The prevalence and risk factors associated with zinc deficiency after pancreatic surgery.

PURPOSE: To clarify the prevalence, risk factors, and clinical implications associated with zinc deficiency in patients undergoing pancreatic surgery. METHODS: The serum zinc levels were measured in 329 patients post-pancreatic surgery between January and April 2021. The postoperative serum zinc levels and clinicopathological variables were retrospectively analyzed. RESULTS: The median serum zinc level was 73 µg/dL (33-218). Zinc deficiency (zinc level < 60 µg/dL) was observed in 52 patients (16%). A total of 329 patients were classified into zinc-deficient (n = 52) and non-deficient (zinc ≥ 60 µg/dL, n = 277) groups. A univariate analysis revealed significant differences in sex, postoperative body mass index, serum albumin, total cholesterol, creatinine, aspartate aminotransferase (AST), HbA1c levels, diabetes, surgical procedures, and operative blood loss. According to a multivariate analysis, male sex [odds ratio (OR) 3.70; 95% confidence interval (CI) 1.67-8.20; p = 0.001], postoperative serum albumin levels < 3.9 g/dL (OR 6.39; 95% CI 3.30-12.37; p < 0.001), postoperative serum AST ≥ 51 U/L (OR, 4.6; 95% CI 0.07-0.29; p < 0.001), and total pancreatectomy (OR 3.68; 95% CI 1.37-9.85; p = 0.009) were found to be independent predictors of zinc deficiency after pancreatic surgery. CONCLUSIONS: Zinc deficiency frequently occurs in patients undergoing pancreatic surgery. Lower postoperative zinc levels could be linked to sex, the serum albumin and AST levels, and surgery type.

Women's and Partners' Experiences with a Closed-Loop Insulin Delivery System to Manage Type 1 Diabetes in the Postpartum Period.

BACKGROUND: Closed-loop insulin delivery has the potential to offer women with type 1 diabetes a break from intense diabetes self-care efforts during postpartum. AIMS: To explore the views and opinions of hybrid closed-loop users and their partners in the first 24 weeks postpartum. METHODS: This qualitative study was embedded in a controlled study of women with type 1 diabetes randomized to (MiniMed™ 670G/770G) closed-loop insulin delivery or sensor augmented pump use 1-11 weeks 6 days postpartum, with all on closed-loop from 12 to 24 weeks postpartum. Semi-structured interviews were conducted with 16 study participants and their partners at 12 and 24 weeks postpartum. Thematic analyses were used to examine participants' and partners' experiences. RESULTS: Participants' positive perceptions of the closed-loop use related to reduced hypoglycemia, in contrast to previous experiences with nonautomated insulin delivery. These were balanced against frustrations with the system allowing blood glucose levels to be above what they desired. Closed-loop use did not influence infant feeding choice. Yet, infant feeding and care impacted participants' diabetes management. Partners expressed uncertainty about the closed-loop taking away control from participants who were highly skilled with diabetes self-management. CONCLUSIONS: Participants reported that the closed-loop resulted in less time spent in hypoglycemia; compared to previously used nonautomated insulin delivery. Yet, participants desired greater understanding into the workings of the closed-loop algorithm. This study provides potential users with realistic expectations about the user experience with the MiniMed™ 670G/770G closed-loop in the postpartum period.

Advances in Management of Nonfunctional Pancreas Neuroendocrine Tumors.

This article presents updates in the surgical management of non-functional sporadic pancreas neuroendocrine tumors NET, including considerations for assessment of biologic behavior to support decision-making, indications for surgery, and surgical approaches tailored to the unique nature of neuroendocrine tumors.

Indications for Radiation in Pancreatic Adenocarcinoma: A Review.

Pancreatic adenocarcinoma remains a deadly disease with 5 year overall survival of 10% among all stages. Standard of care for resectable disease remains surgical resection and adjuvant systemic therapy, but paradigms for borderline resectable and unresectable cases remain more nuanced. Radiation has been explored in the neoadjuvant, adjuvant, and definitive settings in a variety of randomized and non-randomized trials with mixed results. There is strong evidence to support the use of neoadjuvant radiation for borderline resectable pancreatic cancer. Utilization of radiation in the adjuvant setting remains unclear while the results of radiation therapy oncology group (RTOG) 0848 are pending.

Pancreatic Cancer Screening among High-risk Individuals.

Pancreatic ductal adenocarcinoma (PDAC) continues to remain one of the leading causes of cancer-related death. Unlike other malignancies where universal screening is recommended, the same cannot be said for PDAC. The purpose of this study is to review which patients are at high risk of developing PDAC and therefore candidates for screening, methods/frequency of screening, and risk for these groups of patients.

Minimally Invasive Pancreas Surgery: Is There a Benefit?

Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.

The Grade C Pancreatic Fistula.

Grade C pancreatic fistulas are associated with severe morbidity and a significant risk of mortality. High-risk pancreatic anastomoses can be predicted to allow best practice fistula mitigation techniques. In these high-risk glands, any deviation from a stable postoperative clinical course should prompt early computed tomography and aggressive, percutaneous drainage of the operative bed. If salvage surgery is necessary, drainage of the operative bed and/or external diversion of pancreatic juice via stenting while completion pancreatectomy should be avoided. Senior mentorship in the perioperative period offers an opportunity to decrease this complication even in early career surgeons.

Data privacy-aware machine learning approach in pancreatic cancer diagnosis.

PROBLEM: Pancreatic ductal adenocarcinoma (PDAC) is considered a highly lethal cancer due to its advanced stage diagnosis. The five-year survival rate after diagnosis is less than 10%. However, if diagnosed early, the five-year survival rate can reach up to 70%. Early diagnosis of PDAC can aid treatment and improve survival rates by taking necessary precautions. The challenge is to develop a reliable, data privacy-aware machine learning approach that can accurately diagnose pancreatic cancer with biomarkers. AIM: The study aims to diagnose a patient's pancreatic cancer while ensuring the confidentiality of patient records. In addition, the study aims to guide researchers and clinicians in developing innovative methods for diagnosing pancreatic cancer. METHODS: Machine learning, a branch of artificial intelligence, can identify patterns by analyzing large datasets. The study pre-processed a dataset containing urine biomarkers with operations such as filling in missing values, cleaning outliers, and feature selection. The data was encrypted using the Fernet encryption algorithm to ensure confidentiality. Ten separate machine learning models were applied to predict individuals with PDAC. Performance metrics such as F1 score, recall, precision, and accuracy were used in the modeling process. RESULTS: Among the 590 clinical records analyzed, 199 (33.7%) belonged to patients with pancreatic cancer, 208 (35.3%) to patients with non-cancerous pancreatic disorders (such as benign hepatobiliary disease), and 183 (31%) to healthy individuals. The LGBM algorithm showed the highest efficiency by achieving an accuracy of 98.8%. The accuracy of the other algorithms ranged from 98 to 86%. In order to understand which features are more critical and which data the model is based on, the analysis found that the features "plasma_CA19_9", REG1A, TFF1, and LYVE1 have high importance levels. The LIME analysis also analyzed which features of the model are important in the decision-making process. CONCLUSIONS: This research outlines a data privacy-aware machine learning tool for predicting PDAC. The results show that a promising approach can be presented for clinical application. Future research should expand the dataset and focus on validation by applying it to various populations.

Gastric and Pancreatic Ectopic Mucosa in the Gallbladder: A Unique Mimicker of Polypoid Lesions.

A 46-year-old woman with upper quadrant pain and nausea, diagnosed with cholelithiasis, underwent cholecystectomy. A 0.7 cm polypoid lesion in the gallbladder showed mostly heterotopic gastric mucosa with antral and oxyntic glands and foveolar epithelium. A focal area of the heterotopic pancreas, comprising acini and ducts with positive trypsin staining but no islet cells, was found. Additional findings included minimal inflammation, an adenomyoma on the opposite wall, and black gallstones, leading to a diagnosis of a heterotopic polyp. This case underscores the importance of thorough histopathological examination in diagnosing rare heterotopic tissues in the gallbladder, preventing misdiagnosis with malignant entities.

Small Donors, Big Impact: Optimizing Organ Utilization in Simultaneous Pancreas and Kidney Transplantation From Extra Small Pediatric Donors.

INTRODUCTION: Simultaneous pancreas-kidney transplantation (SPK) is the preferred treatment for individuals with type-1 diabetes and end-stage renal disease. However, a limited supply of "Ideal Pancreas Donors" contributed to a growing disparity between available organs and recipients. Even though SPK outcomes from pediatric donors match those from adult donors, unclear guidelines on minimum age and weight criteria for extra small pediatric pancreas donors lead to hesitancy among several transplant centers to utilize these grafts due to concerns about inadequate islet mass, technical challenges, and increased risk of allograft thrombosis. METHODS: This report details the successful outcomes of SPK transplantations performed at the study center between December 2021 and January 2024, using four extra small pediatric brain-dead donors (ESPDs). Each donor was aged ≤5 years and weighed <20 kg. RESULTS: All SPK recipients achieved immediate posttransplant euglycemia without requiring insulin. None of the recipients experienced graft pancreatitis, graft thrombosis, allograft rejection, or required re-exploration. During a 5-27-month follow-up period, all ESPD recipients maintained optimal graft function, as evidenced by normal glucose tolerance tests and HbA1c (4.9%-5.2%), with 100% graft and patient survival. CONCLUSION: This report examines the usage of ESPDs in SPK transplantation, highlighting their potential to expand the donor pool and reduce wait times in areas with scarce deceased organ donations, thereby increasing the number of available organs for transplantation with acceptable outcomes. Revising donor selection guidelines to reflect the diverse risk-benefit profiles of waitlisted individuals is crucial to addressing geographical disparities and reducing organ discard rates.

Optimized Spatial Transformer for Segmenting Pancreas Abnormalities.

The precise delineation of the pancreas from clinical images poses a substantial obstacle in the realm of medical image analysis and surgical procedures. Challenges arise from the complexities of clinical image analysis and complications in clinical practice related to the pancreas. To tackle these challenges, a novel approach called the Spatial Horned Lizard Attention Approach (SHLAM) has been developed. As a result, a preprocessing function has been developed to examine and eliminate noise barriers from the trained MRI data. Furthermore, an assessment of the current attributes is conducted, followed by the identification of essential elements for forecasting the impacted region. Once the affected region has been identified, the images undergo segmentation. Furthermore, it is crucial to emphasize that the present study assigns 80% of the data for training and 20% for testing purposes. The optimal parameters were assessed based on precision, accuracy, recall, F-measure, error rate, Dice, and Jaccard. The performance improvement has been demonstrated by validating the method on various existing models. The SHLAM method proposed demonstrated an accuracy rate of 99.6%, surpassing that of all alternative methods.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction (MBO) where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible. Lumen apposing metal stents (LAMS) are deployed during EUS-BD, with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip. EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO, with bleeding, cholangitis, and stent occlusion being the most common adverse events. Recent studies have even suggested comparable efficacy between EUS-BD and endoscopic retrograde cholangiopancreatography as the primary approach for distal MBO. In this editorial, we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

A rare convergence: Gangrenous bowel secondary to closed-loop obstruction with elevated urine amylase levels - A comprehensive case report.

Urine amylase levels are usually used to diagnose acute pancreatitis. However, there are reported cases where urine amylase levels are slightly increased in individuals without pancreatitis. Herein, we report the case of a young lady who presented with acute abdominal pain for 3 days. Her urine amylase level was 1717 U/L upon admission, and her condition was initially treated as acute pancreatitis. Unfortunately, the patient demonstrated abdominal guarding after 24 h; thus, urgent computed tomography (CT) was performed. CT revealed the presence of a dilated small bowel. She underwent emergency laparotomy, wherein a gangrenous small bowel with no evidence of saponification at the lesser sac was noted. Due to the non-specific nature of hyperamylasaemia, an alternative diagnosis other than acute pancreatitis should be considered if the clinical symptoms are not suggestive of pancreatitis or the condition worsens despite conservative management.

Outcomes After Multimodality Treatment of Pancreatic Cancer in an Unselected Single-Center Cohort.

Background: Pancreatic ductal adenocarcinoma (PDAC) remains a lethal and rarely resectable malignancy. Here we explore the outcomes of surgery, as compared to definitive radiotherapy (dRT) or systemic therapy only in PDAC. Methods: Pancreatic surgery and radiotherapy in Southwest Finland have been centralized to Turku University Hospital. Previously validated population-based electronic health records database was searched for all unselected PDAC patients from the years 2009-2019. Main outcome was median overall survival (mOS). Demographics, pathology, surgery, and oncological treatment data were collected. Results: We identified 1006 patients with PDAC, 49% male, median age 71 years and 77% presenting with metastatic disease. In total, 405 patients were treated; 92 resected, 26 dRT without resection and 287 systemic therapy only. mOS was 34.6 months for resected, 26.7 months for dRT, and 7.5 months for systemic therapy patients. Among the 88 patients with locally advanced inoperable PDAC, dRT was independently associated with longer mOS (26.7 months) as compared to systemic therapy only (mOS 10.6 months). Among the 287 patients treated with systemic therapy only, combination chemotherapy was independently associated with longer mOS (11.6 months) as compared to gemcitabine-monotherapy (6.8 months). In patients progressing to second-line systemic treatment after gemcitabine failure, mOS was the same (5.0 months) with single or combination regimens. Conclusion: Surgery remains the only curative approach for PDAC. In locally advanced PDAC, dRT was associated with longer survival as compared to systemic therapy only. Concerning first-line systemic therapy, our results support the use of combination chemotherapy over single-agent therapy.

Low incidence of pancreatic fistula and well-preserved endocrine function with non-reconstructed small remnant pancreas after pancreaticoduodenectomy.

Aim: Pancreatic reconstruction after pancreaticoduodenectomy (PD) that leaves a small remnant pancreas is often difficult. Pancreatic fistula is a major complication after PD, and fistulas are rare in patients with hard pancreas. However, the clinical impact of non-reconstructed small remnant after PD with hard pancreas is unknown. Methods: We included all patients who underwent PD for pancreatic tumor without pancreatic reconstruction in two institutions supervised by one surgeon between January 2004 and March 2021. Their short- or long-term outcome after surgery was retrospectively analyzed. Results: PD was performed in 774 patients, of whom 16 patients were without reconstruction (2.1%) with negative margins at the pancreatic stump. Pancreatic transection was performed above or to the left of the superior mesenteric artery, with a median remnant pancreas length of 3.7 cm (range, 1.3-10.0). A major complication (≥ Clavien-Dindo Grade IIIa) occurred in one patient (6%). Fistula of grade B occurred in one patient (6%). After a median follow-up of 44 months (95%CI, 10.6-77.3), insulin administration was unnecessary in 11 patients. Conclusion: The preservation of a small pancreatic remnant without reconstruction after PD can be performed safely and may enable the keeping of pancreatic endocrine function for some selected patients with hard pancreas.

Extracellular volume fraction of liver and pancreas using spectral CT in hypertensive patients: A comparative study.

BACKGROUND: Besides the direct impact on the cardiovascular system, hypertension is closely associated with organ damage in the kidneys, liver, and pancreas. Chronic liver and pancreatic damage in hypertensive patients may be detectable via imaging. OBJECTIVE: To explore the correlation between hypertension-related indicators and extracellular volume fraction (ECV) of liver and pancreas measured by iodine maps, and to evaluate corresponding clinical value in chronic damage of liver and pancreas in hypertensive patients. METHODS: A prospective study from June to September 2023 included abdominal patients who underwent contrast-enhanced spectral CT. Normal and various grades of hypertensive blood pressure groups were compared. Upper abdominal iodine maps were constructed, and liver and pancreatic ECVs calculated. Kruskal-Wallis and Spearman analyses evaluated ECV differences and correlations with hypertension indicators. RESULTS: In 300 patients, hypertensive groups showed significantly higher liver and pancreatic ECV than the normotensive group, with ECV rising alongside hypertension severity. ECVliver displayed a stronger correlation with hypertension stages compared to ECVpancreas. Regression analysis identified hypertension severity as an independent predictor for increased ECV. CONCLUSIONS: ECVliver and ECVpancreas positively correlates with hypertension indicators and serves as a potential clinical marker for chronic organ damage due to hypertension, with ECVliver being more strongly associated than ECVpancreas.

Ductal Intervention in Chronic Pancreatitis: Impact on Glycemic Control and Endocrine Insufficiency Management.

Background and aim Pancreatic endotherapy has been established as a viable and effective modality for the management of pain in chronic pancreatitis (CP). However, its impact on endocrine insufficiency has been rarely reported. In this retrospective study, we aimed to assess the impact of endotherapy on glycemic status and the management of diabetes in these patients. Methods A retrospective review of a prospectively maintained database of patients with CP with pain presenting to the King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India, from December 2021 to May 2023 was done. Detailed clinical, laboratory, imaging, and treatment data were recorded. Endocrine dysfunction was defined as glycosylated hemoglobin (Hba1C) ≥6.5 g/dl. The status of endocrine function (Hba1C values) before and after endotherapy, as well as the requirement of oral hypoglycemic agent (OHA) and/or insulin, was recorded. Results One hundred forty-one patients underwent endoscopic retrograde cholangiopancreatography for the management of pain (mean age: 35 years, 74.5% males). Prior to endotherapy, pathological endocrine dysfunction was seen in 60 patients (42.5%). The mean HbA1c value was 8.46 g/dl (4.5-16.1g/dl). OHAs alone were used in 13/60 (21.6%), and 34/60 (56.6%) required insulin. A combination of OHA and insulin was required in 13/60 (21.6%) of patients. Post-endotherapy, none of the patients were on a combination of OHAs and insulin; 5/13 (38.4%) patients were on OHAs alone, while 8/13 (61.5%) patients were shifted to insulin. Out of the total 47 patients who required insulin, insulin could be stopped in 15/47 (31.9%) of patients. Patients who demonstrated improvement in endocrine dysfunction had significantly lower HbA1c values (6.38 vs. 8.07 g/dl, p < 0.001), a higher proportion of patients with idiopathic pancreatitis (73.3% vs. 22.2%, p = 0.004), and a lower proportion of patients with concomitant exocrine insufficiency (13.3% vs. 53.3%, p = 0.007). Conclusions One-third of the patients had improvements in endocrine dysfunction. Early ductal intervention in a selected subset of patients with CP may have the potential to improve glycemic status.

Shedding light on pancreatic metastasis of clear cell sarcoma: An exceptional journey.

This editorial comments on the study by Liu et al investigating pancreatic metastasis of clear cell sarcoma (CCS) published in the World Journal of Clinical Cases. CCS is a rare and aggressive melanocytic tumor, that typically arises from tendons and aponeuroses of the limbs, and metastasizes to the lungs, bones, and brain. However, pancreatic metastasis has rarely been reported, presenting unique diagnostic and therapeutic challenges. Elucidating the clinical characteristics, imaging features, prognostic factors, and treatment outcomes of patients with pancreatic CCS metastasis is crucial. Surgery remains an effective management strategy for CCS. However, the high recurrence rate and low effectiveness of traditional adjuvant treatments necessitate a shift towards more personalized and targeted treatment plans. Research is needed to investigate and validate novel therapeutic approaches specifically tailored to the distinct genetic and molecular characteristics of rare malignancies like CCS. Additionally, the development of late metastases after a long disease-free interval is common in CCS patients. Therefore, routine postoperative surveillance for metastasis using computed tomography, magnetic resonance imaging, bone scans, and positron emission tomography scans is crucial. Moving forward, enhanced collaboration, investigation, and creative thinking among scientists, medical professionals, and legislators are essential to gain a deeper understanding of these rare presentations.