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1.
JAMA ; 323(3): 237-247, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961419

RESUMO

Importance: For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. Objective: To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. Design, Setting, and Participants: The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. Interventions: There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. Main Outcomes and Measures: The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. Results: Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. Conclusions and Relevance: Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. Trial Registration: ISRCTN Identifier: ISRCTN45877994.


Assuntos
Cálculos/terapia , Drenagem , Endoscopia , Litotripsia , Manejo da Dor/métodos , Ductos Pancreáticos/cirurgia , Pancreatite Crônica/terapia , Adulto , Analgésicos Opioides/uso terapêutico , Área Sob a Curva , Cálculos/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Medição da Dor , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia
3.
Int J Cancer ; 146(3): 610-616, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30861115

RESUMO

Statins (HMG-CoA reductase inhibitors) have antiinflammatory and possibly anticancer properties. We hypothesized that statin use is associated with lower risk of pancreatic cancer in patients with chronic pancreatitis. This nationwide population-based cohort study included all Danish patients diagnosed with incident chronic pancreatitis from 1 January 1996 to 31 December 2012. We used the Danish National Prescription Registry to ascertain information on statin prescriptions for members of the study population before and after their pancreatitis diagnosis. We computed crude incidence rates, incidence rate ratios (IRRs) and adjusted hazard ratios (HRs) with associated 95% confidence intervals (CIs) for pancreatic cancer, comparing statin users with nonusers. We computed HRs using Cox proportional hazards regression with statins treated as a time-varying exposure lagged by 1 year, adjusting for age, sex, socioeconomic status and individual comorbidities. The study included 8,311 chronic pancreatitis patients with a median age of 54 years. We observed 153 pancreatic cancers during 60,365 person-years of follow-up. The unadjusted IRR comparing statin users with nonusers was 1.00 (95% CI: 0.60-1.60). Adjustment for potential confounders only had a small impact on the estimate (adjusted HR: 0.90; 95% CI: 0.56-1.44). Our findings suggest that statin use is not associated with pancreatic cancer risk in patients with chronic pancreatitis.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Neoplasias Pancreáticas/epidemiologia , Pancreatite Crônica/complicações , Adulto , Idoso , Comorbidade , Dinamarca , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/etiologia , Neoplasias Pancreáticas/prevenção & controle , Pancreatite Crônica/epidemiologia , Sistema de Registros/estatística & dados numéricos , Fatores de Risco
4.
Khirurgiia (Mosk) ; (12): 137-140, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31825355

RESUMO

Diagnosis of chronic pancreatitis is not associated with any difficulties in patients with CT signs of pancreatic duct stones as a rule. However, 'classical' picture of chronic pancreatitis is usually absent in case of predominant protein matrix in the calculi. Two cases of X-ray-negative pancreatic dust stones in patients with protein stones of the pancreatic duct are reported.


Assuntos
Cálculos/diagnóstico por imagem , Ductos Pancreáticos/diagnóstico por imagem , Pancreatite Crônica/diagnóstico por imagem , Humanos , Pancreatite Crônica/complicações , Raios X
5.
Medicine (Baltimore) ; 98(48): e17984, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770208

RESUMO

Pediatric patients suffer from chronic pancreatitis (CP), especially those with diabetes mellitus (DM). This study aimed to identify the incidence of and risk factors for DM in pediatric CP.CP patients admitted to our center from January 2000 to December 2013 were assigned to the pediatric (<18 years old) and adult group according to their age at onset of CP. Cumulative rates of DM and risk factors for both groups were calculated and identified.The median follow-up duration for the whole cohort was 7.6 years. In these 2153 patients, 13.5% of them were pediatrics. The mean age at the onset and the diagnosis of CP in pediatrics were 11.622 and 19.727, respectively. DM was detected in 13.1% patients and 31.0% patients in the pediatric group and adult group, respectively. Age at the onset of CP, smoking history, body mass index (BMI), and etiology of CP were identified risk factors for DM in pediatrics.DM was detected in 13.1% pediatric patients. Age at the onset of CP, smoking history, BMI, and etiology of CP were identified risk factors for the development of DM in pediatric CP patients. The high-risk populations were suggested to be monitored frequently. They could also benefit from a lifestyle modification.


Assuntos
Diabetes Mellitus/epidemiologia , Diabetes Mellitus/etiologia , Pancreatite Crônica/complicações , Adolescente , Criança , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
6.
Khirurgiia (Mosk) ; (11): 42-51, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31714529

RESUMO

OBJECTIVE: To evaluate quality of life in long-term postoperative period in patients with chronic pancreatitis. MATERIAL AND METHODS: There were 31 (21 males and 10 females) patients with complicated forms of chronic pancreatitis who underwent surgery in 2015-2017. Mean age was 49 (44; 53) years, body mass index - 22.4 (20.4; 24) kg/m2. HR-QOL was determined using the questionnaires SF-36, QLQ EORTS C30, VAS. Postoperative control was made no earlier than 6 months after surgery. Median follow-up 11.5 months. The data were analyzed using non-parametric methods. Quantitative data are shown as median with interquartile range. Differences between quantitative values were determined using the Mann-Whitney test. RESULTS: Physical status value (SF-36) before surgery was 30.5 (24.8; 37.5), after surgery - 50.8 (46.7; 56.5). Mental status value was 30.2 (26.7; 36.4) prior to surgery and 53.8 (48.7; 57.3) after operation. Improvement of QoL (QLQ C30) from 29.17 (0; 50.0) before surgery to 75.0 (54.2; 83.3) after operation was observed. VAS-score of pain severity was 8 (8; 10) prior to surgery and 3 (2; 5) after surgery. Differences were significant (p<0.05). CONCLUSION: Surgical treatment of complicated chronic pancreatitis significantly reduces pain and improves HR-QoL. However, recurrent symptoms of chronic pancreatitis in long-term period cannot be excluded due to short follow-up period (median less than one year). The further investigation is needed.


Assuntos
Pancreatite Crônica/cirurgia , Qualidade de Vida , Dor Abdominal/etiologia , Dor Abdominal/cirurgia , Adulto , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatectomia , Pancreatite Crônica/complicações , Resultado do Tratamento
7.
World J Gastroenterol ; 25(40): 6077-6093, 2019 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-31686764

RESUMO

BACKGROUND: Central sensitization plays a pivotal role in the maintenance of chronic pain induced by chronic pancreatitis (CP). We hypothesized that the nucleus tractus solitarius (NTS), a primary central site that integrates pancreatic afferents apart from the thoracic spinal dorsal horn, plays a key role in the pathogenesis of visceral hypersensitivity in a rat model of CP. AIM: To investigate the role of the NTS in the visceral hypersensitivity induced by chronic pancreatitis. METHODS: CP was induced by the intraductal injection of trinitrobenzene sulfonic acid (TNBS) in rats. Pancreatic hyperalgesia was assessed by referred somatic pain via von Frey filament assay. Neural activation of the NTS was indicated by immunohistochemical staining for Fos. Basic synaptic transmission within the NTS was assessed by electrophysiological recordings. Expression of vesicular glutamate transporters (VGluTs), N-methyl-D-aspartate receptor subtype 2B (NR2B), and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor subtype 1 (GluR1) was analyzed by immunoblotting. Membrane insertion of NR2B and GluR1 was evaluated by electron microscopy. The regulatory role of the NTS in visceral hypersensitivity was detected via pharmacological approach and chemogenetics in CP rats. RESULTS: TNBS treatment significantly increased the number of Fos-expressing neurons within the caudal NTS. The excitatory synaptic transmission was substantially potentiated within the caudal NTS in CP rats (frequency: 5.87 ± 1.12 Hz in CP rats vs 2.55 ± 0.44 Hz in sham rats, P < 0.01; amplitude: 19.60 ± 1.39 pA in CP rats vs 14.71 ± 1.07 pA in sham rats; P < 0.01). CP rats showed upregulated expression of VGluT2, and increased phosphorylation and postsynaptic trafficking of NR2B and GluR1 within the caudal NTS. Blocking excitatory synaptic transmission via the AMPAR antagonist CNQX and the NMDAR antagonist AP-5 microinjection reversed visceral hypersensitivity in CP rats (abdominal withdraw threshold: 7.00 ± 1.02 g in CNQX group, 8.00 ± 0.81 g in AP-5 group and 1.10 ± 0.27 g in saline group, P < 0.001). Inhibiting the excitability of NTS neurons via chemogenetics also significantly attenuated pancreatic hyperalgesia (abdominal withdraw threshold: 13.67 ± 2.55 g in Gi group, 2.00 ± 1.37 g in Gq group, and 2.36 ± 0.67 g in mCherry group, P < 0.01). CONCLUSION: Our findings suggest that enhanced excitatory transmission within the caudal NTS contributes to pancreatic pain and emphasize the NTS as a pivotal hub for the processing of pancreatic afferents, which provide novel insights into the central sensitization of painful CP.


Assuntos
Dor Crônica/fisiopatologia , Sistema Nervoso Entérico/fisiopatologia , Hiperalgesia/fisiopatologia , Pancreatite Crônica/complicações , Núcleo Solitário/fisiopatologia , Vias Aferentes/fisiopatologia , Animais , Dor Crônica/etiologia , Modelos Animais de Doenças , Humanos , Hiperalgesia/etiologia , Masculino , Neurônios/fisiologia , Pâncreas/inervação , Pancreatite Crônica/induzido quimicamente , Técnicas de Patch-Clamp , Ratos , Ratos Sprague-Dawley , Núcleo Solitário/citologia , Técnicas Estereotáxicas , Transmissão Sináptica/fisiologia , Ácido Trinitrobenzenossulfônico/toxicidade
9.
EBioMedicine ; 46: 431-443, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31401195

RESUMO

BACKGROUND: Pain due to pancreatic cancer/PCa or chronic pancreatitis/CP, is notoriously resistant to the strongest pain medications. Here, we aimed at deciphering the specific molecular mediators of pain at surgical-stage pancreatic disease and to discover novel translational targets. METHODS: We performed a systematic, quantitative analysis of the neurotransmitter/neuroenzmye profile within intrapancreatic nerves of CP and PCa patients. Ex vivo neuronal cultures treated with human pancreatic extracts, conditional genetically engineered knockout mouse models of PCa and CP, and the cerulein-induced CP model were employed to explore the therapeutic potential of the identified targets. FINDINGS: We identified a unique enrichment of neuronal nitric-oxide-synthase (nNOS) in the pancreatic nerves of CP patients with increasing pain severity. Employment of ex vivo neuronal cultures treated with pancreatic tissue extracts of CP patients, and brain-derived-neurotrophic-factor-deficient (BDNF+/-) mice revealed neuronal enrichment of nNOS to be a consequence of BDNF loss in the progressively destroyed pancreatic tissue. Mechanistically, nNOS upregulation in sensory neurons was induced by tryptase secreted from perineural mast cells. In a head-to-head comparison of several genetically induced, painless mouse models of PCa (KPC, KC mice) or CP (Ptf1a-Cre;Atg5fl/fl) against the hypersecretion/cerulein-induced, painful CP mouse model, we show that a similar nNOS enrichment is present in the painful cerulein-CP model, but absent in painless genetic models. Consequently, mice afflicted with painful cerulein-induced CP could be significantly relieved upon treatment with the specific nNOS inhibitor NPLA. INTERPRETATION: We propose nNOS inhibition as a novel strategy to treat the unbearable pain in CP. FUND: Deutsche Forschungsgemeinschaft/DFG (DE2428/3-1 and 3-2).


Assuntos
Neuralgia/diagnóstico , Neuralgia/etiologia , Óxido Nítrico Sintase Tipo I/metabolismo , Pancreatite Crônica/complicações , Pancreatite Crônica/metabolismo , Adulto , Animais , Biomarcadores , Fator Neurotrófico Derivado do Encéfalo/metabolismo , Modelos Animais de Doenças , Inibidores Enzimáticos/farmacologia , Inibidores Enzimáticos/uso terapêutico , Feminino , Humanos , Imuno-Histoquímica , Masculino , Camundongos , Camundongos Transgênicos , Pessoa de Meia-Idade , Terapia de Alvo Molecular , Neuralgia/tratamento farmacológico , Óxido Nítrico Sintase Tipo I/antagonistas & inibidores , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/cirurgia , Pancreatite Crônica/cirurgia
10.
Medicine (Baltimore) ; 98(27): e15856, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31277088

RESUMO

RATIONALE: Duodenal obstruction (DO) sometimes induces the groove pancreatitis. However, the case of DO due to chronic pancreatitis in pancreas tail (CPPT) is extremely rare. Therefore, the managements of DO caused by CPPT have not been established yet. PATIENT CONCERNS: A 68-year-old man, who was under the treatment of chronic pancreatitis, presented to our hospital with nausea and abdominal pain. He was diagnosed as DO caused by CPPT. The Conservative treatment, including the nasogastric aspiration and intravenous infusion under the absence of food, was performed. The drainage fluid from naso-gastric tube had been more than 2000 ml per a day although continuing treatment for 14 days. Hence, we decided that the conservative therapy was failed and the surgical intervention was required. DIAGNOSIS: Computed tomography showed gastroduodenal expansion due to stenosis at the horizontal portion of the duodenum with increasing pancreatic pseudocyst. The contrast radiography of the duodenum showed severe stenosis around Treitz ligament. His pre-surgical diagnosis was DO due to CPPT through exclusion of other etiologies for DO such as annular pancreas, SMA syndrome, duodenal diaphragm and Crohn disease. INTERVENTION: Spleen preserving distal pancreatectomy (Warshaw operation) was performed with gastrojejunostomy. During surgery, marked redness and thickness of the mesenteric serosa around Treiz ligament were observed. His surgical findings were supported our preoperative prediction. OUTCOMES: The patient was successfully treated and discharged uneventfully after postoperative day 14. At the 9 months follow-up visit, the patient is still doing well without any symptoms. CONCLUSION: Combination of gastrojejunostomy and Warshaw operation is one of the ideal surgical procedures for patients of DO due to CPPT.


Assuntos
Obstrução Duodenal/cirurgia , Derivação Gástrica/métodos , Pancreatectomia/métodos , Pseudocisto Pancreático/cirurgia , Pancreatite Crônica/complicações , Idoso , Obstrução Duodenal/etiologia , Humanos , Masculino , Tratamentos com Preservação do Órgão , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/etiologia , Tomografia Computadorizada por Raios X
11.
Chirurgia (Bucur) ; 114(3): 369-375, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31264575

RESUMO

Background: Chronic pancreatitis is a progressive loss of exocrine and endocrine pancreatic function. Surgical procedures are required in cases of intractable pain, biliary obstruction or intestinal obstruction, complications from pseudocysts, or pancreatic fistulae. Objective: To assess the outcomes after surgical management of chronic pancreatitis, in a long-term follow-up. Methods: Patients that underwent surgical management of chronic pancreatitis,from 2006 to 2017, were reviewed. Demographics and complications of the procedures were recorded. Visual analogue pain scale was used for pain control evaluation. The 12-Item Short-Form Health Survey questionnaire was used for quality of life assessment. Results: Sixty-five patients were included in the study. Mean follow-up was 60.26 months. Twenty patients underwent lateral pancreatojejunostomy, 22 to Roux-en-Y cystojejunostomy, 7 to transgastric cyst-gastrostomy,1 to Frey procedure, 4 to hepaticojejunostomy, 1 to Frey procedure and hepaticojejunostomy, 1 to lateral pancreatojejunostomy and cyst-gastrostomy, 7 to lateral pancreatojejunostomy and hepaticojejunostomy and 2 to cystojejunostomy and hepaticojejunostomy. No cases of perioperative deaths were recorded. A Pancreatic fistula was found in 5 cases, and all of them followed non-operative management. Of the 65 patients included in the study, 39 answered the questionnaires. Mean scores on SF-12, physical and mental scales were respectively 42.72 +- 10.76 and 49.84 +- 11.75. Conclusion: Surgical management of chronic pancreatitis is safe, with low mortality and morbidity rates. These procedures are effective in assuaging pain and in providing good quality of life.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Pâncreas/cirurgia , Pancreatite Crônica/cirurgia , Seguimentos , Humanos , Pancreatite Crônica/complicações , Qualidade de Vida , Resultado do Tratamento
12.
BMC Surg ; 19(1): 83, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31286902

RESUMO

BACKGROUND: Chronic pancreatitis (CP) is considered to be a risk factor for pancreatic cancer. A retrospective study was conducted to evaluate the incidence of pancreatic cancer after surgery for CP and to determine the risk factors. METHODS: The patients who underwent surgery for histologically documented CP between January 2009 and December 2017 were reviewed. The baseline characteristics, operative data, postoperative complications, and follow-up information were analysed. We calculated standardized incidence ratio on the base of the incidence of pancreatic cancer in the standard population in China. The risk factor for pancreatic cancer was assessed using Cox regression. RESULTS: Among 650 patients, pancreatic cancer was detected in 12 patients (1.8%) after a median follow-up of 4.4 years. The standardized incidence ratio of pancreatic cancer was 68.12 (95% CI, 35.20-118.99). Two independent risk factors for the development of pancreatic cancer in patients with chronic pancreatitis after surgery were identified: time interval to surgery [HR 1.005, 95% CI (1.002-1.008), P = 0.002] and de novo endocrine insufficiency [HR 10.672, 95% CI (2.567-44.372), P = 0.001]. CONCLUSIONS: Patients who require surgery for CP are at a very high risk of developing pancreatic cancer. Early surgical intervention plays a protective role in the development of pancreatic cancer from CP. A high index of suspicion for pancreatic cancer should be maintained in CP patients with de novo postoperative diabetes after surgery.


Assuntos
Neoplasias Pancreáticas/epidemiologia , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia , Adulto , China/epidemiologia , Insuficiência Pancreática Exócrina/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pancreatectomia , Neoplasias Pancreáticas/etiologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/prevenção & controle , Pancreaticojejunostomia , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento
14.
Int J Med Sci ; 16(4): 583-592, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31171910

RESUMO

Aims: Carcinoembryonic antigen-related cell adhesion molecules (CEACAMs) are members of the glycosylphosphatidylinositol (GPI)-linked immunoglobulin (Ig) superfamily and take part in regulation of cell adhesion, tumor suppression and angiogenesis. Overexpression of CEACAM 1, 5 and 6 is widely described in several gastrointestinal epithelial tumors. The aim of study was to evaluate the expression of CEACAM 1, CEACAM 5 and CEACAM 6 in the most common precursor lesions of pancreatic ductal adenocarcinoma -pancreatic intraepithelial neoplasia (PanIN). Methods and results: The study group consisted of 32 patients treated for chronic pancreatitis and 38 patients with pancreatic ductal adenocarcinoma who also had pancreatic intraepithelial neoplasia. The expression of CEACAM was performed by immunohistochemical method and evaluated using 3-point scale: 0 - lack of positive reaction in pancreatic intraepithelial neoplasia, 1 (weak and moderate) - reaction present in 1-30% epithelial cells in PanIN and 2 (strong) - reaction present in >30% epithelial cells in PanIN. Expression of CEACAM 1, 5 and 6 increased with increasing degree of advancement of PanIN. Differences in expression of CEACAM 1, 5 and 6 between normal pancreatic ducts and different degrees of PanIN were statistically significant (p<0.001). We observed relationship between CEACAM1 expression and localization of PanIN in different parts of the pancreas. Conclusions: CEACAM 1, CEACAM 5 and CEACAM 6 expression appears to be an early event in pancreatic carcinogenesis. Moreover, expression of CEACAM 1, 5 and 6 may represent a useful biomarker that may aid in the identification of precancerous lesions in the pancreas.


Assuntos
Adenocarcinoma/genética , Antígenos CD/genética , Antígeno Carcinoembrionário/genética , Carcinoma Ductal Pancreático/genética , Moléculas de Adesão Celular/genética , Adenocarcinoma/complicações , Adenocarcinoma/patologia , Idoso , Biomarcadores Tumorais/genética , Carcinogênese/genética , Carcinoma in Situ/complicações , Carcinoma in Situ/genética , Carcinoma in Situ/patologia , Carcinoma Ductal Pancreático/patologia , Feminino , Proteínas Ligadas por GPI/genética , Regulação Neoplásica da Expressão Gênica/genética , Humanos , Masculino , Pessoa de Meia-Idade , Pâncreas/metabolismo , Pâncreas/patologia , Pancreatite Crônica/complicações , Pancreatite Crônica/genética , Pancreatite Crônica/patologia
15.
Surgery ; 166(3): 263-270, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31085044

RESUMO

BACKGROUND: The rationale for total pancreatectomy in painful, treatment refractory, chronic pancreatitis is pain control. Concomitant islet cell autotransplantation can prevent the loss of islet cell function. This study aimed to systematically examine the impact of total pancreatectomy with islet cell autotransplantation on pain and quality of life. METHODS: This meta-analysis was conducted according the Meta-analyses of Observational Studies in Epidemiology guideline. The Cochrane Library, PubMed, and Embase were searched for the following terms (1990 through April 2018): total pancreatectomy and chronic pancreatitis. Studies were included when addressing total pancreatectomy with islet cell autotransplantation for chronic pancreatitis in adults. Studies that reported no data on pain, endocrine function, or quality of life were excluded. Quality was assessed using the Newcastle-Ottawa scale for evaluation of all studies. RESULTS: We included 15 observational studies evaluating 1,255 patients, of whom 28% had had endoscopic and 23% operative therapy. One year after total pancreatectomy with islet cell autotransplantation, the opioid-free rate had improved from between 0% and 15% to 63% (95% CI 46-77), and the insulin-free rate had decreased from between 89.5% and 100% to 30% (95% CI 20-43). An alcoholic etiology was associated with a lesser insulin-free rate after total pancreatectomy with islet cell autotransplantation. Quality of life improved statistically after total pancreatectomy with islet cell autotransplantation. Publication bias was present for both opioid and insulin outcomes. CONCLUSION: In selected patients with painful, treatment refractory, chronic pancreatitis, evidence shows that total pancreatectomy with islet cell autotransplantation is effective for pain control in almost two-thirds of patients, whereas the insulin-free rate is relatively low.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Insulina/administração & dosagem , Transplante das Ilhotas Pancreáticas , Pancreatectomia , Pancreatite Crônica/complicações , Pancreatite Crônica/terapia , Feminino , Humanos , Transplante das Ilhotas Pancreáticas/efeitos adversos , Transplante das Ilhotas Pancreáticas/métodos , Masculino , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Pancreatite Crônica/epidemiologia , Prognóstico , Transplante Autólogo , Resultado do Tratamento
18.
Curr Gastroenterol Rep ; 21(7): 29, 2019 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-31098767

RESUMO

PURPOSE OF REVIEW: Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage. RECENT FINDINGS: Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.


Assuntos
Colestase/cirurgia , Stents , Colestase/etiologia , Constrição Patológica , Humanos , Transplante de Fígado , Pancreatite Crônica/complicações , Plásticos , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Stents Metálicos Autoexpansíveis
19.
Pancreas ; 48(5): 690-697, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31091217

RESUMO

OBJECTIVES: Pancreatic duct stones contribute to pain in patients with chronic pancreatitis, and per-oral pancreatoscopy (POP) allows visualization, fragmentation, and removal of these stones. This study compared the safety and efficacy of endoscopic retrograde pancreatography (ERP) with and without POP. METHODS: This single-center retrospective review compared ERP with and without POP for treatment of main-duct pancreatic duct stones. The primary outcome was technical success, defined as partial or complete stone removal, which was compared between the 2 groups. RESULTS: In all, 223 patients underwent 549 ERPs with a technical success rate of 92.4% and complete stone clearance rate of 74.9%. Patients undergoing ERP with POP (n = 94) had higher technical success than patients undergoing ERP without POP (n = 129, 98.9% vs 87.6%, P < 0.001), but required more ERPs (3.1 vs 1.9, P = 0.02). Endoscopic retrograde pancreatography with POP was associated with larger stone size (8.9 vs 6.1 mm, P = 0.001), more stones per case (5+ stones: 33.8% vs 21.1%, P = 0.002), and more impacted stones (48.8% vs 10.3%, P < 0.001). CONCLUSIONS: Per-oral pancreatoscopy-guided lithotripsy permits effective stone removal in cases not amenable to standard ERP techniques, including those with larger or more numerous stones.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Endoscopia Gastrointestinal/métodos , Litotripsia/métodos , Pancreatopatias/terapia , Ductos Pancreáticos/patologia , Cálculos Urinários/terapia , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Adulto , Idoso , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Feminino , Humanos , Litotripsia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Dor/complicações , Dor/prevenção & controle , Pancreatite Crônica/complicações , Pancreatite Crônica/terapia , Estudos Retrospectivos , Resultado do Tratamento , Cálculos Urinários/complicações
20.
Pancreas ; 48(5): 726-733, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31091222

RESUMO

OBJECTIVES: The pancreatic burnout hypothesis postulated an increasing absence of pain with simultaneous functional insufficiency in advanced stages of chronic pancreatitis (CP). However, the underlying data remain scarce and contradictory. We aimed to analyze, first, the frequency of a pancreatic burnout in CP, and, second, its association with etiological risk factors. METHODS: We performed a multicenter, retrospective, cross-sectional study with 741 patients with CP categorized according to the M-ANNHEIM classification. Pancreatic burnout was defined by different combinations of exocrine or endocrine insufficiency with partial or complete absence of abdominal pain. RESULTS: The frequency of a pancreatic burnout increased with prolonged disease duration and was observed in a maximum of 38% of patients after 20 years. Development of a pancreatic burnout was significantly associated with alcohol consumption (P < 0.05, Mann-Whitney U test), but not with other etiological risk factors. After a disease duration of more than 10 years, the likelihood of a burnout was 8 times higher in alcoholic CP than in nonalcoholic CP (95% confidence interval, 1.5-42.0; P = 0.015, logistic regression analysis). CONCLUSIONS: A pancreatic burnout does not regularly occur in CP. Increased burnout rates are only observed in patients with alcoholic CP.


Assuntos
Insuficiência Pancreática Exócrina/fisiopatologia , Pâncreas/fisiopatologia , Pancreatite Alcoólica/fisiopatologia , Pancreatite Crônica/fisiopatologia , Dor Abdominal/etiologia , Dor Abdominal/fisiopatologia , Adulto , Estudos Transversais , Insuficiência Pancreática Exócrina/etiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pancreatite Alcoólica/complicações , Pancreatite Crônica/complicações , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
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