Textbook outcome after pancreatoduodenectomy and distal pancreatectomy with postoperative hyperamylasemia-a propensity score matching analysis.

PURPOSE: Postoperative serum hyperamylasemia (POH) is a part of the new, increasingly highlighted, definition for postpancreatectomy pancreatitis (PPAP). This study aimed to analyze whether the biochemical changes of PPAP are differently associated with postoperative complications after distal pancreatectomy (DP) compared with pancreatoduodenectomy (PD). The textbook outcome (TO) was used as a summary measure to capture real-world data. METHODS: The data were retrospectively extracted from a prospective clinical database. Patients with POH, defined as levels above our institution's upper limit of normal on postoperative day 1, after DP and the corresponding propensity score-matched cohort after PD were evaluated on postoperative complications by using logistic regression analyses. RESULTS: We analyzed 723 patients who underwent PD and DP over a period of 9 years. After propensity score matching, 384 patients (192 patients in each group) remained. POH was observed in 78 (41.1%) and 74 (39.4%) after PD and DP correspondingly. There was a significant increase of postoperative complications in the PD group: Clavien-Dindo classification system ≥3 (P < .01 vs P = .71), clinically relevant postoperative pancreatic fistula (P < .001 vs P = .2), postpancreatectomy hemorrhage (P < .001 vs P = .11), and length of hospital stay (P < .001 vs P = .69) if POH occurred compared with in the DP group. TO was significantly unlikely in cases with POH after PD compared with DP (P > .001 vs P = .41). Furthermore, POH was found to be an independent predictor for missing TO after PD (odds ratio [OR], 0.29; 95% CI, 0.14-0.60; P < .001), whereas this was not observed in patients after DP (OR, 0.53; 95% CI, 0.21-1.33; P = .18). CONCLUSION: As a part of the definition for PPAP, POH is a predictive indicator associated with postoperative complications after PD but not after DP.

Long-term outcomes and adverse effects of teduglutide in patients with short bowel syndrome: Highlighting hyperamylasemia and hyperlipasemia.

PURPOSE: Short bowel syndrome is a malabsorptive condition that occurs due to surgical removal or a congenital absence of a significant portion of the small intestine. Patients with short bowel syndrome often rely on parenteral support for extended periods or even their entire lives. Teduglutide, a glucagon-like peptide-2 analog, has shown promising results in reducing dependency on parenteral support in these patients by promoting intestinal adaptation and enhancing nutrient absorption. However, the long-term safety of teduglutide remains a concern, particularly with respect to its potential for the development of hyperamylasemia and hyperlipasemia. METHODS: This study involved patients who received teduglutide from December 2012 to December 2022 at Boston Medical Center. We evaluated outcomes and adverse events, focusing on hyperamylasemia and hyperlipasemia, through chart review. RESULTS: Thirteen eligible patients were identified who had used teduglutide. Of these, the majority (84.6%) experienced a reduction in parenteral support. A high incidence (72.7%) of nonpathological pancreatic enzyme elevation was observed in patients treated with teduglutide. These elevations were often dose dependent and were not associated with any clinical signs of acute pancreatitis or abnormal imaging findings. CONCLUSION: This study highlights the need for further investigations into the long-term safety of teduglutide and the importance of closely monitoring amylase and lipase levels in patients undergoing treatment with teduglutide.

Efficacy of rectal indomethacin in prevention of post-operative hyperamylasemia following pancreatoduodenectomy: a randomized controlled trial.

BACKGROUND: Post-operative hyperamylasemia (POH) following pancreatoduodenectomy (PD) may play a key role in pathogenesis of post-operative pancreatic fistula (POPF). Aim of the current study was to evaluate efficacy of perioperative administration of indomethacin in preventing POH. METHODS: Single-center, double-blind, randomized controlled trial (RCT) conducted on consecutive patients undergoing PD. Patients received either 100 mg of indomethacin per-rectally at induction of anesthesia or standard care. Primary endpoint was incidence of POH in the two arms. POH was defined as postoperative day (POD) 1 serum amylase (S. amylase) levels greater than the upper limit of normal. RESULTS: After exclusion 44 patients were randomized. The two arms were comparable for preoperative and intraoperative parameters. POH was noted in 20/44 (45.5%) with significantly lower incidence of POH (60.9% vs. 28.6%, p = 0.032) in intervention arm (IA). Median S. amylase, POD 1, 3, and 5 drain amylase, and incidence of clinically relevant POPF (CR-POPF) were lower in IA but failed to reach statistical significance (30.4% vs. 14.3%, p = 0.18). The severity of delayed gastric emptying (DGE) was significantly lower in the IA (grade B/C DGE 23.8% vs. 47.8%, p = 0.023). Evaluation of risk factors for POH showed IA to confer an independent protective effect and increased risk with soft pancreas. CONCLUSION: Perioperative per-rectal indomethacin administration is effective in decreasing the incidence of POH following pancreatoduodenectomy.

Impact and Consequences of Recipient Gastroduodenal Artery Ligation Before Hepatic Artery Anastomosis During Orthotopic Liver Transplantation.

OBJECTIVES: The recipient's gastroduodenal artery is often ligated before the hepatic artery anastomosis during orthotopic liver transplant, to gain either mobility or length of recipient's hepatic artery, potentially protecting the anastomosis by preventing "steal syndrome." In this study, our aim was to evaluate the consequences of gastroduodenal artery ligation and its effect on prevention of hepatic artery thrombosis. MATERIALS AND METHODS: We retrospectively analyzed deceased-donor orthotopic liver transplant procedures (n = 210) performed at a single center between January 2016 and July 2021 to compare outcomes between recipients with (group 1) and recipients without (group 2) gastroduodenal artery ligation. Group 1 included 78 patients (37%), in which the recipient's common hepatic artery was used for arterial anastomosis; group 2 included 132 patients (63%), in which the right hepatic artery orthe proper hepatic artery was used for arterial anastomosis. Occurrences of hepatic artery thrombosis, postoperative hyperamylasemia, nausea and vomiting, and delayed feeding were compared between the groups. RESULTS: There was no incidence of hepatic artery thrombosis reported in either group. In group 1, 31 patients (39.7%) were reported to have postoperative hyperamylasemia, ranging from 200 to 4700 U/L accompanied by delayed feeding, whereas, in group 2, only 16 of 132 patients (12%) had postoperative hyperamylasemia, ranging from 200 to 1400 U/L (P < .01). CONCLUSIONS: Ligation of recipient's gastroduodenal artery is not associated with decreased risk of hepatic artery thrombosis compared with nonligation. However, the procedure does have consequences in the form of possible postoperative hyperamylasemia, leading to delayed feeding probably due to decreased oral tolerance.

Case Report: Durable complete response of metastatic hepatocellular carcinoma with asymptomatic hyperamylasemia to combined immunotherapy of anti-cytotoxic T lymphocyte-associated antigen 4 plus anti-programmed cell death-1 antibodies.

Background: Combined immunotherapy has shown promising results in the treatment of advanced HCC, whereas the priority population that would respond to the combined immunotherapy is still elusive. In addition, HCC with asymptomatic hyperamylasemia was not reported previously. Case presentation: An aged patient was diagnosed as HCC with BCLC stage C (bone metastasis). Notably, this patient showed asymptomatic hyperamylasemia. The patient was then enrolled in a trial evaluating combined immunotherapy of anti-PD-1 antibody sintilimab (IBI308) plus anti-CTLA-4 antibody (IBI310) in advanced HCC. After being treated with combined immunotherapy, this patient rapidly achieved complete response (CR) according to mRECIST criteria or immune partial response (iPR) according to iRECIST criteria and maintain the CR state for more than 12 months. Interestingly, serum levels of amylase and lipase in this patient were reduced after treatment. Conclusion: We reported, for the first time, a case of metastatic HCC with asymptomatic hyperamylasemia, and suggested that HCC patients with asymptomatic hyperamylasemia may benefit from combined immunotherapy of anti-CTLA-4 and PD-1 antibodies.

Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis based on prospective, randomized, and controlled trials.

OBJECTIVES: To evaluate the efficacy of nafamostat mesilate in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) by conduct a systematic review and meta-analysis. METHOD: We retrieved for all randomized controlled trials (RCTs) about compare nafamostat mesilate with placebo in preventing PEP published before August 23, 2022, in 5 major electronic databases. The primary outcome was PEP rate, and the secondary outcome was post-ERCP hyperamylasemia (PEHA) rate. Subgroup analyses were performed to reveal the factors that may affect the preventive effect of nafamostat. Assessment of the quality of evidence was conducted based on Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. RESULTS: According to the search strategy and criteria of inclusion and exclusion, 8 articles with a number of 3210 patients were included. The PEP incidence of the nafamostat group was inferior compared with the placebo group (4.6% vs 8.5%, RR = 0.50, 95% CI: 0.38-0.66). Subgroup analyses revealed that nafamostat had a preventive effect on patients with different risk stratification (High-risk: RR = 0.61, 95% CI: 0.43-0.86, Low-risk: RR = 0.28; 95% CI: 0.17-0.47). Different doses (20 mg: RR = 0.50, 95% CI: 0.36-0.69, 50 mg: RR = 0.45, 95% CI: 0.27-0.74) and duration (<12 hour: RR = 0.55, 95% CI: 0.37-0.81, ≥12 h: RR = 0.44, 95% CI: 0.29-0.66) of administration of nafamostat are adequate for the prevention of PEP, but postoperative administration may not help (preoperative: RR = 0.52, 95% CI: 0.39-0.69, postoperative: RR = 0.54, 95% CI: 0.23-1.23). Nafamostat may not efficacious in preventing severe PEP (Mild: RR = 0.49, 95% CI, 0.35-0.68, Moderate: RR = 0.47, 95% CI: 0.25-0.86, Severe: RR = 0.91, 95% CI, 0.25-3.29) or in low-quality studies (Low-quality: RR = 0.69, 95% CI: 0.13-3.60, High-quality: RR = 0.49, 95% CI: 0.37-0.65). CONCLUSION: Preoperative use of nafamostat can effectively prevent PEP in patients with various risk stratification. Nafamostat can prevent mild and moderate PEP, but may not prevent severe PEP and PEHA. There should be more high-quality RCTs in future to strengthen the evidence of nafamostat in preventing PEP.

No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis.

BACKGROUND: While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD). METHODS: Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias. RESULTS: Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.

Incidence and risk factors of postoperative hyperamylasemia and pancreatitis following total knee arthroplasty: a retrospective study.

BACKGROUND: Postoperative hyperamylasemia and pancreatitis are recognized complications after abdominal and spinal surgeries. The aim of this study is to investigate the incidence and identify risk factors for postoperative hyperamylasemia and pancreatitis following total knee arthroplasty. METHODS: 170 patients undergoing total knee arthroplasty were retrospectively identified from our database from January 2017 to January 2021. Patients were divided into normal and hyperamylasemia groups based on the presence of serum amylase level within or greater than the normal range. The diagnosis of postoperative pancreatitis was based on the 2012 revised Atlanta Classification of Acute Pancreatitis. Patient demographics, perioperative parameters were investigated with student t test, chi square test and multivariate logistic regression analysis. RESULTS: 43 patients (25.3%) exhibited postoperative hyperamylasemia while eight patients (4.7%) exhibited serum amylase < 5 times the normal upper limit. One patient (0.6%) was designated as having postoperative pancreatitis. More patients with Hypertriglyceridemia (HTG) were noted in hyperamylasemia group (P = 0.009) compared with normal group. Hyperamylasemia group showed higher preoperative serum amylase (74.95 vs. 55.62 IU/L, P < 0.001), higher intra-operative blood loss (IBL) (117.67 vs. 77.01 mL, P = 0.040) and longer surgical duration (132.98 vs. 107.01 min, P = 0.041). Multivariate logistic analysis revealed that HTG (OR = 0.189, P = 0.006), preoperative serum amylase (OR = 1.042, P < 0.001) and IBL (OR = 1.004, P = 0.022) were independent risk factors for postoperative hyperamylasemia. CONCLUSIONS: A significant percentage of patients developed hyperamylasemia after total knee arthroplasty. Patients with HTG, higher preoperative serum amylase and higher IBL had an increased risk of developing postoperative hyperamylasemia and pancreatitis.

Effects of Somatostatin and Indomethacin Mono or Combination Therapy on High-risk Hyperamylasemia and Post-pancreatitis Endoscopic Retrograde Cholangiopancreatography Patients: A Randomized Study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive technique widely used to diagnose and treat pancreatic and biliary diseases; however, it is linked with imminent hyperamylasemia and post-ERCP pancreatitis (PEP). Somatostatin and indomethacin are the classic recommended drugs used for PEP prevention. OBJECTIVE: To elucidate the effects of somatostatin and indomethacin mono or in combination to prevent hyperamylasemia and PEP in high-risk individuals. METHODS: Altogether 1458 patients who underwent ERCP in our hospital from January 2016 to May 2022 were included in this investigation and categorized into 4 groups based on the treatment regimen: placebo, indomethacin, somatostatin, and indomethacin + somatostatin. The pre operation and post operation (at 6, 12, and 24 h) hospitalization cost, length of stay, the occurrence of hyperamylasemia and PEP, levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-8, and VAS pain score were determined in the 4 groups. In all the groups, VAS and IL-6, TNF-α, and IL-8 levels substantially increased in the pretreatment and decreased sequentially from 6 to 24 h post operation. The individuals in the indomethacin revealed substantially reduced hyperamylasemia, VAS, and levels of IL-6, TNF-α, and IL-8, 6 h post operation, whereas the hospitalization fee, length of stay, PEP incidence, VAS, levels of IL-6, TNF-α, and IL-8, 12 and 24 h post operation were not statistically important in comparison with the individuals who received placebo therapy. The somatostatin and the indomethacin + somatostatin groups indicated markedly alleviated hospitalization fee, length of stay, the occurrence of hyperamylasemia and PEP, VAS, and the levels of IL-6, TNF-α, and IL-8 at 6, 12, and 24 h post operation compared with the placebo cohort. Furthermore, compared with the indomethacin group, the above-determined factors notably reduced at 6, 12, and 24 h post operation in somatostatin and indomethacin + somatostatin groups. It was also observed that the indomethacin + somatostatin group has substantially decreased the occurrence of hyperamylasemia, VAS score, and levels of IL-6, TNF-α, and IL-8, 6 hours post operation, while at 12 and 24 h post operation, the hospitalization fee, length of stay and incidence of PEP, VAS, levels of IL-6, TNF-α, and IL-8 were not statistically important compared with the somatostatin group. It is also worth noting that the side effects of both drugs are rare and mild. RESULTS: For high-risk PEP patients, indomethacin and somatostatin can efficiently alleviate post-operative hyperamylasemia and improve their life standard within 6 hours and 24 hours, respectively. Indomethacin is suitable for individuals who underwent simple, short-duration ERCP with expected mild post-operative abdominal pain, whereas somatostatin is given to patients with complicated, long-duration ERCP and expected severe post-operative abdominal pain. Their combinational therapy produces a synergistic effect and can reduce the incidence of hyperamylasemia, thereby improving patients' quality of life within 6 h and is also effective against individuals who received a more complicated, longer-duration ERCP and were expected to have severer and longer post-operative abdominal pain.

Acute pancreatitis after pancreatoduodenectomy: A prospective study of diffusion-weighted magnetic resonance imaging, serum biomarkers, and clinical features.

BACKGROUND: Postpancreatectomy acute pancreatitis is challenging to diagnose and poorly characterized in its early phases. However, it represents the ideal target for novel therapeutic opportunities possibly gleaned from medical acute pancreatitis. This study aims to systematically investigate early radiologic, biochemical, and clinical features of postpancreatectomy acute pancreatitis. METHODS: This was a prospective observational study of patients undergoing pancreatoduodenectomy from September 2019 to January 2021. Diffusion-weighted magnetic resonance imaging was performed on postoperative day 3. Serum pancreatic amylase and lipase were assessed daily until postoperative day 5. Postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis were defined based on the International Study Group for Pancreatic Surgery definition. RESULTS: A total of 65 patients were enrolled according to the sample size calculation. Patients with postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis had significantly lower apparent diffusion coefficient values at diffusion-weighted magnetic resonance imaging but no macroscopic features consistent with acute pancreatitis. Subsequently, 21 patients (32.3%) underwent computed tomography imaging for clinical worsening, and 6 had radiologic features of acute pancreatitis. All these latter patients had postoperative serum hyperamylasemia and worse outcomes, characterized by local (postoperative pancreatic fistula: 83%) and systemic morbidity (sepsis: 66.7%). The postoperative serum hyperamylasemia incidence was 21.5% (n = 14), and postpancreatectomy acute pancreatitis occurred in 6 patients (9.2%), with 4 grade B (6.1%) and 2 grade C (3%). CONCLUSION: Postpancreatectomy acute pancreatitis is characterized by early serum hyperamylasemia and hyperlipasemia. Although pancreatic changes may appear at postoperative day 3 diffusion-weighted magnetic resonance imaging, its standard use has no impact on postoperative management. Macroscopic radiologic features appear later and correlate with worse clinical scenarios. This paper paves the ground for including postpancreatectomy acute pancreatitis in the spectrum of acute pancreatitis, promoting the transfer of treatment strategies for acute pancreatitis into managing postpancreatectomy acute pancreatitis.

Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)?

PURPOSE: We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study. METHODS: Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP. RESULTS: We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group. CONCLUSION: Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.

Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders. GOALS: Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients. STUDY: In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 µg somatostatin followed by an infusion of 500 µg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11). RESULTS: A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred. CONCLUSIONS: In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.

Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy.

OBJECTIVE: To evaluate whether postoperative serum hyperamylasemia (POH), with drain fluid amylase (DFA) and C-reactive protein (CRP), improves the Fistula Risk Score (FRS) accuracy in assessing the risk of a postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA: The FRS predicts POPF occurrence using intraoperative predictors with good accuracy but intrinsic limits. METHODS: Outcomes of patients who underwent pancreaticoduodenectomies between 2016 and 2021 were evaluated across FRS-risk zones and POH occurrence. POH consists of serum amylase activity greater than the upper limit of normal (52 U/l), persisting within the first 48 hours postoperatively (postoperative day -POD- 1 and 2). RESULTS: Out of 905 pancreaticoduodenectomies, some FRS elements, namely soft pancreatic texture (odds ratio (OR) 11.6), pancreatic duct diameter (OR 0.80), high-risk pathologic diagnosis (OR 1.54), but not higher blood loss (OR 0.99), were associated with POH. POH was an independent predictor of POPF, which occurred in 46.8% of POH cases ( P <0.001). Once POH occurs, POPF incidence rises from 3.8% to 42.9%, 22.9% to 41.7%, and 48.9% to 59.2% in patients intraoperatively classified at low, moderate and high FRS risk, respectively. The predictive ability of multivariable models adding POD 1 drain fluid amylase, POD 1-2 POH and POD 3 C-reactive protein to the FRS showed progressively and significantly higher accuracy (AUC FRS=0.82, AUC FRS-DFA=0.85, AUC FRS-DFA-POH=0.87, AUC FRS-DFA-POH-CRP=0.90, DeLong always P <0.05). CONCLUSIONS: POPF risk assessment should follow a dynamic process. The stepwise retrieval of early, postoperative biological markers improves clinical risk stratification by increasing the granularity of POPF risk estimates and affords a possible therapeutic window before the actual morbidity of POPF occurs.

Efficacy and safety of three endoscopic techniques for small common bile duct stones (≤ 10 mm): a multicenter, retrospective, cohort study with propensity score matching.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a major option for common bile duct (CBD) stones. Endoscopic sphincterotomy (EST), endoscopic papillary balloon dilatation (EPBD), and endoscopic sphincterotomy plus balloon dilatation (ESBD) are procedures for opening the bile duct orifice to extract CBD stones during ERCP. The optimal method for extracting small CBD stones (≤ 10 mm) has not yet been proposed. We aimed to compare the efficacy and safety of these three techniques in extracting small CBD stones. METHODS: ERCP for small stones was performed between January 2009 and November 2020 at three tertiary care centers. The incidence of post-ERCP pancreatitis (PEP) was compared among EST, EPBD, and ESBD groups. First and overall success rates of stone extraction, utilization rate of mechanical lithotripsy, and other ERCP complications such as bleeding, perforation, infection, and hyperamylasemia were compared. RESULTS: A total of 2181 patients were enrolled between January 2009 and November 2020. The proportion of young patients (≤ 45 years) in EPBD group was more than those in EST and ESBD group. Stone size in ESBD group was much larger than EST and EPBD group. After propensity score matching, the success rates of first and overall stone extraction in the three groups were high, and the rates of mechanical lithotripsy were low, with no significant difference. The PEP incidences showed no differences among the three groups. The incidence of bleeding complication in EST group was higher than that in EPBD group. No significant differences were observed in other complications between EPBD group and ESBD group. ESBD group had higher incidence of overall, infection, and hyperamylasemia complications than EST group. CONCLUSION: EPBD is equivalent to ESBD in stone removal efficiency and complication rate, but brings a lower bleeding risk than EST. Therefore, we recommend EPBD as the first choice for small CBD stones.

Gastroduodenal artery pseudoaneurysm presenting with hyperamylasemia.

We present the case of a 75-year-old male admitted due to severe epigastric pain. His medical history was remarkable for chronic alcohol abuse, diabetes mellitus type 2, arterial hypertension, dyslipidemia. At admission he was hemodynamically stable. The initial workup showed elevated amylase, and the abdominal ultrasound excluded gallstone disease, so the diagnosis of acute pancreatitis was assumed. Despite appropriate fluid therapy, the patient developed hemodynamic instability. No signs of GIB were detected. An urgent laboratory workup revealed a new onset anemia and liver tests, including hyperbilirrubinemia. He underwent an urgent abdominal computed tomography with contrast, which showed a bleeding gastroduodenal artery (pseudoaneurysm and a hematoma adjacent to the second part of the duodenum. The patient underwent coil embolization achieving hemostasis without complications. GAD (pseudo)aneurysm is rare, accounting for 1.5% of all visceral artery aneurysms. Our patient presented with elevated pancreatic and liver enzymes, a more unique and challenging presentation since another more common differential diagnosis should be considered. The aneurysm can cause extrinsic common bile duct and main pancreatic duct pressure, which could explain the raised liver tests. Gastroenterologists should be aware of this rare and life-threatening entity, especially among patients presenting with common findings such as elevated amylase, jaundice, or altered liver tests. Hemodynamic instability is the main clue unmasking this diagnosis.

The Incidence of Acute Pancreatitis After Device Assisted Enteroscopy: a Systematic Review and Meta-analysis.

Background: The diagnosis of small bowel diseases is challenging and device assisted enteroscopy (DAE) is a technique for visualizing the entire small bowel. DAE is considered as a safe procedure and the reported rate of adverse events associated with DAE in the literature is low. Objective: The present study tried to investigate the actual incidence of AP after DAE with a systematic review and meta-analysis of available relevant studies. Methods: Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following data were extracted from all eligible studies: author, country, publication year, publication type, study design, type of DAE used, route of DAE, number of patients with AP after DAE, and number of patients with hyperamylasemia after DAE.A random-effects model with RStudio version 4.2.0 was performed in all analyses. Heterogeneity was assessed using the I2 test. The risk of bias was assessed by the Newcastle-Ottawa Scale criteria and the publication bias was assessed by the Egger test. Results: Twenty three studies involving a total of 11145 patients were included in the analysis. The overall, pooled AP rate after DAE was 1% (95% CI:0-1%). There was significant heterogeneity among the studies (I2 = 65%; P < 0.01).The pooled AP rate was 1% (95% CI:0-2 %)in peroral route group. The pooled proportion of patients having hyperamylasemia after DAE was 29% (95% CI: 16-46%).Among the patients who had hyperamylasemia AP were identified in 2% (95% CI: 0-6%) of patients. Conclusion: The incidence of AP after DAE is about 1%. Hyperamylasemia is a common change in the patients undergoing DAE and only 2% of the patients with hyperamylasemia present with AP.

ß-hydroxybutyrate inhibits ferroptosis-mediated pancreatic damage in acute liver failure through the increase of H3K9bhb.

Acute pancreatitis and hyperamylasemia are often seen in patients with acute liver failure (ALF). However, the underlying mechanisms remain elusive. This study describes pancreatic tissue damage and exocrine dysfunction in a mouse model of major-liver-resection-induced ALF. The analysis of 1,264 clinical cases of liver failure (LF) showed that the incidence of hyperamylasemia and hyperlipasemia in patients with LF is 5.5% and 20%, respectively. Metabolomic studies indicate that glutathione (GSH)-deficiency-caused ferroptosis contributes to pancreatic damage in mouse ALF. ß-hydroxybutyrate (ß-HB) is the only metabolite downregulated in the liver, serum, and pancreas. Our data suggest that ß-HB protects pancreatic cells and tissues from GSH-deficiency-caused ferroptosis. ß-HB administration in ALF mice restores the expression of ferroptosis-suppressor genes through histone H3 lysine 9 ß-hydroxybutyrylation (H3K9bhb)-mediated chromatin opening. Our findings highlight ß-HB as an endogenous metabolite regulating ferroptosis in the pancreas and extend our understanding of the pathophysiology of ALF-induced pancreatitis.