Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

BACKGROUND

Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation.

METHODS

This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN.

RESULTS

Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths).

CONCLUSION

A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.

A common variant rs2272804 in the 5'UTR of RIBC2 inhibits downstream gene expression by creating an upstream open reading frame

OBJECTIVE

The RIB43A domain with coiled-coils 2 (RIBC2) encodes an uncharacterized vertebrate protein exhibiting similarity with Chlamydomonas protofilament ribbon proteins, required for ciliary motility. To date, no functional variants capable of triggering a change in the expression of RIBC2 have been reported.

PATIENTS AND METHODS

The genotypes of rs2272804 in 30 individuals were identified with Sanger sequencing to estimate allele frequencies. Dual-Luciferase and mutagenesis assays were carried out to investigate the impact of rs2272804 on transcriptional and translational levels. The microarray data of 7 types of cancer were obtained from the Gene Expression Omnibus (GEO) to explore the role of rs2272804 in those diseases.

RESULTS

In this study, we identified a common variant in the 5'UTR of RIBC2, rs2272804, which can create an upstream open reading frame (uORF) in the 5'UTR significantly inhibiting the expression of its host gene. Using Dual-Luciferase constructs, we found that this variant leads to an 85% reduction in translational efficiency, but only a 20% decrease was observed at the transcriptional level. In terms of population studies, mRNA levels of RIBC2 varied according to their rs2272804 genotypes. The "A" allele homozygotes, which created a uORF, showed the lowest transcriptional levels while the transcriptional activity of the "C" allele homozygotes without an uORF was the highest, consistent with the in-vitro studies. Furthermore, we explored its role in 7 types of cancer and identified RIBC2 as a significantly differentially expressed gene (DEG) in breast cancer (BRCA), ovarian serous cystadenocarcinoma (OV), and kidney renal clear cell carcinoma (KIRC). Finally, we showed that the overexpression of RIBC2 enhanced the expression of TRIM37 and down-regulated TRAF2. TRIM37 is a member of the tripartite motif (TRIM) family involved in developmental patterning and oncogenesis while TRAF2 is associated with the signal transduction from members of the TNF receptor superfamily.

CONCLUSIONS

Our reports identified a common variant that exerts a dramatic impact on expression efficiency and provides further functional insight into RIBC2.

[Non-surgical treatment of acute pancreatitis with colonic fistula]

Objective: To examine the effectiveness of non-operative of colonic fistula following acute pancreatitis. Methods: Retrospective analysis of 354 patients with acute pancreatitis who were admitted to Department of Hepatobiliary Surgery of Chinese People's Liberation Army General Hospital from January 2013 to December 2018. Age of the patients was (46±14) years (range: 14-85 years); 249 cases (70.3%) were males. There were 41 cases of acute edematous pancreatitis and 313 cases of acute necrotising pancreatitis. Two hundred and fifteen cases were diagnosed as moderate severe acute pancreatitis and 139 were diagnosed as severe acute pancreatitis. Among 313 cases of acute necrotising pancreatitis, 62 cases underwent non-surgical treatment, 251 cases underwent surgical treatment in which 218 of minimal access retroperitoneal pancreatic necrosectomy underwent percutaneous nephroliguectomy with peripancreatic necrotic tissue removal technique. Results: There were 15 cases of colon fistula following acute necrotising pancreatitis, and the incidence rate was 4.2%(15/354). There were 7 males and 8 females, with age of (39±8) years (range: 27 to 50 years). The median interval between acute pancreatitis onset and diagnosis of colonic fistula was 71 days(27-134) days. Two cases occurred at the hepatic flexure of the colon, 4 cases at transverse colon, and 9 cases at splenic flexure of colon. Of the 354 patients, 39 cases died and the mortality was 11.0%. Two patients underwent laparotomy, and one of them died. The remaining 13 patients underwent non-surgical treatment and were discharged. Conclusion: Acute pancreatitis with colonic fistula can be treated with non-surgical treatment and can achieve good prognosis.

[The research advances and applications of genome editing in hereditary eye diseases]

Genome editing is a cutting-edge technology that generates DNA double strand breaks at the specific genomic DNA sequence through nuclease recognition and cleavage, and then achieves insertion, replacement, or deletion of the target gene via endogenous DNA repair mechanisms, such as non-homologous end joining, homology directed repair, and homologous recombination. So far, more than 600 human hereditary eye diseases and systemic hereditary diseases with ocular phenotypes have been found. However, most of these diseases are of incompletely elucidated pathogenesis and without effective therapies. Genome editing technology can precisely target and alter the genomes of animals, establish animal models of the hereditary diseases, and elucidate the relationship between the target gene and the disease phenotype, thereby providing a powerful approach to studying the pathogenic mechanisms underlying the hereditary eye diseases. In addition, correction of gene mutations by the genome editing brings a new hope to gene therapy for the hereditary eye diseases. This review introduces the molecular characteristics of 4 major enzymes used in the genome editing, including homing endonucleases, zinc finger nucleases, transcription activator-like effector nucleases, and clustered regularly interspaced short palindromic repeats (CRISPR)/ CRISPR-associated protein 9 (Cas9), and summarizes the current applications of this technology in investigating the pathogenic mechanisms underlying the hereditary eye diseases. (Chin J Ophthalmol, 2017, 53: 386-371).

[Analysis of the spectrum and resistance of pathogen causing sepsis in patients with severe acute pancreatitis]

Objective: To investigate the characteristics of spectrum and drug resistance of pathogens causing sepsis in patients with severe acute pancreatitis(SAP). Methods: The clinical data of 63 SAP patients with sepsis admitted in Department of Hepatobiliary, People's Liberation Army General Hospital from January 2014 to December 2015 were retrospectively studied. There were 47 males and 16 females, aged from 22 to 73 years, with an average age of (52±11)years. Samples were collected mainly from: (1)pancreatic and peripancreatic necrosis and abdominal drainage; (2)bile; (3) blood or deep venous catheter; (4) sputum and tracheal catheter and thoracic drainage; (5) urine. Strain identification and drug-resistance test were preformed on positive specimens. Results: Of 244 pathogenic isolates, mainly derived from abdominal cavity(36.0%), blood stream (14.0%), central venous catheter(11.8%), necrotic tissue(9.1%) and sputum(8.1%); 154(63.1%) were gram-negative bacteria, 68 cases(27.9%) were gram-positive bacteria and 22 cases(9.0%) were fungi respectively. The top six common pathogens isolated were E. coli(16.0%), E.faecium and faecalis(15.2%), P.aeruginosa(10.7%), K.pneumonia(9.8%), Acinetobacter baumanni(8.2%), Stenotrophomonas maltophilia(5.3%)respectively. The detection rate of E. coli and K. pneumonia extended-spectrum β-lactamases(ESBL) was 84.6%(33/39) and 70.8%(17/24), the resistance rate to imipeniem was 12.8% and 25.0%, to cefperazone-sulbactam was 28.2% and 29.2%. As to P. aeruginosa and Acinetobacter bacillus, the resistance rate to imipeniem was 50.0% and 75.0%, to cefperazone-sulbactam was 42.3% and 70.0%; Stenotrophomonas maltophilia was completely resistant to cefperazone-sulbactam, but sensitive to minocycline, SMZ-TMP with the resistance rate less than 40.0%. Gram-positive bacterium strains mainly included E. faecium(38.2%, 26/68), E.faecalis(16.2%, 11/68) and Staphylococcus(35.3%, 24/68) which maintained high sensitivity to vancomycin, teicoplanin and linezolid, there was only one isolate resistant to vancomycin. Candida were the sole pathogens of fungal infections, sensitive to common antifungal drugs overall. Conclusions: The gram-negative bacteria are the predominant pathogens mainly including ESBL-producing isolates(E.coli and K. pneumonia) and non-fermentation bacteria(P.aeruginosa and Acinetobacter bacillus) causing sepsis in SAP. The infection rate and drug-resistance rate of these two kinds of pathogens are relatively higher.

[Experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis]

Objective: To explore the experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis(IPN). Methods: A retrospective review was performed on 12 patients with IPN who underwent minimal-access video-assisted retroperitoneal debridement between June 2008 and June 2013 in People's Liberation Army General Hospital and First Affiliated Hospital of People's Liberation Army General Hospital, respectively.There were 10 male patients and 2 female patients aging from 33 to 55 years with mean age of(43±8)years.Pancreas infective necrosis, the serious complications of severe acute pancreatitis occurred in all of the patients among which there were 2 patients with infection after percutaneous catheter drainage(PCD)in early phase of disease, and 12 patients with spontaneous during the late phase. The technical strategies of the minimally invasive treatment mainly included PCD, minimal-access video-assisted retroperitoneal debridement, and irrigation. Results: Ten patients received PCD and the median time from onset of acute necrotizing pancreatitis to PCD was mean of 24 days(range 8-86 days). Minimal-access video-assisted retroperitoneal debridement was performed after 18 days(range 3-29 days) after PCD.Three patients died after surgery.Five patients had hemorrhage complication and 3 had colonic fistula.Pancreatic fistula occurred in 2 patients. Conclusions: The technique of minimal-access video-assisted retroperitoneal debridement has advantage and some minor disadvantage.Delayed minimal-access video-assisted retroperitoneal debridement is recommended.

Microarray based analysis of gene expression patterns in pancreatic neuroendocrine tumors

OBJECTIVE

Pancreatic neuroendocrine tumors (PanNETs) are a small subgroup of tumors with a variety of biological behaviors.

MATERIALS AND METHODS

We sought to identify the specially expressed genes and characterize significant pathways in PanNETs compared with non-neoplastic samples. Gene expression profile GSE43795 was obtained from Gene Expression Omnibus database, which included 6 PanNETs and 5 non-neoplastic samples. The differentially expressed genes (DEGs) were identified using Limma package. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were used to enrich the functions and pathways of DEGs. Transcription factors (TFs) and tumor-associated genes (TAGs) were also identified. Finally, a protein-protein interaction (PPI) network was constructed, and hub proteins and functional module were screened out.

RESULTS

Total of 821 DEGs (421 down-regulated, 400 up-regulated) were selected. GO and KEGG enrichment analyses showed that up-regulated DEGs were related to several pathways, including type 2 diabetes mellitus, Ca2+ signaling pathway, long-term potentiation, and long-term depression pathways. Down-regulated DEGs were enriched in several pathways, such as pancreatic secretion, protein digestion and absorption, and metabolic pathway. Interferon-stimulated gene protein 15 (ISG15), somatostatin (SST), and synaptosomal-associated protein 25 kDa (SNAP25) were identified as hub proteins.

CONCLUSIONS

The genes involved in type 2 diabetes mellitus pathway may play important roles in the development of PanNETs. SNAP25, SST, and ISG15 may be used as potential targets for treatment of PanNETs.

Cadmium exposure and health effects among residents in an irrigation area with ore dressing wastewater

About 0.05 mg Cd l-1 was found in the irrigation water contaminated by the wastewater discharged from tungsten ore dressing plants, and about 1 mg Cd kg-1 was found in irrigated acid soils. The main sources of cadmium intake by residents of the polluted areas are agricultural products. The average intake of cadmium was 367-382 micrograms day-1, and for smokers 417 micrograms day-1. Among the residents who have been exposed to cadmium for more than 25 years, cadmium absorption (urinary cadmium greater than or equal to 10 micrograms g-1 creatine) was 60% and an early effect on the target organ (urinary cadmium greater than or equal to 15 micrograms g-1 creatinine and urinary beta 2-microglobulin greater than 500 micrograms g-1 creatinine) was detected in 17% of the sample of 433 persons. Levels of urinary cadmium and blood cadmium exceeded the critical value in the exposed group. The concentrations of urinary calcium, beta 2-microglobulin and N-acetyl-beta-D-glucosaminidase were significantly higher in residents of contaminated areas than in those of control areas. Case-control study of the residents shows that many have suffered from a nephropathy with tubulo-interstitial abnormalities. Owing to the combined cadmium effect, the cases with fractional beta 2-microglobulin excretion greater than 0.10 were 46% in the exposed population, and were much higher than that in the control group (20.3%).

[Cadmium exposure and health effects among residents in irrigation area with ore dressing wastewater]

About 0.05 mg Cd/L was found in the irrigation water contaminated by the wastewater discharged from the wolfram ore dressing plants, and about 1 mg Cd/kg was found in irrigated acid soil. The main sources of the cadmium intake by residents, living in pollution areas, were agricultural products. The average intake of cadmium was 366.7-381.9 micrograms/d, smokers 416.6 micrograms/d. Among residents, who have been exposed to cadmium for more than 25 years, cadmium absorption (CdU greater than or equal to 10 micrograms/g Cre) was 60% and early effect of target organ (CdU greater than or equal to 15 micrograms/g Cre and beta 2 -mU greater than or equal to 500 micrograms/g Cre) was 17%. Levels of CdU and CdB were beyond the critical value in the observation areas. The concentrations of CaU, beta 2-mU and NAGU were significantly higher among residents in observation areas compared with control areas. Owing to the combined cadmium effect the cases with fractional beta 2-m excretion greater than 0.10 were 46% in the observation areas, and it was much higher than that in control areas (20.3%) in a case-control study among residents who have been suffering from an original nephropathy with tubulo-interstitial abnormalities.