Pancreatic Duct Injury Research Articles

CONCEPTUAL APPROACHES TO THE DIAGNOSIS AND TREATMENT OF PENETRATING GUNSHOT WOUNDS OF THE ABDOMEN WITH DAMAGE TO THE PANCREAS

Summary. The goal is to determine the main directions of the concept of diagnosis and treatment of penetrating gunshot wounds of the abdomen with damage to the pancreas. Materials and methods. A retrospective analysis of the medical records of inpatient patients treated in the VMC of the Northern region, who received combat trauma of the pancreas during the war in Ukraine, was conducted. All the wounded were examined, complaints, medical history were studied, general clinical blood and urine tests were performed, biochemical analysis of blood and abdominal secretions, ultrasound examination of the abdomen and pleural cavity, radiographic examinations of the chest and abdomen, multispiral computed tomography of the chest and abdomen with contrast and without, video endoscopic methods, X-ray spectral and X-ray structural analysis of secretions from the abdomen and pancreatic tissues, electron microscopy, world microscopy, immunohistochemistry, mathematical and statistical methods. The results. The diagnostic component of the concept is implemented through the study of complaint data, anamnesis, local examination, laboratory, instrumental, hardware, histological and immunohistochemical studies. The therapeutic component, which combines conservative and operative measures depending on the patient’s geodynamic stability, is aimed at correcting hemodynamic disorders and influencing the four directions of the conceptual model of treatment of penetrating gunshot wounds to the abdomen with pancreatic damage. It is mandatory to study the foreign bodies of firearm origin that injured the pancreas and the possibilities of modern magnetic surgical instruments for the removal of ferromagnetic foreign bodies. The examination and control of treatment carried out covers research at the atomic and molecular level, at the subcellular level, at the cellular and tissue level, at the organ and clinical levels. All these studies are implemented within the framework of clinical and experimental research design with data analysis using mathematical and statistical methods. Conclusions. Conceptual approaches to the diagnosis and treatment of penetrating gunshot wounds to the abdomen with damage to the pancreas are based on a systematic analysis. The conceptual model is based on the following areas: localization of pancreatic injury, presence or absence of pancreatic duct injury, severity of pancreatic injury according to AAST, presence of combined injuries to other organs.

Restoring CFTR function with Orkambi decreases the severity of alcohol-induced acute pancreatitis.

Heavy alcohol intake is one of the most common causes of acute pancreatitis (AP). We have previously shown that ethanol (EtOH) decreases the expression and activity of the cystic fibrosis transmembrane conductance regulator (CFTR), which plays a key role in alcohol-induced AP development. The prescription drug, Orkambi (a combination of ivacaftor and lumacaftor) can correct impaired CFTR function and expression in cystic fibrosis (CF) patients. Thus, the present study aimed to investigate whether Orkambi can mitigate alcohol-induced AP. Intact guinea-pig pancreatic ducts were pre-treated with different concentrations of ethanol (EtOH; 30, 50 and 100mm) for 12h alone or in combination with ivacaftor (VX770) and/or lumacaftor (VX-809), and CFTR expression and activity were evaluated by immunostaining and by the patch clamp technique, respectively. Alcoholic AP was induced in Orkambi-treated guinea-pigs, and standard laboratory and histological parameters were measured. Ivacaftor and lumacaftor alone or in combination dose-dependently restored the apical expression and activity of CFTR after EtOH treatment in vitro. Oral administration of Orkambi reduced the severity of alcohol-induced AP and restored impaired CFTR activity and expression. Orkambi is able to restore the CFTR defect caused by EtOH and decreases the severity of alcohol-induced pancreatitis. This is the first in vivo pre-clinical evidence of Orkambi efficacy in the treatment of alcohol-induced AP. KEY POINTS: Acute pancreatitis is one of the leading causes of hospital admission among gastrointestinal diseases in which the lack of a specific drug therapy plays a crucial role. The cystic fibrosis transmembrane conductance regulator (CFTR) plays an essential role in pancreatic ductal HCO3 - secretion; inappropriate CFTR function, as seen in heavy alcohol consumption, increases the risk of pancreatitis development. CFTR modulators are able to prevent the inhibitory effect of ethanol and reduce pancreatic ductal injury and the severity of alcohol-induced pancreatitis. CFTR modulators present a novel option in the pharmacotherapy of alcohol-induced pancreatitis by enhancing pancreatic functions or preventing recurrence.

Prospective Outcomes of Standardized Non-operative Management of Pancreatic Trauma With Ductal Injury in Children: Less is More

BackgroundTraumatic pancreatic laceration with ductal injury in children can be managed non-operatively (NOM); however, variable management affects outcomes. We hypothesized that a standardized management approach with early feeding and limited resource utilization is safe and improves outcomes. MethodProspective, multicenter study of 13 pediatric trauma centers (2018–2022). Children with blunt pancreatic trauma with ductal injury were managed per a standard NOM pathway. Outcomes were compared to a historical NOM cohort with variable management. ResultsOf 22 patients, the median age was 7.5 years (range 1–14 years). Low-fat diet was started at median 4 days [IQR 2–7] and median hospital stay was 8 days [IQR 4–10]. One patient failed NOM and underwent distal pancreatectomy. Of the rest, most (17/21, 81%) had early recovery and discharged in median 6 days [IQR 4–8.25] while 4 (19%) had prolonged recovery (median stay 24 days, IQR 19.8–30.5) and higher peri-pancreatic cyst development (early 23.5% vs prolonged 75%,p = 0.05). Pancreatic ascites at presentation correlated with cyst development (p < 0.0001). Endoscopic stent (optional) was placed in 33% and did not prevent cyst development. Delayed exocrine pancreatic insufficiency was noted in 1 patient. Compared to the historic cohort (32 patients), TPN use was lower (pre-protocol 56% vs post 23%, p = 0.02), days to diet was shorter (pre-protocol 7 vs post 4; p = 0.03), and cyst development was lower (pre-protocol 81% vs post 33%, p < 0.001). ConclusionChildren with traumatic pancreatic ductal injury can be safely managed per the PTS NOM clinical pathway and most recover rapidly. Pancreatic ascites may predict pseudocyst formation. Levels of EvidenceIV. Study type: therapeutic, comparative.

Endoscopic ultrasound-guided salvage technique for pancreatic duct injury during endoscopic papillectomy.

Endoscopic ultrasound-guided salvage technique for pancreatic duct injury during endoscopic papillectomy.

Network meta-analysis on the mechanisms underlying alcohol augmentation of acute pancreatitis and diabetes type II.

Pancreatitis is a severe inflammatory pathology that occurs from pancreatic duct and exocrine acinar injury, leading to improper secretion of digestive enzymes, auto-digestion of the pancreas, and subsequent inflammation. Clinical reports show that 60%-90% of pancreatitis patients have a history of chronic alcohol use. More recent studies reveal that exocrine pancreas disorders like acute pancreatitis can precede diabetes type II onset, though mechanisms are not yet fully known. This study identified molecules and key signaling pathways underlying alcohol-induced acute pancreatitis and their effects on diabetes type II onset. Data on human peripheral blood samples with or without acute pancreatitis were retrieved from the National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (accession number GSE194331). Acute pancreatitis-mediated differentially expressed genes (DEGs) were generated from GSE194331 using CLC Genomics Workbench 12. Molecules associated with ethanol (EtOH), acute pancreatitis, and diabetes type II were collected from QIAGEN Knowledge Base (QKB). The relationship between the molecules and signaling pathways associated with EtOH, acute pancreatitis, or diabetes type II was examined using various Ingenuity Pathway Analysis (IPA) tools. Our investigation showed that acute pancreatitis-mediated DEGs were closely associated with EtOH by revealing that EtOH-induced acute pancreatitis appears to lead to the onset of diabetes type II. We found that diabetes type II onset was mediated by pro-inflammatory and metabolic mechanisms underlying EtOH-induced acute pancreatitis, involving increased expression of cytokines including macrophage migration inhibitory factor (MIF), and decreased expression of hormones such as insulin. Exposure to alcohol may promote diabetes type II by affecting the activity of key inflammatory and metabolic mediators involved in acute pancreatitis. These findings call for further investigation into the role of pro-inflammatory and metabolic mediators like resistin, IL-6, and insulin in EtOH-induced diabetes type II associated with acute pancreatitis pathologies.

A LATE COMPLICATION OF BLUNT TRAUMA IN A CHILD: HEMORRHAGIC PANCREATIC PSEUDOCYST

Trauma is the most important cause of morbidity and mortality in the pediatric population. Pancreatic injury is relatively rare but has high morbidity and mortality when the diagnosis is delayed. However, diagnosis of pancreatic trauma is difficult. Ultrasound is limited for diagnosing pancreatic injury. Magnetic resonance imaging (MRI) is very useful for detecting direct and secondary signs of pancreatic injury and its complications such as abscess, fistula, pancreatitis, and pseudocyst. We presented a 10-year-old boy with a hemorrhagic pancreatic pseudocyst due to blunt trauma that happened a week ago. His laboratory findings showed elevated serum amylase and lipase levels. In abdominal ultrasonography, bilobular thick-walled fluid collections in the pancreatic parenchyma and peripancreatic location were observed. MRI showed hemorrhagic pseudocysts in the pancreas and pancreatic duct injury. The pseudocysts were treated by cysto-gastrostomy. Children should be carefully evaluated for pancreatic injury and late complications such as hemorrhagic pancreatic pseudocyst to reduce mortality after blunt trauma.

Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?

Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is amultiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure anew onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, amortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.

Management of Blunt Pancreatic Trauma in Children: A Persistent Controversy-Case Report and Comprehensive Literature Review.

Blunt pancreatic injury (BPI) is relatively uncommon in children, and is associated with relatively high morbidity and mortality, especially if diagnosis is delayed. The aim of this report is to review the literature regarding controversial questions in the early diagnosis and management of pediatric BPI. A representative case of blunt pancreatic trauma in a six-year-old girl with delayed diagnosis and intraoperative and postoperative complications was described. A systematic search of databases and the grey literature in Scopus and Web of Science using relevant keywords was conducted. A total of 26 relevant articles published in last 5 years were found in PubMed. Although early CT performance is considered part of initial pancreatic trauma workup, the sensitivity of CT for detecting main pancreatic duct injuries in children is relatively low. MRCP and ERCP (if available) are useful for assessing ductal injury and should be performed when the status of the pancreatic duct is unclear on the CT. Most patients with low-grade pancreatic damage may be treated conservatively. Although surgery involving distal pancreatectomy remains the preferred approach for most children with high-grade pancreatic injury, there is growing evidence to suggest that non-operative management (NOM) is safe and effective. Most pancreatic pseudo cysts following NOM had relatively mild complications, and most resolved spontaneously. For those children who do require surgery, a conservative operative approach with the least risk is advocated. In conclusion, the optimal management for pediatric pancreatic trauma is controversial. Further clinical trials are required to generate clinical practice guidelines on pancreatic trauma in a child population.

Successful management of bile duct injury with duodenal perforation using endoscopic naso-pancreatic drainage and fully covered self-expandable metallic stent deployment

Video 1A case of bile and pancreatic duct injury with duodenal perforation during endoscopic submucosal dissection for superficial duodenal epithelial neoplasia.

Pancreatic Trauma

Traumatic pancreatic injuries are associated with significant morbidity and mortality. The review analyses recent studies on epidemiology, classification, diagnosis and treatment of patients with pancreatic injury. Pancreatic injury in abdominal trauma is observed from 3% to 12% of cases, the overall mortality ranges from 0% to 31% and is largely determined by damage to other organs. The most widely accepted grading system for defining categories of pancreatic injuries is Organ Injury Scaling developed by the American Association for the Surgery of Trauma. A high index of suspicion is necessary for early diagnosis, since in the first hours after the injury clinical manifestations and laboratory parameters are not specific, and changes in the CT picture do not correlate to the severity of the injury in 20-40% of cases. Contrast-enhanced CT is the first-line diagnostic tool in hemodynamically stable patients. MRI with MRCP and ERCP is used to evaluate the integrity of the pancreatic duct. Nonoperative management is recommended for hemodynamically stable grade I and grade II pancreatic injuries. Patients with pancreatic duct injury require predominantly surgical treatment. The preferred type of surgery for grade III and more severe injuries (distal resection, drainage of the damaged area combined with endoscopic drainage and stenting, or organ-preserving surgery in the form of pancreaticojejunostomy, pancreaticogastrostomy) remains controversial. In case of pancreatic injury proximal to the venous confluence, drainage of the damaged area is the only fairly safe option for the patient, indications for pancreaticoduodenal resection are limited to concomitant injury of the bile duct, duodenum with involvement of the major duodenal papilla, massive bleeding from crushed tissues of the pancreatic head. Larger prospective studies are warranted for better management of patients with pancreatic trauma.

Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit.

The management of high-grade pancreatic trauma is controversial. To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries. A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified. Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies. We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.

The role of main pancreatic duct stent in the enucleation of benign/borderline pancreatic head tumors: a cohort study.

This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation. A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery. Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05). MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula.

Perfusion CT in predicting deep pancreatic necrosis and planning early interventions for severe acute pancreatitis

Aim. To explore the potential of perfusion CT for predicting deep pancreatic necrosis and duct injury as well as for determining treatment strategy. Materials and methods. The prospective study included 74 patients hospitalized within 1–2 days of acute pancreatitis. They were exposed to perfusion CT and examination of their arterial blood flow velocity. In 37 observations, a standard CT was also performed on day 3–9 to study the depth and configuration of the necrosis. The severity of acute pancreatitis was assessed according to standard integral scoring systems, organ failure and severity of peripancreatitis. The alfa-amylase activity in fluid collections was examined. Results. Necrosis was detected in 20 patients: deep necrosis – in 11 cases, shallow – in 9. 17 patients did not reveal necrosis. Necrosis configuration of type 1 was detected in 16 patients, type 2 – in 4. Deep necrosis was preceded by a significant decrease in the arterial blood flow velocity: 39–52 ml/min/100 ml. This rate was greater in patients with shallow necrosis and without necrosis: 72–100 and 95–117 ml/min/100 ml (p &lt; 0.001). In cases of deep necrosis, advanced peripancreatitis was formed, organ failure was noted in 9 patients, 3 patients died. Internal pancreatic fistula was detected in 7 out of 9 patients with deep necrosis and in 1 out of 6 patients with shallow necrosis and type 1 configuration. In cases of necrosis type 2 configuration the pancreatic fistula was not noted. Minimally invasive interventions and transformation of the internal fistula into the external one were performed in 12 out of 20 patients: percutaneous drainage of fluid collections – in 9 observations, stenting of the pancreatic duct – in 3. Conclusion. Perfusion CT can be used to predict pancreatic necrosis on day 1–2 of the disease. A decrease in the arterial blood flow velocity in the range of 39–52 ml/min/100 ml is associated with the risk of parenchyma deep necrosis and duct injury. This parameter can be taken into account when determining indications for early minimally invasive interventions.

Pancreatic duct surgery: From innovation to implementation

Based on the continuous advances in surgical technology and equipment, as well as the recognition of the importance of the normal physiological function of the pancreatic duct, we performed several clinical studies of pancreatic duct repair after injury, and the results initially confirmed the safety and effectiveness of pancreatic duct injury repair. This article reviewed the indications and advantages of pancreatic duct surgery (PDS) and provided an outlook on the future of PDS.

S1798 Pancreatic Duct Injury Secondary to Pancreatic Trauma Successfully Treated With Transgastric Pancreatic Drainage

Introduction: Disconnected pancreatic duct syndrome (DPDS) is an underrecognized complication of pancreatic trauma and acute pancreatitis. DPDS is characterized by a disruption of the main pancreatic duct. Its diagnosis is confirmed by either MR cholangiopancreatography (MRCP) or retrograde cholangiopancreatography (ERCP). In this case, we present a patient who developed DPDS secondary to blunt abdominal trauma, successfully treated with a transgastric pancreatic drainage. Case Description/Methods: A 36-year-old female with a medical history of renal dysplasia and chronic kidney disease stage V arrived at our institution after presenting with epigastric abdominal pain, nausea, and early satiety of a week of evolution. The patient was recently discharged from a trauma center after being admitted for 2 weeks after a domestic violence incident involving blunt abdominal trauma. Upon initial evaluation, the abdominal exam was remarkable for tenderness in the epigastric area upon deep palpation. Laboratory were remarkable for elevated renal parameters and severely elevated pancreatic enzymes. Initial Abdominopelvic CT showed pancreatic transection across the head and neck pancreatic junction, with an associated fluid collection consistent pancreatic fluid extravasation. MRCP was performed, which confirmed the pancreatic transection with an associated pseudocyst at the pancreatic genu consistent with disconnect pancreatic duct syndrome. After interdisciplinary evaluation, an endoscopic ultrasound-guided cystgastrostomy stent was placed. After the procedure, the patient significantly improved symptoms and was discharged 2 days later. The patient was re-evaluated 2 weeks later with a CT scan, which showed transgastric pancreatic drainage with complete resolution of peripancreatic fluid collection. Transgastric pancreatic drainage was removed 2 months later. Follow up Ct scan done 2 months after stent removal showed normal anatomy of the pancreas with no distinct inflammatory tissue reaction and no evidence of peripancreatic collection. Discussion: Pancreatic ductal injury after trauma is mainly managed surgically but may result in high morbidity and mortality. Advances in endoscopy have allowed minimally invasive interventions as an alternative that can be performed in dstan effective and safe manner.

S1828 Recurrent Pancreatitis Secondary to Adderall Use With Pancreatic Ascites: A Sight Typically Unseen

Introduction: Pancreatic ascites is a rare disease with a prevalence of 3.5% resulting from pancreatic duct injury. While small ascites resolves spontaneously, large volume, persistent ascites can cause significant morbidity and mortality. We present a case of pancreatic ascites in a patient with recurrent pancreatitis from Adderall use. Case Description/Methods: 38-year-old female with attention deficit hyperactive disorder (ADHD), remote alcohol use, and recurrent pancreatitis complicated by pseudocyst and ascites presented with acute on chronic epigastric pain. Her last reported alcohol use was 2 years ago. Home medications included Adderall (amphetamine and dextroamphetamine) and benzodiazepines. Physical examination revealed normal vital signs, severe cachexia and peripheral edema. Abdomen was distended with epigastric tenderness. Pertinent labs included hemoglobin of 10.8g/dl, calcium 7.6mg/dl, albumin 1.7g/dl and a lipase of 462U/l. Bilirubin, transaminases, alkaline phosphatase and INR were normal. Quantitative immunoglobulins, IgG4, triglycerides and thyroid stimulating hormone were within normal limits. Blood alcohol and phosphatidylethanol (PETH) levels were negative. Previous CT scan demonstrated pancreatic head cyst (4.6cm), stable pseudocysts in the head and body, peripancreatic inflammation and large abdominal ascites. MRCP this admission revealed pancreatic head fluid collection decreased in size (2.3cm), consistent with walled off necrosis (Figure). Diagnostic paracentesis was significant for: WBC 93 cells/mm3, PMN 25%, RBC 2050 cells/mm3, protein 1.9g/dl, lactate dehydrogenase 102U/L, amylase 1496U/L and a serum ascites-albumin gradient (SAAG) < 1.1. An endoscopic retrograde cholangiopancreatography (ERCP) was pursued due to suspicion for pancreatic ascites which showed abrupt cut off of the pancreatic duct in the head, without filling of the pancreatic duct in the body or tail likely due to stricture. A pancreatic stent was placed into the ventral pancreatic duct to maintain patency with plan for endoscopic ultrasound examination (EUS) to exclude obstructive pathology. Discussion: Pancreatic ascites is often seen with recurrent pancreatitis commonly of alcoholic etiology. Our patient had recurrent pancreatitis and ascites due to chronic adderall use. While pancreatitis from adderall use is rare, presentation with ascites can pose a diagnostic challenge. Hence, clinicians should familiarize themselves with early diagnosis and endoscopic management which improves prognosis in this rare disease.Figure 1.: MRCP images revealing large volume ascites (red arrow), walled off necrosis in the pancreatic head (yellow arrow) and peripancreatic inflammation (blue arrow).

Pancreatic Trauma with Splenic Preservation (A Case Report)

Trauma to the pancreas is rare, occurring in 0.2 to 3% of abdominal injuries. They are associated with high mortality and morbidity if diagnosis is delayed. Their clinical symptomatology is atypical. Abdominal CT scans can diagnose pancreatic injury and rupture of the main pancreatic duct. It is important that surgeons are aware of the issues and principles of management of pancreatic injury. We report the case of a 33-year-old patient with no previous pathological history. Admitted for a closed abdominal contusion following a road traffic accident with an abdominal impact point without initial loss of consciousness and generalized abdominal contracture. Abdominal CT scan showed a hypodense area in the tail of the pancreas not enhanced after contrast injection, possibly related to a pancreatic fracture and a medium-sized peritoneal effusion. The patient underwent corporo-caudal pancreatectomy with splenic preservation. Postoperative follow-up was favorable. The clinical evolution judged on regular controls was favorable over a period of 2 years. We would like to share a very difficult clinical case and our experience with the support of the literature. This is a challenge to clinicians and surgeons above all.

Emodin Alleviates Sodium Taurocholate-Induced Pancreatic Ductal Cell Damage by Inhibiting the S100A9/VNN1 Signaling Pathway.

Because the pathogenesis of the disease is unclear, the treatment of patients with acute pancreatitis, especially severe acute pancreatitis, is still a major challenge for clinicians. Emodin is an anthraquinone compound extracted from rhubarb that can alleviate the damage to pancreatic ductal epithelial cells induced by adenosine triphosphate, but whether it has a similar protective effect on sodium taurocholate (STC)-stimulated pancreatic ductal cells and the underlying mechanism has not yet been reported. A model of STC-induced HPDE6-C7 human pancreatic ductal epithelial cell injury was established, and then apoptosis and the levels of reactive oxygen species (ROS), glutathione, gamma-glutamylcysteine synthetase, and inflammatory cytokines were assessed in the presence or absence of emodin pretreatment. S100 calcium binding protein A9 (S100A9) and Vanin1 (VNN1) protein expression was also measured. Emodin significantly increased HPDE6-C7 cell viability, inhibited apoptosis and ROS release, and elevated glutathione levels and gamma-glutamylcysteine synthetase activity. Furthermore, emodin downregulated S100A9 and VNN1 protein expression and inhibited the production of inflammatory factors, such as interleukin (IL)-1β, IL-6, IL-8, and IL-18. Emodin attenuates STC-induced pancreatic ductal cell injury possibly by inhibiting S100A9/VNN1-mediated ROS release. This finding provides evidence for the future development of emodin as a therapeutic agent.

Predisposing Factors in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Objective: To ascertain the prevalence of risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography at Isra University Hospital in Hyderabad. Methodology: This descriptive case series study was done at the gastroenterology department of Isra University Hospital, Hyderabad, from September 2018 to March 2020. Patients aged 18 to 50 years, both genders, and diagnosed with post-ERCP pancreatitis were included. All the patients were undergoing an ERCP procedure. The procedure was done under conscious sedation or propofol where needed. The serum amylase level was assessed in all patients at 4 hours. Patients had been considered to have post-ERCP pancreatitis if they developed new or worsening pain of abdomen and had a threefold increase in serum amylase. All the cases were assessed regarding risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography. All the data was recorded in the proforma. Results: The mean age of the patients was 42.7 years. The majority of the patients (65.47%) were females and 32.90% were males. The mean duration of pancreatitis was 3.1 days. Sphincter of Oddi dysfunction was found in 17.1% of cases. Precut papillotomy was done in 18(23.7%) cases. Repeated pancreatic duct injury was seen in 10(13.2%) cases. No significant difference was found in the effect of modifiers on predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis, p-values were almost insignificant. Conclusion: Cannulation attempts, Sphincter of Oddi dysfunction, precut papillotomy, repeated pancreatic duct injection, and female gender were observed to be the predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis.

Case report of an isolated pancreatic transection from low impact blunt abdominal trauma necessitating resective surgery

Introduction and importanceIsolated pancreatic injury from blunt force trauma is an extremely rare entity accounting for less than 1 % of trauma presentations. This case highlights the diagnostic difficulties of identifying a ductal injury and presents a rare instance of an isolated pancreatic transection from a relatively low-impact blunt abdominal trauma.Case presentationA 30 year old lady presented to the emergency department 24 h following a low impact abdominal trauma. CT scan showed a complete pancreatic transection with significant peripancreatic free fluid. MRCP showed the main pancreatic duct to be in alignment on either side of the transection plane, however given the significant surrounding free fluid she was taken to the operating theatre for exploration and resective surgery. Intraoperative findings were that of a complete pancreatic transection involving the main pancreatic duct.DiscussionCurrent management guidelines focus on the correct evaluation of main pancreatic duct integrity. Timely intervention is essential for improving mortality and morbidity outcomes. Reported sensitivity and specificity for imaging modalities vary between studies, likely reflecting inherent challenges in accurately identifying pancreatic duct injuries. Multi-modal assessment is recommended to reach a timely diagnosis and hence, institute the appropriate therapy.ConclusionLow-energy trauma can result in isolated injuries of the pancreas. Multi-modal imaging should be encouraged for evaluation of main pancreatic duct integrity. This will facilitate timely decision making regarding the need for definitive surgery.