Generating Human Pancreatic Tissue Slices to Study Endocrine and Exocrine Pancreas Physiology.

It is crucial to study the human pancreas to understand the pathophysiological mechanisms associated with type 1 (T1D) and 2 diabetes (T2D) as well as the pancreas endocrine and exocrine physiology and interplay. Much has been learned from the study of isolated pancreatic islets, but this prevents examining their function and interactions in the context of the whole tissue. Pancreas slices provide a unique opportunity to explore the physiology of normal, inflamed, and structurally damaged islets within their native environment, in turn allowing the study of interactions between endocrine and exocrine compartments to better investigate the complex dynamics of pancreatic tissue. Thus, the adoption of the living pancreas slice platform represents a significant advancement in the field. This protocol describes how to generate living tissue slices from deceased organ donors by tissue embedding in agarose and vibratome slicing as well as their utilization to assess functional readouts such as dynamic secretion and live cell imaging.

[Surgical aspects of pancreas transplantation: exocrine drainage. Part 2]. / Khirurgicheskie aspekty transplantatsii podzheludochnoi zhelezy: otvedenie ekzokrinnogo sekreta transplantata. Chast' 2.

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The article will ensure insight into evolution of techniques of exocrine drainage within the historical context and current state of this issue.

[Surgical techniques of pancreas transplantation: exocrine drainage. Part 1]. / Khirurgicheskie aspekty transplantatsii podzheludochnoi zhelezy: otvedenie ekzokrinnogo sekreta transplantata. Chast' 1.

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The manuscript ensures insight on the evolution and progress of exocrine drainage techniques in pancreas transplantation within the historical context and current state of the problem.

Delivery of pancreatic digestive enzymes into the gastrointestinal tract by pancreatic exocrine tissue transplant.

Exocrine pancreatic insufficiency, caused by disease-induced loss of pancreatic exocrine cells, may be treated through regenerative stem cell technologies that facilitate the production of pancreatic exocrine cells from induced pluripotent stem cells (iPSCs). However, delivering the digestive enzymes produced in the transplanted cells to the gastrointestinal tract remains a challenge. To generate an allogenic transplantation rat model, minced pancreas was transplanted into the gastric submucosal space with ablation of muscularis mucosa. In the allogenic transplantation, transplanted pancreatic cells were engrafted. Elevated amylase was detected in gastric juice, while transplanted cells disappeared through auto-digestion when the muscularis mucosa was not eliminated. Human iPSCs were differentiated into pancreatic exocrine cells by stage-specific treatment with growth factors and chemical compounds, and the differentiated pancreatic cells were implanted into the gastric submucosal space of nude rats. The transplanted cells were engrafted, and amylase was detected in the gastric juice in some cases. These findings suggest that transplantation of pancreatic exocrine cells into the gastric submucosal space with muscularis mucosa elimination will contribute to a regenerative approach for pancreatic exocrine insufficiency.

[Pancreas transplantation followed by stumpless duodenal exocrine drainage]. / Transplantatsiia podzheludochnoi zhelezy s bezkul'tevym duodenal'nym drenirovaniem.

Pancreas transplantation followed by stumpless duodenal exocrine drainage was performed in 2 patients. Primary kidney and pancreas graft function was noted in both cases. Two procedures of pancreas transplantation followed by stumpless duodenal exocrine drainage were carried out for the first time. Perhaps, absent donor duodenal stump has several advantages for the further course of postoperative period that may be confirmed in prospective trials.

Clinico-pathological features and survival of patients with malignant exocrine pancreatic neoplasms: The AC Camargo Cancer Center experience.

BACKGROUND: Pancreatic cancer plays an important role in cancer-related mortality. Few studies have been performed in Brazil to characterize patients affected by this disease. We aimed to describe the clinico-pathological characteristics and the survival of patients with pancreatic cancer seen at AC Camargo Cancer Center (ACCCC). METHODS: We included patients ≥ 18-year old, with a histologically confirmed diagnosis of exocrine pancreatic cancer, that attended at least one visit at ACCCC from 2008 to 2016. RESULTS: The study included 739 patients. Median age at diagnosis was 64 years. Most patients were male. About 5% presented a family history of pancreatic cancer. A total of 40% had diabetes and 51.4% presented with ECOG performance status 1. Tumors most often arose in the pancreatic head and roughly half of the patients had metastatic disease at presentation. Median overall survival of patients with potentially resectable disease submitted to surgery at ACCCC was 35.4 months. Median overall survival times of patients with the unresectable and metastatic disease were 14.1 and 9.3 months, respectively. CONCLUSIONS: The features of our population match those of studies done in developed countries. We believe multicentric data from patients with pancreatic cancer in Brazil could enable more effective preventive and therapeutic approaches to the disease.

KDM4D Predicts Recurrence in Exocrine Pancreatic Cells of Resection Margins from Patients with Pancreatic Adenocarcinoma.

BACKGROUND/AIM: The role of histone demethylators, such as Jumonji domain 2 (JMJD2/KDM4) proteins, and histone deacetylases, such as sirtuins (SIRT) is poorly characterized in pancreatic carcinomas while they have a major role in the carcinogenesis of several other tumours. MATERIALS AND METHODS: We assessed retrospectively with immunohistochemistry the expressions of KDM4A, KDM4B and KDM4D in 81 and SIRT1-4 in 102 pancreatic adenocarcinomas. Immunostaining was evaluated separately in benign pancreatic tissues and in malignant cells. RESULTS: High nuclear KDM4D expression in benign pancreatic tissue from resection margins associated with dismal disease-free survival (DFS) (OR=8.00; 95%CI=1.87-33.9; p=0.005), even more significantly than tumour size and lymph node involvement. High cytoplasmic SIRT2 expression in benign pancreatic tissues also associated with a shorter DFS, but only in univariate analysis (p=0.026). CONCLUSION: Nuclear KDM4D and SIRT2 expression deviated from that of benign pancreatic tissue thus putatively influencing gene expression of tumor cells. Regardless, none of the enzymes studied had a decisive role in the spread of pancreatic cancer. A high nuclear expression of KDM4D in samples of pancreatic resection margins significantly and independently predicted an earlier recurrence and could thus be used in the assessment of risk of relapse in clinical practice.

The pancreatic juice length in the stent tube as the predicting factor of clinical relevant postoperative pancreatic fistula after pancreaticoduodenectomy.

Several risk factors for pancreatic fistula had been widely reported, but there was no research focusing on the exocrine output of remnant gland.During the study period of January 2015 to September 2016, 82 patients accepted pancreaticoduodenectomy (PD, end-to-end dunking pancreaticojejunostomy with internal stent tube). All the data were collected, including preoperative medical status, operative course, final pathology, gland texture, pancreatic duct diameter, size of the stent, length of pancreatic juice in the stent tube, width of the pancreatic stump, diameter of the jejunum and the status of postoperative pancreatic fistula (POPF). POPF was defined according to International Study Group of Pancreatic Fistula criteria.The diameter of pancreatic duct in the POPF group was significantly smaller than that in the group without POPF (1.99 vs 2.90 mm, P = .000). The length of pancreatic juice in the stent tube in the POPF group was significantly longer than that in the group without POPF (18.04 vs 6.92 cm, P = .014). There were more pancreatic ductal adenocarcinoma cases and hard glands in the group without POPF. The length of pancreatic juice in the clinically relevant postoperative pancreatic fistula (CR-POPF) group was significantly longer than that in the grade A group (32.4 vs 9.21 cm, P = .000). Multivariate analysis identified gland texture and length of pancreatic juice as independent predictors for pancreatic fistula. Multivariate analysis also identified the length of pancreatic juice as an independent predictor for CR-POPF.The length of pancreatic juice in the stent tube might be a useful predictive factor of POPF after PD, especially for CR-POPF.

Allograft pancreas: pale acinar nodules.

Microscopic pale-staining acinar nodules were characterized in native pancreas in the 1980s under a variety of names but have been infrequently reported since. We retrospectively studied the frequency and characteristics of pale acinar nodules in allograft pancreas biopsies, as compared to a sampling of native pancreas specimens at our center. Pale acinar nodules were present in 13% (9/69) of allograft biopsies from 22% (7/32) of transplant patients, and 23% (5/22) of native pancreas surgical specimens, although more nodules per pancreas area were present in allograft needle biopsies. Acinar nodules had size of 100 to 700 µm, were periodic acid-Schiff pale, were synaptophysin negative, stained more weakly with keratin CAM 5.2 compared to surrounding parenchyma, and had a low proliferative rate. Ultrastructural evaluation revealed paucity of zymogen granules with dilated cistern-like structures. In our experience, pale acinar nodules have similar features in allograft and native pancreas specimens, yet remain of uncertain etiology and significance.

Thirty-day outcomes underestimate endocrine and exocrine insufficiency after pancreatic resection.

BACKGROUND: Long-term incidence of endocrine and exocrine insufficiency after pancreatectomy is poorly described. We analyze the long-term risks of pancreatic insufficiency after pancreatectomy. METHODS: Subjects who underwent pancreatectomy from 2002 to 2012 were identified from a prospective database (n = 227). Subjects who underwent total pancreatectomy or pancreatitis surgery were excluded. New post-operative endocrine and exocrine insufficiency was defined as the need for new pharmacologic intervention within 1000 days from resection. RESULTS: 28 (16%) of 178 subjects without pre-existing endocrine insufficiency developed post-operative endocrine insufficiency: 7 (25%) did so within 30 days, 8 (29%) between 30 and 90 days, and 13 (46%) after 90 days. 94 (43%) of 214 subjects without pre-operative exocrine insufficiency developed exocrine insufficiency: 20 (21%) did so within 30 days, 29 (31%) between 30 and 90 days, and 45 (48%) after 90 days. Adjuvant radiation was associated with new endocrine insufficiency. On multivariate regression, pancreaticoduodenectomy and chemotherapy were associated with a greater risk of exocrine insufficiency. CONCLUSION: Reporting 30-day functional outcomes for pancreatic resection is insufficient, as nearly 45% of subjects who develop disease do so after 90 days. Reporting of at least 90-day outcomes may more reliably assess risk for post-operative endocrine and exocrine insufficiency.

Predictors of Locoregional Failure and Impact on Overall Survival in Patients With Resected Exocrine Pancreatic Cancer.

PURPOSE: Resection of exocrine pancreatic cancer is necessary for cure, but locoregional and distant relapse is common. We evaluated our institutional experience to better understand risk factors for locoregional failure (LRF) and its impact on overall survival (OS). METHODS AND MATERIALS: We reviewed 1051 consecutive patients with nonmetastatic exocrine pancreatic cancer who underwent resection at our institution between March 1987 and January 2011. Among them, 458 had adequate follow-up and evaluation for study inclusion. All patients received adjuvant chemotherapy (n=80 [17.5%]) or chemoradiation therapy (n=378 [82.5%]). Chemotherapy and chemoradiation therapy most frequently consisted of 6 cycles of gemcitabine and 50.4 Gy in 28 fractions with concurrent 5-fluorouracil, respectively. Locoregional control (LRC) and OS were estimated with the Kaplan-Meier method. Univariate and multivariate analyses were performed with Cox proportional hazards regression models incorporating propensity score. RESULTS: Median patient age was 64.5 years (range: 29-88 years). Median follow-up for living patients was 84 months (range: 6-300 months). Extent of resection was R0 (83.8%) or R1 (16.2%). Overall crude incidence of LRF was 17% (n=79). The 5-year LRC for patients with and without radiation therapy was 80% and 68%, respectively (P=.003; hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.28-0.76). Multivariate analysis, incorporating propensity score, indicated radiation therapy (P<.0001; HR: 0.23; 95% CI: 0.12-0.42) and positive lymph node ratio of ≥0.2 (P=.02; HR: 1.78; 95% CI: 1.10-2.9) were associated with LRC. In addition, LRF was associated with worse OS (P<.0001; HR: 5.0; 95% CI: 3.9-6.3). CONCLUSIONS: In our analysis of 458 patients with resected pancreatic cancer, positive lymph node ratio of ≥0.2 and no adjuvant chemoradiation therapy were associated with increased LRF risk. LRF was associated with poor OS. Radiation therapy should be considered as adjuvant locoregional treatment following pancreatic cancer resection.

Hints to the diagnosis of mixed acinar-endocrine carcinoma on pancreatic fine-needle aspiration: avoiding a potential diagnostic pitfall.

BACKGROUND: Mixed acinar-endocrine carcinoma (MAEC) is a rare mixed tumor of the pancreas defined by both acinar and endocrine cell differentiation. CASE: We present 2 cases of MAEC initially diagnosed as pancreatic endocrine neoplasm on fine-needle aspiration. Both patients were male, aged 51 and 75 years, and presented with 16-mm and 6-mm pancreatic masses, respectively. Aspirates showed loose aggregates and dispersed single plasmacytoid cells with moderate nuclear size variation, slightly irregular nuclear contours, fine to coarsely granular chromatin, occasional prominent nucleoli, and scant to moderate finely granular cytoplasm. Rare mitotic figures and pyknotic forms were noted in one of the cases. Endocrine differentiation was confirmed by immunocytochemistry which led to an initial diagnosis of pancreatic endocrine neoplasm. Trypsin and lipase immunocytochemistry were later obtained, confirming a component of acinar cell differentiation. Findings were confirmed on surgical excision. CONCLUSION: Because of their potentially more aggressive clinical course and different therapeutic implications, MAECs are an important consideration in the differential diagnosis of pancreatic neoplasms. Certain cytomorphologic features and immunocytochemical markers of acinar cell differentiation may be helpful in raising the possibility of MAEC on cytology.

Effects of pancreatectomy on nutritional state, pancreatic function and quality of life.

BACKGROUND: There are concerns about the extent of impaired endocrine and exocrine pancreatic function and poor quality of life (QoL) after pancreatectomy, but there is little information from large prospective follow-up studies. METHODS: Consecutive patients undergoing pancreaticoduodenectomy or distal pancreatectomy between 2007 and 2011 were included. Relative bodyweight (RBW), triceps skinfold thickness (TSFT), serum protein, albumin, transferrin, fasting blood glucose, postprandial 2-h glucose (PP2), glycosylated haemoglobin A1c and stool elastase measurements, and European Organization for Research and Treatment of Cancer QLQ-C30 questionnaires were collected serially for 1 year. RESULTS: Some 136 patients undergoing pancreatic resection completed the study. RBW and TSFT recovered to over 90 per cent of the preoperative value by 12 months, whereas transferrin, albumin and protein had returned to preoperative levels by 3 months. Diabetes mellitus, impaired fasting glucose or raised PP2 was present in 42 of 76 patients at 6 months and 36 of 76 at 12 months. Although steatorrhoea and diarrhoea had mainly resolved by 3 months, stool elastase level decreased after operation and showed no recovery. Nutritional status, pancreatic endocrine function and QoL returned to preoperative levels in 63 (46·3 per cent), 72 (52·9 per cent) and 77 (56·6 per cent) of 136 patients within 6 months of pancreatectomy. Multivariable analysis revealed that age 60 years or more, operation type, chronic pancreatitis and malignant disease had a significant impact on nutritional index, pancreatic function and QoL. CONCLUSION: About half of all patients can expect recovery from pancreatectomy after 6 months, but those with risk factors need more careful follow-up and supportive management.

A noninvasive mucinous cystic neoplasm with intermediate-grade dysplasia of the pancreas and extensive squamous metaplasia: a case report with clinicopathological correlation.

Squamous metaplasia presenting in noninvasive mucinous cystic neoplasm (MCN) of the pancreas is extremely rare. We described a case of 39-year-old Chinese female with a 5-year history of a slow growing mass in the left upper abdomen and an 18-month history of surgical incision exudation. The patient underwent cystojejunostomy, laparotomy and distal pancreatectomy consecutively because of the initial diagnosis of "pancreatic cyst". The histological section showed columnar mucin-producing epithelium formed small papillary projections and extensively visible squamous metaplasia. Therefore the diagnosis of "noninvasive MCN with intermediate-grade dysplasia of the pancreas and extensive squamous metaplasia" was made finally. The squamous component of the pancreas may be derived from pluripotent stem cells, and may be in association with cystojejunostomy. Virtual slides: The virtual slide(s) for this article can be found here http://www.diagnosticpathology.diagnomx.eu/vs/1322364365718540.

Histological loss of pancreatic exocrine cells correlates with pancreatic exocrine function after pancreatic surgery.

OBJECTIVE: The aim of this study was to investigate the relationship between histological findings of the pancreatic stump and postoperative pancreatic exocrine function. METHODS: One hundred ten patients including 80 patients undergoing pancreatoduodenectomy (PD) and 30 patients undergoing distal pancreatectomy (DP) were enrolled into this study. Postoperative exocrine pancreatic function was evaluated by 13C-labeled mixed triglyceride breath test. The areas of acinar cells, fibrotic tissues, and fatty replacement were histologically calculated in surgical specimens of the pancreatic stump. RESULTS: Histologically, acinar cell area of patients undergoing PD was significantly less than that of patients undergoing DP (P = 0.025). The values of the mean percentage dose 13C cumulative 7 hours of patients undergoing PD were significantly lower than those of patients undergoing DP (P < 0.001). The rate of pancreatic exocrine insufficiency in patients undergoing PD is significantly higher than that in patients with DP (P = 0.002). There was a significant correlation between acinar cell area of the pancreatic stump and the percentage dose 13C cumulative 7 hours (R = 0.35, P < 0.001). CONCLUSIONS: Pancreatoduodenectomy induced pancreatic exocrine insufficiency more frequently than DP. Histological loss of acinar cells in the pancreatic stump was strongly correlated with postoperative pancreatic exocrine function.

Role of bone marrow-derived mesenchymal stem cells in a rat model of severe acute pancreatitis.

AIM: To investigate the role and potential mechanisms of bone marrow mesenchymal stem cells (MSCs) in severe acute peritonitis (SAP). METHODS: Pancreatic acinar cells from Sprague Dawley rats were randomly divided into three groups: non-sodium deoxycholate (SDOC) group (non-SODC group), SDOC group, and a MSCs intervention group (i.e., a co-culture system of MSCs and pancreatic acinar cells + SDOC). The cell survival rate, the concentration of malonaldehyde (MDA), the density of superoxide dismutase (SOD), serum amylase (AMS) secretion rate and lactate dehydrogenase (LDH) leakage rate were detected at various time points. In a separate study, Sprague Dawley rats were randomly divided into either an SAP group or an SAP + MSCs group. Serum AMS, MDA and SOD, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α levels, intestinal mucosa injury scores and proliferating cells of small intestinal mucosa were measured at various time points after injecting either MSCs or saline into rats. In both studies, the protective effect of MSCs was evaluated. RESULTS: In vitro, The cell survival rate of pancreatic acinar cells and the density of SOD were significantly reduced, and the concentration of MDA, AMS secretion rate and LDH leakage rate were significantly increased in the SDOC group compared with the MSCs intervention group and the Non-SDOC group at each time point. In vivo, Serum AMS, IL-6, TNF-α and MAD level in the SAP + MSCs group were lower than the SAP group; however serum IL-10 level was higher than the SAP group. Serum SOD level was higher than the SAP group at each time point, whereas a significant between-group difference in SOD level was only noted after 24 h. Intestinal mucosa injury scores was significantly reduced and the proliferating cells of small intestinal mucosa became obvious after injecting MSCs. CONCLUSION: MSCs can effectively relieve injury to pancreatic acinar cells and small intestinal epithelium, promote the proliferation of enteric epithelium and repair of the mucosa, attenuate systemic inflammation in rats with SAP.

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival.

BACKGROUND: The role of laparoscopic resection in patients with pancreatic cancer remains to be clarified, because previous reports have not clearly defined oncologic outcomes. The objective of the present study was to investigate this question with the rate of R0 resection and long-term survival as endpoints. METHODS: This retrospective observational study included prospectively collected data from 40 patients operated laparoscopically with curative intent for exocrine pancreatic malignancies identified among 250 consecutive patients undergoing laparoscopic pancreatic operations since 1997. All 40 patients had histologically verified exocrine pancreatic carcinoma. RESULTS: Ten patients (25%) with typical ductal adenocarcinoma of the pancreas were deemed nonresectable by laparoscopic staging. Laparoscopic distal pancreatectomy was performed in 29 patients; 8 resections were combined with resections of adjacent organs and 1 removal of a malignant intraductal papillary mucinous neoplasm what appeared to be ectopic pancreatic tissue. In 1 patient, the resection was completed by hand-assisted technique, and 1 procedure was converted to open resection. Postoperative morbidity was 23% (n = 7). The median hospital stay was 5 days (range, 1-30). The rate of R0 resections was 93%. Postoperative 3-year survivals rates were 36% for the entire cohort (n = 30) and 30% in typical ductal adenocarcinoma (n = 21). CONCLUSION: Laparoscopic distal pancreatectomy for exocrine pancreatic carcinoma is comparable with outcomes after open surgery and supports the concept that laparoscopic distal pancreatectomy is a safe, oncologic procedure.

Laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis: a case report and review of the literature.

BACKGROUND: Lateral pancreaticojejunostomy (LPJ) is a suitable procedure to treat unremitting abdominal pain of chronic pancreatitis (CP) in the presence of a markedly dilated pancreatic duct containing stones and when an inflammatory mass in the head of the gland is absent; this procedure is rarely performed laparoscopically. CASE REPORT: A 41-year-old woman with alcohol-related calcific CP and pancreatic endocrine and exocrine insufficiency suffered with opiate-dependent abdominal pain that was associated with a dilated pancreatic duct of 8.5 mm containing several calculi, but no mass in the head of the pancreas. A laparoscopic LPJ was performed successfully with no intraoperative or postoperative complications. The patient was discharged on day 5, and reported complete relief from abdominal pain at follow up 7 months later. CONCLUSIONS: In selected patients, laparoscopic LPJ is feasible, safe, and effective in treating abdominal pain of CP.

Discovered on gastrointestinal stromal tumor 1 (DOG1) is expressed in pancreatic centroacinar cells and in solid-pseudopapillary neoplasms--novel evidence for a histogenetic relationship.

Solid-pseudopapillary neoplasms of the pancreas are tumors of low malignant potential whose histogenesis has been discussed controversially. In the series of 15 solid-pseudopapillary neoplasms presented here, we demonstrate that discovered on gastrointestinal stromal tumor 1 is expressed significantly by these tumors (diffuse expression in 8 cases, focal expression in 4 cases, and scarce expression in 3 cases). Similar to the high expression of CD117, this finding parallels the immunohistochemical findings in gastrointestinal stromal tumors. Using double immunohistochemistry and immunofluorescence, we furthermore show that centroacinar cells express discovered on gastrointestinal stromal tumors 1. Thus, our findings suggest that, similarly to CD10 or vimentin, the expression of discovered on gastrointestinal stromal tumors 1 may serve as a novel marker for centroacinar cells and for solid-pseudopapillary neoplasms, which is suggestive of a centroacinar origin of these neoplasms.