Alcoholic vs. non-alcoholic chronic pancreatitis: surgeons' perspective from a tertiary centre in india / Perspectiva dos cirurgiões sobre pancreatite crônica alcoólica vs. não-alcoólica de um centro terciário na índia

ABSTRACT Background: Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. Aim: To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. Method: All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. Results: From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. Conclusion: Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

RESUMO Racional: Embora o álcool seja a causa mais comum de pancreatite crônica em todo o mundo, a forma idiopática é prevalente na Índia. A história natural e a progressão da doença são diferentes entre esses dois grupos. Há escassez de dados comparando o resultado cirúrgico e a qualidade de vida entre eles. Objetivo: Avaliar as características clínicas, o resultado cirúrgico e a qualidade de vida entre esses dois grupos de pacientes. Método: Todos os pacientes com pancreatite crônica operados foram revisados ​​retrospectivamente. Resultados: Do total de 98 pacientes, 42 eram alcoolistas. O número de homens e a idade média no momento da operação foi significativamente maior nos alcoolistas. Tabagismo, taxa de internação pré-operatória e prevalência de complicações locais como massa inflamatória da cabeça do pâncreas, estenose biliar e hipertensão portal do lado esquerdo foram distintamente mais comuns no grupo de alcoolistas e o procedimento de Frey foi exigido mais comumente neste grupo. A média de internação pós-operatória e a taxa geral de complicações pós-operatórias foram comparáveis ​​entre os dois grupos. Ao longo de acompanhamento médio de 18 meses houve melhora significativa na qualidade de vida e pontuação de dor em ambos os grupos. A melhora no escore de funcionamento físico foi significativamente maior no grupo de alcoolistas, mas a necessidade de medicamentos analgésicos foi significativamente maior nos alcoolistas. No entanto, a perda de apetite foi mais percebida pelo grupo não alcoólico. Conclusão: A pancreatite crônica alcoólica se apresenta com mais complicações locais associadas à pancreatite crônica. O procedimento de Frey é operação segura e bem aceita neste grupo. Embora exigissem mais necessidade de analgésicos no acompanhamento em curto prazo, outros aspectos da qualidade de vida são semelhantes ao grupo não alcoólico.

Pseudoaneurisma de aorta abdominal como complicação de pancreatite crônica: relato de caso / Abdominal aortic pseudoaneurysm as a complication of chronic pancreatitis: case report

A pancreatite crônica é uma enfermidade associada a diversas complicações vasculares, como pseudocisto hemorrágico, trombose do sistema venoso portal e formações varicosas e pseudoaneurismáticas. O pseudoaneurisma de aorta abdominal secundário à pancreatite crônica é uma complicação rara, de difícil suspeição clínica, que requer tratamento complexo. A fisiopatologia dessa condição envolve a corrosão enzimática tecidual após a liberação e ativação de enzimas exócrinas proteolíticas das células acinares do pâncreas. O presente estudo relata o caso de um paciente de 52 anos, etilista crônico, internado com dor abdominal difusa, cuja propedêutica revelou se tratar de um pseudoaneurisma em aorta infrarrenal. Optou-se pelo tratamento cirúrgico convencional, levando-se em consideração a idade, as condições clínicas do paciente e a disponibilidade de endopróteses compatíveis com o diâmetro da aorta

Chronic pancreatitis can be complicated by several vascular disorders, such as bleeding pseudocysts, thrombosis of the venous portal system, varicosities, and pseudoaneurysms. Pseudoaneurysm of the abdominal aorta secondary to chronic pancreatitis is a rare complication. It is a challenging clinical situation, demanding a high degree of clinical suspicion, and requires complex therapeutic procedures. The pathophysiology of this condition involves interstitial liberation and activation of enzymes from the exocrine pancreatic glands and subsequent digestion of the surrounding tissues. In the present case report, we describe a 52-year-old patient complaining of diffuse abdominal pains. Clinical investigation revealed chronic alcoholism and imaging examinations showed a pseudoaneurysm of the infrarenal aorta. We decided to perform conventional surgical treatment after considering the patient's age and clinical status and the endoprostheses available at our hospital with diameters compatible with the patient's aorta

Pancreatitis, genes y autotrasplante de islotes: actualizaciones y nuevos horizontes / Pancreatitis, genes and islet cells auto transplant: updates and new horizons

La pancreatitis es una inflamación del páncreas que puede progresar de una presentación aguda, a una presentación aguda recurrente y eventualmente a pancreatitis crónica, caracterizada por cambios morfológicos y formación de cicatriz los cuales son irreversibles. La entidad conocida como pancreatitis hereditaria ha sido reconocida en la literatura por años y ciertamente el hallazgo del gen PRSS1 en 1996 marcó el inicio de una era de descubrimientos genéticos asociados a dicha enfermedad. Desde entonces, múltiples genes han sido descritos como causa de pancreatitis hereditaria o modificadores de la enfermedad, entre los que se destacan el PRSS1, SPINK1, CFTR, CASR, CTRC, CLDN2 y CPA1 entre otros. La selección de pacientes a la que se le va a practicar los estudios genéticos correspondientes debe ser guiada por las recomendaciones de los expertos y debe cumplir con los criterios correspondientes. El tratamiento, una vez hecho el diagnóstico, debe ser adaptado en base a las necesidades particulares de cada paciente. Ciertamente, el advenimiento de la pancreatectomía total con auto trasplante, cuyo principal objetivo es aliviar el dolor ocasionado por la pancreatitis crónica a la vez que se reduce la severidad de la diabetes inducida por la pancreatectomía, es una alternativa atractiva en el tratamiento y manejo de pacientes con diagnóstico de pancreatitis hereditaria. Sin embargo, estrictos criterios y un manejo interdisciplinario son esenciales ya que éste es un procedimiento irreversible y tiene consecuencias médicas por el resto de la vida que todo paciente tiene que conocer y que a su vez, el equipo médico debe saber identificar y tratar a tiempo. Sin embargo, existen muchas áreas potenciales en este campo para investigaciones que sean mayores, mejores y a la vanguardia para lograr un mejor entendimiento y desarrollar potenciales curas para esta enfermedad

Pancreatitis is an inflammation of the pancreas that can progress from an acute presentation to an acute recurring presentation and eventually to chronic pancreatitis, which is characterized by irreversible morphological changes and scarring of the pancreas. The entity known as hereditary pancreatitis has been recognized in the literature for years and certainly the discovery of the PRSS1 gene in 1996 marked the beginning of a new era of genetic discoveries associated with the disease. Since then, multiple genes have been described as the causing agents of pancreatitis or disease modifiers, some of the most important ones being the PRSS1, SPINK1, CFTR, CASR, CTRC, CLDN2, and CPA1. The patient selection process for genetic testing should be guided by the current experts' recommendations and should meet specific corresponding criteria. Once the diagnosis has been made, treatment should be tailored to each patient's particular needs. Certainly, the advent of the total pancreatectomy with auto islet cell transplantation, which has the main goal to improve the pain caused by the chronic pancreatitis and simultaneously reduce the severity of the pancreatectomy induced diabetes, is an attractive alternative in the treatment and management of patient with a diagnosis of hereditary pancreatitis. However, strict criteria and an interdisciplinary management are essential since this surgery is irreversible and carries lifetime health consequences that all patients must be aware of and the medical team must be able to early recognize these and treat accordingly. However, there are many potential areas in this field for more, better and forefront research to be developed aiming for a better understanding of the disease process and for the development of a cure

Tratamiento endoscópico en la pancreatitis crónica: seguimiento a largo plazo / Endoscopic treatment in chronic pancreatitis: long-term results in 18 patients

Background: Intraductal stones, ductal abnormalities and pancreatic pseudocysts are part of chronic pancreatitis (CP). The goal of treatment is pain relief, resolution of local complications and relapse prevention. Endoscopic therapy (ET) can be considered in those who do not respond to medical treatment. Aim: To evaluate the indication, immediate and long-term results of ET in CP patients. Patients and Methods: Review of a database of patients with CP analyzing results of ET in 18 patients aged 16 to 60 years (13 males). Demographics, etiology, endoscopic technique, indication for treatment, pain relief, relapses and complications were recorded. Results: The etiology of CP was alcohol consumption in 5, idiopathic in 11, hereditary in one and autoimmune in one case. The follow-up period was 6 months to 14 years. Seven patients had diabetes mellitus type 3c and eight had moderate to severe exocrine pancreatic insufficiency. Pancreatic papillotomy was performed in all patients, with removal of some stones, without attempting a complete clearance of the pancreatic duct. In addition, a 7-10 French stent was placed in the main pancreatic duct in 15 patients with varying permanence (months to years). The stent was changed guided by recurrence of clinical symptoms. During the follow-up period, 10 patients remained asymptomatic and in three, pain or relapse were significantly reduced. Stenting failed in one patient for technical reasons. Two patients were operated. There were neither immediate nor late complications from ET. Conclusions: Long-lasting improvement of CP was observed in 13 of 18 patients treated with ET, without complications associated with the procedure.

Manejo endoscópico de las complicaciones de la pancreatitis / Endoscopic management of the complications of pancreatitis

Tanto la pancreatitis aguda como crónica causan diferentes complicaciones que antes del advenimiento de la terapéutica endoscópica tenían que ser tratadas con cirugía convencional. El avance de la endoscopía intervencionista nos ha permitido acceder al páncreas y tratar estas complicaciones efectivamente y con menor morbilidad para nuestros pacientes. Aproximadamente el 90% de las pancreatitis aguda son edematosas, tienen una resolución clínica temprana y sin complicaciones. Los pacientes que son admitidos con pancreatitis necrotizante están predispuestos a tener diferentes tipos de complicaciones tanto locales como sistémicas particularmente si hay falla orgánica. Por otro lado la pancreatitis crónica es un proceso inflamatorio crónico del páncreas en donde se ha establecido la fibrosis de la glándula con posible disfunción exocrina y/o endocrina. El objetivo principal de la terapéutica endoscópica en la pancreatitis crónica es aliviar la obstrucción y disminuir la presión del conducto pancreático con la intención de aliviar el dolor abdominal. En esta revisión vamos a hablar acerca de las indicaciones y técnica endoscópica para tratar las diferentes complicaciones de la pancreatitis como, drenaje de pseudoquistes, necrosectomía pancreática, manejo del síndrome de conducto desconectado y terapia endoscópica en pancreatitis crónica.

Acute and chronic pancreatitis may lead to complications that prior the recent advancement of therapeutic endoscopy had to be treated with conventional surgery. The current techniques in interventional endoscopy allow us to access the pancreas and treat some of the complications in a minimally invasive way leading to less morbidity in our patients. Approximately 90% of acute pancreatitis episodes are edematous with early resolution of clinical symptoms and rarely leading to major complications. Patients with necrotizing pancreatitis are susceptible to local and systemic complications particularly in the setting of organ failure. On the other hand chronic pancreatitis is as a chronic inflammatory process that leads to fibrosis of the gland and in occasions to exocrine and/or endocrine insufficiency. The main objective of therapeutic endoscopy in chronic pancreatitis is to relief the obstruction and decreases the pressure in the pancreatic duct with the intention to alleviate abdominal pain. In this review we will address the indications and endoscopic techniques to treat the different complications of pancreatitis such as pseudo cyst drainage, walled off necrosis debridement, disconnected duct syndrome and different options for endoscopic therapy in chronic pancreatitis.

Alterações cutâneas no Kwashiorkor: relato de caso de um homem adulto após cirurgia abdominal / Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery

Kwashiorkor é um tipo de desnutrição proteico-energética em que há deficiência dietética de proteína, embora a ingestão de calorias se mantenha adequada. As manifestações cutâneas incluem pele xerótica, com aspecto de esmalte descascado, típica coloração avermelhada a branco-acinzentada dos cabelos, o sinal da bandeira e edema mais evidente, nos membros inferiores e na face, dando aspecto de lua cheia. O presente artigo relata o caso de um paciente adulto, do sexo masculino, previamente submetido à duodenopancreatectomia para tratamento de pancreatite crônica associada ao pseudotumor em cabeça de pâncreas que evoluiu com alterações cutâneas de kwashiorkor após tuberculose pulmonar.

Kwashiorkor is a type of protein-energy malnutrition where diet protein deficit is found, in spite of appropriate caloric intake. Cutaneous manifestations include xerosis, with abnormally dry skin that has a flaking enamel paint aspect, a typical red to gray-white hair color, the "flag sign" and more evident edema in lower limbs and face, giving it a full moon appearance. This article reports a case of a male adult patient who had undergone Whipple surgery for treatment of chronic pancreatitis associated with pseudotumor of the pancreatic head that progressed to cutaneous manifestations of kwashiorkor after pulmonary tuberculosis.

Pancreatitis crónica: nuevas terapias / Chronic pancreatitis: new therapies

Chronic pancreatitis occurs by the prolonged inflammation of pancreatic tissue that induces the irreversible destruction of the organ, leading to a global pancreatic insufficiency. The most common manifestations are abdominal pain, diarrhea, malabsorption, and possibly diabetes mellitus. Chronic pancreatitis treatment includes dietary restrictions, enzymatic supplementation, vitamins, and endoscopic or surgical methods depending on the degree of ductal involvement. In addition to the known therapies, new therapies are under development and research.

La pancreatitis crónica se desarrolla por la inflamación prolongada del tejido pancreático que induce la destrucción irreversible del órgano, llevando a una insuficiencia pancreática global. Las manifestaciones más frecuentes son dolor abdominal, diarrea, malabsorción y eventualmente diabetes mellitus. El tratamiento en pancreatitis crónica incluye restricciones dietarias, suplementación enzimática, vitamínica, y métodos endoscópicos o quirúrgicos, dependiendo del grado de compromiso ductal. Además de lo descrito, están en desarrollo y experimentación nuevas terapias.