Pancreatic duct pressure: A review of technical aspects and clinical significance.

Pancreatic duct pressure (PDP) dynamics comprise an intricately modulated system that helps maintain homeostasis of pancreatic function. It is affected by various factors, including the rate of pancreatic fluid secretion, patency of the ductal system, sphincter of Oddi function, and pancreatic fluid characteristics. Disease states such as acute and chronic pancreatitis can alter the normal PDP dynamics. Ductal hypertension or increased PDP is suspected to be involved in the pathogenesis of pancreatic pain, endocrine and exocrine pancreatic insufficiency, and recurrent pancreatitis. This review provides a comprehensive appraisal of the available literature on PDP, including the methods used in the measurement and clinical implications of elevated PDP.

Pediatric ERCP: Factors for Success and Complication-A 17-Year, Multisite Experience.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly utilized procedure in pediatric populations. A lack of dedicated pediatric research has led endoscopists to extrapolate adult risk factors and preventative strategies to children. The aim of this multisite, retrospective study was to identify risks for adverse events, procedure failure, and prolonged courses in pediatric patients undergoing ERCP. METHODS: Pediatric patients who had an ERCP at one of our academic centers were identified by query of their electronic medical records. Pre-procedure and post-procedure data were collected with ERCP-related adverse events defined according to the consensus criteria developed by Cotton et al 2010. RESULTS: Between January 2004 and January 2021, 287 children had a total of 716 ERCPs. The procedure success rate was 95.5% with no mortality and an adverse event rate of 12.7%. Younger age was associated with increased case complexity, increased adverse events, and an increased rate of repeat ERCP. Case complexity score correlated with increased procedure time ( P < 0.001) and increased adverse events (tau 0.24, P < 0.01); stent removal and pancreatic stenting were more likely to precede an adverse event. Pancreatitis, pancreatic divisum, and pancreatic stricture/stenosis were associated with increased adverse events and rates of repeat ERCP. CONCLUSIONS: Pediatric ERCP adverse event rates are higher than adults. The complexity grading system proposed by the Cotton et al appears to have applicability to pediatric patients. Young age and interventions affecting the pancreatic duct are associated with adverse ERCP outcomes in pediatrics.

Characterization of thermal and optical properties in porcine pancreas tissue.

BACKGROUND: Photothermal therapies have shown promise for treating pancreatic ductal adenocarcinoma when they can be applied selectively, but off-target heating can frustrate treatment outcomes. Improved strategies leveraging selective binding and localized heating are possible with precision medical approaches such as functionalized gold nanoparticles, but careful control of optical dosage and thermal generation would be imperative. However, the literature review revealed many groups assume liver properties for pancreas tissue or rely on insufficiently rigorous characterization studies. OBJECTIVE: The objective of this study was to determine the thermal conductivity and optical properties at 808/1064 nm wavelengths in healthy samples of fresh and frozen porcine pancreas ex vivo. METHODS: Thermal conductivity of the porcine pancreas tissue was measured by utilizing a hot plate and two K-type thermocouples. Experimental variables such as tissue sample thickness, hot plate temperature, and heat convection coefficient were estimated through the control experiments utilizing specimens with known thermal conductivity. Optical evaluations assessed light attenuation at the 808 and 1064 nm wavelengths (continuous wave, collimated beam) by measuring the light transmittance and reflectance of different tissue thicknesses. In turn, these measurements were input into an inverse adding-doubling program to estimate the optical absorption and reduced scattering coefficients. RESULTS: Interestingly, pancreas tissue thermal conductivity was demonstrated to have no significant difference (p > 0.5) between samples that were fresh, frozen for 7 days, or frozen for 14 days. Conversely, optical property assessment exhibited a significant difference (p < 0.001) between fresh and frozen tissue samples, with increased absorbance and reflectance within the frozen group. However, the optical attenuation values measured were substantially less than that of the liver or reported in previous pancreas studies, suggesting a wide overestimation of these properties. CONCLUSIONS: These thermal and optical properties are critical to the development of novel therapeutic strategies like plasmonic photothermal therapy, but perhaps more importantly, are invaluable towards informing better surgical planning and operative technique among the existing thermal approaches for treating pancreas tissue.

An assessment of pancreatology education in North American pediatric gastroenterology fellowship programs.

BACKGROUND/OBJECTIVES: Within the last two decades, an increased incidence of acute pancreatitis (AP) has been reported in childhood, with some progressing to acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). Training future pancreatologists is critical to improve the care of children with pancreatic diseases. There are no studies to assess whether the pediatric gastroenterology (GI) fellowship curriculum prepares specialists to care for children with pancreatic diseases. METHODS: An electronic survey was distributed to all North American Pediatric Gastroenterology Fellows. The survey included 31 questions on pancreatology training including academic resources, research experience, clinical exposure, clinical confidence, and career plans. RESULTS: A total of 112 (25.8%) fellows responded from 41 (41/72, 56.9%) training centers in North America. Pancreas-specific didactic lectures were reported by 90.2% (n = 101); 49.5% (50/101) had at least quarterly or monthly lectures. Clinical confidence (Likert 4-5) was highest in managing and treating AP (94.6% and 93.8% respectively), relatively lower for ARP (84.8% and 71.4%) and lowest for CP (63.4% and 42.0%). Confidence in diagnosing both ARP and CP was associated with the variety of pancreatic diseases seen (p < 0.001) and total number of patients followed over a 6 month period (p = 0.04). Nine (8%) reported interest in specializing in pancreatology, 12 (10.7%) in pursuing research in the pancreatology. CONCLUSIONS: Trainee confidence is highest in managing AP, lowest in CP, and seems to be directly correlated with the variety of pancreatic diseases and number of patients followed. Continued commitment is necessary to foster training of the next generation of pediatric pancreatologists.

Improving Diagnostic Yield in Indeterminate Biliary Strictures.

Indeterminate biliary strictures are defined as a narrowing of the bile duct that cannot be differentiated as malignant or benign after performing cross-sectional imaging and an ERCP. Identifying the etiology of a bile duct stricture is the single most important step in determining whether a complex and potentially morbid surgical resection is warranted. Due to this diagnostic and therapeutic dilemma, new technologies, laboratory tests, and procedures are emerging to solve this problem.

Expanding the Use of Endoscopic Retrograde Cholangiopancreatography in Pediatrics: A National Database Analysis of Demographics and Complication Rates.

Background: This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates. Methods: The Kids' Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4. Results: Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant. Conclusions: ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.

Assessment and Modeling of Plasmonic Photothermal Therapy Delivered via a Fiberoptic Microneedle Device Ex Vivo.

Plasmonic photothermal therapy (PPTT) has potential as a superior treatment method for pancreatic cancer, a disease with high mortality partially attributable to the currently non-selective treatment options. PPTT utilizes gold nanoparticles infused into a targeted tissue volume and exposed to a specific light wavelength to induce selective hyperthermia. The current study focuses on developing this approach within an ex vivo porcine pancreas model via an innovative fiberoptic microneedle device (FMD) for co-delivering light and gold nanoparticles. The effects of laser wavelengths (808 vs. 1064 nm), irradiances (20-50 mW·mm-2), and gold nanorod (GNR) concentrations (0.1-3 nM) on tissue temperature profiles were evaluated to assess and control hyperthermic generation. The GNRs had a peak absorbance at ~800 nm. Results showed that, at 808 nm, photon absorption and subsequent heat generation within tissue without GNRs was 65% less than 1064 nm. The combination of GNRs and 808 nm resulted in a 200% higher temperature rise than the 1064 nm under similar conditions. A computational model was developed to predict the temperature shift and was validated against experimental results with a deviation of <5%. These results show promise for both a predictive model and spatially selective, tunable treatment modality for pancreatic cancer.

Endoscopic Submucosal Dissection for Resolution of a Symptomatic Pancreatic Rest in a Pediatric Patient: A Case Report and Literature Review.

The pancreatic rest, aberrant, or heterotopic pancreas is a normal function pancreas found in the submucosal layer of the greater curvature of the gastric antrum and occasionally in the duodenum. Most of the patients are asymptomatic and the finding is usually incidental. We describe the case of a child with abdominal pain and history of recurrent ulcers that necessitated esophagogastroduodenoscopy and further evaluation with endoscopic ultrasound that confirmed a submucosal lesion consistent with a pancreatic rest. Endoscopic submucosal dissection was performed without complication, and complete symptom resolution was achieved after dissection of the pancreatic rest.

Management of Non-Variceal Upper GI Bleeding in the Geriatric Population: An Update.

PURPOSE OF REVIEW: Upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality in the geriatric (age > 65 years) population and presents a unique management challenge in the context of multiple medical comorbidities, polypharmacy, and increased risk of adverse outcomes and is confounded by an increased prevalence of obscure GI bleeds. A review of relevant guidelines, literature, and personal observations will enhance management strategies in the elderly. RECENT FINDINGS: Non-variceal bleeding represents a significant proportion of upper GI bleeding (UGIB) in geriatric patients. Peptic ulcer disease (PUD) remains the most common cause in geriatric patients hospitalized for UGIB, but its incidence is decreasing. Esophagogastroduodenoscopy (EGD) is the gold standard for treating UGIB in geriatrics with a therapeutic yield of approximately 75%. Scoring systems such as Glasgow-Blatchford (GBS) and AIMS-65 may be useful for risk stratification but are not validated in trials. Obscure bleeds account for up to 30% of hospitalizations and must be considered during triage and management. Video capsule endoscopy (VCE) technology is efficacious for detecting obscure jejunal bleeding after failed EGD and may enhance the yield of balloon-assisted enteroscopy (BAE). The most significant factor for the increased morbidity and mortality in the geriatric population is the presence of multiple medical comorbidities and polypharmacy. An EGD should be done within 24 h of hospital presentation. If non-diagnostic, VCE may be a viable option for diagnosing an obscure small-bowel bleed, representing up to 30% of GI bleeds in this population.