Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis.

BACKGROUND: Pancreatic pseudocyst (PP) and walled-off necrosis can be managed endoscopically, percutaneously or surgically, but with diverse efficacy. AIMS & METHODS: A comprehensive literature search was carried out from inception to December 2018, to identify articles which compared at least two of the three kinds of treatment modalities, regarding the mortality, clinical success, recurrence, complications, cost and length of hospitalisation (LOH). RESULTS: The outcomes of endoscopic (ED) and percutaneous drainage (PD) were comparable in six articles. The clinical success of endoscopic intervention was better considering any types of fluid collections (OR = 3.36; 95% confidence interval (CI) 1.48, 7.63; p = 0.004). ED was preferable regarding recurrence of PP (OR = 0.23; 95% CI 0.08, 0.66; p = 0.006). Fifteen articles compared surgical intervention with ED. Significant difference was found in postoperative LOH (WMD (days) = -4.61; 95%CI -7.89, -1.33; p = 0.006) and total LOH (WMD (days) = -3.67; 95%CI -5.00, -2.34; p < 0.001) which favored endoscopy, but ED had lower rate of clinical success (OR = 0.54; 95% CI 0.35, 0.85; p = 0.007) and higher rate of recurrence (OR = 1.80; 95% CI 1.16, 2.79; p = 0.009) in the treatment of PP. Eleven studies compared surgical and percutaneous intervention. PD resulted in higher rate of recurrence (OR = 4.91; 95% CI 1.82, 13.22; p = 0.002) and lower rate of clinical success (OR = 0.13; 95% CI 0.07, 0.22, p < 0.001). CONCLUSION: Both endoscopy and surgery are preferable over percutaneous intervention, furthermore endoscopic treatment is associated with shorter hospitalisation than surgery.

The characteristics and prognostic role of acute abdominal on-admission pain in acute pancreatitis: A prospective cohort analysis of 1432 cases.

INTRODUCTION: Pain is the most common symptom in acute pancreatitis (AP) and is among the diagnostic criteria. Therefore, we aimed to characterize acute abdominal pain in AP. METHODS: The Hungarian Pancreatic Study Group prospectively collected multicentre clinical data on 1435 adult AP patients between 2012 and 2017. Pain was characterized by its intensity (mild or intense), duration prior to admission (hours), localization (nine regions of the abdomen) and type (sharp, dull or cramping). RESULTS: 97.3% of patients (n = 1394) had pain on admission. Of the initial population with acute abdominal pain, 727 patients answered questions about pain intensity, 1148 about pain type, 1134 about pain localization and 1202 about pain duration. Pain was mostly intense (70%, n = 511/727), characterized by cramping (61%, n = 705/1148), mostly starting less than 24 h prior to admission (56.7%, n = 682/1202). Interestingly, 50.9% of the patients (n = 577/1134) had atypical pain, which means pain other than epigastric or belt-like upper abdominal pain. We observed a higher proportion of peripancreatic fluid collection (19.5% vs. 11.0%; p = 0.009) and oedematous pancreas (8.4% vs. 3.1%; p = 0.016) with intense pain. Sharp pain was associated with AP severity (OR = 2.481 95% CI: 1.550-3.969) and increased mortality (OR = 2.263, 95% CI: 1.199-4.059) compared to other types. Longstanding pain (>72 h) on admission was not associated with outcomes. Pain characteristics showed little association with the patient's baseline characteristics. CONCLUSION: A comprehensive patient interview should include questions about pain characteristics, including pain type. Patients with sharp and intense pain might need special monitoring and tailored pain management. SIGNIFICANCE: Acute abdominal pain is the leading presenting symptom in acute pancreatitis; however, we currently lack specific guidelines for pain assessment and management. In our cohort analysis, intense and sharp pain on admission was associated with higher odds for severe AP and several systemic and local complications. Therefore, a comprehensive patient interview should include questions about pain characteristics and patients with intense and sharp pain might need closer monitoring.

[Tissue integration of various silicone-coated polypropylene surgical mesh]. / A különbözo szilikonbevonatú polipropilén hálók szöveti integrációja.

INTRODUCTION/AIM: Laparoscopic ventral hernia repair requires a surgical mesh implanted in intraperitoneal position. The combined, double layer meshes are promising in animal models as well as in human practice. The aim of this study was to compare the biological behaviour of two different textured silicone covered polypropylene mesh. MATERIALS AND METHODS: 3 × 4 cm big full thickness defect of the abdominal wall was created in New Zealand White rabbits. The defect was covered in 20 animals with a polypropylene mesh with laminar silicone layer on the visceral surface (LSPP), while the remaining 20 cases the defects were covered with a macroporous textured silicone impregnated polypropylene mesh (MSPP). Intraperitoneal adhesion formation and tissue ingrowth in the meshes were investigated. Immunohistochemistry was used to detect proliferation activity (Ki-67), neovascularization (VEGF), and to visualize mesothelial layer (CK) over the mesh. Scanning electron microscopy was used to investigate the visceral surface of the meshes. RESULTS: While intraperitoneal adhesion formation showed no difference after 1 week, LSPP mesh induced significantly less adhesions after 21 days. The Ki-67 positivity was significantly lower and the number of the VEGF positive cells increased with time in the MSPP group, this was missing in the LSPP group. The thin neoperitoneum layer was detected over MSPP mesh only with CK antibody. CONCLUSION: The material and texture of the mesh are responsible for tissular incorporation which is in accordance with the generated foreign body reaction.

Retrospective Matched-Cohort Analysis of Acute Pancreatitis Induced by 5-Aminosalicylic Acid-Derived Drugs.

OBJECTIVES: This study aimed to compare the clinical course of 5-aminosalicylic acid-derived, drug-induced acute pancreatitis (5-ASA-DIAP) to acute pancreatitis (AP) caused by other etiologies. METHODS: A cohort of patients with 5-ASA-DIAP was established through literature search. As a control AP (CAP) group, a cohort was generated from a registry. Data on the diagnostic procedure, symptoms, enzyme elevation, imaging, severity, and recovery parameters were collected. Causality was assessed using the Naranjo algorithm. RESULTS: Twenty-nine articles were included, which describe 36 patients with fifty-one 5-ASA-DIAP episodes (60.78% female, 39.22% male). There were 88.2% mild, 3.92% moderate, and 7.84% severe cases of AP in the 5-ASA-DIAP group, and 70.6%, 25.5%, and 3.92% such cases in the CAP population, respectively. Symptoms improved significantly faster (mean ± SE, 2.5 ± 0.34 vs 3.74 ± 0.42 days; P = 0.018); however, pancreatic enzyme levels normalized significantly more slowly (6.27 ± 1.53 vs 3.63 ± 0.61 days, P = 0.008) in the 5-ASA-DIAP cohort compared with the CAP group. This study confirms that there are no diagnostic differences between 5-ASA-DIAP and AP of other etiologies. CONCLUSIONS: Fewer moderate but more severe cases were found in the 5-ASA-DIAP group; therefore, 5-ASA-DIAP must be taken as seriously as AP of other etiologies.

Body-mass index correlates with severity and mortality in acute pancreatitis: A meta-analysis.

BACKGROUND: Obesity rates have increased sharply in recent decades. As there is a growing number of cases in which acute pancreatitis (AP) is accompanied by obesity, we found it clinically relevant to investigate how body-mass index (BMI) affects the outcome of the disease. AIM: To quantify the association between subgroups of BMI and the severity and mortality of AP. METHODS: A meta-analysis was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols. Three databases (PubMed, EMBASE and the Cochrane Library) were searched for articles containing data on BMI, disease severity and mortality rate for AP. English-language studies from inception to 19 June 2017 were checked against our predetermined eligibility criteria. The included articles reported all AP cases with no restriction on the etiology of the disease. Only studies that classified AP cases according to the Atlanta Criteria were involved in the severity analyses. Odds ratios (OR) and mean differences (MD) were pooled using the random effects model with the DerSimonian-Laird estimation and displayed on forest plots. The meta-analysis was registered in PROSPERO under number CRD42017077890. RESULTS: A total of 19 articles were included in our meta-analysis containing data on 9997 patients. As regards severity, a subgroup analysis showed a direct association between AP severity and BMI. BMI < 18.5 had no significant effect on severity; however, BMI > 25 had an almost three-fold increased risk for severe AP in comparison to normal BMI (OR = 2.87, 95%CI: 1.90-4.35, P < 0 .001). Importantly, the mean BMI of patients with severe AP is higher than that of the non-severe group (MD = 1.79, 95%CI: 0.89-2.70, P < 0.001). As regards mortality, death rates among AP patients are the highest in the underweight and obese subgroups. A BMI < 18.5 carries an almost two-fold increase in risk of mortality compared to normal BMI (OR = 1.82, 95%CI: 1.32-2.50, P < 0.001). However, the chance of mortality is almost equal in the normal BMI and BMI 25-30 subgroups. A BMI > 30 results in a three times higher risk of mortality in comparison to a BMI < 30 (OR = 2.89, 95%CI: 1.10-7.36, P = 0.026). CONCLUSION: Our findings confirm that a BMI above 25 increases the risk of severe AP, while a BMI > 30 raises the risk of mortality. A BMI < 18.5 carries an almost two times higher risk of mortality in AP.

5-ASA induces mild acute pancreatitis. Case report and review of the literature.

5-aminosalicylic acid has been reported to be able of inducing acute pancreatitis as an adverse reaction. However, in most case reports, rechallenge of the drug is missing; therefore, evidence is still needed to confirm its role in the clinical course of acute pancreatitis and its influence on the outcome. Here, we report a case of recurrent acute pancreatitis secondary to 5-aminosalicylic acid, with positive unintentional rechallenge. A systematic search of the literature was performed and 42 cases from 35 articles were summarized concerning the clinical course of 5-aminosalicylic acid induced acute pancreatitis.

Intralesional steroid is beneficial in benign refractory esophageal strictures: A meta-analysis.

AIM: To analyze the effect of intralesional steroid injections in addition to endoscopic dilation of benign refractory esophageal strictures. METHODS: A comprehensive search was performed in three databases from inception to 10 April 2017 to identify trials, comparing the efficacy of endoscopic dilation to dilation combined with intralesional steroid injections. Following the data extraction, meta-analytical calculations were performed on measures of outcome by the random-effects method of DerSimonian and Laird. Heterogeneity of the studies was tested by Cochrane's Q and I2 statistics. Risk of quality and bias was assessed by the Newcastle Ottawa Scale and JADAD assessment tools. RESULTS: Eleven articles were identified suitable for analyses, involving 343 patients, 235 cases and 229 controls in total. Four studies used crossover design with 121 subjects enrolled. The periodic dilation index (PDI) was comparable in 4 studies, where the pooled result showed a significant improvement of PDI in the steroid group (MD: -1.12 dilation/month, 95%CI: -1.99 to -0.25 P = 0.012; I2 = 74.4%). The total number of repeat dilations (TNRD) was comparable in 5 studies and showed a non-significant decrease (MD: -1.17, 95%CI: -0.24-0.05, P = 0.057; I2 = 0), while the dysphagia score (DS) was comparable in 5 studies and did not improve (SMD: 0.35, 95%CI: -0.38, 1.08, P = 0.351; I2 = 83.98%) after intralesional steroid injection. CONCLUSION: Intralesional steroid injection increases the time between endoscopic dilations of benign refractory esophageal strictures. However, its potential role needs further research.

Comparison of 5 Ki-67 antibodies regarding reproducibility and capacity to predict prognosis in breast cancer: does the antibody matter?

Although several antibodies are available for immunohistochemical detection of Ki-67, even the most commonly used MIB-1 has not been validated yet. Our aim was to compare 5 commercially available antibodies for detection of Ki-67 in terms of agreement and their ability in predicting prognosis of breast cancer. Tissue microarrays were constructed from 378 breast cancer patients' representative formalin-fixed, paraffin-embedded tumor blocks. Five antibodies were used to detect Ki-67 expression: MIB-1 using chromogenic detection and immunofluorescent-labeled MIB-1, SP-6, 30-9, poly, and B56. Semiquantitative assessment was performed by 2 pathologists independently on digitized slides. To compare the 5 antibodies, intraclass correlation and concordance correlation coefficient were used. All the antibodies but immunofluorescent-labeled MIB-1 (at 20% and 30% thresholds, P=.993 and P=.342, respectively) and B56 (at 30% threshold, P=.288) separated high- and low-risk patient groups. However, there were a significant difference (P values for all comparisons≤.005) and a moderate concordance (intraclass correlation, 0.645) between their Ki-67 labeling index scores. The highest concordance was found between MIB-1 and poly (concordance correlation coefficient=0.785) antibodies. None of the antibodies except Ki-67 labeling index as detected by poly (P=.031) at 20% threshold and lymph node status (P<.001) were significantly linked to disease-free survival in multivariate analysis. At 30% threshold, this was reduced to lymph node status (P<.001) alone. Our results showed that there are considerable differences between the different Ki-67 antibodies in their capacity to detect proliferating tumor cells and to separate low- and high-risk breast cancer patient groups.

Capsaicin-sensitive afferentation represents an indifferent defensive pathway from eradication in patients with H. pylori gastritis.

AIM: To study the role of capsaicin-sensitive afferent nerves in Helicobacter pylori (H. pylori) positive chronic gastritis before and after eradication. METHODS: Gastric biopsy samples were obtained from corpus and antrum mucosa of 20 healthy human subjects and 18 patients with H. pylori positive chronic gastritis (n = 18) before and after eradication. Traditional gastric mucosal histology (and Warthin-Starry silver impregnation) and special histochemical examinations were carried out. Immunohistochemistry for capsaicin receptor (TRVP1), calcitonin gene-related peptide (CGRP) and substance P (SP) were carried out by the labeled polymer immunohistological method (Lab Vision Co., USA) using polyclonal rabbit and rat monoclonal antibodies (Abcam Ltd., UK). RESULTS: Eradication treatment was successful in 16 patients (89%). Seven patients (7/18, 39%) remained with moderate complaints, meanwhile 11 patients (11/28, 61%) had no complaints. At histological evaluation, normal gastric mucosa was detected in 4 patients after eradication treatment (4/18, 22%), and moderate chronic gastritis could be seen in 14 (14/18, 78%) patients. Positive immuno-staining for capsaicin receptor was seen in 35% (7/20) of controls, 89% (16/18, P < 0.001) in patients before and 72% (13/18, P < 0.03) after eradication. CGRP was positive in 40% (8/20) of controls, and in 100% (18/18, P < 0.001) of patients before and in 100% (18/18, P < 0.001) after eradication. The immune-staining of gastric mucosa for substance-P was positive in 25% (5/20) of healthy controls, and in 5.5% (3/18, P > 0.05) of patients before and in 0% of patients (0/18, P > 0.05) after H. pylori eradication. CONCLUSION: Distibution of TRVP1 and CGRP is altered during the development of H. pylori positive chronic gastritis. The immune-staining for TRVP1, CGRP and SP rwemained unchanged before and after H. pylori eradication treatment. The capsaicin-sensitive afferentation is an independent from the eradication treatment. The 6 wk time period might not be enough time for the restituion of chronic H. pylori positive chronic gastritis. The H. pylori infection might not represent the main pathological factor in the development of chronic gastritis.

Comparative immunohistochemical study of tissue integration of macroporous and laminar surgical meshes.

Intraperitoneal surgical mesh implantation is required for laparoscopic ventral hernia repair. Composite meshes are well known in animal models and human practice. The aim of our study is to compare the biological behaviour of two different textured silicone-covered polypropylene meshes. Transmural abdominal wall defect was created in 40 rabbits and treated as follows: In 20 animals a polypropylene mesh with a laminar silicone covering (LSPP) and in the rest a macroporous textured mesh knitted of silicone-impregnated polypropylene filaments (MSPP) was applied. One and three weeks after implantation we evaluated the intraperitoneal adhesion formation of the mesh macroscopically, histologically and immunohistochemically to detect the reactive cells, especially inflammatory, endothelial and mesothelial cells, as well as their proliferative activity, and with Scanning Electron microscopy to visualize the surface of the meshes. The adhesion formation caused by the composites showed no statistical difference after one week although in the three weeks old samples the LSPP adhesion was significantly weaker than that of MSPP. As complications, serome formation in both groups, fistulas, abscesses, and sc. haematoma in the LSPP group were found. Only in MSPP containing tissues was the decrease of Ki-67 positive proliferating cells significant. A significant increase in VEGF expressing cells was observed only in MSPP containing three week old samples, suggesting better regulation of vascular growth in tissues surrounding the implants. In one week old specimens we observed an irregular proliferation of cytokeratin containing mesothelial cells in both group. The intraperitoneal surface of MSPP mesh was covered with neoperitoneum, while it was not regularly seen on LSPP mesh after three week.