Recent Articles on Pancreatobiliary #Pathology – 2020-07-20

These are the recent articles on Pancreatobiliary Pathology:

To see all journal watch articles please visit: http://pbpath.org/journal-watch-upcoming-issue/

New Pancreas Articles


  • Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial

Lancet (London, England) 2020 Jul;396(10245):167-176

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32682482

BACKGROUND: It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis.
METHODS: In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133.
FINDINGS: Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group.
INTERPRETATION: In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis.
FUNDING: The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.

doi: https://doi.org/10.1016/S0140-6736(20)30539-0



  • The Influence of Gut and Tumor Microbiome on Pancreatic Cancer Outcomes

Gastroenterology 2020 Jul;():

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32681921

Pancreatic cancer is a highly fatal malignancy with overall 5-year survival of under 10%, within the context of increasing incidence rates worldwide (Clin Gastroenterol Hepatol 2020 Mar 5. pii: S1542-3565(20)30276-7 [Epub ahead of print]). Even among the minority of patients who are diagnosed with early stage disease and undergo resection, most survive less than 5 years (short-term survivors (STS), however a unique subset of patients survive >5 years post-surgery coined long-term survivors (LTS) (Clin Cancer Res 2015;21:1944-1950). Recent human and mice studies suggests that the gut microbiome may play a role in pancreatic cancer initiation and progression through immune system modulation (Cancer Discov 2018;8:403-416, Gastroenterology 2018;155:33-37). Intramural bacteria can also be detected within pancreatic tumor tissue and predict sensitivity to systemic cancer therapy (Science 2017;357:1156-1160). Riquelme et al. addressed this topic in work conducted at the University of Texas MD Anderson Cancer Center (MDACC) and Johns Hopkins Hospital (JHH) to study the association between tumor microbiome and survival using the pancreatic tumor microbiome of LTS vs. STS (Cell 2019;178:795-806).

doi: https://doi.org/10.1053/j.gastro.2020.07.008



  • Electrochemotherapy with Irreversible Electroporation and FOLFIRINOX Improves Survival in Murine Models of Pancreatic Adenocarcinoma

Annals of surgical oncology 2020 Jul;():

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32681477

BACKGROUND: Previously published work has demonstrated that combining gemcitabine with irreversible electroporation (IRE) results in increased drug delivery to pancreatic adenocarcinoma cells in vivo. This study assessed the efficacy of IRE + gemcitabine and IRE + FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin), the impact of the superior regimen on survival, and the safety of electrochemotherapy in human subjects.
METHODS: Histologic analysis was performed after in vitro and in vivo treatment of S2013 and Panc-1 pancreatic cancer cells and S2013 orthotopic tumors, respectively, and levels of apoptotic machinery and cell cycle proteins were evaluated using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) and Western blot.
RESULTS: Electrochemotherapy (ECT) with IRE and FOLFIRINOX resulted in increased tumor cells apoptosis compared with gemcitabine, gemcitabine + IRE, and FOLFIRINOX alone, and significantly improved overall survival when compared with mice treated with IRE or FOLFIRINOX. Increased tumor cell apoptosis, caspase-3 mRNA, active caspase-3 protein, and decreased cell proliferation were noted at the time of death or euthanasia in the ECT group compared with folinic acid alone. In five patients, ECT with either FOLFIRINOX or gemcitabine was well-tolerated and resulted in no dose-limiting toxicities.
CONCLUSIONS: ECT thus results in synergistic antitumor activity compared with either treatment modality used alone, resulting in increased tumor cell apoptosis as well as decreased tumor cell proliferation and improved overall survival. Pilot data suggest that ECT represents a promising modality for the treatment of patients with locally advanced pancreatic cancer.
TRIAL REGISTRATION: The human subject portion of this work was conducted as part of an investigator-initiated clinical trial at the University of Louisville (NCT03484299).

doi: https://doi.org/10.1245/s10434-020-08782-2



  • Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project

Pancreatology : official journal of the International Association of Pancreatology (IAP) … [et al.] 2020 Jul;():

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32680728

BACKGROUND: Several studies comparing internal and external stents have been conducted with the aim of reducing pancreatic fistula after PD. There is still no consensus, however, on the appropriate use of pancreatic stents for prevention of pancreatic fistula. This multicenter large cohort study aims to evaluate whether internal or external pancreatic stents are more effective in reduction of clinically relevant pancreatic fistula after pancreaticoduodenectomy (PD).
METHODS: We reviewed 3149 patients (internal stent n = 1,311, external stent n = 1838) who underwent PD at 20 institutions in Japan and Korea between 2007 and 2013. Propensity score matched analysis was used to minimize bias from nonrandomized treatment assignment. The primary endpoint was the incidence of clinically relevant pancreatic fistula. This study was registered on the UMIN Clinical Trials Registry (UMIN000032402).
RESULTS: After propensity score matched analysis, clinically relevant pancreatic fistula occurred in more patients in the external stents group (280 patients, 28.7%) than in patients in the internal stents group (126 patients, 12.9%) (OR 2.713 [95% CI, 2.139-3.455]; P < 0.001). In subset analysis of a high-risk group with soft pancreas and no dilatation of the pancreatic duct, clinically relevant pancreatic fistula occurred in 90 patients (18.8%) in internal stents group and 183 patients (35.4%) in external stents group. External stents were significantly associated with increased risk for clinically relevant pancreatic fistula (OR 2.366 [95% CI, 1.753-3.209]; P < 0.001).
CONCLUSION: Propensity score matched analysis showed that, regarding clinically relevant pancreatic fistula after PD, internal stents are safer than external stents for pancreaticojejunostomy.

doi: https://doi.org/10.1016/j.pan.2020.06.014


New GallBladder Articles


  • Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

BMC gastroenterology 2020 Jul;20(1):229

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32680467

BACKGROUND: Endoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.
METHODS: We analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990-2019), Embase (1990-2019), and Cochrane (1990-2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.
RESULTS: We retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27-0.53; P < 0.00001; I2 = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26-0.38; P < 0.00001; I2 = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52-1.02; P = 0.07; I2 = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24-0.32; P < 0.00001; I2 = 17%).
CONCLUSION: Early cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

doi: https://doi.org/10.1186/s12876-020-01376-y


New BileDuct Articles


  • Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

BMC gastroenterology 2020 Jul;20(1):229

PubMed: https://www.ncbi.nlm.nih.gov/pubmed/?term=32680467

BACKGROUND: Endoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.
METHODS: We analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990-2019), Embase (1990-2019), and Cochrane (1990-2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.
RESULTS: We retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27-0.53; P < 0.00001; I2 = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26-0.38; P < 0.00001; I2 = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52-1.02; P = 0.07; I2 = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24-0.32; P < 0.00001; I2 = 17%).
CONCLUSION: Early cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

doi: https://doi.org/10.1186/s12876-020-01376-y


New Ampulla Articles

Today there is no new Ampulla Article.

To see all journal watch articles please visit: http://pbpath.org/journal-watch-upcoming-issue/