Association of Postoperative Hyperamylasemia With Clinically Relevant Postoperative Pancreatic Fistula in Pancreatoduodenectomy.

Background In this study, we aimed to determine the association between postoperative hyperamylasemia (POH) and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Methodology A prospective observational study of 140 consecutive PDs between March 2020 and March 2022 was conducted. POH was defined as an elevation in serum pancreatic amylase levels above the institutional upper limit of normal on postoperative day (POD) 1 (>100 U/L). CR-POPF was defined as the International Study Group of Pancreatic Surgery Grade B or C POPF. The primary outcome was the rate of CR-POPF in the study population. The trial was prospectively registered with Clinicaltrials.gov (NCT04514198). Results In our study, 93 (66.42%) patients had POH (serum amylase >100 U/L). CR-POPF developed in 48 (34.28%) patients: 40 type B and 8 type C. CR-POPF rate was 43.01% (40/93) in patients with POH compared to 17.02% (8/47) in patients without POH (p = 0.0022). Patients with POH had a mean serum amylase of 422.7 ± 358.21 U/L on POD1 compared to 47.2 ± 20.19 U/L in those without POH (p < 0.001). Serum amylase >100 U/L on POD1 was strongly associated with developing CR-POPF (odds ratio = 3.71; 95% confidence interval = 1.31-10.37) on logistic regression, with a sensitivity and specificity of 83.3% and 42.4%, respectively. Blood loss >350 mL, pancreatic duct size <3 mm, and elevated POD1 serum amylase >100 U/L were predictive of CR-POPF on multivariate analysis (p < 0.001). Conclusions An elevated serum amylase on POD1 may help identify patients at risk for developing POPF following PD.

Robot-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia.

BACKGROUND & AIMS: Endoscopic submucosal dissection (ESD) is a new technique for endoscopic resection of early-stage gastrointestinal cancers. Though ESD achieves high rate of en bloc resection, it is technically difficult to master. The development of a novel robotic endoscopic system that has 2 arms attached to an ordinary endoscope-Master and Slave Transluminal Endoscopic Robot (MASTER)-has improved the performance of complex endoluminal procedures. We evaluated the efficacy of MASTER-assisted ESD in treatment of patients with early-stage gastric neoplasia. METHODS: We performed a multicenter prospective study of 5 patients with early-stage gastric neoplasia, limited to the mucosa. After markings and circumferential mucosal incision, all submucosal dissections were performed using the MASTER system. We measured baseline demographics, tumor characteristics, and perioperative and clinical outcomes. RESULTS: All patients underwent successful MASTER-assisted ESD. The mean submucosal dissection time was 18.6 minutes (median, 16 minutes; range, 3-50 minutes). No perioperative complications were encountered. Three patients were discharged from the hospital within 12 hours and 2 on the third day after the procedures. Two patients were found to have intramucosal adenocarcinoma, 1 had high-grade dysplasia, 1 had low-grade dysplasia, and 1 had a hyperplastic polyp. The resection margins were clear of tumors in all 5 patients. No complications were observed at the 30-day follow-up examination. Follow-up endoscopic examinations revealed that none of the patients had residual or recurrent tumors. CONCLUSIONS: A flexible endoscopy robotic system can be used to perform ESD and effectively treat patients with early gastric neoplasia.

Evaluation of ultrasound based acoustic radiation force impulse (ARFI) and eSie touch sonoelastography for diagnosis of inflammatory pancreatic diseases.

CONTEXT: Pathology changes the consistency of the tissues. OBJECTIVE: To prospectively assess the accuracy of per-abdominal US elastography in the form of acoustic radiation force impulse--virtual touch tissue quantification (ARFI-VTQ) and eSie touch elasticity imaging in characterizing and differentiating inflammatory pancreatic diseases. PATIENTS: One-hundred and 66 patients from among the patients that visited the Asian Institute of Gastroenterology, Hyderabad, India, during the period April 2009 to December 2010, for master health check-up, blood donation and those with pancreatic pathology. SETTING: Based on the clinical symptomatic criteria and diagnostic imaging findings, the patients were divided into normal, chronic and acute, or acute resolving, pancreatitis group. MAIN OUTCOME MEASURES: The ultrasound based ARFI-VTQ and eSie touch elasticity imaging techniques were applied. DESIGN: Prospective single-center study. RESULTS: The mean ARFI-VTQ values were 1.28 m/s, 1.25 m/s and 3.28 m/s for the normal, chronic and acute pancreas, respectively. The eSie touch gray scale and color elastograms were light gray and purple-greenish, respectively for both normal and chronic pancreas, while for acute pancreas the elastograms were dark black on the gray scale and orange to red on color scale. CONCLUSION: Both the ARFI-VTQ and eSie touch elasticity imaging techniques may be successfully adopted in order to diagnose acute pancreatitis, to assess extent of inflammation (whether focal or diffuse), to assess peripancreatic edema, to identify presence of necrotic areas and early pseudocyst formation, to early diagnose acute recurrent attacks and to monitor patient's response to treatment.

Prophylactic Perioperative Terlipressin Therapy for Preventing Acute Kidney Injury in Living Donor Liver Transplant Recipients: A Systematic Review and Meta-Analysis.

Background: Acute kidney injury (AKI) is common in the perioperative transplant period and is associated with poor outcomes. Few studies reported a reduction in AKI incidence with terlipressin therapy by counteracting the hemodynamic alterations occurring during liver transplantation. However, the effect of terlipressin on posttransplant outcomes has not been systematically reviewed. Methods: A comprehensive search of electronic databases was performed. Studies reporting the use of terlipressin in the perioperative period of living donor liver transplantation were included. We expressed the dichotomous outcomes as risk ratio (RR, 95% confidence interval [CI]) using the random effects model. The primary aim was to assess the posttransplant risk of AKI. The secondary aims were to assess the need for renal replacement therapy (RRT), vasopressors, effect on hemodynamics, blood loss during surgery, hospital and intensive care unit (ICU) stay, and in-hospital mortality. Results: A total of nine studies reporting 711 patients (309 patients in the terlipressin group and 402 in the control group) were included for analysis. Terlipressin was administered for a mean duration of 53.44 ± 28.61 h postsurgery. The risk of AKI was lower with terlipressin (0.6 [95% CI, 0.44-0.8]; P = 0.001). However, on sensitivity analysis including only four randomized controlled trials (I2 = 0; P = 0.54), the risk of AKI was similar in both the groups (0.7 [0.43-1.09]; P = 0.11). The need for RRT was similar in both the groups (0.75 [0.35-1.56]; P = 0.44). Terlipressin therapy reduced the need for another vasopressor (0.34 [0.25-0.47]; P < 0.001) with a concomitant rise in mean arterial pressure and systemic vascular resistance by 3.2 mm Hg (1.64-4.7; P < 0.001) and 77.64 dyne cm-1.sec-5 (21.27-134; P = 0.007), respectively. Blood loss, duration of hospital/ICU stay, and mortality were similar in both groups. Conclusions: Perioperative terlipressin therapy has no clinically relevant benefit.

Safety Assessment of Autologous Stem Cell Combination Therapy in Patients With Decompensated Liver Cirrhosis: A Pilot Study.

BACKGROUND: Haematopoietic stem cell (HSC) infusion has demonstrated short-term improvement in liver functions in patients with chronic liver disease. The combination of HSC with mesenchymal stem cells (MSCs), which has an immunomodulatory effect, may augment the effects and enhance the duration of improvements on liver functions. The aim of the present study was to assess the safety of infusing the combination of autologous HSCs and MSCs in decompensated liver cirrhosis. METHODS: In phase I of the study, in vitro assessment was performed to observe the effect of coculturing MSCs with HSCs on their viability and cytokine profiles. Phase II of the study was to assess the safety of combination of stem cell infusions. Bone marrow (50 ml) was aspirated for MSC isolation and expansion using standard protocol. Patients received subcutaneous doses (n = 5) of granulocyte colony-stimulating factor (G-CSF) for stem cell mobilization followed by leukapheresis for harvesting HSCs using CliniMacs. HSCs and MSCs were infused through the hepatic artery under fluoroscopic guidance and were monitored for any adverse effects. RESULTS: In vitro studies revealed 94% viable HSCs in coculture similar to monoculture. HSCs released only interleukin (IL)-8, whereas MSCs secreted IL-8 and IL-6 in monocultures, and both IL-8 and IL-6 were secreted in coculture. G-CSF administration- and bone marrow aspiration-related complications were not observed. Infusion of the cells through the hepatic artery was safe, and no postprocedural complications were noted. CONCLUSION: The combination of autologous HSC and MSC infusion is a safe procedure in patients with decompensated liver cirrhosis, and the outcomes needed to be assessed in larger studies. TRIAL NUMBER: NCT04243681.

A Pro-Endocrine Pancreatic Islet Transcriptional Program Established During Development Is Retained in Human Gallbladder Epithelial Cells.

BACKGROUND & AIMS: Pancreatic islet ß-cells are factories for insulin production; however, ectopic expression of insulin also is well recognized. The gallbladder is a next-door neighbor to the developing pancreas. Here, we wanted to understand if gallbladders contain functional insulin-producing cells. METHODS: We compared developing and adult mouse as well as human gallbladder epithelial cells and islets using immunohistochemistry, flow cytometry, enzyme-linked immunosorbent assays, RNA sequencing, real-time polymerase chain reaction, chromatin immunoprecipitation, and functional studies. RESULTS: We show that the epithelial lining of developing, as well as adult, mouse and human gallbladders naturally contain interspersed cells that retain the capacity to actively transcribe, translate, package, and release insulin. We show that human gallbladders also contain functional insulin-secreting cells with the potential to naturally respond to glucose in vitro and in situ. Notably, in a non-obese diabetic (NOD) mouse model of type 1 diabetes, we observed that insulin-producing cells in the gallbladder are not targeted by autoimmune cells. Interestingly, in human gallbladders, insulin splice variants are absent, although insulin splice forms are observed in human islets. CONCLUSIONS: In summary, our biochemical, transcriptomic, and functional data in mouse and human gallbladder epithelial cells collectively show the evolutionary and developmental similarities between gallbladder and the pancreas that allow gallbladder epithelial cells to continue insulin production in adult life. Understanding the mechanisms regulating insulin transcription and translation in gallbladder epithelial cells would help guide future studies in type 1 diabetes therapy.

Primary Pancreatic Leiomyosarcoma: A Rare Malignant Transformation of Primary Pancreatic Head Leiomyoma.

Primary pancreatic leiomyosarcoma and primary pancreatic leiomyoma are rare tumors of the pancreas. Primary pancreatic leiomyoma is a benign tumor and its conversion to leiomyosarcoma has never been reported. We report a case of malignant transformation of pancreatic leiomyoma. In this case, a 75-year-old male, who presented with a mass in the head of the pancreas, was diagnosed with primary pancreatic leiomyoma. The patient maintained well on symptomatic treatment for 13 years. However, later the patient presented with loss of appetite, significant weight loss, and an abdominal lump, which was diagnosed to be locally advanced primary pancreatic leiomyosarcoma. The patient was provided the best supportive care and died after 11 months of diagnosis. Hence, we conclude that a more radical treatment approach is needed in patients with primary pancreatic leiomyoma.

A novel endoscopic device for repeated right-side colonic access during colonoscopy (with video).

BACKGROUND: Megachannel is a newly developed colonic access system allowing rapid and multiple passes of the colonoscope to the right side of the colon. OBJECTIVE: The aim of this study was to evaluate the safety and clinical feasibility of placing a 100 cm Megachannel prototype in the right side of the colon. SETTING: Six centers, international, both surgeons and gastroenterologists performing endoscopy. DESIGN AND INTERVENTION: Patients scheduled for colonoscopy with suspected right-side colonic polypoid lesions were included. The prototype was loaded onto a 160 cm lower GI endoscope and introduced via colonoscopic guidance. MAIN OUTCOME MEASUREMENT: The ability to place this device in the right side of the colon. RESULTS: The Megachannel prototype was introduced in 41 patients (19 female, mean age 54 years) undergoing colonoscopy. The cecum was reached in 27 cases (66%) within 18 minutes (range, 3-35 minutes) and with 73 cm (range, 40-100 cm) of the device being inserted into the colon. Mild tissue bruises and mild pain were observed in 5 and 3 patients, respectively. In 14 patients, the device assisted the removal of multiple polyps (2-12) as tissue was repeatedly retrieved through the channel. The device also allowed delivery of an endoscopic US scope or suction caps to the right side of the colon. LIMITATIONS: Prototype performance may differ from the actual product (80 cm in length, redesigned introducer plugs). Small number of patients, difficult in diverticular disease. CONCLUSIONS: This newly developed colonic access system can be safely placed in the right side of the colon and is useful for a variety of advanced procedures that require repeated insertion of the colonoscope or delivery of bulky instruments. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00987896.).

Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases.

BACKGROUND AND AIM: Single-balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders. METHODS: One hundred and six patients (mean age 40.1 years, range 12-76 years, 65 men) with suspected small bowel diseases underwent 131 SBE procedures between February 2007 and July 2008. RESULTS: Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40), chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 +/- 84.5 cm beyond the duodenojejunal flexure by the oral route and 163 +/- 59.3 cm proximal to the ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade and retrograde enteroscopy was 65.9 +/- 19.5 min and 72.3 +/- 18.3 min, respectively. Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in 46% and the extent of known disease was assessed in 15% of cases. In 21% of patients, therapeutic interventions were carried out while surgical treatment was directed to 8.4% of the patients. No major complications were observed. CONCLUSION: SBE is well tolerated and has good diagnostic yield, having a similar yield to previous double-balloon enteroscopy reports.

Virtual MR pancreatoscopy in the evaluation of the pancreatic duct in chronic pancreatitis.

The main pancreatic duct and the common bile duct can be evaluated with a variety of evolving invasive and non-invasive techniques. Virtual CT pancreatoscopy obtained using special computer software is a recent non-invasive innovation which shows the details of the ductal surface (endoluminal view) with greater precision. The use of special computer software in MRI in order to obtain pancreatic ductal surface details or a virtual MR pancreatoscopy has not been described up to now. We report a short series of four patients suffering from chronic pancreatitis who underwent virtual MR pancreatoscopy with an impact on their management and clinical outcome.

Successful closure of spontaneous esophageal perforation (Boerhaave's syndrome) by endoscopic clipping.

Endoscopic clips have been used mainly for control of gastrointestinal (GI) bleeding and occasionally for closure of GI perforations. However, closure of spontaneous esophageal perforation (Boerhaave's syndrome) by clipping has not been reported. We described successful non-surgical closure of spontaneous esophageal perforation by endoscopic clipping in a patient with bilateral pyopneumothorax and septicemia.

Infliximab in the treatment of ulcerative colitis with toxic megacolon.

Toxic megacolon is a gastrointestinal emergency requiring prompt management to avoid fatal outcome. Although a majority of patients respond to conservative treatment, those not responding have been treated with intravenous cyclosporine or emergency surgery. Infliximab has been tried in patients with severe steroid-refractory ulcerative colitis. We report the successful use of this drug in the management of toxic megacolon in a 48-year-old woman not responding to the routine measures and who refused surgery.

Modified technique of high-resolution ultrasonography of the normal cervical esophagus.

BACKGROUND AND AIM: To study a modified technique of neck ultrasound for the visualization of cervical esophagus using a high-resolution and high frequency linear transducer in normal subjects. METHODS: Consecutive control subjects were patients who underwent abdominal sonography for other diseases and had no past or current history of dysphagia or esophageal disorders. The thyroid gland was used as a transducer window to obtain images. We used a slightly flexed neck position with the head turned 45 degrees to the opposite side while scanning the neck on either side. RESULTS: One-hundred subjects were scanned and their age range was 10-74 years (male:female ratio 1:1). In 36% of cases it was difficult to visualize the right lateral 2/3rd in the traditional scanning position of the neck. This improved to 2% with the modified neck position. All patients had the left window visualized with both neck positions. The transverse diameter, anterior-posterior diameter and wall thickness measures were all significantly greater with the modified technique. All patients tolerated the procedure with no reported discomfort. CONCLUSIONS: This modified technique provides superior views of the cervical esophagus, particularly from the right window, in almost all patients. Normal parameters using ultrasound have now been established.

Multiple main pancreatic duct stones in tropical pancreatitis: safe clearance with extracorporeal shockwave lithotripsy.

BACKGROUND AND AIM: Extracorporeal shockwave lithotripsy (ESWL) has an established role in the management of pancreatic ductal stones. Its efficacy in management of multiple stones in tropical pancreatitis is unknown. The aim of this study was to prospectively evaluate: (i) the efficacy of main pancreatic duct stone clearance; and (ii) associated complications with ESWL therapy in tropical pancreatitis. METHODS: Consecutively recruited patients with tropical pancreatitis underwent fragmentation of main pancreatic duct stones using ESWL. Endoscopic retrograde cholangiopancreatography (ERCP) using standard techniques was performed to manage residual stones. Complete, partial and unsatisfactory clearance was defined as >90%, 50-90% and <50% of stone clearance, respectively. Clinical and technical data were collected on a pre-formatted data sheet. Statistical analysis was performed on an intention-to-treat basis. RESULTS: A total of 250 patients (mean+/-SD age 35.2+/-11.9 years; 66% men), 86.8% with multiple radio-opaque stones, underwent ESWL between February 2004 and May 2005. Of the 250 patients, 149 (59.6%) achieved complete clearance and 59 (23.6%) achieved partial clearance of pancreatic calculi. Main pancreatic ductal decompression was achieved in 70.0% (175/250) of patients. Complications occurred in 5.6% (14/250) during ESWL and in 1.2% (3/250) during ERCP. A mean of 1.3 sessions, with mean+/-SD 5.5+/-0.7 intensity setting, 85.8+/-13.5 pulses per minute and 3862+/-1426 shocks per session were required. CONCLUSION: Clearance of multiple main pancreatic duct stones in patients with tropical pancreatitis is safely performed via ESWL followed by ERCP ductal drainage.

Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique.

BACKGROUND: Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques. METHODS: We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-upward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later. RESULTS: A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of pre-cut techniques. CONCLUSIONS: The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.