Obstructive Chronic Pancreatitis Research Articles

The radiological morphology of mesopancreas: A new variable to predict a positive vascular margin after pancreatoduodenectomy for pancreatic ductal adenocarcinoma?

615 Background: The most frequently invaded surgical margins on pancreatoduodenectomy (PD) specimens of pancreatic ductal adenocarcinoma (PDAC) are vascular margins, especially the superior mesenteric artery (SMA), also called mesopancreatic margin. Considering embryology, it may be hypothesized that PDAC cells tend to infiltrate the retroperitoneum through the contents of mesopancreas, justifying the frequent SMA positive margin. Because the radiological aspect of mesopancreas has been poorly studied, the aim of this original research was to assess the mesopancreatic infiltration on diagnostic imaging, corroborate with the corresponding margin pathology and evaluate the impact on survival in PDAC patients who underwent PD. Methods: From 2015 to 2021, all patients who underwent PD for PDAC with curative intent were reviewed, excluding patients lost to follow-up, who died postoperatively or within the first year for non-oncological reason, and those with unavailable preoperative imaging. Surgical margins of pathological specimens were reassessed. Blinded reviewing of preoperative radiographic images was conducted. According to qualitative assessment, the mesopancreas tissue was defined as normal fat (NF), fat stranding (FS) or solid infiltration (SI). Results: 133 patients were included in the study, including 51 (38%) who received neoadjuvant therapy. The tumor location was into the head or the uncinate process in 54% and 46%, respectively. At diagnosis, PDAC were classified as resectable (51%), borderline resectable (28%) and locally advanced (9%) according to the NCCN classification. FS or SI in the mesopancreas was present in 45 (34%) and 18 (14%) patients, respectively. Tumor size on imaging, tumor location, chronic obstructive pancreatitis, vascular contacts and NCCN resectability status were predictive factors of mesopancreas infiltration (p<0.001). Median overall and disease-free survivals were significantly lower in case of SI compared to NF and FS in the mesopancreas. When comparing patients with mesopancreatic FS at diagnosis who received neoadjuvant therapy (n=20) to those who underwent upfront surgery (n=25), no significant impact was observed in survivals. R0 resection was obtained in 36%; in all patients with R1 resection, a vascular margin was involved. Tumor size at pathology, SMA margin and resection status were factors that were significantly influenced by the radiological infiltration of the mesopancreas. Conclusions: The SI of mesopancreas on diagnostic imaging was associated with a poor prognosis, but not FS, in patients who underwent PD for PDAC. SMA margin and resection status were correlated with the radiological texture of the mesopancreas, which suggests to further explore underlying mechanisms related to tumoral invasion of vascular margin and mesopancreas.

Imaging of paraduodenal pancreatitis: A systematic review.

Paraduodenal pancreatitis (PP) represents a diagnostic challenge, especially in non-referral centers, given its potential imaging overlap with pancreatic cancer. There are two main histological variants of PP, the cystic and the solid, with slightly different imaging appearances. Moreover, imaging findings in PP may change over time because of disease progression and/or as an effect of its risk factors exposition, namely alcohol intake and smoking. To describe multimodality imaging findings in patients affected by PP to help clinicians in the differential diagnosis with pancreatic cancer. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses 2009 guidelines. A Literature search was performed on PubMed, Embase and Cochrane Library using (groove pancreatitis [Title/Abstract]) OR (PP [Title/Abstract]) as key words. A total of 593 articles were considered for inclusion. After eliminating duplicates, and title and abstract screening, 53 full-text articles were assessed for eligibility. Eligibility criteria were: Original studies including 8 or more patients, fully written in English, describing imaging findings in PP, with pathological confirmation or clinical-radiological follow-up as the gold standard. Finally, 14 studies were included in our systematic review. Computed tomography (CT) findings were described in 292 patients, magnetic resonance imaging (MRI) findings in 231 and endoscopic ultrasound (EUS) findings in 115. Duodenal wall thickening was observed in 88.8% of the cases: Detection rate was 96.5% at EUS, 91.0% at MRI and 84.1% at CT. Second duodenal portion increased enhancement was recognizable in 76.3% of the cases: Detection rate was 84.4% at MRI and 72.1% at CT. Cysts within the duodenal wall were detected in 82.6% of the cases: Detection rate was 94.4% at EUS, 81.9% at MRI and 75.7% at CT. A solid mass in the groove region was described in 40.9% of the cases; in 78.3% of the cases, it showed patchy enhancement in the portal venous phase, and in 100% appeared iso/hyperintense during delayed phase imaging. Only 3.6% of the lesions showed restricted diffusion. The prevalence of radiological signs of chronic obstructive pancreatitis, namely main pancreatic duct dilatation, pancreatic calcifications, and pancreatic cysts, was extremely variable in the different articles. PP has peculiar imaging findings. MRI is the best radiological imaging modality for diagnosing PP, but EUS is more accurate than MRI in depicting duodenal wall alterations.

Incidence and risk of pancreatic cancer in patients with chronic pancreatitis: defining the optimal subgroup for surveillance

We aimed to present the incidence and risk factors for pancreatic cancer in a multicenter retrospective cohort of patients with chronic pancreatitis (CP). Patients with ICD-10 codes for CP (K86.0, K86.1) who underwent abdominal CT or MRI between January 2010 and December 2021 in seven academic hospitals were analyzed. After exclusions, we identified 727 patients with definite CP with a median follow-up of 3.6 years (range 1.0‒12.9). During 3290 person-years of observation, pancreatic cancers were diagnosed in 16 patients (2.20%, 0.49% per year) after a median follow-up of 2.4 years (range 1.4‒6.6), with an age- and sex-standardized incidence ratio of 18.1 (95% CI 10.4‒29.5). The underlying CPs in the 16 pancreatic cancers were classified as chronic obstructive pancreatitis (10, 63%), chronic obstructive and calcifying pancreatitis (4, 25%), chronic calcifying pancreatitis (1, 6%), and autoimmune pancreatitis (1, 6%). Factors associated with pancreatic cancer development included age (HR 4.830, p = 0.006), parenchymal calcification (HR 0.213, p = 0.003), pancreatic duct stricture (HR 2.706, p = 0.048), and serum CA 19‒9 level (HR 3.567, p = 0.014). After adjustment, age over 60 years (HR 4.540, p = 0.009) and serum CA 19‒9 levels greater than 100 U/mL (HR 3.528, p = 0.015) were independent risk factors for pancreatic cancer.

Abstract A044: Incidence and risk of pancreatic cancer in patients with chronic pancreatitis: define optimal subgroup for surveillance

Abstract Background/Aims: Patients with chronic pancreatitis (CP) have an increased risk of developing pancreatic cancer. The true incidence of pancreatic cancer in CP patients in South Korea remains unclear, and reliable methods for identifying patients with CP at increased risk for pancreatic cancer are still lacking. We aimed to present the incidence and risk factors of pancreatic cancer in a multicenter retrospective cohort of patients with CP. Methods: Patients with ICD-10 code for CP (K86.0, K86.1) who underwent abdominal CT or MRI between January 2010 and December 2021 in seven academic hospitals were retrospectively analyzed. Patients who did not have definite CP, had follow-up less than 1 year, and developed pancreatic cancer less than 1 year after diagnosis of CP were excluded. A standardized incidence ratio was demonstrated using the incidence of pancreatic cancer in all populations in South Korea. Risk factors of pancreatic cancer were determined in patients with CP using the Cox-proportional hazards model. Results: After exclusions, we identified 727 patients with definite CP with a median follow-up of 3.6 years. There were 588 (80.9%) males and 139 (19.1%) females (median age 56.5 years, range 18-93). During 3,290 person-years of observation, 16 pancreatic cancers (2.20%, 0.49% year) were diagnosed after a median follow-up of 2.4 years (range 1.4-6.5); 5 (31%) developed between 1 and 2 years, 4 (25%) between 2 and 3 years, 3 (19%) between 3 and 4 years, and 3 (25%) between 4-7 years. Age and sex-standardized incidence ratio of pancreatic cancer was 18.1 (95% CI 10.4-29.5). Patients with pancreatic cancer were older (p = 0.008), more experienced exacerbation of pancreatitis (p = 0.031), had less parenchymal calcification (p = 0.009), and had higher CA 19-9 levels (p < 0.001) compared to those without pancreatic cancer. Among 16 developed pancreatic cancers, underlying CPs were 10 (63%) chronic obstructive pancreatitis, 4 (25%) chronic obstructive and calcifying pancreatitis, 1 (6%) chronic calcifying pancreatitis, and 1 (6%) autoimmune pancreatitis. Factors associated with pancreatic cancer development included age (hazard ratio 4.830, 95% CI 1.556-14.99, p = 0.006), parenchymal calcification (hazard ratio 0.213, 95% CI 0.077-0.586, p = 0.003), pancreatic duct stricture (hazard ratio 2.706, 95% CI 1.007-7.271, p = 0.048), and CA 19-9 level (hazard ratio 22.49, 95% CI 6.272-80.67, p <0.001). By multivariable analysis, age (hazard ratio 5.580, 95% CI 1.604-19.41, p = 0.007) and CA 19-9 level (hazard ratio 25.56, 95% CI 7.022-93.06, p <0.001) were the independent risk factors for pancreatic cancer. Conclusions: Patients with CP have a high risk of developing pancreatic cancer in South Korea. High risks in CP patients with more 60-year age at CP diagnosis and high CA 19-9 level warrant careful surveillance for pancreatic cancer. Citation Format: Seunghwan Noh, Jae Hyuck Chang. Incidence and risk of pancreatic cancer in patients with chronic pancreatitis: define optimal subgroup for surveillance [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A044.

Extracorporeal shockwave lithotripsy in combination with endoscopy as a treatment modality for painful chronic obstructive pancreatitis – a case report

Chronic pancreatitis (CP) is a serious condition with a great impact on the quality of life, and it can lead to some serious long-term consequences such as pancreatic cancer or secondary diabetes mellitus. Associated pancreatic exocrine insufficiency leads to malnutrition with weight loss; however, the main symptom of the disease is abdominal pain, often very severe. The primary treatment option for painful CP is pharmacotherapy (pancreatic enzyme replacement therapy, analgesics). If this is not effective, CP can be treated via endoscopy, extracorporeal shockwave lithotripsy (ESWL), their combination, or surgery. We present a case of painful chronic obstructive pancreatitis in a patient successfully treated with ESWL in combination with endoscopy.

Chronic Calcifying Pancreatitis Associated with Secondary Diabetes Mellitus and Hepatosplenic Abscesses in a Young Male Patient: A Case Report

Background: Chronic pancreatitis (CP) has been described as a multifactorial, ongoing inflammatory condition of the pancreas of varying intensity that produces persistent pain, leading to exocrine and endocrine insufficiency and a decreased lifespan. Currently, there are three primary forms of chronic pancreatitis: chronic autoimmune pancreatitis (steroid-sensitive pancreatitis), chronic obstructive pancreatitis, and chronic calcific pancreatitis, the latter being closely related to excessive alcohol consumption for one or even two decades before the onset of symptoms. Case report: We present the case of a 29 year old man who required medical attention for a significant unintentional weight loss and a history of upper abdominal pain. Blood tests revealed substantial abnormalities, and the patient was admitted for further investigation. CT and MRI confirmed the presence of a pancreatic pseudocyst and extensive pancreatic parenchymal calcifications and revealed multiple hepatosplenic microabscesses of fungal etiology. Conclusions: Chronic calcifying pancreatitis is a complex clinical entity that can lead to secondary diabetes due to progressive destruction of the pancreatic parenchyma. Protein malnutrition, caused by malabsorption syndrome, immune cell dysfunction, and a high glucose environment caused by diabetes mellitus, may create a state of immunodeficiency, predisposing the patient to opportunistic infections.

Intraductal pressure in experimental models of acute and chronic pancreatitis in mice

Background/ObjectivesPancreatic intraductal pressure is related to the development of pancreatitis, including post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. In this study, we investigate pancreatic intraductal pressure in various mouse models of acute and chronic pancreatitis. MethodsPost-ERCP pancreatitis was induced by retrograde infusion of normal saline or radiocontrast at the constant rate of 10 or 20 μL/min. Obstructive pancreatitis was induced by ligation of the pancreatic duct followed by a single injection of caerulein and the changes of intraductal pressure were recorded in day 3 for obstructive acute pancreatitis and day 14 for obstructive chronic pancreatitis. Non-obstructive pancreatitis was induced by repetitive intraperitoneal injections of caerulein. The changes of intraductal pressure were recorded right after the last caerulein injection for non-obstructive acute pancreatitis and after the completion of 4-week caerulein injections for non-obstructive chronic pancreatitis. ResultsElevated pancreatic intraductal pressure was observed in both normal saline and radiocontrast infusion groups and was furtherly indicated that was positively correlated with the viscosity of solution but not genders. In the models of obstructive pancreatitis, a rise in intraductal pressure was observed in both acute and chronic pancreatitis; whereas in the models of non-obstructive pancreatitis, a rise in intraductal pressure was only observed in chronic, but not acute pancreatitis. ConclusionsDuring ERCP, the elevations in pancreatic intraductal pressure are induced by increasing rate or viscous solution of infusion. During different forms of experimental acute and chronic pancreatitis, obstructive or non-obstructive etiologies of pancreatitis also induces the elevations in pancreatic intraductal pressure.

Генетически детерминированная сочетанная патология поджелудочной железы: муковисцидоз, панкреатит, диабет

In this article, we report a case of cystic fibrosis (CF) with untypical manifestations, including obstructive pancreatitis with relative pancreatic insufficiency, complicated by pancreatolithiasis and type 1 diabetes mellitus (DM1). Interestingly, the patient had almost none clinical manifestations of CF in the lower respiratory tract. The first manifestation was abdominal pain associated with chronic obstructive pancreatitis. The patient had only laboratory manifestations of DM1 without any clinical signs. DM1 treatment led to an increase in the child's body weight and increased external respiration, which allowed an operation for pancreatitis. We removed calculi and performed longitudinal pancreaticojejunostomy. The surgery alleviated pain and increased the external secretion of the pancreas. Thus, this case demonstrates difficulties associated with CF diagnosis, as well as effectiveness and feasibility of surgical treatment for obstructive pancreatitis, even in cases when it is believed to be an inherited and incurable disease. Key words: cystic fibrosis, pancreatitis, pancreatic insufficiency, pancreatolithiasis, type 1 diabetes mellitus

News of European Pancreatology (based on the materials of the 53rd meeting of the European Pancreatic Club)

The 53rd meeting of the European Pancreatic Club (online) took place in Verona (Italy) on June 9–11, 2021. The meeting was attended by 690 delegates from 40 countries. More than 400 oral and poster presentations were presented.
 The results of advances in the diagnosis and treatment of chronic pancreatitis, as well as the crucial research directions, were summarized in a lecture by E. de-Madaria et al. (Italy). The main medical and social characteristics of chronic pancreatitis (CP): chronic disease; often manifests itself in pain, which is often disabling; leads to complications, including pancreatic cancer; diagnosis and treatment are complex. Despite this, the number of randomized controlled trials (RCTs) on CP is significantly less than on acute pancreatitis, and in recent years, the annual number of studies on CP has even decreased. Problems to be solved: we do not have antifibrotic drugs, a “gold standard” for diagnosis, and we do not even have good methods for diagnosing early CP. The main etiological CP options are alcoholic and idiopathic ones. A more detailed analysis showed that toxic CP (alcoholic and smoking-induced) account for 46% of cases of the disease, idiopathic CP — 24%, genetically predisposed CP — 7%, obstructive CP — 7%, autoimmune CP — 2%, CP of other etiology — 12% of cases. We have made progress in the study of autoimmune pancreatitis, however, the frequency of pancreatic cancer due to autoimmune CP, features of the disease in children, increased accuracy of pancreas imaging and the effectiveness of treatment require further study in RCTs.
 Lithotripsy, endoscopy, and surgery are used to treat CP with dilated pancreatic ducts. There were 3 RCTs that showed the advantages of surgical treatment over endoscopic one (long-term pain relief, fewer complications, higher efficiency), but lithotripsy and endoscopy were not compared.
 “Small ducts disease” is treated by the blockade of the solar plexus and/or nn. splanchnici, V-shaped excision of the pancreas, pancreatectomy with autotransplantation of the islets of Langerhans (only in specialized centers). The effectiveness of these techniques requires further study. The main techniques for diagnosing exocrine pancreatic insufficiency (EPI) are: probe (laborious), fecal elastase test (low sensitivity in mild EPI), tests for assessing trophological status (low specificity), breath tests (not available everywhere and laborious).
 Thus, we need an more RCTs (international efforts), definition of early CP; we need to better understand the relationship between genetic and environmental factors, advance in understanding of the autoimmune pancreatitis, and understanding the role of endoscopy and lithotripsy in pain management; it is necessary to develop new techniques of treating pain in the “small ducts disease”; we need easy-to-perform, accurate and widespread tests to diagnose EPI.
 The article analyzes the results of studies on the diagnosis and treatment of pancreatitis, cysts and pancreatic tumors.

Single incision laparoscopic appendectomy: A prospective study

Background: Appendicitis is one of the common pathologies encountered in surgical practice. Except in minority of the cases, the treatment is usually surgical. Till recent past, open appendectomy has been the procedure of choice for appendicitis. With increasing expertise in laparoscopic surgeries more and more surgeons are utilizing the laparoscopic approach for appendectomy. Laparoscopic surgeries have distinct advantages such as less surgical trauma, improved and quick postoperative recovery, and esthetic results. Single-incision laparoscopic surgery (SILS) is rapidly gaining acceptability in young population because of its cosmetic advantages. Moreover, these surgeries also avoid the risk of port-site hernias and the possibility of wound infection. Aims and Objective: The purpose of this study is to present our initial experience with this surgery using a single incision laparoscopic appendectomy (LA) using conventional instruments. Materials and Methods: This was a prospective cohort study conducted in the department of surgery of a tertiary care medical college situated in an urban area. The duration of the study was 2 years. All adult patients diagnosed to be having uncomplicated appendicitis and undergoing appendectomy by SILS were included in this study on the basis of a predefined inclusion and exclusion criteria. Pre-operative data collected included age, sex, weight, duration of complaint, concomitant medical conditions (like ischemic heart disease, chronic obstructive airway disease, diabetes mellitus, pancreatitis, and liver cirrhosis) and previous upper or lower abdominal surgery. All patients were treated by SILS except 1 patient in whom the procedure was converted to open surgery. Mean surgical time, Intraoperative procedure details and postoperative complications were studied in all the cases. p < 0.05 was taken as statistically significant. Statistical analysis was done using SSPS 21.0 software. Results: Out of 30 patients in this study 26 patients were female and 4 patients were male. The male to female ratio was found to be 1:6.15. Mean age of studied cases was found to be 26.2 years. Operative time required for the first 15 cases in an average was 120.00 min however it was reduced for the next 15 cases was 73.73 min. Overall time required in an average was 96.86 min. Out of 30 cases, The procedure was completed with Single Incision LA in 23 Patients, i.e., 76.6 %. In the initial cases, we started with two 5 mm and one 10mm port. To reduce crowding we replaced the 5 mm port to 3 mm port. The 10 mm port was also replaced by 5 mm in the past few cases in 1 patient the procedure was converted to open surgery. The analysis of postoperative complications showed that five patients had Post-Operative wound Infection. One patient had post-operative peritonitis. Conclusion: SILS is a feasible and safe surgical method for appendectomy and is being increasingly preferred particularly by young patients due to its excellent cosmetic results.

Endoscopic versus Surgical Intervention for Painful Obstructive Chronic Pancreatitis: A Systematic Review and Meta-Analysis.

There is limited evidence on the standard care for painful obstructive chronic pancreatitis (CP), while comparisons of endoscopic and surgical modes for pain relief have yielded conflicting results from small sample sizes. We aimed to obtain a clear picture of the matter by a meta-analysis of these results. We searched the Pubmed, Embase, and Cochrane Library databases to identify studies comparing endoscopic and surgical treatments for painful obstructive CP. Pooled effects were calculated by the random effect model. Primary outcomes were overall pain relief (complete and partial), and secondary outcomes were complete and partial pain relief, complication rate, hospitalization duration, and endocrine insufficiency. Seven studies with 570 patients were included in the final analysis. Surgical drainage was associated with superior overall pain relief [OR 0.33, 95% CI 0.23–0.47, p < 0.001, I2 = 4%] and lesser incidence of endocrine insufficiency [OR 2.10, 95% CI 1.20–3.67, p = 0.01, I2 = 0%], but no significant difference in the subgroup of complete [OR 0.57, 95% CI 0.32–1.01, p = 0.054, I2 = 0%] or partial [OR 0.67, 95% CI 0.37–1.22, p = 0.19, I2 = 0%] pain relief, complication rates [OR 1.00, 95% CI 0.41–2.46, p = 0.99, I2 = 49%], and hospital stay [OR −0.54, 95% CI −1.23–0.15, p = 0.13, I2 = 87%] was found. Surgery is associated with significantly better overall pain relief and lesser endocrine insufficiency in patients with painful obstructive CP. However, considering the invasiveness of surgery, no significant differences in complete or partial pain relief, and heterogeneity of a few parameters between two groups, endoscopic drainage may be firstly performed and surgical drainage may be considered when endoscopic drainage fails.

Solitary Fibrous Tumor of the Liver: Case Report

Introduction: Solitary fibrous tumor (SFT) of the liver is a rare mesenchymal tumor. Most patients are asymptomatic. Clinic-radiological features are non-specific. Definitive diagnosis of SFT is usually made based on the histological features and immunohistochemistry data of the resected specimen. In this case report, we describe the case of an elderly female who presented with a large mass in the left lobe of the liver with normal level of tumor markers and atypical radiological findings. The patient successfully underwent resection of the tumor and the diagnosis was confirmed on histopathology. Methods: A 81-year old woman with abdominal pain for the past 2 months. Examination revealed a large mass palpable in the epigastric region. CT and MRI showed a 25×16 cm-sized hypervascular mass arising from the left lobe of liver. The mass displace stomach, the transverse colon and cause a chronic obstructive pancreatitis due to the compression. The level of tumor markers was within the normal limits: AFP 3.3 ng/ml, CEA 2.3 ng/ml, and CA 19-9−27 U/ml. Liver functions were in the normal range. Based on the atypical imaging findings biopsy of the lesion was done. It was suggestive of solitary fibrous tumor. Since the lesion was resectable, surgery was planned. Trans-arterial chemoembolization was done before the surgery without incidences. The patient underwent left lateral sectionectomy. Intraoperatively, a solitary large tumor arising from the segment II and III of the liver was identified and no evidence of distant metastasis. The postoperative course was uneventful. The tumor measured 19 ×14 x9,5 cm-sized, with an external well delimited surface. Microscopic examination showed atypia with spindle cells and collagen bundles between the tumor cells. On IHC, the tumor was positive for STAT6, CD34, Bcl2, and focal and patched positive for CD34 y CD99. There was no evidence of recurrence on follow-up for 7 months. Conclusion: SFT of the liver is a rare entity. Most patients are asymptomatic, but in some cases, abdominal fullness and palpable masses are present. Definitive diagnosis is made based on the histological features and immunohistochemistry data of the resected specimen. IHC remains the most important tool for conclusive diagnosis of SFT. Complete surgical excision is the treatment for hepatic SFT. Follow up is advised as some of the patients with benign tumors on initial histological examination developed distant metastasis later.

Biliary - pancreatic - digestive bypass for chronic obstructive pancreatitis

Introduction: In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2-45.6% of patients, off whom only 5-10% require operative decompression. Obstruction of the duodenum is much less common occurring in less than 1-2% of patients. Pancreaticoduodenectomy with or without a drainage procedure or isolated bypass procedures to the biliary tract or stomach are common procedures in the algorithm to treat this disease. Also, improvement in endoscopic techniques have decreased the need for surgical intervention overall.

Chronic Pancreatitis in Thai Patients: A Comprehensive Review of 236 Patients from One Institution

Background: Reports of chronic pancreatitis (CP) in Thailand are rare. Clinical information is lacking. Objective: To study the etiology, genetics, presentations, clinical courses, complications, treatments, and outcomes of CP in Siriraj Hospital. Materials and Methods: Retrospective study of all CP patients during 2005 to 2018 was done. CP was diagnosed by abdominal radiography, ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography (EUS). Etiology, genetics, presentations, clinical courses, complications, treatments and outcomes were analyzed. Results: There were 236 CP patients. The median follow-up was 37 months. There were 160 patients (68%) with alcoholic CP (ACP), 35 (15%) with early-onset idiopathic CP (E-ICP), 36 (15%) with late-onset idiopathic CP (L-ICP), 1 (0.4%) with tropical CP, 3 (1%) with hereditary pancreatitis (HP) and 1 (0.4%) with obstructive CP. Mean ages of onset were 47, 28 and 60 years in ACP, E-ICP and L-ICP, respectively (p&lt;0.001). Male was predominant in all types of CP (98%, 40% and 56%; p&lt;0.001). Initial presentations were abdominal pain (59%), recurrent acute pancreatitis (RAP, 22%), diabetes (DM, 8%) and steatorrhea (8%). Clinical manifestations during the course were abdominal pain in 89%, 89% and 83% (p = 0.832), RAP in 41%, 48% and 11% (p = 0.001), steatorrhea in 31%, 25% and 25% (p = 0.661), weight loss in 38%, 31% and 44% (p = 0.526), DM in 29%, 37% and 25% (p = 0.502), respectively. Median time to pain relief were 33, 74, and 16 months (p = 0.002). Common complications were pseudocyst (16%) and biliary obstruction (15%). SPINK1 mutation was detected in 83% of E-ICP, 45% of L-ICP and 21% of ACP (p&lt;0.001). PRSS1 mutation was found in all HP. Medical therapy included analgesics (62%), pancreatic enzymes (76%) and antioxidants (9%). Endoscopic therapy was done in 48 patients (20%). Surgery was performed in 31 patients (13%). Conclusion: ACP, E-ICP and L-ICP are common etiologies of CP. Presentations were RAP, abdominal pain, DM and steatorrhea. Painless L-ICP was uncommon. Spontaneous pain relief occurred quickly. SPINK1 mutation was common in ICP. Endoscopic and surgical therapy were required in one-fifth. Keywords: Chronic pancreatitis, Etiology, Genetics, Management, Manifestation, Natural course, Review &nbsp;

INVESTIGATION OF EXTERNAL RESPIRATORY FUNCTION AND HEMOSTASIS SYSTEM’S STATUS IN PATIENTS WITH CHRONIC OBSTRUCTIVE LUNG DISEASE WITH CONCOMITANT CHRONIC PANCREATITIS

INTRODUCTION: It can be assumed that the comorbidity course of сhronic obstructive pulmonary disease (COPD) and chronic pancreatitis (CP) can enhance the clinical symptoms of both diseases and lead to frequent relapses of the pathological process due to changes in the proteolysis intensity of high and low molecular weight plasma proteins and the state of the hemocoagulation.&#x0D; OBJECTIVE: To establish the features of hemocoagulation and proteolytic hemostasis at COPD with concomitant CP.&#x0D; METHODS: 120 patients with COPD and CP were examined. The function of external respiration, total coagulation potential of blood plasma, the state of enzymatic and non-enzymatic fibrinolysis, total fibrinolytic activity were investigated.&#x0D; RESULTS: CP contributes to the development of broncho-obstructive syndrome, and the maximum indicators of reduction of FEV1 relative to the proper values are observed in patients with a comorbid course of COPD and CP. Reducing the intensity of collagenolysis in patients of groups 1-2 contributed to the development of diffuse pulmonary fibrosis in response to chronic inflammation. The imbalanced increase in the intensity of proteolysis due to reduced expression of its inhibitors in COPD patients with CP led to progressive destruction of the cell membranes of alveolocytes, acinar epithelium of pancreas and epithelium of the bronchial mucosa, acceleration of their apoptosis and development of desquamation, atrophic changes, metaplasia, and the like. The above factors are active as inducers of inflammation, and the formation of pulmonary fibrosis and fibrosis of the pancreas.&#x0D; CONCLUSIONS: In COPD patients with accompanying CP are an increase in the lysis rate of low and high molecular weight proteins and a decrease in blood collagenolytic activity on the background of a significant imbalance in the activity of plasma proteinase inhibitors. Defined suppression of the activity of the anti-coagulation system factors and enzymatic, Hageman-factor-dependent fibrinolysis indicates the formation of hypercoagulation syndrome in these patients.

Chronic pancreatitis with IBS-like syndrome: approach to therapy

To determine approaches of the exacerbations treatment of chronic pancreatitis (CP) with IBS (irritable bowel syndrome)-like syndrome. 312 patients with exacerbation of CP were observed and received standard therapy: antispasmodics, enzymes, proton pump inhibitors. 85 (27.2%) patients had no response to treatment. After excluding obstructive CP, celiac disease, decompensation of diabetes (DD), ischemic and microscopic colitis, small intestinal bacterial overgrowth (SIBO) as a cause of abdominal pain and intestinal dysfunction, a group of 54 patients with exacerbation of CP and IBS-like syndrome was isolated. They were divided into 2 groups: group 1 persons receiving with standard treatment of CP ciprofloxacin in a dose of 500 mg 2 times a day for 10 days (26 patients), group 2 rifaximin 400 mg 3 times a day for 10 days (28 patients). The dynamics of clinical picture, biocenosis indices, endoscopic, morphological features of the colon, interleukin-2 (IL-2), IL-6, IL-8 concentration in the colon mucosa (CA) were evaluated. IBS-like syndrome was determined in 54 (63.5%) patients with prolonged (more than 4 weeks) exacerbation of CP. A modification of therapy is proposed with the results of clinical and instrumental, laboratory, bacteriological studies. 68% of patients with exacerbation of CP, receiving in addition to the standard regimen rifaximin, achieved clinical improvement, normalization of intestinal biocenosis, reduced concentrations of cytokines in tissues, reducing signs of chronic inflammation in the colon mucosa with reducing concentrations of IL-2, IL-6, IL-8 in colon mucosa (p0.05). Exacerbation of CP, resistant to standard therapy, may be associated with the formation of IBS-like syndrome. The inclusion of rifaximin in the complex therapy of prolonged exacerbation of CP contributes to the relief of intestinal dysfunction, abdominal pain of intestine, improves biocenosis, reduces inflammatory modifications, and reduces the concentration of cytokines in the colon mucosa.

Laparoscopic longitudinal pancreaticojejunostomy for chronic pancreatitis: systematic review of the literature

Background: Patients with chronic pancreatitis (CP) may present severe and recurrent abdominal pain that limits their quality of life. Several studies have shown that surgery achieves greater long-term pain reduction than endoscopy in the treatment of obstructive CP, but it is also more cost-effective.Longitudinal pancreaticojejunostomy (LPJ), also known as modified Puestow or Partington-Rochelle procedure, is a surgical technique for the treatment of CP. It is usually performed by laparotomy, but it has been performed by laparoscopic or robot-assisted approach in a very small cases. Our aim is to clarify the current status of laparoscopic LPJ. Material & Methods: Adhering to the PRISMA guidelines, a systematic search about laparoscopic LPJ for the treatment of chronic pancreatitis without limits was performed. Results: Seventeen studies were included for critical appraisal: 8 case reports, 8 retrospective case series, and 1 case/control series without randomization. All of them had a grade of recommendation C and a level of evidence 4 according to CEBM.The patients were relatively young (median 37 years) and slight preponderance of males (ratio 1.3:1). Patients presented a long-standing pancreatic disease, endoscopic retrograde cholangiopancreatography before surgery and a dilated duct (11 mm).The surgery was usually performed by four trocars, the conversion rate was very low (5%), bleeding was minimal, the morbidity rate was 11% and there was no mortality. Mean hospital stay was 5.6 days. The follow-up period varied but was usually short, and the Results for pain control were very good since 90% of patients do not report pain (table I). Conclusions: Laparoscopic LPJ seems to be a safe, feasible and effective technique in patients with CP. Literature is scarce, and there are no studies with high scientific evidence comparing laparoscopic LPJ with open surgery or with endoscopic treatment that would allow us to draw firmer Conclusions at the present time. Tabled 1TABLE I: PUBLISHED ARTICLES ABOUT ON LAPAROSCOPIC LPJ. M: male, F female, CPY: years of chronic pancreatitis, LAP: Laparoscopy:, LLPJ: longitudinal la.

Clinical types of nutritional status in patients with chronic pancreatitis

Background: Malnutrition is among the predictors of unfavorable outcome of chronic pancreatitis (CP). Our previous study has shown that the malnutrition prevalence in CP patients was 92%; body mass index (BMI) ≤ 19 kg/m2 was found only in 15.5%.Aim: To identify clinical variants of nutrition status in CP patients. Materials and methods: We have analyzed the data from the first step of an open-label randomized prospective study on 148 patients (80 male) with CP of various etiologies, aged from 22 to 82 years (mean age, 51.8 ± 13.2 years). According to TIGAR-O, the patients were allocated into two groups: the first group with chronic alcoholic pancreatitis (CAP) included 71 patients (57 male and 14 female, mean age 46.3 ± 11.2 years), the second one with chronic obstructive pancreatitis (COP) consisted of 77 patients (29 male and 48 female; mean age 56.81 ± 3 years). Exocrine pancreatic function was assessed by fecal elastase 1 levels. Nutritional status was determined by V.M. Luft classification based on comparison of various anthropometrical parameters, as well as on some laboratory parameters (hemoglobin, total protein, albumin levels, lymphocyte counts, etc.). The anthropometrical and laboratory parameters, as well as smoking and alcohol overconsumption were included into the correlational analysis.Results: In the CAP group, the number of smoking patients was 2.5-fold higher than that in the COP group (р &lt; 0.001). The smokers had a lower BMI (р = 0.002) and lower pre-albumin levels (р = 0.04), compared to the non-smokers. There were associations between: the number of cigarettes per day and the daily amount of alcohol (r = 0.55), the smoking index and thickness of the skin/fat fold over the triceps muscle of the arm (r = -0.4), severity of chronic alcohol abuse and malnutrition grade (r = -0.5), duration of excess alcohol consumption and thickness of the skin/fat fold over the triceps (r = -0.4), hemoglobin levels and malnutrition grade (r = 0.5), hemoglobin level and shoulder circumference (r = 0.47), blood cholesterol level and shoulder circumference (r = 0.37), low density lipoprotein level and shoulder circumference (r = 0.41). Four basic clinical types of nutrition status could be identified: malnutrition of various grades (66%), overweight/obesity without malnutrition (3%), sarcopenic obesity with some malnutrition (26%), euthrophic type (5%). In the patients with malnutrition without sarcopenia, the etiology of CP had no effect on the prevalence of malnutrition. Low albumin levels were found in 54% (80/98) of the patients with pancreatic exocrine insufficiency and malnutrition, indicating a risk of sarcopenia. Sarcopenic obesity with malnutrition was most prevalent in COP (24 vs. 14 patients with CAP) and at higher age (56.8 vs. 46.3 years, respectively, р &lt; 0.001).Conclusion: Smoking, chronic alcohol abuse, low hemoglobin levels are associated (negative correlation) with the development of malnutrition in CP patients. The most prevalent clinical types of nutrition status in CP patients are characterized by various degrees of malnutrition, as well as by malnutrition with sarcopenic obesity.

Morphological advantages of endoscopic treatment in obstructive chronic pancreatitis

Backgroundand study aims: Chronic pancreatitis is associated with recurrent or persistent abdominal pain over the course of the disease. Ductal hypertension showing obstructed and dilated pancreatic duct has been suggested as a major factor in the mechanism of pain in chronic pancreatitis. Many studies investigating pain relief after endoscopic treatment of pancreatic duct (PD) are available, but the number of studies regarding the morphological changes to pancreas such as changes in PD caliber, pancreatic parenchyma, and especially pancreatic volume is far fewer. As such, we analyzed the changes of ductal caliber and parenchymal volume after endoscopic treatment of PD in patients with obstructive chronic pancreatitis. Patients and methodsIn this retrospective study, we compared two groups of patients with obstructive chronic pancreatitis that either received endoscopic management of PD or conservative treatment without such endoscopic management. After we obtained age, sex, etiology of chronic pancreatitis, diabetic status, smoking and alcohol abuse status from the database, we compared the incidence for changes in pancreatic parenchymal volume and PD caliber between two groups. ResultIn our study population, total of 480 patients was diagnosed with chronic pancreatitis between January 2006 and December 2016, and 166 (34.5%) of these patients were diagnosed with obstructive chronic pancreatitis with obstructed and dilated PD. After reviewing the population with the exclusion criteria, 71 patients were available for the final analysis. 28 of those patient received endoscopic treatment of pancreatic duct and 43 received conservative treatment without any endoscopic treatment of PD. Statistical analysis with Cox proportional hazards models showed that diabetes and endoscopic PD management were significant predictors for progression of PD caliber and in pancreatic parenchyma, and that only PD management influenced the pancreatic volume loss. ConclusionEndoscopic management of PD in obstructive chronic pancreatitis have advantages on morphologic change such as pancreatic volume loss and progression of PD caliber in long follow-up period.

OBSTRUCTION OF BILE DUCTS IN CHRONIC PANCREATITIS AND POSSIBILITIES OF ITS SURGICAL CORRECTION

Purpose of the study: optimize surgical tactics for bile duct obstruction in patients with various forms of chronic pancreatitis (CP). Materials and methods: The results of the examination and treatment of 503 patients with CP, 354 of whom were operated on, were analyzed. Mechanical jaundice was detected in 76 (21.5%) patients. The main type of relief of symptoms of biliary tract obstruction were transpapillary endoscopic and laparoscopic techniques or their combinations, which in 37 (47.4%) patients were the final treatment option, and in 35 (46.1%) - a preliminary stage before performing traditional surgical interventions. Traditional interventions were the only treatment method in 4 (6.4%) patients. Results: Based on the modified Marseille-Rome classification of CP (1988), a systematic approach was developed to assist this category of patients. It has been established that the use of endoscopic techniques in patients with obstructive CP allows not only to stop the symptoms of biliary hypertension, but also to influence the course of the underlying disease, by ensuring adequate drainage of both the bile and pancreatic ducts. The use of transduodenal and laparoscopic techniques for the relief of obstructive jaundice in patients with inflammatory CP, calcifying CP is best justified as a preliminary stage of treatment. The preferred option of surgical correction in patients with inflammatory and calcific CP with primary lesions of the pancreas head should be resection of the pancreas head according to Beger or Frey. Conclusion: The optimal combination of minimally invasive surgical treatment options and traditional surgical interventions, taking into account the shape and variation of CP, complicated by the development of obstructive jaundice, allows for maximum correction of the course of the disease in the near term and in the long term.