Prescription patterns of pancreatic enzyme replacement therapy for patients with pancreatic cancer in the United States.

BACKGROUND: Exocrine pancreatic insufficiency (EPI) is frequently seen in patients with pancreatic cancer (PDAC) and is thought to contribute to nutritional complications. While EPI can be pharmacologically temporized with pancreatic enzyme replacement therapy (PERT), there is lack of clear evidence informing its use in PDAC. Here we aim to survey pancreatic surgeons regarding their utilization of PERT in the management of EPI for PDAC. METHODS: An online survey was distributed to the members of The Americas Hepato-Pancreato-Biliary Association (AHPBA) and The Pancreas Club. RESULTS: 86.5% (180/208) of surgeons prescribe PERT for at least some resectable/borderline resectable PDAC cases. Only a minority of surgeons order investigations to confirm EPI before starting PERT (28.1%) or test for adequacy of therapy (28.3%). Few surgeons believe that PERT has an effect on overall survival (19.7%) or disease-free survival (6.25%) in PDAC. CONCLUSION: PERT is widely prescribed in patients with resectable/borderline resectable PDAC, but investigations establishing EPI and assessing PERT adequacy are underutilized. A substantial proportion of surgeons are unclear as to the effect of PERT on survival outcomes in PDAC. These data call for prospective studies to establish guidelines for optimal use of PERT and its effects on survival outcomes in PDAC.

Hsp70 modulates immune response in pancreatic cancer through dendritic cells.

Heat shock protein 70 (Hsp70), a protein chaperone, is known to promote cell survival and tumor progression. However, its role in the tumor microenvironment (TME) is largely unknown. We specifically evaluated Hsp70 in the TME by implanting tumors in wild-type (WT) controls or Hsp70-/- animals, thus creating a TME with or without Hsp70. Loss of Hsp70 led to significantly smaller tumors; there were no differences in stromal markers, but interestingly, depletion of CD8 + T-cells abrogated this tumor suppressive effect, indicating that loss of Hsp70 in the TME affects tumor growth through the immune cells. Compared to WT, adoptive transfer of Hsp70-/- splenocytes exhibited greater antitumor activity in immunodeficient NSG and Rag 1-/- mice. Hsp70-/- dendritic cells showed increased expression of MHCII and TNF-α both in vitro and in vivo. These results suggest that the absence of Hsp70 in the TME inhibits tumors through increased dendritic cell activation. Hsp70 inhibition in DCs may emerge as a novel therapeutic strategy against pancreatic cancer.

Analgesic efficacy of ultrasound guided transversus abdominis plane block versus local anesthetic infiltration in adult patients undergoing single incision laparoscopic cholecystectomy: A randomized controlled trial.

BACKGROUND: Transversus abdominis plane (TAP) block has been used to provide intra- and post-operative analgesia with single incision laparoscopic (SIL) bariatric and gynecological surgery with mixed results. Its efficacy in providing analgesia for SIL cholecystectomy (SILC) via the same approach remains unexplored. AIMS: The primary objective of our study was to compare the efficacy of bilateral TAP block with local anesthetic infiltration for perioperative analgesia in patients undergoing SILC. SETTINGS AND DESIGN: This was a prospective, randomized, controlled, double-blinded trial performed in a tertiary care hospital. MATERIALS AND METHODS: Forty-two patients undergoing SILC were randomized to receive either ultrasound-guided (USG) bilateral mid-axillary TAP blocks with 0.375% ropivacaine or local anesthetic infiltration of the port site. The primary outcome measure was the requirement of morphine in the first 24 h postoperatively. STATISTICAL ANALYSIS: The data were analyzed using t-test, Mann-Whitney test or Chi-square test. RESULTS: The 24 h morphine requirement (mean ± standard deviation) was 34.57 ± 14.64 mg in TAP group and 32.76 ± 14.34 mg in local infiltration group (P = 0.688). The number of patients requiring intraoperative supplemental fentanyl in TAP group was 8 and in local infiltration group was 16 (P = 0.028). The visual analog scale scores at rest and on coughing were significantly higher in the local infiltration group in the immediate postoperative period (P = 0.034 and P = 0.007, respectively). CONCLUSION: USG bilateral TAP blocks were not effective in decreasing 24 h morphine requirement as compared to local anesthetic infiltration in patients undergoing SILC although it provided some analgesic benefit intraoperatively and in the initial 4 h postoperatively. Hence, the benefits of TAP blocks are not worth the effort and time spent for administering them for this surgery.

Gastrointestinal Stromal Tumour in a Patient with Multiple Cutaneous and Uterine Leiomyomatosis- Implications and Anaesthetic Management.

Multiple cutaneous leiomyomatosis have been associated with uterine leiomyomatosis and known as Reed's syndrome or Multiple Cutaneous and Uterine Leiomyomatosis (MCUL). Gastrointestinal Stromal Tumours (GIST) have been reported to be associated with this syndrome only once previously in literature to the best of our knowledge. Here we report a rare case of GIST and multiple uterine leiomyomatosis in a middle aged patient with longstanding cutaneous leiomyomatosis who underwent GIST excision and hysterectomy. A 35 year old female patient with multiple cutaneous leiomyomatosis for the past 20 years was diagnosed to have gastrointestinal stromal tumour and multiple uterine leiomyomatosis for which she underwent laparotomy for GIST excision and hysterectomy. In the report we have elaborated the clinical and pathological observations as well as the anaesthetic management. This case report further substantiates the association of GIST with multiple cutaneous and uterine leiomyomatosis and also reminds us that cutaneous lesions can be clues to the diagnosis of underlying malignancy.