To drain or not to drain: a cumulative meta‐analysis of the use of routine abdominal drains after pancreatic resection

BackgroundTo warrant the adoption or rejection of health care interventions in daily practice, it is important to establish the point at which the available evidence is considered sufficiently conclusive. This process must avoid bias resulting from multiple testing and take account of heterogeneity across studies. The present paper addresses the issue of whether the available evidence may be considered sufficiently conclusive to continue or discontinue the current practice of postoperative abdominal drainage after pancreatic resection.MethodsA systematic review was conducted of randomized and non‐randomized studies comparing outcomes after routine intra‐abdominal drainage with those after no drainage after pancreatic resection. Studies were retrieved from the PubMed, Cochrane Central Trial Register and EMBASE databases and meta‐analysed cumulatively, adjusting for multiple testing and heterogeneity using the iterated logarithm method.ResultsThree reports, describing, respectively, one randomized and two non‐randomized studies with a comparative design, met the inclusion criteria predefined for primary studies reporting on drain management and complications after pancreatic resection. These studies included 89, 179 and 226 patients, respectively. The absolute differences in rates of postoperative complications in these studies were −6.4%, −9.5% and −6.3%, respectively, in favour of the no‐drain groups. The cumulative risk difference in major complications, adjusted for multiple testing and heterogeneity, was −7.8%, with a 95% confidence interval of −20.2% to 4.7% (P = 0.214).ConclusionsThe routine use of abdominal drains after pancreatic resection may result in a higher risk for major complications, but the evidence is inconclusive.     

Incidence and risk factors for anastomotic bile leakage in hepatic resection with bilioenteric reconstruction – A international multicenter study

BackgroundAnastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions.MethodsData from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases.ResultsWithin 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001).ConclusionThis multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients’ postoperative course negatively.     

Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses： A multicenter study

AIM： To evaluate the ability of endoscopic ultrasound （EUS） elastography to distinguish benign from malignant pancreatic masses and lymph nodes.
METHODS： A multicenter study was conducted and included 222 patients who underwent EUS examination with assessment of a pancreatic mass （n = 121） or lymph node （n = 101）, The classification as benign or malignant, based on the real time elastography pattern, was compared with the classification based on the B-mode EUS images and with the final diagnosis obtained by EUS-guided fine needle aspiration （EUS- FNA） and/or by surgical pathology. An interobserver study was performed.
RESULTS： The sensitivity and specificity of EUS elastography to differentiate benign from malignant pancreatic lesions are 92.3% and 80.0%, respectively, compared to 92.3% and 68.9%, respectively, for the conventional B-mode images. The sensitivity and specificity of EUS elastography to differentiate benign from malignant lymph nodes was 91.8% and 82.5%, respectively, compared to 78.6% and 50.0%, respectively, for the B-mode images. The kappa coefficient was 0.785 for the pancreatic masses and 0.657 for the lymph nodes.
CONCLUSION： EUS elastography is superior compared to conventional B-mode imaging and appears to be able to distinguish benign from malignant pancreatic masses and lymph nodes with a high sensitivity, specificity and accuracy. It might be reserved as a second line examination to help characterise pancreatic masses after negative EUS-FNA and might increase the yield of EUS-FNA for lymph nodes.     

Machine learning model for prediction of low anterior resection syndrome following laparoscopic anterior resection of rectal cancer:A multicenter study

BACKGROUND Low anterior resection syndrome(LARS) severely impairs patient postoperative quality of life,especially major LARS. However,there are few tools that can accurately predict major LARS in clinical practice.AIM To develop a machine learning model using preoperative and intraoperative factors for predicting major LARS following laparoscopic surgery of rectal cancer in Chinese populations.METHODS Clinical data and follow-up information of patients who received laparoscopic anterior resecti...     

Hyperventilation in asthma: A validation study of the Nijmegen Questionnaire – NQ

Introduction: The Nijmegen questionnaire (NQ) has previously been used for screening the hyperventilation syndrome (HVS) in asthmatics. However, no validity study has been reported so far. Objective: To examine the validity and reliability of the NQ in asthma patients and identify the prevalence of HVS. Methods: The NQ (n?=?162) was examined for translation, construct, cross-sectional and discriminant validity as well as for internal consistency and test–retest reliability. Results: Principal component analysis and exploratory factor analysis revealed a single factor solution with 11 items and 58.6% of explained variability. These 11 NQ items showed high internal consistency (Cronbach's alpha?=?0.92) and test–retest reliability (IR?=?0.98). Higher NQ scores were found in the following subgroups: women versus men (p?p?p?p?2 (ETCO₂) ≤35 versus >35?mmHg (p?17 discriminated the participants with regard to the presence of HVS. The NQ showed 92.73% sensitivity and 91.59% specificity. The total NQ score was found significantly correlated with ETCO₂ (r?=??0.68), RR (r?=?0.66) and BHT (r?=??0.65). The prevalence of HVS was found 34%. Conclusion: The NQ is a valid and reliable questionnaire for screening HVS in patients with stable mild-to-moderate asthma.     

Usefulness of magnifying endoscopy in post-endoscopic resection scar for early gastric neoplasm： A prospective short-term follow-up endoscopy study

AIM： To investigate the relationship between postendoscopic resection （ER） scars on magnifying endoscopy （ME） and the pathological diagnosis in order to validate the clinical significance of ME. METHODS： From January, 2007 to June, 2008, 124 patients with 129 post-ER scar lesions were enrolled. Mucosal pit patterns on ME were compared with conventional endoscopy （CE） findings and histological results obtained from targeted biopsies. RESULTS： CE findings showed nodular scars （53/129）, erythematous scars （85/129）, and ulcerative scars （4/129）. The post-ER scars were classified into four pit patterns of sulci and ridges on ME： （ Ⅰ ） 47 round; （Ⅱ） 54 short rod or tubular; （Ⅲ） 19 branched or gyrus-like;and （Ⅳ） 9 destroyed pits. Sensitivity and specificity were 88.9% and 62.5%, respectively, by the presence of nodularity on CE. Erythematous lesions were high sensitivity （100%）, but specificity was as low as 36.7%. The range of the positive predictive va ue （PPV） on CE was as low as 10.6%-25%. Nine type N pit patterns were diagnosed as tumor lesions, and 120 cases of type Ⅰ-Ⅲ pit patterns revealed non-neoplastic lesions. Thus, the sensitivity, specificity, and the PPV of ME were 100%. CONCLUSION： ME findings can detect the presence of tumor in post-ER scar lesions, and make evident the biopsy target site in short-term follow-up. Further large-scale and long-term studies are needed to determine whether ME can replace endoscopic biopsy.     

Combined endoscopic trangastric drainage and video assisted retroperitoneal pancreatic debridement – The best of both worlds for extensive pancreatic necrosis with enteric fistulae

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.     

Current controversies and challenges for resection of pancreatic ductal adenocarcinoma in pancreatic head aiming at cure

<正>Pancreatic ductal adenocarcinoma(PDAC) is a very common but a highly lethal malignancy due to its biological aggressive behavior. PDAC more commonly affects the head than other parts of the pancreas. As PDAC in the head of pancreas is located at an anatomical position with a lot of adjacent vital structures, and the cornerstone of treatment aiming at cure is pancreaticoduodenectomy(PD),     

Management of cholelithiasis in Italian children：A national multicenter study

AIM：To evaluate the management of Italian children with cholelithiasis observed at Pediatric and Surgical Departments linked to Italian Society of Pediatric Gastroenterology Hepatology and Nutrition.
METHODS： One-hundred-eighty children （90 males, median age at diagnosis 7.3 years; range, 0-18 years） with echographic evidence of cholelithiasis were enrolled in the study; the data were collected by an anonymous questionnaire sent to participating centers.
RESULTS： One hundred seventeen patients were treated with ursodeoxycholic acid; in 8 children dissolution of gallstones was observed, but the cholelithiasis recurred in 3 of them. Sixty-five percent of symptomatic children treated became asymptomatic. Sixty-four patients were treated with cholecystectomy and in only 2 cases a postoperative complication was reported. Thirty- four children received no treatment and were followed with clinical and echographic controls; in no case thedevelopment of complications was reported.
CONCLUSION： The therapeutic strategies were extremely heterogeneous. Ursodeoxycholic acid was ineffective in dissolution of gallstones but it had a positive effect on the symptoms. Laparoscopic cholecystectomy was confirmed to be an efficacy and safe treatment for pediatric gallstones.     

The role of peroxidation of mitochondrial membrane phospholipids in pancreatic β -cell failure

Type 2 diabetes (T2D) is characterized by peripheral insulin resistance and pancreatic islet β-cell failure. Accumulating evidence indicates that mitochondrial dysfunction is a central contributor to β-cell failure in the pathogenesis of T2D. This review focuses on mechanisms whereby reactive oxygen species (ROS) produced by β-cell in response to metabolic stress affect mitochondrial structure and function and lead to β-cell failure. Specifically, ROS oxidize mitochondrial membrane phospholipids such as cardiolipin, which impairs membrane integrity and leads to cytochrome c release and apoptosis. In addition, ROS activate UCP2 via peroxidation of the mitochondrial membrane phospholipids, which results in proton leak leading to reduced ATP synthesis and content in β-cells - critical parameters in the regulation of glucose-stimulated insulin secretion. Group VIA Phospholipase A2 (iPLA2β) appears to be a component of a mechanism for repairing mitochondrial phospholipids that contain oxidized fatty acid substituents, and genetic or acquired iPLA2β-deficiency increases β-cell mitochondrial susceptibility to injury from ROS and predisposes to development of T2D. Interventions that attenuate the adverse effects of ROS on β-cell mitochondrial phospholipids may prevent or retard the development of T2D.     

The redundant role of JAK2 in regulating pancreatic β-cell mass

Janus kinase (JAK) 2 is a non-receptor tyrosine kinase that mediates the downstream effects of various growth factors, including growth hormone, prolactin, placental lactogen, and erythropoietin (EPO). EPO is a hematopoietic growth factor that is largely known for its role in promoting proliferation, differentiation and survival of cells in the erythroid lineage. Global loss of the EPO receptor (EPO-R) has been shown to be embryonically lethal in mice due to anemia attributed to defects in erythropoiesis. Interesting, mice with global deficiency of JAK2 share a similar developmental phenotype as the EPO-R knockout mice, demonstrating that JAK2 is essential in eliciting the biological effects of EPO, particularly in erythrocytosis. Recent studies from our group have shown that exogenous EPO protects mice against diabetes through direct effects on pancreatic β-cells, and these protective effects are dependent on the presence of JAK2 in the β-cells. Here, we briefly highlight the cytoprotective effects of exogenous EPO in the pancreatic β-cells as well as our new findings on the redundant role of JAK2 in β-cell expansion after high-fat feeding in mice.     

The role of hypoxia in recurrence following resection of Dukes’ B colorectal cancer

Goals  Tumour hypoxia has been shown to be a predictor of early distant relapse in node-negative breast and cervical cancer. The purpose of the present study was to determine the role of hypoxia in predicting patients who are at high risk of disease recurrence in Dukes B colorectal cancers. Materials and methods  Archival tissue was retrieved from 52 patients who had undergone surgical resection for primary colorectal cancer. Tissue micro-arrays were constructed using tissue from the margin and the centre of the tumour. Hypoxia markers hypoxia-inducible factor (Hif)-1α, vascular endothelial growth factor (VEGF), carbonic anhydrase (CA)-9 and glucose transporter (Glut)-1 were visualised using immunohistochemical detection and quantified using semi-quantitative analysis of the digitised images. Clinical details and outcome data were retrieved by case note review and collated with hypoxia markers data in a statistical database. Results  Primary colorectal cancers with a high Hif-1α expression tended to have a significantly worse disease-free survival (log rank p < 0.001) and overall survival (log rank p = 0.012). VEGF was also a significant predictor of disease recurrence in primary colorectal cancers (p = 0.015). Significant correlations were also noted between Hif-1α and VEGF (Pearson’s p = 0.009). Glut-1 and CA-9 did not show a similar pattern with no differences in the expression pattern and no correlation observed with any of the markers. Multivariate analysis of prognostic factors showed vascular invasion (p < 0.001) and Hif-1α at the tumour margin (p < 0.001) to be independent predictors for the development of liver metastases. Conclusion  These results suggest an important role for Hif-1α and VEGF in colorectal cancer progression, with both markers biological mechanisms directly interlinked through the hypoxic pathway. Identification of high-risk patients using the above factors will improve treatment strategies in node-negative disease and help improve patient outcome.     

Trends in management and outcome of cystic pancreatic lesions – analysis of 322 cases undergoing surgical resection

Abstract

Background: Several guidelines for the management of cystic pancreatic lesions (CPL) exists. From 2013, Oslo University Hospital adapted the European consensus guidelines (ECG) in the decision-making as to whether patients should be advised to have resection or observation for CPL. The aims of the study were to assess changes over time in the workup and diagnostic accuracy of resected CPL, and the short-term surgical outcome.

Methods: Preoperative radiological workup, clinicopathological characteristics, and perioperative outcomes were retrospectively reviewed in three consecutive time periods (early: 2004–2008, intermediate: 2009–2012, late: 2013–2016). The rate of concordance between the ECG recommendations for resection (ECG+) or observation (ECG–) and the final histological diagnosis were assessed.

Results: A total of 322 consecutive patients underwent resection for CPL (early: n?=?89, intermediate: n?=?108, late: n?=?125). The most common diagnoses were intraductal papillary mucinous neoplasia (IPMN, 36.0%), serous cystic neoplasm (SCN, 23.9%), mucinous cystic neoplasm (10.6%), pseudocyst (9.6%), solid pseudopapillary neoplasm (7.8%), and cystic pancreatic neuroendocrine tumour (5.3%). The proportion of ECG+?CPL undergoing surgery increased significantly (42.7% vs. 60.7% vs. 70.4%, p?<?.001). The relative proportion of patients undergoing resection for SCN decreased (38.2% vs. 21.3% vs. 16.0%), whereas it increased for IPMN (31.5% vs. 30.6% vs. 44.0%). The use of magnetic resonance imaging and endoscopic ultrasound increased. There were no differences in postoperative severe complications (23.0% vs. 23.6%) or 90-day mortality (2.3% vs. 0.8%) between ECG+?and ECG– patients.

Conclusion: Several changes in the management of CPL were revealed during time. Adherence to guidelines is important in order to avoid unnecessary surgery for CPL.     

The role of aspirin in post-polypectomy bleeding – a retrospective survey

Background

Keratins 8/18 (K8/K18) are established hepatoprotective proteins and K8/K18 variants predispose to development and adverse outcome of multiple liver disorders. The importance of K8/K18 in alcoholic liver disease as well as in established cirrhosis remains unknown.

Methods

We analyzed the K8 mutational hot-spots in 261 prospectively followed-up patients with alcoholic cirrhosis (mean follow-up 65 months). PCR-amplified samples were pre-screened by denaturing high-performance liquid chromatography and conspicuous samples were sequenced.

Results

67 patients developed hepatocellular carcinoma (HCC) and 133 died. Fourteen patients harbored amino-acid-altering K8 variants (5xG62C, 8xR341H). The presence of K8 variants did not associate with development of HCC (log-rank=0.5) or death (log-rank=0.7) and no significant associations were obtained for the single K8 variants after a correction for multiple testing was performed.

Conclusions

Keratin variants are expressed in a low percentage of patients with alcoholic cirrhosis and do not influence HCC development. Further studies conducted in larger prospective cohorts are needed to find out whether presence of K8 R341H variant predispose to non-HCC-related liver mortality.

     

The endoscopist’s role in the diagnosis and management of pancreatic cancer

Pancreatic cancer remains one of the most lethal malignancies with little improvement in survival over the past several decades in spite of advances in imaging, risk factor identification, surgical technique and chemotherapy. This disappointing outcome is mainly due to failures to make an early diagnosis. In fact, the majority of the patients present with inoperable advanced stages of the disease. Though some of the new tumor markers are promising, we are still in search of the one that has a high sensitivity and accuracy, yet is inexpensive and easy to obtain. The paradigm of management has shifted from up-front surgery followed by adjuvant chemotherapy to neoadjuvant chemoradiation followed by surgery, especially for borderline resectable cancers and even for some resectable cancers. In this article, we will critically assess the limitations of tumor markers and review the advancements in endoscopic techniques in the management of pancreatic cancer.     

The outcome of initial percutaneous drainage versus surgical drainage for intra-abdominal abscesses in Crohn’s disease

Purpose  

Percutaneous drainage (PD) of Crohn’s related abscesses is becoming popular with the development of techniques. We retrospectively analyzed the outcome of initial PD versus initial surgical drainage for intra-abdominal abscesses in Crohn’s disease.     

Leptin to adiponectin ratio – A surrogate biomarker for early detection of metabolic disturbances in obesity

Aim

To study if the leptin to adiponectin (L:A) ratio, can be a potential biomarker for postprandial triglyceride clearance, insulin resistance (IR) or leptin resistance (LR) in apparently healthy obese, and obese individuals with established metabolic disease.

Portal blood – A new source of dendritic cells for pancreatic cancer vaccine

IntroductionCohort study evaluated dendritic cells (DCs) subsets in portal and peripheral blood of patients with pancreatic cancer (PC) and chronic pancreatitis (CHP).Material and methodsMyeloid type 1 (mDCs1) and 2 (mDCs2), plasmocytoid (pDCs) and SLAN + DCs were assessed in PC (n = 20) and CHP (n = 6) patients.ResultsPercentage of mDCs1 was significantly lower in PC patients when compared to CHP (0.48 ± 0.26 vs 0.76 ± 0.3; p = 0.038) only in portal, but not peripheral blood.DiscussionFurther studies to assess the functional properties of portal blood DCs and their applicability in anticancer vaccination are needed.