinoma of the pancreas are mainly gastrointestinal in nature, the extra-pancreatic symptoms are also important. These include skin symptoms, such as pancreatic panniculitis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema, cutaneous signs of hemorrhage, as in persons with severe acute pancreatitis, or the finding of cutaneous metastases of pancreatic carcinoma, which may be a sign of advanced disease. The pancreas is therefore one of those organs for which diagnosis and therapy are often multidisciplinary. In this review article, we summarize current knowledge of the possible skin manifestations of pancreatic disorders.

Differentiating Primary Sclerosing Cholangitis from Similar Diseases of Autoimmune Origin

BACKGROUND AND AIMS

Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease. Differential diagnostics can confuse it with immunoglobulin (Ig) G4-related sclerosing cholangitis (SC), an IgG4-related disease with clearly proven autoimmune origin. Differential diagnosis is made even more challenging because PSC with increased IgG4 levels (PSC-increased IgG4) also occurs. In order to facilitate their differential diagnosis, we reviewed recent literature regarding the etiologies, identifying characteristics, the most useful diagnostics, treatment, and the progression of these partially similar diseases. It is clear that PSC's pathogenesis differs from that of IgG4-related SC. In any differential diagnosis between PSC and PSC-increased IgG4, high IgG1 and low or normal IgG2 levels are characteristic for patients with PSC. Histological examination of the biliary tree wall in patients with IgG4-related SC typically reveals such changes as storiform fibrosis, obliterative phlebitis, and venulitis. These are absent in PSC-increased IgG4, which is characterized by a typical circular thickness in different parts of the biliary ducts. Finally, PSC is associated with inflammatory bowel disease, which is rare in IgG4-related SC, and more frequently is associated with cholangiocarcinomas and colon cancers. As distinct from IgG4-related SC, PSC is not a primary autoimmune disease.

Helicobacter pylori infection and other bacteria in pancreatic cancer and autoimmune pancreatitis

Helicobacter pylori (H. pylori) is an infectious agent influencing as much as 50% of the world’s population. It is the causative agent for several diseases, most especially gastric and duodenal peptic ulcer, gastric adenocarcinoma and mucosa-associated lymphoid tissue lymphoma of the stomach. A number of other, extragastric manifestations also are associated with H. pylori infection. These include neurological disorders, such as Alzheimer’s disease, demyelinating multiple sclerosis and Parkinson’s disease. There is also evidence for a relationship between H. pylori infection and such dermatological diseases as psoriasis and rosacea as well as a connection with infection and open-angle glaucoma. Generally little is known about the relationship between H. pylori infection and diseases of the pancreas. Most evidence about H. pylori and its potential role in the development of pancreatic diseases concerns pancreatic adenocarcinoma and autoimmune forms of chronic pancreatitis. There is data (albeit not fully consistent) indicating modestly increased pancreatic cancer risk in H. pylori-positive patients. The pathogenetic mechanism of this increase is not yet fully elucidated, but several theories have been proposed. Reduction of antral D-cells in H. pylori-positive patients causes a suppression of somatostatin secretion that, in turn, stimulates increased secretin secretion. That stimulates pancreatic growth and thus increases the risk of carcinogenesis. Alternatively, H. pylori, as a part of microbiome dysbiosis and the so-called oncobiome, is proven to be associated with pancreatic adenocarcinoma development via the promotion of cellular proliferation. The role of H. pylori in the inflammation characteristic of autoimmune pancreatitis seems to be explained by a mechanism of molecular mimicry among several proteins (mostly enzymes) of H. pylori and pancreatic tissue. Patients with autoimmune pancreatitis often show positivity for antibodies against H. pylori proteins. H. pylori, as a part of microbiome dysbiosis, also is viewed as a potential trigger of autoimmune inflammation of the pancreas. It is precisely these relationships (and associated equivocal conclusions) that constitute a center of attention among pancreatologists, immunologists and pathologists. In order to obtain clear and valid results, more studies on sufficiently large cohorts of patients are needed. The topic is itself sufficiently significant to draw the interest of clinicians and inspire further systematic research. Next-generation sequencing could play an important role in investigating the microbiome as a potential diagnostic and prognostic biomarker for pancreatic cancer.

Pancreatic cancer in patients with autoimmune pancreatitis: A scoping review

BACKGROUND

Chronic pancreatitis is a known risk factor of pancreatic cancer (PDAC). A similar association has been suggested but not demonstrated for autoimmune pancreatitis (AIP).

OBJECTIVE

The aim of our study was to identify and analyse all published cases of AIP and PDAC co-occurrence, focusing on the interval between the diagnoses and the cancer site within the pancreas.

METHODS

Relevant studies were identified through automatic searches of the MEDLINE, EMBASE, Scopus, and Web of Science databases, and supplemented by manual checks of reference lists in all retrieved articles. Missing/unpublished data were obtained from the authors of relevant publications in the form of pre-prepared questionnaires.

RESULTS

A total of 45 cases of PDAC in AIP patients were identified, of which 12 were excluded from the analysis due to suspicions of duplicity or lack of sufficient data. Thirty-one patients (94%) had type 1 AIP. Synchronous occurrence of PDAC and AIP was reported in 11 patients (33%), metachronous in 22 patients (67%). In the metachronous group, the median period between diagnoses was 66.5 months (2-186) and a majority of cancers (86%) occurred more than two years after AIP diagnosis. In most patients (70%), the cancer originated in the part of the pancreas affected by AIP.

CONCLUSIONS

In the literature, there are reports on numerous cases of PDAC in AIP patients. PDAC is more frequent in AIP type 1 patients, typically metachronous in character, and generally found in the part of the pancreas affected by AIP.

Vitamin D levels in IBD: a randomised trial of weight-based versus fixed dose vitamin D supplementation

Objectives: Body weight is one of the factors affecting blood levels of 25-hydroxyvitamin D (25OHD). The aim of this study was to establish whether a vitamin D (vitD) weight-based dosing is more appropriate to a fixed daily dose in patients with inflammatory bowel disease (IBD).Materials/methods: This was an open label randomised trial. Patients with IBD were assigned to receive oral cholecalciferol at a dose of 28 IU/kg (IU/kg) or 2000 IU per day (IU/day) for 12 weeks during winter months. 25OHD plasma levels and other biochemical parameters were measured at baseline and after supplementation period. The primary outcome measure was 25OHD level after a follow-up period.Results: A total of 173 patients were analysed. The mean BMI was 25.5 ± 5.1 and initial mean 25OHD level was 62.7 ± 25.5 nmol/l. A similar increase (9.7 ± 26.9 vs 9.8 ± 26.7 nmol/l) in 25OHD levels occurred both in IU/kg and IU/day group. The proportion of subjects with normal and sub-normal levels following the substitution was comparable irrespective of body weight. The change in 25OHD level correlated positively only with the dose of vitD (p < .001) and negatively with the baseline 25OHD level (p < .001). A sustained 25OHD level of 75 nmol/l corresponds with a calculated daily vitD dose of 2034 IU.Conclusions: Weight-based dosing of vitamin D is not superior to a fixed dose in order to maintain stable 25OHD levels in IBD patients. Cholecalciferol dose of 2,000 IU/day is safe and sufficient during winter period.

Nonalcoholic Fatty Pancreas Disease: Clinical Consequences

Metabolic syndrome and its components such as obesity, hypertriglyceridemia, type-2 diabetes mellitus (DM-T2), and arterial hypertension are unequivocally serious problems for every society. This is especially true in economically developed countries where the imbalance in lifestyle between caloric intake and caloric output still gets greater and greater. This fact is not only a concern for the adult population but for children as well. However, metabolic syndrome does not only affect society and health in regards to cardiovascular diseases, it significantly concerns gastroenterology where it is classified as nonalcoholic fatty pancreas disease (NAFPD). The data gained from several trials show that the prevalence of NAFDP is 33% (95% CI 24-41%). When it comes to the diagnostic procedures concerning the presence of pancreatic fat, a whole spectrum of suitable methods are recommended. Probably, the most exact method is the use of magnetic resonance imaging. However, for common clinical practice, the abdominal sonographic examination based on the comparison of the pancreatic parenchymatous echogenity versus renal or hepatic echogenity is used. The clinical consequences of pancreatic steatosis and steatopancreatitis are significant. These diseases are connected with DM-T2 and insulin resistance. In recent years, changes of exocrine pancreatic function, particularly its decrease, have also been described. It is known that there is a close correlation between NAFPD and nonalcoholic hepatic steatosis and also with the increased thickness of aortic intima-media. There is also an important relationship between NAFPD and pancreatic carcinoma. Pancreatic steatosis, and especially its NAFPD form, is a serious state which can be treatable by the possible effective management of metabolic syndrome parameters, including obesity.

Pancreatic Solid Focal Lesions: Differential Diagnosis between Autoimmune Pancreatitis and Pancreatic Cancer

BACKGROUND

Diagnosis of pancreatic cancer (PC) in early stages is still challenging for gastroenterologists. The early detection of cancer is one of the utmost importance for the successful therapy of this malignancy. An accurate differential diagnosis of focal pancreatic lesions plays also an important role, whether it is differential diagnosis of chronic pancreatitis from PC or autoimmune pancreatitis (AIP) from PC. Raised serum immunoglobulin G4 (IgG4) levels to twice the normal value are considered one of significant diagnostic features of type 1 AIP. However, IgG4 can be increased also in patients with PC, but levels usually do not exceed twice the normal value.

METHODS

In years 2012-2017, IgG4 serum levels were examined in 115 patients with histologically confirmed PC. Patients with PC and elevated IgG4 level (above 135 mg/dL) had tested their histological resection specimens or bioptic specimens from pancreatic lesion, with targeted detection of the presence of IgG4 and plasmocytes in the pancreatic tissue and changes characteristic for type 1 AIP.

RESULTS

A plasmatic IgG4 level in 115 patients with diagnosed PC was higher than 135 mg/dL in 14 patients (12.2%). Out of them, 2 patients (1.7%) revealed a serum IgG4 level higher than double the normal value, that is, higher than 270.0 mg/dL (suggestive of AIP). One patient met histological criteria for diagnosis of AIP in the simultaneous presence of PC.

CONCLUSION

Diagnosis of early cancer stages, particularly differentiating AIP from PC can be sometimes problematic. IgG4 levels can be slightly elevated also in case of PC. A targeted biopsy of the pancreas is the method of choice in cases suspected from a focal form of AIP and we recommend to prefer it over other modalities, such as, for example, response to steroid therapy.

Crohn's disease - genetic factors and progress of the disease

BACKGROUND AND OBJECTIVES

Crohn's disease is a multifactorial inflammatory disease affecting mainly the gastrointestinal tract. The genetic factors that are involved in the disease include mainly three mutations of the gene NOD2/CARD15 (R702W, G908R, 3020insC). The aim of this study was to determine the relationship between the presence of these variants and disease phenotype.

MATERIAL AND METHODS

70 patients with Crohn's disease were examined for the presence of the above-mentioned mutations. The researchers used the medical records to retrospectively obtain clinical data and together with the information obtained prospectively according to the protocol they analysed the connection between gene mutations and disease phenotype.

RESULTS

At least one mutation was found in 22 patients with Crohn's disease (32%), four patients were found to have two different mutations (composed heterozygotes - 6%) and six patients (9%) were homozygotes for the 3020insC gene. No significant differences were found between the groups with wild-type form and the mutated form of the NOD2 / CARD15 gene with respect to age at the time of diagnosis, form of the disease or localization according to the Montreal classification.

CONCLUSION

Mutations of the NOD2 / CARD15 gene did not significantly affect the frequency of reoperations, homozygotes with 3020insC gene mutations, however, represented a high risk group. The phenotype was not related significantly to the presence of the examined mutations.

Serological survey of mumps antibodies in adults in the Czech Republic and the need for changes to the vaccination strategy

Mumps outbreaks, especially in adolescents and young adults, have been reported in the Czech Republic. The aim of the presented study was to determine the seroprevalence of specific IgG antibodies against mumps in the adult population of the Czech Republic. The study was designed as a multicenter serological survey of adults aged 18 years and over. Specific IgG antibodies against mumps were detected in blood samples using an enzyme-linked immunosorbent assay (ELISA). A total of 1,911 serum samples were examined. The overall seropositivity reached 55.3%. In individual age groups, the highest seropositivity 63% (63.5-65.2%) was recorded in adults aged 40 years and over; the lowest seropositivity was found in adults aged 18-29 years (27.4%). The difference in seropositivity rate between the 18-29 years age group and the 40 years and over age groups was statistically significant (p < 0.001). Only the 18-29 years age group included both vaccinated and unvaccinated (born in the pre-vaccine era) individuals. In vaccinated individuals, seropositivity was reported in only 19.1% of persons; in unvaccinated individuals, seropositivity reached 48.2%. Our results demonstrate the long-term persistence of antibodies following natural infection and the decrease in seropositivity that occurs after vaccination over time. This immunity waning may account for the higher susceptibility of adolescents and young adults to mumps. Therefore, the current vaccination program in the Czech Republic could be considered as less effective. It will be modified with the shifting of the second dose of vaccine from two years of age to the preschool age.

Seroepidemiology of whooping cough in the Czech Republic: estimates of incidence of infection in adults

OBJECTIVES

Despite widespread vaccination programmes, pertussis remains a significant health burden in many countries. Low awareness of the disease, the high rate of asymptomatic cases in adults and difficulties with diagnosis could explain the under-reporting of pertussis. The lack of data on actual incidence constitutes an obstacle for public health authorities for the implementation of a vaccination strategy against pertussis in adults. The aim of this study was to evaluate the seroprevalence of antibodies against Bordetella pertussis infection in adults and to estimate the actual incidence of the disease compared with the reported incidence.

STUDY DESIGN

Prospective, multicentre seroprevalence study.

METHODS

The study was conducted in 2000 adult subjects aged ≥18 years who had not received pertussis vaccination within the last 5 years. All enrolled subjects provided a blood sample for serum testing of IgG antibodies against pertussis toxin, performed by enzyme-linked immunosorbent assay, to indicate if they had an acute infection or if they had been infected with pertussis within the last 12 months or earlier. Results were validated in accordance with the guidelines of the European Sero-epidemiology Network 2 and were expressed in ESEN units/ml.

RESULTS

A positive concentration of anti-pertussis toxin antibodies, indicating previous pertussis infection, was demonstrated in 39.9% (n = 799) of all study subjects, and 0.40% (n = 8) of subjects had a concentration suggestive of a recent infection (within the last 12 months). The highest antibody seroprevalence was observed in subjects aged 18-29 years (1.46%). No cases of acute infection were detected.

CONCLUSIONS

During the study period, the reported incidence of pertussis in the adult population was 0.84/100,000 inhabitants. Based on the seroprevalence results from this study, it is estimated that the actual incidence of pertussis could be as much as 699/100,000 inhabitants. The actual incidence of pertussis in adults in the Czech Republic could therefore be at least 200-fold higher than the reported incidence. These findings support the need for pertussis vaccination in the adult population.

Prevalence of hepatitis C virus in adult population in the Czech Republic - time for birth cohort screening

Chronic hepatitis C is curable disease. Low detection rate could be one of the reasons of poor treatment uptake. It is important to identify HCV prevalence and anti-hepatitis C virus (HCV) positive patients in population by effective screening strategy such as risk-based or birth cohort screening programs. There are no national population-based estimates of the HCV prevalence in the Czech Republic (CZ). The most recent seroprevalence survey determined a prevalence of positive anti-HCV antibodies of 0.2% (in 2001). The aim of the study was to determine the seroprevalence of HCV, HCV viraemia and HCV genotype in the CZ adult population. We also estimated the number of persons living with chronic hepatitis C in CZ. The examined group included 3000 adults, 18–90 years of age enrolled in 2015. All serum samples were examined to determined anti-HCV antibodies positivity, HCV-RNA positivity and genotypes. Of the 3000 samples, 50 were found to be anti-HCV-positive, for a seroprevalence of 1.67% (2.39% in males, 0.98% in females). The overall prevalence of positive HCV RNA was 0.93%: 1.5% in males, 0.39% in females. HCV genotype (GT) 1a was determined in 25%, GT 1b in 25% and GT 3a in 46%. Since 2001, the HCV seroprevalence has increased 8-fold. The highest HCV seroprevalence occurred in males aged 30–44 years. We can estimate that there are more than 140,000 people with HCV antibodies and more than 80,000 people with chronic hepatitis C living in the CZ. The introduction of birth cohort HCV screening could be beneficial for the country.

Decreasing Seroprevalence of Measles Antibodies after Vaccination - Possible Gap in Measles Protection in Adults in the Czech Republic

Aims

In recent years, Europe has recorded an increase in the number of measles outbreaks despite the implementation of vaccination into the National Immunization Programs. The Czech Republic introduced vaccination against measles into National Immunization Program in 1969. The aim of this study was to determine seroprevalence of IgG antibodies against measles in adults.

Methods

Our study was designed as a prospective, multicenter cohort study. Samples of blood were taken from adults aged 18 years and over. Specific IgG antibodies were determined by ELISA method.

Results

A number of 1911 sera samples were obtained. The total seropositivity reached 83.3%, 14.3% of the results were negative and 2.4% were borderline. When comparing the individual age groups, the highest antibody seropositivity (> 96%) was detected in persons aged 50 years and over who were naturally infected in pre-vaccine era. The lowest seropositivity was recorded in the age groups 30–39 years (61.5%), 40–49 years (77.5%) and 18–29 years (81.1%).

Conclusions

A long term high rate of seropositivity persists after natural measles infection. By contrast, it decreases over time after vaccination. Similarly, the concentrations of antibodies in persons with measles history persist for a longer time at a higher level than in vaccinated persons. Our results indicate possible gap in measles protection in adults born after implementation of vaccination into the National Immunization Programs. There are two probable reasons, decrease of measles antibody seropositivity in time after vaccination in setting of limited natural booster and one-dose vaccination schedule used in the first years after implementation.

A RARE PARASITIC DISEASE OF THE LIVER - ALVEOLAR ECHINOCOCCOSIS

Alveolar echinococcosis is a rare parasitic disease, especially of the liver, caused by the larval stage of the tapeworm Echinococcus multilocularis. At the end of the last century France, Germany, Austria and Switzerland were the regions where this disease most often manifested itself, these days this infection is diagnosed also in our territory. We describe the case of the disease of a twenty-five-year-old male with nonspecific signs and hepatomegaly, who was diagnosed on the basis of imaging and laboratory sampling. Due to inoperability the patient is now in infectologist follow-up on long-term treatment with Albendazole. He is clinically stable, included on the waiting list for liver transplantation.

Comparison of the prevalence of KRAS-LCS6 polymorphism (rs61764370) within different tumour types (colorectal, breast, non-small cell lung cancer and brain tumours). A study of the Czech population

AIMS

A germline SNP (rs61764370) is located in a let-7 complementary site (LCS6) in the 3'UTR of KRAS oncogene, and it was found to alter the binding capability of the mature let-7 microRNA to the KRAS mRNA. The aim of the study was to evaluate the frequency of the KRAS-LCS6 variant allele in different cancer types that included patients with colorectal cancer (CRC), breast cancer (BC), non-small cell lung cancer (NSCLC) and brain tumour patient subgroups from the Czech Republic. The occurrence of this genetic variant was correlated with the presence of selected somatic mutations representing predictive biomarkers in the respective tumours.

METHODS

DNA of tumour tissues was isolated from 428 colorectal cancer samples, 311 non-small cell lung cancer samples, 195 breast cancer samples and 151 samples with brain tumour. Analysis of SNP (rs61764370) was performed by the PCR+RFLP method and direct sequencing. KRAS, BRAF and EGFR mutation status was assessed using real-time PCR. The status of the HER2 gene was assessed using the FISH method.

RESULTS

The KRAS-LCS6 TG genotype has been detected in 16.4% (32/195) of breast cancer cases (in HER2 positive breast cancer 3.3%, in HER2 negative breast cancer 20.1%), in 12.4% (53/428) of CRC cases (KRAS/BRAF wild type CRC in 10.6%, KRAS mutant CRC in 10.1%, BRAF V600E mutant CRC in 18.5%), in 13.2% (41/311) of NSCLC samples, (EGFR mutant NSCLC patients in 8%, EGFR wild type NSCLC in 12.9%), and 17.9% (27/151) of brain tumour cases. The KRAS-LCS6 TG genotype was not significantly different across the studied tumours. In our study, the GG genotype has not been found among the cancer samples.

CONCLUSIONS

Based on the findings, it is concluded that the occurrence of the KRAS-LCS6 TG genotype was statistically significantly different in association with status of the HER2 gene in breast cancer. Furthermore, significant association between the mutation status of analysed somatic variants in genes of the EGFR signalling pathway (KRAS, BRAF, EGFR) and the KRAS-LCS6 genotype in colorectal cancer and NSCLC has not been established.

Dietary habits of colorectal neoplasia patients in comparison to their first-degree relatives

AIM: To compare the dietary habits between colorectal neoplasia patients, their first-degree relatives, and unrelated controls.

METHODS: From July 2008 to April 2011, we collected epidemiological data relevant to colorectal cancer from patients with colorectal neoplasias, their first-degree relatives, and also from a control group consisting of people referred for colonoscopy with a negative family history of colorectal cancer and without evidence of neoplasia after colonoscopic examination. The first-degree relatives were divided into two groups following the colonoscopic examination: (1) patients with neoplasia or (2) patients without neoplasia. Dietary habits of all groups were compared. A χ² test was used to assess the association between two dichotomous categorical variables.

RESULTS: The study groups consisted of 242 patients with colorectal neoplasias (143 men, 99 women; mean age: 64 ± 12 years) and 160 first-degree relatives (66 men, 94 women; mean age: 48 ± 11 years). Fifty-five of the first-degree relatives were found to have a neoplastic lesion upon colonoscopy, while the remaining 105 were without neoplasia. The control group contained 123 individuals with a negative family history for neoplastic lesions (66 men, 57 women; mean age: 54 ± 12 years). Two hypotheses were tested. In the first, the dietary habits of first-degree relatives with neoplasia were more similar to those of patients with neoplasia, while the dietary habits of first-degree relatives without neoplasia were similar to those of the control group. In the second, no sex-related differences in dietary habits were expected between the particular groups. Indeed, no significant differences were observed in the dietary habits between the groups of patients, controls and first-degree relatives with/without neoplastic lesions. Nevertheless, statistically significant sex-related differences were observed in all groups, wherein women had healthier dietary habits than men.

CONCLUSION: In all groups examined, women had healthier dietary habits than men. Modification of screening guidelines according to sex may improve the efficiency of screening programs.

Pitfalls of pancreatobiliary endoscopy after Billroth II gastrectomy

BACKGROUND/AIMS

The aim of this retrospective study is the analysis of the success rate of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in our group of patients with Billroth II gastrectomy.

METHODOLOGY

The study of the group was carried out during 14 years, i.e. from November 1994 to December 2008. It retrospectively evaluates 120 patients with Billroth II gastrectomy.

RESULTS

A cannulation success rate of 90.8% (109 of 120 patients) was reached in performing ERCP in 120 patients with Billroth II gastrectomy. There were normal ERCP results in 4 patients. ERCP results in the remaining 105 patients were pathological. Endoscopic treatment was started in all of these 105 patients immediately after diagnostic ERCP. Overall, therapeutic ERCP was completely successful in 91 of 105 patients (86.66%) who were originally treated with endoscopy.

CONCLUSIONS

ERCP in patients with Billroth II gastrectomy is much more demanding in contrast with standard procedure due to different postoperative anatomy. ERCP success is determined mainly by great personal experience and skillfulness of the endoscopist. ERCP performed lege artis in patients with Billroth II gastrectomy is a highly effective and safe method where the success rate reached can be almost the same as in a normal anatomical situation.

Clinicopathological correlations of nestin expression in surgically resectable pancreatic cancer including an analysis of perineural invasion

BACKGROUND AND AIMS

Nestin is considered to be a marker of stem/progenitor cells in different tissues. Nestin expression was also described in various tumors. In pancreatic ductal adenocarcinoma (PDAC), its role in cancer cell migration, invasion, and metastases has been suggested. The study aimed at examining the expression of nestin in PDAC, and to evaluate its clinicopathological correlations.

METHODS

The expression of nestin was immunohistochemically examined in 117 PDAC resection specimens, analyzed, and correlated with clinico-pathological parameters including perineural invasion (PNI). Analysis of nestin expression in nerve fibers in tissues of chronic pancreatitis (CP) was added.

RESULTS

Immunohistochemical analysis of nestin expression showed 79 nestin negative (67.5 %) and 38 nestin positive (32.5 %) PDACs. No significant correlations of nestin expression in tumor cells with the analyzed clinicopathological parameters were demonstrated. Tumor grade (p<0.001) and nodal status (p=0.009) proved to represent independent prognostic factors. PNI was identified in 94 PDAC (80.3 %), and did not correlate with nestin expression. Nestin immunostaining was displayed in nerve fibers of both CP and PDAC tissues.

CONCLUSION

An intimate link of nestin to a biological process of pancreatic cancer was confirmed. The expression of nestin did not prove to be a valuable prognostic factor and an immunohistochemical assessment of nestin expression is not superior to conventional prognostic factors in PDAC. A correlation between nestin expression in tumor cells and PNI was not confirmed and expression of nestin in nerve fibers of both PDAC and CP tissues seems to reflect the process of neural remodeling responsible for pancreatic neuropathy.

Comparative analysis of clinicopathological correlations of cyclooxygenase-2 expression in resectable pancreatic cancer

AIM: To perform a comparative analysis of clinicopathological correlations of cyclooxygenase-2 (COX-2) expression in pancreatic cancer, examined by monoclonal and polyclonal antibodies.

METHODS: The COX-2 expression in 85 resection specimens of pancreatic ductal adenocarcinoma was immunohistochemically examined using both monoclonal and polyclonal antibodies. The final immunoscores were obtained by multiplying the percentage of positive cells with the numeric score reflecting the staining intensity. COX-2 expression levels were classified into three categories (0, 1+, and 2+) and the clinicopathological correlations were statistically evaluated and analyzed.

RESULTS: The positive tumor expression rates of COX-2 were 80.5% using monoclonal antibody and 69.4% using polyclonal antibody. In the Kaplan-Meier analysis, no significant correlations were found between levels of COX-2 expression and overall survival (OS), but trends to longer OS were found in COX-2 negative cases using monoclonal antibody. Significantly longer disease free survival was revealed in COX-2 negative cases using monoclonal antibody (P = 0.019). No correlations between COX-2 expression levels and grade (G), tumor (T) status and nodal (N) status were demonstrated. Low histological grade showed a strong association with a longer OS (P < 0.001). Correlation of survival and T status revealed a shorter OS in T3 tumors, but the results reached only marginal statistical significance (P = 0.070). In the multivariate Cox proportional hazards regression model, histological grade, T and N status remained valuable predictors of a worse survival with borderline significance for T [hazards ratio (HR) = 4.18 for G (if G = 3, P < 0.001); HR = 1.64 for T (if T = 3, P = 0.065); HR = 2.53 for N (if N = 1, P = 0.006)]. Higher grade, T or N status was associated with a worse OS.

CONCLUSION: The immunohistochemically assessed level of COX-2 expression does not seem to represent a valuable independent prognostic factor and is not superior to the conventional prognostic factors.

Increased markers of oxidative stress in plasma of patients with chronic pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is a heterogeneous disease defined as chronic inflammatory changes of the pancreatic tissue caused by variety of aetiologies. Oxidative stress accompanying the inflammatory processes has been suggested as an important factor contributing to CP development. The aim of this study was to determine levels of lipid peroxidation products malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE), together with nitrites and the total antioxidant capacity in the plasma of patients with CP and control subjects.

DESIGN

One hundred and five patients with chronic pancreatitis and twenty seven healthy controls were included into this study. Levels of MDA and 4-HNE were analyzed using high-performance liquid chromatography. The total antioxidant capacity of plasma against peroxyl radicals was evaluated using chemiluminescent determination. Nitrites were determined using Griess reaction. Biochemical and haematological parameters were measured by standard methods.

RESULTS

The plasma levels of both MDA and 4-HNE, together with the plasma levels of nitrites, were significantly higher in CP patients, compared to healthy controls. The total antioxidant capacity did not differ significantly. Biochemical parameters were in the normal range. The MDA and 4-HNE levels correlated positively with the levels of high-density lipoprotein cholesterol. Nitrite levels correlated positively with C-reactive protein, total white blood cells, and triglycerides.

CONCLUSION

The significantly increased plasma levels of MDA, 4-HNE, and nitrites indicate that oxidative stress is present in patients with CP and that it may play a role in initiation and maintenance of inflammation within the pancreatic tissue in CP patients.

Autoimunne pancreatitis

Since Sarles et al. in 1961 reported a particular type of pancreatitis with hypergammaglobulinemia, many investigators have suggested that an autoimmune mechanism may be involved in some patients with pancreatitis. Recently, the concept of autoimmune pancreatitis (AIP) has been proposed in which several unique clinical, biochemical and imaging signs have been shown. In the TIGARO risk factor classification system of chronic pancreatitis proposed in 2001, autoimmunity was categorized as one of six of the risk factors. AIP is a chronic fibroinflammatory condition primary affecting pancreas. It is an atypical form of chronic pancreatitis characterized by sonolucent swelling of the pancreas, diffuse irregular narrowing of the pancreatic duct, and high serum IgG4 concentrations. Co-occurrence of extrapancreatic involvement, such as sclerosing cholangitis, retroperitoneal fibrosis, or salivary gland swelling were found: Histopathologic examinations detected extrapancreatic lesions such as lymphoplasmacytic inflammation and fibrosis, similar to those present in the pancreatic tissue, suggesting a common pathogenesis. These findings suggest that the disease involves a general involvement of the digestive system, although the presence of such involvement has not been fully elucidated. Steroids are a main therapeutic option in AIP.

Occurrence of metabolic osteopathy in patients with chronic pancreatitis

INTRODUCTION

Chronic pancreatitis is an inflammatory disease manifested by maldigestion and, in an advanced stage, by malabsorption. The aim of our research was to monitor the occurrence of metabolic osteopathies (osteopenia, osteoporosis and osteomalacia) in patients with chronic pancreatitis.

PATIENTS AND METHODS

The group consisted of 73 patients (17 women and 56 men) in different stages of chronic pancreatitis. In all patients we determined serum concentrations of Ca, P, 25-OH vitamin D, 1,25-(OH)(2) vitamin D, alkaline phosphatase and its bone isoenzyme. Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA) in the lumbar spine (L(1)-L(4)) and in the proximal femur. When bone pathology was identified by DXA, we determined the other to exclude other causes of secondary osteopathy and the 24-hour loss of calcium and phosphorus in the urine.

RESULTS

Osteopathy was found in 39% of patients, i.e. osteopenia in 26%, osteoporosis in 5% and osteomalacia in 8% of cases.

CONCLUSION

The occurrence of relatively high percentages of metabolic osteopathies in patients with chronic pancreatitis may correlate, namely in advanced stages of the disease, with the malabsorption of vitamin D to the enterohepatic circulation. In initial forms of pancreatitis, it is not possible to exclude progression of osteopathy due to changes of the intestinal flora, with disturbance of vitamin D absorption to the intestinal mucosa.

Autoimmune pancreatitis

Autoimmune pancreatitis is a form of chronic pancreatitis of presumed autoimmune aetiology. The disease is characterised with clinical, serological, histomorphological and imaging features. Autoimmune pancreatitis is recognised as a T-cell-mediated specific disease with lymphoplasmatic infiltration of pancreatic tissue and pancreatic parenchyma fibrosis. Serum immunoglobulin IgG or IgG4 and antibodies (rheumatoid factor, lactoferrin antibodies, carbonic anhydrase II, etc) are usually increased. But the lack of specific biochemical markers is a major drawback in the diagnosis of autoimmune pancreatitis. The Japan Pancreas Society proposed diagnostic criteria for autoimmune pancreatitis as the presence antibodies, pancreas enlargement and pancreatic duct narrowing, lymphoplasmatic infiltration, response to corticosteroid therapy, and association with other autoimmune diseases such as autoimmune hepatitis, sclerosing cholangitis, primary biliary cirrhosis, sialoadenitis, inflammatory bowel disease and Sjögren syndrome. New criteria (HISORt Criteria) incorporate imaging changes, organ involvement, specific elevation of IgG4 subclass and histopathological markers. Autoimmune pancreatitis could be associated with diabetes mellitus and exocrine pancreatic dysfunction. Clinically, autoimmune pancreatitis is a disease with mild symptoms; severe attacks of abdominal pain are not typical. Typically, pancreatic calcifications and pseudocyst are absent; on the other hand jaundice and/or pancreatic mass are frequent signs, and both make differential diagnosis with pancreatic cancer difficult. From a practical point of view, in an elderly male presenting with obstructive jaundice and pancreatic mass, autoimmune pancreatitis is one of the differential diagnoses to avoid unnecessary surgical therapy.

Celecoxib for the prevention of colorectal adenomatous polyps

BACKGROUND

Overexpression of cyclooxygenase 2 (COX-2) has been associated with colorectal adenomatous polyps and cancer, prompting researchers to propose its inhibition as a chemopreventive intervention.

METHODS

The Prevention of Colorectal Sporadic Adenomatous Polyps trial was a randomized, placebo-controlled, double-blind study of the COX-2 inhibitor celecoxib given daily in a single 400-mg dose. At 107 centers in 32 countries, we randomly assigned 1561 subjects who had had adenomas removed before enrollment to receive celecoxib (933 subjects) or placebo (628 subjects) daily, after stratification according to the use or nonuse of low-dose aspirin. The primary outcome was detection of adenomas at either year 1 or year 3 by colonoscopy and was compared among the groups with the use of the Mantel-Cox test.

RESULTS

Colonoscopies were performed at year 1 on 88.7 percent of the subjects who had undergone randomization and at year 3 on 79.2 percent. Of the 557 subjects in the placebo group and the 840 subjects in the celecoxib group who were included in the efficacy analysis, 264 and 270, respectively, were found to have at least one adenoma at year 1, at year 3, or both. The cumulative rate of adenomas detected through year 3 was 33.6 percent in the celecoxib group and 49.3 percent in the placebo group (relative risk, 0.64; 95 percent confidence interval, 0.56 to 0.75; P<0.001). The cumulative rate of advanced adenomas detected through year 3 was 5.3 percent in the celecoxib group and 10.4 percent in the placebo group (relative risk, 0.49; 95 percent confidence interval, 0.33 to 0.73; P<0.001). Adjudicated serious cardiovascular events occurred in 2.5 percent of subjects in the celecoxib group and 1.9 percent of those in the placebo group (relative risk, 1.30; 95 percent confidence interval, 0.65 to 2.62).

CONCLUSIONS

The use of 400 mg of celecoxib once daily significantly reduced the occurrence of colorectal adenomas within three years after polypectomy. (ClinicalTrials.gov number, NCT00141193 [ClinicalTrials.gov].).

[The relation of GERD, bronchial asthma and the upper respiratory tract]

Gastroesophageal reflux disease (GERD) is one of the most common diseases affecting upper gastrointestinal tract. It is a chronic disease, whith stadily growing incidence and prevalence in west countries during last 30 years. GERD is caused by pathologic gastroesophageal reflux (GER). GERD includes endoscopically positive, endoscopically negative and extraesophageal reflux disease. Extraesophageal symptoms of GERD have been of a growing attention and discussion during last few years. The most discussed topics are the relation of GERD and bronchial asthma (BA), chronic cough and symptomatology from ear, nose and throught (ENT) regions, but also non - cardial chest pain and many others.

AIM

In our clinic we ran a 5 years study which aim was to evaluate the presence of GERD in patients with bronchial asthma, chronic cough and affections from ENT regions. To assess if 3 months GERD treatment would improve lung function, subjective complaints (cough) and GERD control in asthmatics; if this treatment would allow to step - down with antiasthma medication. To assess if 3 months GERD treatment can improve objective and subjective assessments in patients with chronic cough and findings in ENT regions. As for GERD, we evaluated the improvement of pH and subjective complaints (pyrosis).

METHODS

We examined 86 patients with different severity of bronchial asthma, 54 patients with chronic cough and 31 patients with ENT symptoms. All patients underwent 24 hour esophageal pH metry, spirometry with lung function evaluation and objective ENT examination by flexible laryngoscopy. In case of pathologic finding on 24 hour pH-metry 3 months full antireflux treatment with proton pump inhibitors (PPI) and prokinetics was introduced. After 3 months of GERD treatment we performed control 24 hour esophageal pH metry, control spirometry and ENT examination by flexible laryngoscopy. Patients were asked to make their subjective symptoms assessments.

RESULTS

We found that GERD prevalence in patients with respiratory symptoms was very high. Three months GERD treatment improved lung function (FEV1) with statistical significance (p = 0.0319), and so improved GERD control (in 60.7% of patients with high statistical significance p = 0.0009). Subjective complaints (cough) also improved in most patients. 3 months GERD treatment did not allow to step down with maintenance BA therapy according to GINA guidelines, but it enabled to decrease the rescue medications in 50% of patients. Patients with chronic cough can benefit from GERD treatment as cough improved in 75.8% of patients.

CONCLUSION

Objective findings as well as subjective complaints improved in 75% of patients with ENT symptomatology. GERD control (DeMeester score and pyrosis if present) was highly statistically significant in all three groups of patients. It is necessary to mention, that there is a high presence of nocturnal acid breakthrough (NAB) in patients with respiratory symptoms: 30.3 % in patients with bronchial asthma, 63.6 % in patients with chronic cough and 45 % of patients with ENT manifestations.

Efficacy and safety of chronic hepatitis C treatment in hemophilic patients

BACKGROUND/AIMS

Chronic hepatitis C infection is very common among hemophiliacs in the developed World.

METHODOLOGY

Retrospective evaluation of the treatment results in hemophiliacs with chronic hepatitis C, all infected with genotype 1b. Twelve patients were treated with interferon-alpha monotherapy, 21 patients with interferon-alpha and ribavirin, and 3 patients with pegylated interferon and ribavirin, all for 48 weeks.

RESULTS

Sustained virologic response (defined as an undetectable serum HCV RNA level 24 weeks after treatment was completed) was not achieved in any of 12 patients treated with interferon-alpha alone. Combination therapy with interferon-alpha and ribavirin was associated with better results: 4/10 (40%) patients still untreated with interferon-alpha, 2/4 (50%) relapsers, and 2/7 (29%) non-responders to previous interferon-alpha monotherapy achieved sustained virologic responses. Combination therapy with pegylated interferon and ribavirin has been used in 3 patients. Sustained response was achieved in one patient who had relapsed after treatment with interferon-alpha and ribavirin and in 1 of 2 non-responders to this combination therapy. There were no serious adverse events and it was not necessary to reduce dosages or even cease therapy prematurely.

CONCLUSIONS

The efficacy and tolerability of antiviral treatment in hemophiliacs did not differ from other patients with chronic hepatitis C.

Immunosuppressive treatment of Crohn's disease with fistulae

The rise of fistulae in Crohn's disease has been classed with the disorder complications, although it is a possible component of natural development of the so-called A type (De Dombal classification) or aggressive-perforating type (Greenstein's classification) of this idiopathic intestinal inflammation. Fistulae are accompanying colic localization of Crohn's disease in 20%, ileocolic affection in 40%, where 35% of them are perianal fistulae, and about 34% entero-enteral or entero-cutaneous ones. Other complications (urogenital tract, biliary tract) are mentioned infrequently in literature. Besides surgical approaches in the therapy, dominant post in the conservative area is taken up by an antitumor necrotizing factor, antibiotics and immunosuppressives whose position is, however, the most problematic although the literature references about the effectiveness of azathioprine, 6-mercaptopurine, cyclosporine, tacrolime and methotrexate have had nearly 25-years tradition. The authors present their own experience with applying a combination of cyclosporine, azathioprine in the treatment of perianal fistulae in a set of 21 patients from the period of 1995-2000. In their opinion, the therapy success is limited especially by early starting the treatment (11 cases of effective therapy) and choosing a resolute method that is, according to them, sequential immunosuppression. (Tab. 2, Ref. 32.)

Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding

BACKGROUND/AIMS

1) To compare the effect of 2-day application of 0.2 mg terlipressin i.v. every 4 hours (group I) with that of 5-day application of 1 mg i.v. every 4 hours (group II) in the treatment of bleeding esophageal varices and portal gastropathy. 2) To assess the incidence of adverse events.

METHODOLOGY

Eighty-six patients with liver cirrhosis (54 men and 32 women, average age 51 years) were randomized over a period of 2 years into 2 groups. Acute bleeding was diagnosed endoscopically within 24 hours of its onset. The two groups fully comparable; treatment failure rated according to "Baveno II".

RESULTS

Success rate in group I was 78% at day 2 and 75% at day 5; in group II 89% and 79%, respectively (no statistical significance). Rebleeding had occurred by day 5 in 15% in group I, and in 16.3% in group II. Transfusion needs by day 2 were significantly lower in group II (2.4 units compare to 3.4 units in I). The 30-day mortality was 17.1% in group I and 20% in group II. No statistical difference between I and II in the occurrence of adverse events.

CONCLUSIONS

At a dosage of 1 mg i.v. every 4 hours, the success rate at day 2 was as much as 90% while blood consumption was significantly lower compared with the lower dosage. Rebleeding during first 48 hours occurred almost exclusively at lower dosage. There was no increase in the rate of adverse events relative to the higher dosage.

One week of treatment with esomeprazole-based triple therapy eradicates Helicobacter pylori and heals patients with duodenal ulcer disease

BACKGROUND

Proton pump inhibitor (PPI) monotherapy is commonly continued for 3 weeks after Helicobacter pylori eradication with PPI-based triple therapy regimens to ensure duodenal ulcer (DU) healing. This randomized, double-blind, multicentre study evaluated whether only 1 week of triple therapy with the new PPI esomeprazole was sufficient to ensure high rates of ulcer healing and H. pylori eradication.

METHODS

A total of 446 H. pylori-positive patients with active DU received twice daily treatment with esomeprazole 20 mg (n = 222) or omeprazole 20 mg (n = 224) in combination with amoxicillin 1 g and clarithromycin 500 mg for 1 week (EAC and OAC, respectively). Patients in the OAC group then received 3 weeks' monotherapy with omeprazole 20 mg once daily; those treated with EAC received placebo. Ulcer healing was assessed by endoscopy on completion of therapy and H. pylori status was assessed by (13)C-urea breath testing and histology 4-6 weeks later.

RESULTS

Ulcer healing rates (95% CI) for intention-to-treat and per-protocol populations were: EAC + placebo 91% (87-95%) and 94% (90-97%); OAC + omeprazole 92% (88-95%) and 96% (92-98%). Corresponding H. pylori eradication rates were: EAC + placebo 86% (81-90%) and 89% (84-93%); OAC + omeprazole 88% (83-92%) and 90% (85-93%). Both eradication regimens were well tolerated, and patient compliance was high.

CONCLUSIONS

A 1-week regimen of esomeprazole-based triple therapy is sufficient for DU healing and H. pylori eradication in patients with DU disease.

Helicobacter pylori and gastric cancer: current status of the Austrain-Czech-German gastric cancer prevention trial (PRISMA-Study)

AIM: To test the hypothesis that Helicobacter pylori eradication alone can reduce the incidence of gastric cancer in a subgroup of individuals with an increased risk for this fatal disease.

METHODS: It is a prospective, randomized, double blind, placebo controlled multinational multicenter trial. Men between 55 and 65 years of age with a gastric cancer phenotype of Helicobacter pylori gastritis are randomized to receive a 7 day course of omeprazole 2 × 20 mg, clarithromycin 2 × 500 mg, and amoxicillin 2 × 1 g for 7 days, or omeprazole 2 × 20 mg plus placebo. Follow-up endoscopy is scheduled 3 months after therapy, and thereafter in one-year intervals. Predefined study endpoints are gastric cancer, precancerous lesions (dysplasia, adenoma), other cancers, and death.

RESULTS: Since March 1998, 1524 target patients have been screened, 279 patients (18.3%) had a corpus dominant type of H. pylori gastritis, and 167 of those were randomized (58.8%). In the active treatment group (n = 86), H. pylori infection infection was cured in 88.9% of patients. Currently, the cumulative follow-up time is 3046 months (253. 38 patient years, median follow up 16 months). So far, none of the patients developed gastric cancer or any precancerous lesion. Three (1.8%) patients reached study endpoints other than gastric cancer.

CONCLUSION: Among men between 55 and 65 years of age, the gastric cancer phenotype of H. pylori gastritis appears to be more common than expected. Further follow up and continuing recruitment are necessary to fulfil the main aim of the study.

[Barrett's esophagus]

Barrett's esophagus is a pre-malignant change in esophageal mucosa. Its relation to the reflux disease of the esophagus and the origin of adenocarcinoma (which currently has an increasing incidence) experiences its renaissance. The pathogenesis of this disease is based on the composite effect of reflux contents of hydrochloric acid and duodenal juices. In addition to endoscopy and histology, chromoendoscopy and fluorescent endoscopy are gradually starting to be put into diagnostic routine practice. The control of patients is a necessity which depends on the degree of pathohistological changes within the epithelium. The therapy of the Barrett's esophagus can be either conservative which is currently carried out by proton pump inhibitors or surgical. Ablation of epithelium in combination with a subsequent long-term antisecretory therapy appears to be a promising treatment. (Ref. 23.)

Restoration of propulsive peristalsis of the esophagus in achalasia

The set consisting of 3 patients with esophageal achalasia diagnosed by manometry, pseudoachalasia excluded by esophagoscopy and endosonography, was treated with combined conservative procedure. Botulinum toxin 250u (Dysport) was applied to the area of lower esophageal sphincter and after 7 days balloon dilatation was carried out. Treatment efficacy was evaluated by the data obtained about the subjective condition, manometrically and endoscopically. The spine condition was evaluated in all patients before treatment and functional blockades were released by manual medicine and even by acupuncture. We succeeded in restoring propulsive peristalsis of the esophagus in all of them. It is objectively proven in the longest duration of 44 months in the case of a patient treated with a balloon dilatation.

Our approach to the surgical treatment of chronic pancreatitis

BACKGROUND/AIMS

Optimal surgical management of the patients suffering of chronic pancreatitis still remains a controversial problem. The base for the evaluation of patients is for us the Marseille-Roma classification from 1988 with 4 fundamental types of the disease. Surgical therapy is usually indicated in patients with intractable or continuous pain, stenosis of the common bile duct and duodenal stenosis. The source of the above mentioned problems is related to the head of the pancreas and we prefer as the procedure of choice duodenum sparing resection of the pancreatic head.

METHODOLOGY

Seventy patients were treated by our team in the years from 1985 to 1995 surgically and 55 of these patients underwent resection of the head of the pancreas.

RESULTS

Eighteen patients were treated by hemipancreatoduodenectomy and 37 patients by the duodenum sparing resection of the pancreatic head.

CONCLUSION

Left sided resection and drainage procedures appear to be much less effective from the point of view of long term follow-up.

Duodenum-sparing resection of the pancreatic head combined with pancreatogastroanastomosis in the treatment of chronic pancreatitis--surgical technique

Chronic pancreatitis is defined as progressively developing disease which reduces exocrine parenchyma and decreasing exocrine capacity of the pancreas. The disease is commonly manifested by recurrent attacks of severe and often incapacitating upper abdominal and back pain. The goal of surgical therapy is pain relief and unblocking of the stenosis of the common bile duct and duodenum. Our method of solving this problem is a duodenum sparing resection of the pancreatic head followed by simple reconstruction of the gastrointestinal tract using pancreatogastroanastomosis. All unnecessary anastomoses are thus reduced and the risk of anastomotic leak is minimized. The substantial advantage of this operation is the removal of the pancreatic head where the source of symptoms related to chronic pancreatitis is localized.

Endoscopic therapy of chronic pancreatitis

BACKGROUND/AIMS

Endoscopic therapy of chronic obstructive pancreatitis is an indubitable contribution to patients which brings immediate pain relief, enables an increased caloric food intake and improves the quality of patient's life. The authors describe their experience in a set of 42 subjects, in whom endoscopic papillotomy of the pancreatic duct was carried out after diagnosis of chronic obstructive pancreatitis.

MATERIAL AND METHODS

Endoscopic papillotomy was performed in 42 patients. In 17 patients, papillotomy was followed by the drainage of the pancreatic duct.

RESULTS

The treatment led to disappearance or significant decrease of the epigastric pain in 85.7% patients shortly after the treatment; in 47.1% of patients the painless period lasted for further 24 months after the therapy. Increase in body weight of about 2 kg occurred in 53% of treated subjects during the 2 years since the therapy. Complications in treatment, such as acute pancreatitis in 3 patients and bleeding in 2 were mastered conservatively.

CONCLUSION

Endoscopic therapy of chronic pancreatitis is an alternative approach of managing the algic form of chronic obstructive pancreatitis. Changes in the area of Vater papilla, pathological content of pancreatic duct, structure or complications of chronic pancreatitis could be solved endoscopically with a minimum burden on patient. According to the experience of the authors, endoscopic papillotomy of pancreatic duct with contingent drainage led to the pain disappearence nearly in 50% of patients in the set of 42 subjects 24 months after the performance. This fact was followed with an increase in body weight in more than 50% of treated subjects. Minimum of complications put the endoscopic therapy among relatively safe and at the same time effective approach to chronic pancreatitis.