Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis.

OBJECTIVE: Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission. DESIGN: Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated. RESULTS: After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP. CONCLUSIONS: The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts. TRIAL REGISTRATION NUMBER: NCT04777812.

Hospital mortality rate and predictors in acute pancreatitis in Poland: A single-center experience.

BACKGROUND: Despite advances in medicine, acute pancreatitis remains a disorder that is associated with a high mortality rate. The objective of this study was to analyze in-hospital mortality in patients hospitalized with acute pancreatitis. METHODS: A prospective analysis of patients hospitalized with acute pancreatitis in a single surgical center was performed. Etiological factors, concomitant diseases, age, and intensive care unit treatment status were assessed to determine their impact on the cause and time of patient death. In addition, conventional laboratory tests performed in the emergency ward were evaluated for their potential as predictors of mortality. RESULTS: The study included 476 (n) patients hospitalized with acute pancreatitis in a single surgical center. The presentations included mild disease in 261 (54.8%) patients, moderate disease in 132 (27.7%) patients, and severe disease in 83 (17.5%) patients. The overall mortality rate was 7.14% (n = 34), including 41% in the severe disease group. The mean and median hospitalization times for these patients were 13.9 and 7 days, respectively. Respiratory failure is the main cause of patient death. CONCLUSIONS: Acute pancreatitis remains one of the most common gastroenterological diseases that may lead to death. Acute pancreatitis-related respiratory failure is the most common cause of death among patients with alcohol etiology of the disease. Moreover, the mortality rate was higher among older patients. Therefore, actions should be taken to discover prognostic factors of the severe form and initiate appropriate treatment.

Perioperative Elective Management in Patients Treated with Direct Oral Anticoagulants - Practical Guide.

<b>Introduction:</b> Despite clear, relatively easy-to-use guidance, many clinicians find the perioperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate antithrombotic management can delay procedures and lead to bleeding or thromboembolic complications.<b>Aim:</b> We aimed to describe perioperative management practices related to planned procedures regarding DOACs in accordance with the applicable guidelines of cardiological and surgical societies.<b>Results:</b> Perioperative management of DOAC therapy depends on many factors, and recommendations in the guidelines are not consistent.<b>Conclusions:</b> The best approach to managing these patients is therefore to strike a balance between the risks of bleeding and thromboembolism.

A 22-G or a 25-G Needle: Which One to Use in the Diagnostics of Solid Pancreatic Lesions? A Systematic Review and Meta-Analysis.

With the 12th highest incidence and a common late diagnostic at advanced stages, neoadjuvant therapies for pancreatic cancer are important, but they require a confirmed diagnosis. Being a diagnostic standard, the clarification of the clinical relevance of needle gauges is needed, as larger ones may retrieve more tissue for diagnostics, but may also increase the risk of complications. We performed a meta-analysis to compare the efficiency of the most commonly used 22-G and 25-G needles for EUS guided biopsy in solid pancreatic lesions. The MEDLINE (via PubMed), Embase, Cochrane (CENTRAL), and Scopus databases were searched with "EUS", "needle", "FNA", "pancreas", "prospective", "22G", and "25G" keywords. Mixed effects were assessed in the model, with a mean of 86% and a 95% confidence interval. Fourteen prospective studies that compared the efficiency of 22-G and 25-G biopsy needles in 508 and 524 lesions, respectively, were analyzed, along with 332 specimens biopsied using both needle sizes. The groups did not significantly differ in the outcomes. A low degree of heterogeneity was observed overall, except for specimen adequacy. Moreover, 22-G and 25-G needles have comparable safety and efficacy for focal pancreatic lesion biopsies without a high risk of complications.

NOS2 Polymorphism in Aspect of Left and Right-Sided Colorectal Cancer.

Background: The NOS2 gene polymorphism rs2297518 is associated with an increased level of NO, which could contribute to colorectal cancer (CRC) development. We hypothesized that the potential influence of the NOS2 gene polymorphism on cancer development may vary between right-sided and left-sided colon cancers, and rectal cancers. The aim of this study was to determine the rs2297518 polymorphism influence on colorectal cancer development with regard to tumor localization. Methods: This case-control study included 199 patients with CRC and 120 controls. The qPCR endpoint genotyping was conducted using the TaqMan® genotyping assay. Results: This study revealed significant differences in tumor characteristic and in the minor alelle A frequency in the NOS2 genotype between colorectal cancers with different localizations. The mucinous adenocarcinoma was diagnosed significantly more often in right-sided cancers than in left-sided (30.6% vs. 10.9%, p = 0.009) and rectal cancers (30.6% vs. 7.1%, p = 0.0003). The minor allele A of the NOS2 genotype was observed more frequently in right-sided cancers than in left-sided cancers (44.9% vs. 23.1%, p = 0.0137) and more frequently in rectal cancers than in left-sided cancers (40.0% vs. 23.1%, p = 0.0285). Conclusions: In conclusion, the results support the hypothesis that the SNP rs2297518 of the NOS2 gene influences colorectal cancer development with regard to tumor localization.

Timing of Loop Ileostomy Closure Does Not Play a Pivotal Role in Terms of Complications-Results of the Liquidation of iLEOstomy (LILEO) Study.

Loop ileostomy is commonly performed by colorectal and general surgeons to protect newly created large bowel anastomoses. The optimal timing for ileostomy closure remains debatable. Defining the timing associated with the best postoperative outcomes can significantly improve the clinical results for patients undergoing ileostomy closure. The LILEO study was a prospective multicenter cohort study conducted in Poland from October 2022 to December 2023. Full data analysis involved 159 patients from 19 surgical centers. Patients were categorized based on the timing of ileostomy reversal: early (<4 months), standard (4-6 months), and delayed (>6 months). Data on demographics, clinical characteristics, and perioperative outcomes were analyzed for each group separately and compared. No significant differences were observed in length of hospital stay (p = 0.22), overall postoperative complications (p = 0.43), or 30-day reoperation rates (p = 0.28) across the three groups. Additional analysis of Clavien-Dindo complication grades was performed and did not show significant differences in complication severity (p = 0.95), indicating that the timing of ileostomy closure does not significantly impact perioperative complications or hospital stay. Decisions on ileostomy reversal timing should be personalized and should consider individual clinical factors, including the type of adjuvant oncological treatment and the preventive measures performed for common postoperative complications.

[Treatment of esophageal anastomotic leak with self-expanding metal stent]. / Leczenie nieszczelnosci zespolenia przelykowo-zoladkowego z zastosowaniem protezy samorozprezalnej.

Esophageal anastomotic leak after resection surgery is very hard to treat and Has a high mortality rate. Surgical treatment is extremely difficult, burdened by complications of subsequent postoperative complications (inability to repair). The authors present a case of a patient who underwent a resection of upper stomach and lower esophagus due to adenocarcinoma of the esophagus- stomach junction (Siewert II). A digestive tract X-ray with water-soluble kontrast was performer after seven days- it show and anastomotic leak. However, the patient was hemodynamically stable. It enabled to implant a self-expanding metal stent (Ultraflex) to the place of leak. In this case the procedure was successful, and radiological examination on the 14th day confirmed closure of the leak. Implantation of a self-expanding metal prosthesis as a way to treat anastomotic leak is a therapeutic option worth recommendation.

Endoscopic changes in patients diagnosed with acute pancreatitis.

BACKGROUND: There have been long debates on the introduction of proton pump inhibitors into acute pancreatitis therapy as standard treatment. The aim of the study was to assess endoscopic lesions of the upper gastrointestinal tract in patients hospitalized for acute pancreatitis. METHODS: We carried out a prospective analysis of patients hospitalized in one surgical center who had an upper gastrointestinal tract endoscopic examination performed during the first 48 hours of hospitalization. We performed analysis of basic descriptive statistics along with the Shapiro-Wilk Test, logistic order regression analysis, One-Way Analysis of Variance, and Student's t-test for independent trials. RESULTS: From January 2016 to December 2019, 476 patients were hospitalized because of acute pancreatitis. The upper gastrointestinal tract endoscopic examination was performed in 85 patients (N.) in the first 48 hours. From the examined group 45 patients (52.94%) developed mild acute pancreatitis, 28 (32.94%) moderate pancreatitis, and 12 (14.12%) severe pancreatitis. Lesions in the endoscopic imaging were observed in 80 patients (94.12%). CONCLUSIONS: A very high percentage of patients hospitalized for acute pancreatitis present lesions in the endoscopic imaging of the upper gastrointestinal tract. The standard treatment of AP is the administration of non-steroidal anti-inflammatory drugs, which themselves can cause gastric and duodenal mucosal defects. All these factors indicate the need for standard use of proton pump inhibitors in patients hospitalized for acute pancreatitis.

GERD as a Complication of Laparoscopic Sleeve Gastrectomy for the Treatment of Obesity: A Systematic Review and Meta-Analysis.

INTRODUCTION: The incidence of obesity is increasing in developed societies, and surgical treatment is one treatment option. The most common surgical treatment for obesity is laparoscopic sleeve gastrectomy (LSG). Gastroesophageal reflux disease (GERD) is a complication of both obesity and the surgical treatment of obesity. MATERIALS AND METHODS: In this study, the PubMed database was searched using the keywords "GERD" and "bariatric surgery", and 987 papers published between 1 July 2017 and 30 June 2022 were retrieved. RESULTS: Nine papers met the inclusion criteria and were included in the meta-analysis. The articles were analyzed for the de novo occurrence of GERD after the treatment of its symptoms, the occurrence of erosive esophagitis, and Barrett's esophagus. In addition, interesting conclusions are presented from the papers that did not meet the inclusion criteria but shed light on the pathophysiology of GERD in obese patients undergoing LSG. CONCLUSION: In conclusion, the authors draw attention to the need for endoscopic surveillance in patients undergoing LSG, even in the absence of clinical signs of GERD.

[Impact of COVID-19 on morbidity, management, and course of acute appendicitisa retrospective cohort study].

BACKGROUND: Acute appendicitis is one of the most common causes of abdominal pain requiring surgical intervention. This study aimed to assess the impact of the COVID-19 pandemic on the morbidity, therapeutic management, and course of acute appendicitis. METHODS: This study retrospectively analyzed patients hospitalized at a general surgery department between 1 January 2019 and 19 March 2020 and compared them to patients hospitalized between 20 March 2020 (global pandemic declaration date) and 6 June 2021. Therefore, our analysis encompassed the period 443 days preceding the pandemic and 443 days after the start thereof. Other factors evaluated herein included sex, length of hospital stay, time from symptom onset, type of surgery, laboratory test results, histopathological diagnosis, and polymerase chain reaction test results for SARS-CoV-2 infection. RESULTS: Statistical analysis was conducted using statistical software IBM SPSS version 27. Significant differences in length of hospital stay, time from symptom onset to hospital admission, number of leukocytes, and type of surgical procedure were observed between groups of patients treated before and after the pandemic. CONCLUSION: Acute appendicitis remained one of the most commonly encountered diseases requiring surgical intervention during the COVID-19 pandemic. Overall, significant differences were observed between patients treated before and after COVID-19 had been declared a pandemic.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience.

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences.

Splanchnic vein thrombosis (SVT) is a serious vascular complication that can occur in patients with acute pancreatitis. We assessed the incidence of SVT and its relationship with acute pancreatitis (AP) and associated complications. We carried out a retrospective analysis of medical histories from patients hospitalized with AP in a single surgical center. Histories were acquired from patients with abdominal and pelvic computed tomography scans performed between the 2nd and 3rd day of hospitalization. We assessed the impact and extent of thrombosis over the disease course. We found a strong positive correlation (Cramer's V coefficient = 0.34) between SVT and disease severity. Mortality in the study group was 7.2% (8 patients) of which 5 patients (62.5%) were diagnosed with SVT. We observed an increased incidence of death among patients with thrombosis, with results approaching significance (P = 0.056). In our study, we found that SVT has a negative effect on the course of AP and is associated with more severe disease and increased mortality.

The Effect of Bariatric Surgery on Weight Loss and Metabolic Changes in Adults with Obesity.

Methods of treating obesity, such as changes in lifestyle, physical activity, restrictive diets, and psychotherapy, are not sufficient. Currently, it is considered that in the case of patients who meet the eligibility criteria for surgery, the treatment of choice should be bariatric surgery. The aim of this study was to assess the weight loss and metabolic changes in a group of adults with obesity undergoing bariatric surgery. The study involved 163 patients whose body mass index (BMI) exceeded 40 or 35 kg/m2, concurrent with at least one metabolic sequelae. In 120 of the cases (74%), sleeve gastrectomy was used; in 35 (21%), gastric bypass was used; and in 8 (5%), laparoscopic Roux-en-Y bypass was used. Metabolic parameters such as total cholesterol, LDL-cholesterol (low-density lipoprotein cholesterol), HDL-cholesterol (high-density lipoprotein cholesterol), triglycerides, and glucose were measured preoperatively and postoperatively, as well as the creatinine, creatine kinase (CK-MB), and leptin activity. In patients undergoing bariatric surgery, a significant decrease in excess weight (p < 0.001) was observed at all the analyzed time points, compared to the pre-surgery value. Weight loss after surgery was associated with a significant improvement in glycemia (109.6 ± 48.0 vs. 86.6 ± 7.9 mg/dL >24 months after surgery; p = 0.003), triglycerides (156.9 ± 79.6 vs. 112.7 ± 44.3 mg/dL >24 months after surgery; p = 0.043) and leptin (197.50 ± 257.3 vs. 75.98 ± 117.7 pg/mL 12 months after surgery; p = 0.0116) concentration. The results of the research confirm the thesis on the effectiveness of bariatric surgery in reducing excess body weight and improving metabolic parameters in patients with extreme obesity.

Can urea breath test (UBT) replace rapid urea test (RUT)?

BACKGROUND: Helicobacter pylori (Hp) is classified by the International Agency for Research on Cancer (IARC) as a Group 1 carcinogen. Its influence on the carcinogenesis of gastric cancer has been confirmed in many researches. The conclusion is obvious- early detection and eradication of Hp can prevent the development of the disease. METHODS: The objective of the study was to analyse the clinical and practical value of Carbon-13 urea breath test (UBT) in patients hospitalized due to pain complaints in the upper abdomen and dyspeptic symptoms. Fifty patients were enrolled in the study. Each patient underwent urea breath test according to the instruction included by the producer. Thereafter, each patient included in the study group was performed endoscopy of the upper gastrointestinal tract with the biopsy of the mucosa to determine the urease activity with rapid urease test (RUT). RESULTS: In the study group, 14 patients (28%) achieved a positive urease test result which was confirmed in RUT. Four (8%) patients, despite a positive breath test, did not have a positive result in urease activity from gastric mucosa. In 2 cases (4%) despite negative result of UBT there was urease actitvity confirmed in gastroscopic sections. The remaining 30 patients (60%) had a negative result in both studies. CONCLUSIONS: The limited availability of the gold standard for diagnostics of upper gastrointestinal tract diseases (gastroscopy) is the basis for the search for new methods for the detection of Helicobacter pylori infection. The urea breath test is a method of high sensitivity and specificity. The positive result of urea breath test may be the basis for the inclusion of eradication therapy.

Reoperations in bariatric surgery - indications and initial evaluation of postoperative complications.

UNLABELLED: Obesity, at present, seems to be a very serious health problem all over the world. The surgery is said to be the most successful treatment of obesity. With the increase in the quantity of conducted bariatric procedures, the number of revision treatments increases as well. The aim of the study was to analyze the indications, results and complications after repeated bariatric surgeries. MATERIAL AND METHODS: The repeated bariatric procedures performed in 2009-2015 have been retrospectively analyzed. The endpoint of the study was the evaluation of early surgical treatment results-up to 30th day after repeated surgery. RESULTS: Overall, amongs 103 obese patients with a BMI over 35 kg / m2, qualified for bariatric treatment 7 revision surgeries were conducted (6.8%). Two operations were carried out by laporotomy, other by laparoscopy. In the study group, neither any deaths were noted in perioperative period nor life-threatening complications. The frequency of complications-Surgical site infection and bleeding from the staple lines of stapler in the study group appeared to be 28.6%. CONCLUSIONS: Qualification for repeated bariatric surgeries should be based on a thorough analysis of the condition of the patient, previous outcome of the bariatric treatment: evaluation of weight loss as well as possible complications of the original surgery.

Subcapsular liver haematoma as a complication of laparoscopic cholecystectomy.

Cholecystectomy is a common procedure for the treatment of symptomatic cholecystitis. A rare complication is the occurrence of subcapsular haematoma of the liver. In the literature, there are only a few case reports of this type. A 25-year-old woman was admitted to the Surgical Department for surgical treatment of cholecystitis. No complications were observed intra-operatively. On the first day after surgery, the patient manifested symptoms of hypovolaemic shock. The patient was qualified for surgical treatment in the mode of emergency surgery - a giant subcapsular haematoma was found. She was referred to the Clinic of General, Transplant and Liver Surgery of the Medical University of Warsaw for further treatment. This case shows the importance of monitoring the life parameters of patients who have undergone laparoscopic surgery due to symptomatic cholecystitis during the first day after surgery.

Severe Vascular Complications Of Acute Pancreatitis.

UNLABELLED: Acute pancreatitis (AP) develops as a result of the imbalance of the mechanisms inhibiting the activity of enzymes in the pancreatic cells, which causes their autoactivation in the pancreas. The incidence of AP ranges from 10 up to 100 cases per 100,000 population per year in different parts of the world. The overall mortality rate for acute pancreatitis is 10-15%. The mortality rate in patients diagnosed with the severe form of acute pancreatitis is up to 30-40%. MATERIAL AND METHODS: The study included 10 patients treated due to acute pancreatitis in two surgical departments run by one of the authors (S.G.) in the years 2004-2014, who developed a serious complication in the form of haemorrhage into the inflammatory tumour/pancreatic cyst or an adjacent organ. Haemorrhage was diagnosed based on the clinical picture, most often a sudden drop in blood pressure, peritonitis symptoms and imaging findings--abdominal ultrasound and abdominal computed tomography. Therapeutic methods included conservative treatment, endovascular embolisation and, in the absence of efficacy of the above mentioned methods, surgical treatment. Patients age and gender, the etiological factor, comorbidities, Atlanta Classification, treatment outcomes and mortality rate were assessed. RESULTS: Alcohol was the most common etiological factor in the investigated AP cases. The patients received conservative treatment, interventional radiology treatment (endovascular embolisation) or surgical treatment. In the study group, 6 patients required surgical treatment, 3 patients received invasive radiology treatment, and conservative treatment was used in one patient. The mortality rate in the study group was 30%. CONCLUSIONS: Haemorrhages into the inflammatory cisterns or adjacent organs (stomach, transverse colon mesentery) secondary to AP are the most severe complications, which are difficult to manage. The successful use of interventional radiology methods to inhibit and prevent the recurrence of bleeding in some of the patients is a significant milestone.