AIM: To study the feasibility and safety of middle segmental pancreatectomy (MSP) compared with pancreaticoduodenectomy (PD) and extended distal pancreatectomy (EDP). METHODS: We studied retrospectively 36 cases that ...AIM: To study the feasibility and safety of middle segmental pancreatectomy (MSP) compared with pancreaticoduodenectomy (PD) and extended distal pancreatectomy (EDP). METHODS: We studied retrospectively 36 cases that underwent MSP, 44 patients who underwent PD, and 26 who underwent EDP with benign or low-grade malignant lesions in the mid-portion of the pancreas, between April 2003 and December 2009 in Ruijin Hospital. The perioperative outcomes and long-term outcomes of MSP were compared with those of EDP and PD. Periop-erative outcomes included operative time, intraoperative hemorrhage, transfusion, pancreatic fistula, intraabdominal abscess/infection, postoperative bleeding, reoperation, mortality, and postoperative hospital time. Long-term outcomes, including tumor recurrence, newonset diabetes mellitus (DM), and pancreatic exocrine insufficiency, were evaluated. RESULTS: Intraoperative hemorrhage was 316.1 ± 309.6, 852.2 ± 877.8 and 526.9 ± 414.5 mL for the MSP, PD and EDP groups, respectively (P < 0.05). The mean postoperative daily fasting blood glucose level was significantly lower in the MSP group than in the EDP group (6.3 ± 1.5 mmol/L vs 7.3 ± 1.5 mmol/L, P < 0.05). The rate of pancreatic fistula was higher in the MSP group than in the PD group (42% vs 20.5%, P = 0.039), all of the fistulas after MSP corresponded to grade A (9/15) or B (6/15) and were sealed following conservative treatment. There was no significant difference in the mean postoperative hospital stay between the MSP group and the other two groups. After a mean follow-up of 44 mo, no tumor recurrences were found, only one patient (2.8%) in the MSP group vs five (21.7%) in the EDP group developed new-onset insulin-dependent DM postoperatively (P = 0.029). Moreover, significantly fewer patients in the MSP group than in the PD (0% vs 33.3%, P < 0.001) and EDP (0% vs 21.7%, P = 0.007) required enzyme substitution. CONCLUSION: MSP is a safe and organ-preserving option for benign or low-grade malignant lesions in the neck and proximal bod展开更多
This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases a...This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases associated with exocrine pancreatic insufficiency(EPI)which are of common interest to internists/gastroenterologists,oncologists and surgeons,fully aware that EPI may also occur together with many other diseases,but less frequently.A preliminary manuscript based on an extended literature search(Medline/PubMed,Cochrane Library and Google Scholar)of published reports was prepared,and key recommendations were proposed.The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012.Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached.The final draft of the manuscript was then sent to the AISP Council for approval and/or modification.All concerned parties approved the final version of the manuscript in June 2013.展开更多
AIM:To evaluate long-term endocrine and exocrine pancreatic function,quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis(SAP).METHODS:Patients prospectively included in 20...AIM:To evaluate long-term endocrine and exocrine pancreatic function,quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis(SAP).METHODS:Patients prospectively included in 2001-2005 were followed-up after 42(36-53)mo.Pancreatic function was evaluated with laboratory tests,the oral glucose tolerance test(OGTT),fecal elastase-1 and a questionnaire.Short Form(SF)-36,was completed.RESULTS:Fourteen patients with a history of SAP and 26 with mild acute pancreatitis were included.Plasma glucose after OGTT was higher after SAP(9.2 mmol/L vs 7.0 mmol/L,P=0.044).Diabetes mellitus or impaired glucose tolerance in fasting plasma glucose and/or 120 min plasma glucose were more common in SAP patients(11/14 vs 11/25,P=0.037).Sick leave,time until the patients could take up recreational activities and time until they had recovered were all longer after SAP(P <0.001).No significant differences in SF-36 were seen between the groups,or when comparing with age and gender matched reference groups.Total hospital costs,including primary care,follow-up and treatment of complications,were higher after SAP(median€16572 vs €5000,P<0.001).CONCLUSION:Endocrine pancreatic function was affected,especially after severe disease.SAP requires greater resource use with long recovery,but most patients regained a good quality of life.展开更多
Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of ...Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of digestive enzymes by pancreatic acinar cells,a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food.Failure in any of these steps may result in pancreatic exocrine insufficiency,which leads to steatorrhea,weight loss and malnutrition-related complications,such as osteoporosis.Methods evaluating digestion,such as fecal fat quantification and the13C-mixed triglycerides test,are the most accurate tests for pancreatic exocrine insufficiency,but the probability of the diagnosis can also be estimated based on symptoms,signs of malnutrition in blood tests,fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging.Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption,dietary consultation,enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment.Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicro-spheres during meals.The dose should be in proportion to the fat content of the meal,usually 40-50000 lipase units per main meal,and half the dose is required for a snack.In cases that do not respond to initial treatment,the doses can be doubled,and proton inhibitors can be added to the treatment.This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.展开更多
AIM:To evaluate the effects of disease severity and necrosis on organ dysfunctions in acute pancreatitis(AP).METHODS:One hundred and nine patients treated as AP between March 2003 and September 2007 with at least 6 mo...AIM:To evaluate the effects of disease severity and necrosis on organ dysfunctions in acute pancreatitis(AP).METHODS:One hundred and nine patients treated as AP between March 2003 and September 2007 with at least 6 mo follow-up were included.Patients were classified according to severity of the disease,necrosis ratio and localization.Subjective clinical evaluation and fecal pancreatic elastase-Ⅰ(FPE-Ⅰ)were used for exocrine dysfunction evaluation,and oral glucose tolerance test was completed for endocrine dysfunction.The correlation of disease severity,necrosis ratio and localization with exocrine and endocrine dysfunction were investigated.RESULTS:There were 58 male and 51 female patients,and mean age was 56.5±15.7.Of the patients,35.8%had severe AP(SAP)and 27.5%had pancreatic necrosis.Exocrine dysfunction was identified in 13.7%of the patients[17.9%were in SAP,11.4%were in mild AP(MAP)]and 34.7%of all of the patients had endocrine dysfunction(56.4%in SAP and 23.2%in MAP).In patients with SAP and necrotizing AP(NAP),FPE-Ⅰlevels were lower than the others(P<0.05 and0.001 respectively)and in patients having pancreatic head necrosis or near total necrosis,FPE-1 levels were lower than 200μg/g stool.Forty percent of the patients who had undergone necrosectomy developed exocrine dysfunction.Endocrine dysfunction was more significant in patients with SAP and NAP(P<0.001).All of the patients in the necrosectomy group had endocrine dysfunction.CONCLUSION:Patients with SAP,NAP,pancreatic head necrosis and necrosectomy should be followed for pancreatic functions.展开更多
AIM:To obtain reference values for pancreatic flow output rate(PFR)and peak time(PT)in healthy volunteers and chronic pancreatitis(CP);to correlate quantification of secretin enhanced magnetic resonance cholangiopancr...AIM:To obtain reference values for pancreatic flow output rate(PFR)and peak time(PT)in healthy volunteers and chronic pancreatitis(CP);to correlate quantification of secretin enhanced magnetic resonance cholangiopancreatography(SMRCP)of pancreatic fluid output following secretin with fecal elastase-1(FE-1)tests.METHODS:The present study includes 53 subjects comprised of 17 healthy individuals and 36 patients with CP from April 2011 to January 2013.The 36 patients with CP were divided into three groups of mild CP(n=14),moderate CP(n=19)and advanced CP(n=3)by M-ANNHEIM classification for CP..Fifty-three cases underwent FE-1 test and magnetic resonance imaging using 3.0 T-device(Signa EXCITE,GE Healthcare).Coronal T2-weighted single-shot turbo spin-echo,spiratory triggered,covering the papillae,duodenum and small bowel.MRCP was performed with a heavily T2-weighted fat-suppressed long TE HASTE sequence (thick slab 2D MRCP sequence),repeated every 2 min up to 11 min after 0.1 mL/kg secretin injection(Secrelux,Sanochemia,Germany).FE-1 test used sandwich enzyme-linked immunosorbent assay(ELISA)test(ScheBo.Tech,Germany).RESULTS:A good linear correlation showed between the calculated volume and the actual volume by Phantom experiments.Fifty-three paired Quantification of secretin enhanced magnetic resonance cholangiopancreatography(MRCPQ)and FE-1 data sets were analyzed.The mean FE-1 of 53 cases was 525.41±94.44μg/g for 17 healthy volunteers,464.95±136.13μg/g for mild CP,301.55±181.55μg/g for moderate CP,229.30±146.60μg/g for advanced CP.Also,there was statistically significant difference in FE-1(P=0.0001)between health and CP.The mean values of PFR and PT were 8.18±1.11 mL/min,5.76±1.71 min for normal;7.27±2.04 mL/min,7.71±2.55 min for mild CP;4.98±2.57 mL/min,9.10±3.00 min for moderate CP;4.13±1.83 mL/min,12.33±1.55 min for advanced CP.Further,statistically significant difference in PFR(P=0.0001)and PT(P=0.0001)was observed between health and CP.Besides,there was correlation(r=0.79)and consistency(K=0.6)展开更多
Magnetic resonance imaging(MRI)techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pa...Magnetic resonance imaging(MRI)techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pancreatitis(CP)patients.Standard MRI including fat-suppressed T1-weighted and T2-weighted imaging techniques reveal decreased signal and glandular atrophy of the pancreas in CP.In contrast-enhanced MRI of the pancreas in CP the pancreatic signal is usually reduced and delayed due to decreased perfusion as a result of chronic inflammation and fibrosis.Thus,morphological changes of the ductal system can be assessed by magnetic resonance cholangiopancreatography(MRCP).Furthermore,secretin-stimulated MRCP is a valuable technique to evaluate side branch pathology and the exocrine function of the pancreas and diffusion weighted imaging can be used to quantify both parenchymal fibrotic changes and the exocrine function of the pancreas.These standard and advanced MRI techniques are supplementary techniques to reveal morphological and functional changes of the pancreas in CP.Recently,spectroscopy has been used for assessment of metabolite concentrations in-vivo in different tissues and may have the potential to offer better tissue characterization of the pancreas.Hence,the purpose of the present review is to provide an update on standard and advanced MRI techniques of the pancreas in CP.展开更多
The exocrine structure is significantly affected by diabetes because of endocrine structure-function disorder within the pancreas. Exocrine pancreatic dysfunction (EPD) is the general name of the malabsorption process...The exocrine structure is significantly affected by diabetes because of endocrine structure-function disorder within the pancreas. Exocrine pancreatic dysfunction (EPD) is the general name of the malabsorption process resulting from inadequate production, release, decreased activation, and/or insufficient degradation of enzymes required for digestion from pancreatic acinar cells. It is important to diagnose patients early and correctly, since there may be both macro- and micro-nutrient deficiency in EPD. In this paper, EPD, the diabetes- EPD relationship, and the predictive, effective factors affecting the emergence of EPD are briefly explained and summarized with contemporary literature and our experienced based on clinical, lab, and radiological findings.展开更多
AIM:To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods. METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. Afte...AIM:To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods. METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. After 4 wk ligation, a total of 36 piglets were divided randomly into four groups. The piglets in the control group underwent laparotomy only; the others were treated by three anastomoses: (1) end-to-end pancreaticojejunostomy invagination (EEPJ); (2) end-to-side duct-to- mucosa sutured anastomosis (ESPJ); or (3) binding pancreaticojejunostomy (BPJ). Anastomotic patency was assessed after 8 wk by body weight gain, intrapancreatic ductal pressure, pancreatic exocrine function secretin test, pancreatography, and macroscopic and histologic features of the anastomotic site. RESULTS: The EEPJ group had significantly slower weight gain than the ESPJ and BPJ groups on postoperative weeks 6 and 8 (P < 0.05). The animals in both the ESPJ and BPJ groups had a similar body weight gain.Intrapancreatic ductal pressure was similar in ESPJ and BPJ. However, pressure in EEPJ was significantly higher than that in ESPJ and BPJ (P < 0.05). All three functional parameters, the secretory volume, the flow rate of pancreatic juice, and bicarbonate concentration, were significantly higher in ESPJ and BPJ as compared to EEPJ (P < 0.05). However, the three parameters were similar in ESPJ and BPJ. Pancreatography performed after EEPJ revealed dilation and meandering of the main pancreatic duct, and the anastomotic site exhibited a variable degree of occlusion, and even blockage. Pancreatography of ESPJ and BPJ, however, showed normal ductal patency. Histopathology showed that the intestinal mucosa had fused with that of the pancreatic duct, with a gradual and continuous change from one to the other. For EEPJ, the portion of the pancreatic stump protruding into the jejunal lumen was largely replaced by cicatricial fibrous tissue. CONCLUSION: A mucosa-to-mucosa pancreatico- jejunostomy is the best choice for anastomotic patency when展开更多
Pancreatic exocrine insufficiency(PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condi...Pancreatic exocrine insufficiency(PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1(FE-1) stool test is widely available and has been shown to be as effective as the 13 C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.展开更多
AIM: To determine the prevalence and time course of pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis.
Exocrine pancreatic insufficiency(EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and ...Exocrine pancreatic insufficiency(EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases(diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin(CCK); celiac or inflammatory bowel disease(IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery(asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy(PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI(66%-92%). EPI occurs in patients with type 1(26%-57%) or type 2 diabetes(20%-36%) and is typically mild to moderate; by definition, all patients with type 3 c(pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease(4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD(14%-74%) and up to 100% of gastrointestinal surgery patients(47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.展开更多
Intraductal papillary mucinous neoplasms(IPMNs) can involve the main pancreatic duct(MD-IPMNs) or its secondary branches(BD-IPMNs) in a segmental of multifocal/diffuse fashion.Growing evidence indicates that BDIPMNs a...Intraductal papillary mucinous neoplasms(IPMNs) can involve the main pancreatic duct(MD-IPMNs) or its secondary branches(BD-IPMNs) in a segmental of multifocal/diffuse fashion.Growing evidence indicates that BDIPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively.For surgery,clarification is required on:(1) when to resect an IPMN;(2) which type of resection should be performed;and(3) how much pancreas should be resected.In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations.However,oncological radicality is of paramount importance,and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs.In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed,evaluating perioperative and long-term outcomes.The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.展开更多
Ribonucleic acid （RNA） was previously thought to remain inside cells as an intermediate between genes and proteins during translation. However, it is now estimated that 98% of the mammalian genomic output is transcr...Ribonucleic acid （RNA） was previously thought to remain inside cells as an intermediate between genes and proteins during translation. However, it is now estimated that 98% of the mammalian genomic output is transcribed as noncoding RNAs, which are involved in diverse gene expression regulatory mechanisms and can be transferred from one cell to another through extracellular communication. For instance, microRNAs are 22-nucleotide-long noncoding RNAs that are generated by endonuclease cleavage of precursors inside the cells and are secreted as extracellular microRNAs to regulate target cell posttranscriptional gene expression via RNA interference. We and others have shown that different populations of microRNAs are expressed in distinct regions of the human epididymis and regulate the expression of target genes that are involved in the control of male fertility as indicated by knock-out mouse models. Importantly, some microRNAs, including the microRNA-888 （miR-888） cluster that is exclusively expressed in the reproductive system of human and nonhuman primates, are released in the sperm-surrounding fluid in the epididymis via extracellular vesicles, the so-called epididymosomes. In addition to interacting with the membrane of maturing spermatozoa, these extracellular vesicles containing microRNAs communicate with epithelial cells located downstream from their release site, suggesting a role in the luminal exocrine control of epididymal functions. Apart from their potential roles as mediators of intercellular communication within the epididymis, these extracellular microRNAs are potent molecular targets for the noninvasive diagnosis of male infertility.展开更多
基金Supported by The Ministry of Health Sector Funds of China,No. 201002020
文摘AIM: To study the feasibility and safety of middle segmental pancreatectomy (MSP) compared with pancreaticoduodenectomy (PD) and extended distal pancreatectomy (EDP). METHODS: We studied retrospectively 36 cases that underwent MSP, 44 patients who underwent PD, and 26 who underwent EDP with benign or low-grade malignant lesions in the mid-portion of the pancreas, between April 2003 and December 2009 in Ruijin Hospital. The perioperative outcomes and long-term outcomes of MSP were compared with those of EDP and PD. Periop-erative outcomes included operative time, intraoperative hemorrhage, transfusion, pancreatic fistula, intraabdominal abscess/infection, postoperative bleeding, reoperation, mortality, and postoperative hospital time. Long-term outcomes, including tumor recurrence, newonset diabetes mellitus (DM), and pancreatic exocrine insufficiency, were evaluated. RESULTS: Intraoperative hemorrhage was 316.1 ± 309.6, 852.2 ± 877.8 and 526.9 ± 414.5 mL for the MSP, PD and EDP groups, respectively (P < 0.05). The mean postoperative daily fasting blood glucose level was significantly lower in the MSP group than in the EDP group (6.3 ± 1.5 mmol/L vs 7.3 ± 1.5 mmol/L, P < 0.05). The rate of pancreatic fistula was higher in the MSP group than in the PD group (42% vs 20.5%, P = 0.039), all of the fistulas after MSP corresponded to grade A (9/15) or B (6/15) and were sealed following conservative treatment. There was no significant difference in the mean postoperative hospital stay between the MSP group and the other two groups. After a mean follow-up of 44 mo, no tumor recurrences were found, only one patient (2.8%) in the MSP group vs five (21.7%) in the EDP group developed new-onset insulin-dependent DM postoperatively (P = 0.029). Moreover, significantly fewer patients in the MSP group than in the PD (0% vs 33.3%, P < 0.001) and EDP (0% vs 21.7%, P = 0.007) required enzyme substitution. CONCLUSION: MSP is a safe and organ-preserving option for benign or low-grade malignant lesions in the neck and proximal bod
基金Supported by An unrestricted grant from Abbott Italia s.r.l
文摘This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas(AISP).We covered the main diseases associated with exocrine pancreatic insufficiency(EPI)which are of common interest to internists/gastroenterologists,oncologists and surgeons,fully aware that EPI may also occur together with many other diseases,but less frequently.A preliminary manuscript based on an extended literature search(Medline/PubMed,Cochrane Library and Google Scholar)of published reports was prepared,and key recommendations were proposed.The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012.Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached.The final draft of the manuscript was then sent to the AISP Council for approval and/or modification.All concerned parties approved the final version of the manuscript in June 2013.
基金Supported by Skane county council research and development foundation
文摘AIM:To evaluate long-term endocrine and exocrine pancreatic function,quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis(SAP).METHODS:Patients prospectively included in 2001-2005 were followed-up after 42(36-53)mo.Pancreatic function was evaluated with laboratory tests,the oral glucose tolerance test(OGTT),fecal elastase-1 and a questionnaire.Short Form(SF)-36,was completed.RESULTS:Fourteen patients with a history of SAP and 26 with mild acute pancreatitis were included.Plasma glucose after OGTT was higher after SAP(9.2 mmol/L vs 7.0 mmol/L,P=0.044).Diabetes mellitus or impaired glucose tolerance in fasting plasma glucose and/or 120 min plasma glucose were more common in SAP patients(11/14 vs 11/25,P=0.037).Sick leave,time until the patients could take up recreational activities and time until they had recovered were all longer after SAP(P <0.001).No significant differences in SF-36 were seen between the groups,or when comparing with age and gender matched reference groups.Total hospital costs,including primary care,follow-up and treatment of complications,were higher after SAP(median€16572 vs €5000,P<0.001).CONCLUSION:Endocrine pancreatic function was affected,especially after severe disease.SAP requires greater resource use with long recovery,but most patients regained a good quality of life.
文摘Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of digestive enzymes by pancreatic acinar cells,a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food.Failure in any of these steps may result in pancreatic exocrine insufficiency,which leads to steatorrhea,weight loss and malnutrition-related complications,such as osteoporosis.Methods evaluating digestion,such as fecal fat quantification and the13C-mixed triglycerides test,are the most accurate tests for pancreatic exocrine insufficiency,but the probability of the diagnosis can also be estimated based on symptoms,signs of malnutrition in blood tests,fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging.Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption,dietary consultation,enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment.Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicro-spheres during meals.The dose should be in proportion to the fat content of the meal,usually 40-50000 lipase units per main meal,and half the dose is required for a snack.In cases that do not respond to initial treatment,the doses can be doubled,and proton inhibitors can be added to the treatment.This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.
基金Supported by Uludag University Resources Committee
文摘AIM:To evaluate the effects of disease severity and necrosis on organ dysfunctions in acute pancreatitis(AP).METHODS:One hundred and nine patients treated as AP between March 2003 and September 2007 with at least 6 mo follow-up were included.Patients were classified according to severity of the disease,necrosis ratio and localization.Subjective clinical evaluation and fecal pancreatic elastase-Ⅰ(FPE-Ⅰ)were used for exocrine dysfunction evaluation,and oral glucose tolerance test was completed for endocrine dysfunction.The correlation of disease severity,necrosis ratio and localization with exocrine and endocrine dysfunction were investigated.RESULTS:There were 58 male and 51 female patients,and mean age was 56.5±15.7.Of the patients,35.8%had severe AP(SAP)and 27.5%had pancreatic necrosis.Exocrine dysfunction was identified in 13.7%of the patients[17.9%were in SAP,11.4%were in mild AP(MAP)]and 34.7%of all of the patients had endocrine dysfunction(56.4%in SAP and 23.2%in MAP).In patients with SAP and necrotizing AP(NAP),FPE-Ⅰlevels were lower than the others(P<0.05 and0.001 respectively)and in patients having pancreatic head necrosis or near total necrosis,FPE-1 levels were lower than 200μg/g stool.Forty percent of the patients who had undergone necrosectomy developed exocrine dysfunction.Endocrine dysfunction was more significant in patients with SAP and NAP(P<0.001).All of the patients in the necrosectomy group had endocrine dysfunction.CONCLUSION:Patients with SAP,NAP,pancreatic head necrosis and necrosectomy should be followed for pancreatic functions.
文摘AIM:To obtain reference values for pancreatic flow output rate(PFR)and peak time(PT)in healthy volunteers and chronic pancreatitis(CP);to correlate quantification of secretin enhanced magnetic resonance cholangiopancreatography(SMRCP)of pancreatic fluid output following secretin with fecal elastase-1(FE-1)tests.METHODS:The present study includes 53 subjects comprised of 17 healthy individuals and 36 patients with CP from April 2011 to January 2013.The 36 patients with CP were divided into three groups of mild CP(n=14),moderate CP(n=19)and advanced CP(n=3)by M-ANNHEIM classification for CP..Fifty-three cases underwent FE-1 test and magnetic resonance imaging using 3.0 T-device(Signa EXCITE,GE Healthcare).Coronal T2-weighted single-shot turbo spin-echo,spiratory triggered,covering the papillae,duodenum and small bowel.MRCP was performed with a heavily T2-weighted fat-suppressed long TE HASTE sequence (thick slab 2D MRCP sequence),repeated every 2 min up to 11 min after 0.1 mL/kg secretin injection(Secrelux,Sanochemia,Germany).FE-1 test used sandwich enzyme-linked immunosorbent assay(ELISA)test(ScheBo.Tech,Germany).RESULTS:A good linear correlation showed between the calculated volume and the actual volume by Phantom experiments.Fifty-three paired Quantification of secretin enhanced magnetic resonance cholangiopancreatography(MRCPQ)and FE-1 data sets were analyzed.The mean FE-1 of 53 cases was 525.41±94.44μg/g for 17 healthy volunteers,464.95±136.13μg/g for mild CP,301.55±181.55μg/g for moderate CP,229.30±146.60μg/g for advanced CP.Also,there was statistically significant difference in FE-1(P=0.0001)between health and CP.The mean values of PFR and PT were 8.18±1.11 mL/min,5.76±1.71 min for normal;7.27±2.04 mL/min,7.71±2.55 min for mild CP;4.98±2.57 mL/min,9.10±3.00 min for moderate CP;4.13±1.83 mL/min,12.33±1.55 min for advanced CP.Further,statistically significant difference in PFR(P=0.0001)and PT(P=0.0001)was observed between health and CP.Besides,there was correlation(r=0.79)and consistency(K=0.6)
基金Supported by The Danish Council for Strategic Research
文摘Magnetic resonance imaging(MRI)techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pancreatitis(CP)patients.Standard MRI including fat-suppressed T1-weighted and T2-weighted imaging techniques reveal decreased signal and glandular atrophy of the pancreas in CP.In contrast-enhanced MRI of the pancreas in CP the pancreatic signal is usually reduced and delayed due to decreased perfusion as a result of chronic inflammation and fibrosis.Thus,morphological changes of the ductal system can be assessed by magnetic resonance cholangiopancreatography(MRCP).Furthermore,secretin-stimulated MRCP is a valuable technique to evaluate side branch pathology and the exocrine function of the pancreas and diffusion weighted imaging can be used to quantify both parenchymal fibrotic changes and the exocrine function of the pancreas.These standard and advanced MRI techniques are supplementary techniques to reveal morphological and functional changes of the pancreas in CP.Recently,spectroscopy has been used for assessment of metabolite concentrations in-vivo in different tissues and may have the potential to offer better tissue characterization of the pancreas.Hence,the purpose of the present review is to provide an update on standard and advanced MRI techniques of the pancreas in CP.
文摘The exocrine structure is significantly affected by diabetes because of endocrine structure-function disorder within the pancreas. Exocrine pancreatic dysfunction (EPD) is the general name of the malabsorption process resulting from inadequate production, release, decreased activation, and/or insufficient degradation of enzymes required for digestion from pancreatic acinar cells. It is important to diagnose patients early and correctly, since there may be both macro- and micro-nutrient deficiency in EPD. In this paper, EPD, the diabetes- EPD relationship, and the predictive, effective factors affecting the emergence of EPD are briefly explained and summarized with contemporary literature and our experienced based on clinical, lab, and radiological findings.
文摘AIM:To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods. METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. After 4 wk ligation, a total of 36 piglets were divided randomly into four groups. The piglets in the control group underwent laparotomy only; the others were treated by three anastomoses: (1) end-to-end pancreaticojejunostomy invagination (EEPJ); (2) end-to-side duct-to- mucosa sutured anastomosis (ESPJ); or (3) binding pancreaticojejunostomy (BPJ). Anastomotic patency was assessed after 8 wk by body weight gain, intrapancreatic ductal pressure, pancreatic exocrine function secretin test, pancreatography, and macroscopic and histologic features of the anastomotic site. RESULTS: The EEPJ group had significantly slower weight gain than the ESPJ and BPJ groups on postoperative weeks 6 and 8 (P < 0.05). The animals in both the ESPJ and BPJ groups had a similar body weight gain.Intrapancreatic ductal pressure was similar in ESPJ and BPJ. However, pressure in EEPJ was significantly higher than that in ESPJ and BPJ (P < 0.05). All three functional parameters, the secretory volume, the flow rate of pancreatic juice, and bicarbonate concentration, were significantly higher in ESPJ and BPJ as compared to EEPJ (P < 0.05). However, the three parameters were similar in ESPJ and BPJ. Pancreatography performed after EEPJ revealed dilation and meandering of the main pancreatic duct, and the anastomotic site exhibited a variable degree of occlusion, and even blockage. Pancreatography of ESPJ and BPJ, however, showed normal ductal patency. Histopathology showed that the intestinal mucosa had fused with that of the pancreatic duct, with a gradual and continuous change from one to the other. For EEPJ, the portion of the pancreatic stump protruding into the jejunal lumen was largely replaced by cicatricial fibrous tissue. CONCLUSION: A mucosa-to-mucosa pancreatico- jejunostomy is the best choice for anastomotic patency when
文摘Pancreatic exocrine insufficiency(PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1(FE-1) stool test is widely available and has been shown to be as effective as the 13 C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.
文摘AIM: To determine the prevalence and time course of pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis.
文摘Exocrine pancreatic insufficiency(EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases(diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin(CCK); celiac or inflammatory bowel disease(IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery(asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy(PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI(66%-92%). EPI occurs in patients with type 1(26%-57%) or type 2 diabetes(20%-36%) and is typically mild to moderate; by definition, all patients with type 3 c(pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease(4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD(14%-74%) and up to 100% of gastrointestinal surgery patients(47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.
文摘Intraductal papillary mucinous neoplasms(IPMNs) can involve the main pancreatic duct(MD-IPMNs) or its secondary branches(BD-IPMNs) in a segmental of multifocal/diffuse fashion.Growing evidence indicates that BDIPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively.For surgery,clarification is required on:(1) when to resect an IPMN;(2) which type of resection should be performed;and(3) how much pancreas should be resected.In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations.However,oncological radicality is of paramount importance,and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs.In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed,evaluating perioperative and long-term outcomes.The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.
文摘Ribonucleic acid （RNA） was previously thought to remain inside cells as an intermediate between genes and proteins during translation. However, it is now estimated that 98% of the mammalian genomic output is transcribed as noncoding RNAs, which are involved in diverse gene expression regulatory mechanisms and can be transferred from one cell to another through extracellular communication. For instance, microRNAs are 22-nucleotide-long noncoding RNAs that are generated by endonuclease cleavage of precursors inside the cells and are secreted as extracellular microRNAs to regulate target cell posttranscriptional gene expression via RNA interference. We and others have shown that different populations of microRNAs are expressed in distinct regions of the human epididymis and regulate the expression of target genes that are involved in the control of male fertility as indicated by knock-out mouse models. Importantly, some microRNAs, including the microRNA-888 （miR-888） cluster that is exclusively expressed in the reproductive system of human and nonhuman primates, are released in the sperm-surrounding fluid in the epididymis via extracellular vesicles, the so-called epididymosomes. In addition to interacting with the membrane of maturing spermatozoa, these extracellular vesicles containing microRNAs communicate with epithelial cells located downstream from their release site, suggesting a role in the luminal exocrine control of epididymal functions. Apart from their potential roles as mediators of intercellular communication within the epididymis, these extracellular microRNAs are potent molecular targets for the noninvasive diagnosis of male infertility.
