Interventional endoscopic ultrasound in pancreatic disease

The use of endoscopic ultrasound (EUS) in pancreatic disease is rapidly evolving as the field moves from a primarily diagnostic role to one of therapeutic intervention. Therapeutic EUS includes techniques such as the celiac block and transmural pseudocyst drainage. Newer techniques include EUS-guided fine-needle injection therapy in which a variety of agents are being investigated for the treatment of pancreatic cancer. Novel EUS-guided techniques are being devised to drain and alleviate pancreaticobiliary and gastroduodenal obstruction.     

Treatment of renal diseases with plasma exchange: a single center experience

Over the last decades, plasma exchange (PE) has been applied in the treatment of over 150 different diseases including nephrological, hematological, neurological, and rheumatological. Clinical benefit has been demonstrated in only about 40 of them and the best results were achieved in diseases with pathogenic autoimmune mechanisms. We used PE most frequently in patients with immune and autoimmune nephropathies aiming to decrease pathologically elevated antibody levels, autoantibodies and immune complexes. PE was applied in 40 patients with chronic glomerulonephritis, 29 patients with lupus nephritis, and 9 patients with Schoenlein‐Henoch nephritis. After 3 to 4 PE sessions, continuous immunosuppressive drug therapy was initiated. Significant reduction of antibody titers and immune complexes was achieved. PE was also applied in 45 plasmacytoma patients with nephropathy to reduce plasma viscosity and slow down the progression of myeloma nephropathy. The result was a significant reduction of pathologically elevated plasma viscosity and a detoxification effect. In our clinic plasma exchange procedures were performed by either centrifugal method with Haemonetics M‐30 device or by plasma filtration. An average of 1316 mL plasma was removed during a PE session. For substitution purposes donor plasma and saline solutions were used. Clinical remission was achieved in 61.3% of all patients without slowing the progression of renal failure, however.     

Ambivalent roles of carboxypeptidase B in the lytic susceptibility of fibrin

Background

Removal of C-terminal lysine residues that are continuously exposed in lysing fibrin is an established anti-fibrinolytic mechanism dependent on the plasma carboxypeptidase TAFIa, which also removes arginines that are exposed at the time of fibrinogen clotting by thrombin.

Objective

To evaluate the impact of alterations in fibrin structure mediated by constitutive carboxypeptidase activity on the function of fibrin as a template for tissue plasminogen activator-(tPA) induced plasminogen activation and its susceptibility to digestion by plasmin.

Methods and results

We used the stable carboxypeptidase B (CPB), which shows the same substrate specificity as TAFIa. If 1.5 – 6 μM fibrinogen was clotted in the presence of 8 U/mL CPB, a denser fibrin network was formed with thinner fibers (the median fiber diameter decreased from 138 – 144 nm to 89 – 109 nm as established with scanning electron microscopy). If clotting was initiated in the presence of 5 – 10 μM arginine, a similar decrease in fiber diameter (82 -95 nm) was measured. The fine structure of arginine-treated fibrin enhanced plasminogen activation by tPA, but slowed down lysis monitored using fluorescent tPA and confocal laser microscopy. However, if lysis was initiated with plasmin in CPB-treated fibrin, the rate of dissolution increased to a degree corresponding to doubling of the plasmin concentration.

Conclusion

The present data evidence that CPB activity generates fine-mesh fibrin which is more difficult to lyse by tPA, but conversely, CPB and plasmin together can stimulate fibrinolysis, possibly by enhancing plasmin diffusion.     

Uncommon and rarely reported adverse events of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has become a primary tool for the treatment of biliary and pancreatic ductal diseases. It is essential for the endoscopist carrying out the ERCP to have a thorough understanding of the potential adverse events. Typically, endoscopists are well familiar with common adverse events such as post‐ERCP pancreatitis, cholangitis, post‐sphincterotomy bleeding, post‐sphincterotomy perforation, and sedation‐related cardiopulmonary compromises. However, there are other less common adverse events that arecritical to promptly recognize in order to provide appropriate therapy and prevent disastrous outcomes. This review focuses on the presentation and management of the less common and rare adverse events of an ERCP from the perspective of the practicing endoscopist.