Traumatic pancreatitis

Still water run deep: Therapeutic TP effect of ucMSC-Ex via regulating mTOR to enhance autophagy

Our previous study confirmed that umbilical cord mesenchymal stem cells-exosomes (ucMSC-Ex) inhibit apoptosis of pancreatic acinar cells to exert protective effects. However, the relationship between apoptosis and autophagy in traumatic pancreatitis (TP) has rarely been reported. We dissected the transcriptomics after pancreatic trauma and ucMSC-Ex therapy by high-throughput sequencing. Additionally, we used rapamycin and MHY1485 to regulate mTOR. HE, inflammatory factors and pancreatic enzymatic assays were used to comprehensively determine the local versus systemic injury level, fluorescence staining and electron microscopy were used to detect the effect of autophagy, and observe the expression levels of autophagy-related markers at the gene and protein levels. High-throughput sequencing identified that autophagy played a crucial role in the pathophysiological process of TP and ucMSC-Ex therapy. The results of electron microscopy, immunofluorescence staining, polymerase chain reaction and western blot suggested that therapeutic effect of ucMSC-Ex was mediated by activation of autophagy in pancreatic acinar cells through inhibition of mTOR. ucMSC-Ex can attenuate pancreas injury by inhibiting mTOR to regulate acinar cell autophagy after TP. Future studies will build on the comprehensive sequencing of RNA carried by ucMSC-Ex to predict and verify specific non-coding RNA.

From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries

BACKGROUND

Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries.

METHODS

We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed.

RESULTS

We identified 1553 patients (NOP ​= ​1092; OP ​= ​461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR ​= ​1.47; p ​= ​0.03), intraabdominal abscesses (aOR ​= ​2.7; p ​< ​0.01), pancreatic pseudocyst (aOR ​= ​2.4; p ​= ​0.04), and need for percutaneous or endoscopic management (aOR ​= ​5.8; p ​< ​0.001).

CONCLUSION

Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.

Diagnosis and Contemporary Management of Necrotizing Pancreatitis

BACKGROUND

Acute pancreatitis is a common diagnosis which requires a prompt diagnosis and management by a multidisciplinary team with often general surgeons as the initial provider. Morbidity and mortality from an acute pancreatitis can be very high, especially in patients with a progressive worsening acute pancreatitis developing into pancreatic necrosis in the setting of multiple underlying medical comorbidities.

PURPOSE

In this review paper, we discuss all aspects of acute pancreatitis and its potential complications, as well providing updates in the modern management of necrotizing pancreatitis. Practicing general surgeons need to be aware of the evolution in the diagnosis and treatment of this disease.

RESEARCH DESIGN

We conducted a review of literature of evidence and management options for acute pancreatitis, including all published manuscripts from 2012 to 2022.

RESULTS

Diagnosis and management of this disease can vary among specialiaties. The decision to utilize a percutaneous or endoscopic techniques are relevant points of discussion within general surgery and gastroenterology societies. In the past decade, the use of advanced endoscopic interventions has slowly replaced conventional open surgery in managing complications of acute severe pancreatitis.

CONCLUSION

Acute pancreatitis is a disease which requires multidisciplinary approach with evolving treatment options to less invasive nonsurgical methods.

The Effects of Umbilical Cord Mesenchymal Stem Cells on Traumatic Pancreatitis in Rats

OBJECTIVE

This study explored the therapeutic and protective effects of umbilical cord mesenchymal stem cells (ucMSCs) on traumatic pancreatitis (TP) to provide a theoretical basis for TP treatment with MCSs by establishing a TP rat model.

METHODS

We used 60 healthy adult male Sprague Dawley (SD) rats to create four experimental groups: sham, ucMSC control, TP, and ucMSC treatment. We observed ucMSC homing in the rats by fluorescence microscopy and assessed the degree of pancreatic tissue injury by hematoxylin and eosin (HE) staining on days 1, 3, and 7 after transplantation. Furthermore, we used an in vivo imaging system to evaluate the localization of cell membrane-stained ucMSCs in rats with TP. Finally, we measured the serum levels of amylase, lipase, pro-and anti-inflammatory factors, and oxidative stress factors by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The pancreatic histopathological score and the serum amylase and lipase levels were lower in the ucMSC treatment group than in the TP group (P < 0.05). Interleukin (IL)-6, tumor necrosis factor-α (TNF-α), and oxidase malondialdehyde (MOD) levels were significantly higher in the ucMSC treatment group than in the TP group. However, IL-10, transforming growth factor-β, and superoxide dismutase (an antioxidant enzyme, SOD) levels were significantly higher in the ucMSC treatment group than in the TP group (P < 0.05).

CONCLUSION

ucMSCs can migrate and implant in injured areas of the pancreas in rats. Furthermore, they participate in pancreatic tissue repair and regulate immunity by inhibiting the systemic inflammatory response and oxidative stress.

Pancreatitis in the Complex Care Population: Presentation, Incidence, and Severity

OBJECTIVES

To describe the incidence and presentation of pancreatitis in Children with Medical Complexity (CMC) while evaluating severity of disease and outlining risk factors.

METHODS

This was a retrospective chart review between January 2010 and December 2019 of patients seen in the complex care clinic at Nationwide Children's Hospital (NCH) and Cincinnati Children's Hospital Medical Center (CCHMC). Data collected included sex, underlying diagnosis, family history of pancreatitis, type of pancreatitis, signs/symptoms, abdominal imaging, severity of attack, and presence of various risk factors associated with pancreatitis. Severity and diagnosis of pancreatitis was determined based on North American Society for Pediatric Gastroenterology, Hepatology and Nutrition criteria.

RESULTS

One hundred and twelve patients from both institutions were included, 62% from NCH, median age 11.5 [interquartile range (IQR): 5-16 years], 50% male. Most patients were less than 18 years of age with a median age of 8 years (IQR: 4-13 years). Underlying diagnoses included seizures (67%), cerebral palsy/spastic quadriplegia (65%), diabetes (3.6%), and mitochondrial disease (3%). Majority of patients were found to have multiple underlying diagnoses (88%). Incidence of pancreatitis for both institutions was 336 of 100,000 patients/year which is significantly higher than the general pediatric population ( P < 0.0001). Majority of first episodes of pancreatitis were mild (82%) with abdominal pain as the predominant symptom (50%). Adult patients were more likely to have pancreatitis related to medication use than pediatric patients (70% vs 38%, respectively P = 0.007).

CONCLUSIONS

Individuals in the CMC population at our institutions have a high incidence of pancreatitis with unique risk factors compared to the general pediatric/young adult populations.

The Clinical Characteristics and Outcome of Elderly Patients With Acute Pancreatitis

OBJECTIVES

This study aimed to identify the risk factors for the progression of acute pancreatitis (AP) to severe acute pancreatitis (SAP) and death in elderly patients.

METHODS

This was a single-center retrospective study conducted in a tertiary teaching hospital. Data on patient demographics, comorbidities, duration of hospitalization, complications, interventions, and mortality rates were collected.

RESULTS

Between January 2010 and January 2021, 2084 elderly patients with AP were included in this study. The mean age of the patients was 70.0 years (standard deviation, 7.1 years). Among them, 324 (15.5%) had SAP and 105 died (5.0%). The 90-day mortality rate in the SAP group was significantly higher than that in the AP group (P < 0.0001). Multivariate regression analysis revealed that trauma, hypertension, and smoking were risk factors for SAP. After multivariate adjustment, acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage were associated with higher 90-day mortality.

CONCLUSIONS

Traumatic pancreatitis, hypertension, and smoking are independent risk factors for SAP in elderly patients. Acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage are independent risk factors for death in elderly patients with AP.

Indications for the surgical management of pancreatic trauma: An update

Pancreatic trauma is rare compared to other abdominal solid organ injuries, accounting for 0.2%-0.3% of all trauma patients. Moreover, this type of injury may frequently be overlooked or not readily appreciated on initial clinical examinations and investigations. The organ injury scale determines the severity of the trauma. Nonetheless, there are conflicting recommendations for the best strategy in severe cases. Overall, conservative management of induced severe traumatic pancreatitis is adequate. Modern imaging modalities such as ultrasound scanning and computed tomography scanning can detect injuries in fewer than 60% of patients. However, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) have diagnostic accuracies approaching 90%-100%. Thus, management options include ERCP and stent placement or distal pancreatectomy in cases of complete gland transection and wide drainage only for damage control surgery, which can prevent mortality but increases the risk of morbidity. In the majority of cases, surgical intervention is not required and should be reserved for only severe grade III to grade V injuries.

Acute pancreatitis in children: a review with clinical perspectives to enhance imaging interpretation

Pediatric acute pancreatitis has distinct etiologic, clinical and prognostic characteristics in contrast to the adult form of the disease. This review offers a comprehensive imaging update that emphasizes the importance of recognizing specific findings that are relevant from the clinical standpoint. Knowledge of these features facilitates communication among multidisciplinary team members and ultimately could lead to the improved care of pediatric acute pancreatitis patients.

Pancreatic Trauma: Imaging Review and Management Update

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ^©RSNA, 2020 See discussion on this article by Patlas.

Laparoscopy for traumatic pancreatitis. Case report

Introduction: Traumatic pancreatitis (TP) comprises less than 10% of all abdominal traumas but can reach mortality and morbidity rates of up to 34% and 64%, respectively. The treatment of TP has a conservative approach, followed by minimally invasive procedures and surgery if the evolution is torpid.Case report: A 54-year-old male patient with blunt trauma in right hypochondrium due to a bovine kick developed moderate-severe TP and grade IV pancreatic injury (PI). He underwent laparoscopic surgery twice with adequate clinical evolution. He required antibiotic therapy for 19 days and hospitalization for 29 days, of which 9 were in the ICU.Conclusion: The diagnosis of TP is difficult to achieve due to the retroperitoneal location of the pancreas. The treatment of this condition is usually conservative, preferring clinical management with percutaneous or endoscopic drainage over surgical drainage due to its low morbidity and mortality. The recommended surgical approach to these patients is laparotomy; however, the laparoscopic approach is a therapeutic option to be considered for comprehensive management.