1
|
Guan SW, Lin Q, Yu HB. Intratumour microbiome of pancreatic cancer. World J Gastrointest Oncol 2023; 15:713-730. [PMID: 37275446 PMCID: PMC10237023 DOI: 10.4251/wjgo.v15.i5.713] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/26/2023] [Accepted: 04/04/2023] [Indexed: 05/12/2023] Open
Abstract
Pancreatic cancer is a high mortality malignancy with almost equal mortality and morbidity rates. Both normal and tumour tissues of the pancreas were previously considered sterile. In recent years, with the development of technologies for high-throughput sequencing, a variety of studies have revealed that pancreatic cancer tissues contain small amounts of bacteria and fungi. The intratumour microbiome is being revealed as an influential contributor to carcinogenesis. The intratumour microbiome has been identified as a crucial factor for pancreatic cancer progression, diagnosis, and treatment, chemotherapy resistance, and immune response. A better understanding of the biology of the intratumour microbiome of pancreatic cancer contributes to the establishment of better early cancer screening and treatment strategies. This review focuses on the possible origins of the intratumour microbiome in pancreatic cancer, the intratumour localization, the interaction with the tumour microenvironment, and strategies for improving the outcome of pancreatic cancer treatment. Thus, this review offers new perspectives for improving the prognosis of pancreatic cancer.
Collapse
Affiliation(s)
- Shi-Wei Guan
- Department of Surgery, Wenzhou Central Hospital, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Quan Lin
- Department of Surgery, Wenzhou Central Hospital, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Hai-Bo Yu
- Department of Surgery, Wenzhou Central Hospital, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| |
Collapse
|
2
|
Hong D, Wang P, Chen Y, Zhang J, Jiang W, Ye B, Li G, Zhou J, Mao W, Tong Z, Li W, Ke L. Detection of potential pathogen in pancreatic fluid aspiration with metagenomic next-generation sequencing in patients with suspected infected pancreatic necrosis. Dig Liver Dis 2023; 55:243-248. [PMID: 35948458 DOI: 10.1016/j.dld.2022.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Timely and accurate microbial diagnosis is important in managing patients with infected pancreatic necrosis (IPN). AIMS To evaluate the diagnostic performance of Metagenomic next-generation sequencing (mNGS) in patients with suspected IPN. METHODS The clinical data of 40 patients with suspected IPN who underwent CT-guided pancreatic fluid aspiration were retrospectively analyzed. Microbial culture and mNGS were simultaneously applied to identify the potential pathogens. The diagnostic performance of the mNGS was assessed by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS The mNGS report can be obtained significantly earlier than culture methods (42 (36-62 h) vs. 60 (42-124 h), P = 0.032). Across all the study samples, seven species of bacteria and two species of fungi were reported accordingly to the culture results, while 22 species of bacteria and two species of fungi were detected by mNGS. The sensitivity, specificity, NPV, and PPV of mNGS were 88.0%, 100%, 83.33%, and 100%, respectively. CONCLUSIONS The diagnostic accuracy of mNGS in patients with suspected IPN is satisfactory. Moreover, mNGS may broaden the range of identifiable infectious pathogens and provide a more timely diagnosis.
Collapse
Affiliation(s)
- Donghuang Hong
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Peng Wang
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yingjie Chen
- Department of Critical Care Medicine, Jinjiang Hospital of Traditional Chinese Medicine, Jinjiang, China
| | - Jingzhu Zhang
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wendi Jiang
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bo Ye
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Zhou
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenjian Mao
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhihui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiqin Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China; Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing, China.
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing, China.
| |
Collapse
|
3
|
Pollini T, Adsay V, Capurso G, Molin MD, Esposito I, Hruban R, Luchini C, Maggino L, Matthaei H, Marchegiani G, Scarpa A, Wood LD, Bassi C, Salvia R, Mino-Kenudson M, Maker AV. The tumour immune microenvironment and microbiome of pancreatic intraductal papillary mucinous neoplasms. Lancet Gastroenterol Hepatol 2022; 7:1141-1150. [PMID: 36057265 PMCID: PMC9844533 DOI: 10.1016/s2468-1253(22)00235-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 01/19/2023]
Abstract
Pancreatic intraductal papillary mucinous neoplasms (IPMNs) have gained substantial attention because they represent one of the only radiographically identifiable precursors of invasive pancreatic ductal adenocarcinoma. Although most of these neoplasms have low-grade dysplasia and will remain indolent, a subset of IPMNs will progress to invasive cancer. The role of the immune system in the progression of IPMNs is unclear, but understanding its role could reveal the mechanism of neoplastic progression and targets for immunotherapy to inhibit progression or treat invasive disease. The available evidence supports a shift in the immune composition of IPMNs during neoplastic progression. Although low-grade lesions contain a high proportion of effector T cells, high-grade IPMNs, and IPMNs with an associated invasive carcinoma lose the T-cell infiltrate and are characterised by a predominance of immunosuppressive elements. Several possible therapeutic strategies emerge from this analysis that are unique to IPMNs and its microbiome.
Collapse
Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA,Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Volcan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine, Istanbul, Turkey
| | - Gabriele Capurso
- Department of Pancreatobiliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, Milan, Italy
| | - Marco Dal Molin
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Irene Esposito
- Department of Pathology, Heinrich Heine University and University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Ralph Hruban
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology University of Verona, Verona, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Hanno Matthaei
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology University of Verona, Verona, Italy
| | - Laura D Wood
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
4
|
Hashimoto A, Handa H, Hata S, Hashimoto S. Orchestration of mesenchymal plasticity and immune evasiveness via rewiring of the metabolic program in pancreatic ductal adenocarcinoma. Front Oncol 2022; 12:1005566. [PMID: 36408139 PMCID: PMC9669439 DOI: 10.3389/fonc.2022.1005566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most fatal cancer in humans, due to its difficulty of early detection and its high metastatic ability. The occurrence of epithelial to mesenchymal transition in preinvasive pancreatic lesions has been implicated in the early dissemination, drug resistance, and cancer stemness of PDAC. PDAC cells also have a reprogrammed metabolism, regulated by driver mutation-mediated pathways, a desmoplastic tumor microenvironment (TME), and interactions with stromal cells, including pancreatic stellate cells, fibroblasts, endothelial cells, and immune cells. Such metabolic reprogramming and its functional metabolites lead to enhanced mesenchymal plasticity, and creates an acidic and immunosuppressive TME, resulting in the augmentation of protumor immunity via cancer-associated inflammation. In this review, we summarize our recent understanding of how PDAC cells acquire and augment mesenchymal features via metabolic and immunological changes during tumor progression, and how mesenchymal malignancies induce metabolic network rewiring and facilitate an immune evasive TME. In addition, we also present our recent findings on the interesting relevance of the small G protein ADP-ribosylation factor 6-based signaling pathway driven by KRAS/TP53 mutations, inflammatory amplification signals mediated by the proinflammatory cytokine interleukin 6 and RNA-binding protein ARID5A on PDAC metabolic reprogramming and immune evasion, and finally discuss potential therapeutic strategies for the quasi-mesenchymal subtype of PDAC.
Collapse
Affiliation(s)
- Ari Hashimoto
- Department of Molecular Biology, Hokkaido University Faculty of Medicine, Sapporo, Japan
- *Correspondence: Ari Hashimoto, ; Shigeru Hashimoto,
| | - Haruka Handa
- Department of Molecular Biology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Soichiro Hata
- Department of Molecular Biology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Shigeru Hashimoto
- Division of Molecular Psychoimmunology, Institute for Genetic Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- *Correspondence: Ari Hashimoto, ; Shigeru Hashimoto,
| |
Collapse
|
5
|
Jaffey JA. Feline cholangitis/cholangiohepatitis complex - what have we learned? J Small Anim Pract 2022; 63:573-589. [PMID: 35522164 DOI: 10.1111/jsap.13508] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 02/19/2022] [Accepted: 04/11/2022] [Indexed: 12/07/2022]
Abstract
Cholangitis/cholangiohepatitis complex in cats is commonly encountered in clinical practice worldwide. Diagnosis and management of cats with this complex is difficult because of the ambiguity of clinical signs, diagnostic test results and commonality of comorbid disorders. These impediments can delay disease identification and treatment, which can increase morbidity and mortality. In this narrative review, we aimed to provide a thorough review of the unique physioanatomic features of the biliary system as well as clinically relevant updates on cholangitis/cholangiohepatitis complex in cats.
Collapse
Affiliation(s)
- J A Jaffey
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, Arizona, 85308, USA
| |
Collapse
|
6
|
Chen Z, Zhang S, Dong S, Xu H, Zhou W. Association of the Microbiota and Pancreatic Cancer: Opportunities and Limitations. Front Immunol 2022; 13:844401. [PMID: 35309293 PMCID: PMC8928443 DOI: 10.3389/fimmu.2022.844401] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
The human body is thoroughly colonized by a wide variety of microorganisms, termed microbiota. Pancreatic cancer, one of the most aggressive forms of cancer, is no exception. The microbiota of pancreatic cancer largely influences and even dominates the occurrence, development and outcome of pancreatic cancer in many ways. Studies have shown that microbiota could change the malignant phenotype and prognosis of pancreatic cancer by stimulating persistent inflammation, regulating the antitumor immune system, changing the tumor microenvironment and affecting cellular metabolism. This is why the association of the microbiota with pancreatic cancer is an emerging area of research that warrants further exploration. Herein, we investigated the potential microbial markers of pancreatic cancer, related research models, the mechanism of action of microbiota in pancreatic cancer, and pancreatic cancer-microbiota-related treatment.
Collapse
Affiliation(s)
- Zhou Chen
- Department of General Surgery, The First Hospital of Lanzhou University, The First Clinical Medical School of Lanzhou University, Lanzhou University, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Shaofeng Zhang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Shi Dong
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Hao Xu
- Department of General Surgery, The First Hospital of Lanzhou University, The First Clinical Medical School of Lanzhou University, Lanzhou University, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wence Zhou
- Department of General Surgery, The First Hospital of Lanzhou University, The First Clinical Medical School of Lanzhou University, Lanzhou University, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| |
Collapse
|
7
|
He L, Sun Y. Advances in research of early use of prophylactic antibiotics in severe acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2021; 29:609-614. [DOI: 10.11569/wcjd.v29.i11.609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP) is a common critical digestive system disease with high mortality, which can lead to multiple organ failure. SAP is often accompanied by massive necrosis of the pancreas, which is prone to secondary infection. Infected pancreatic necrosis is associated with an increased mortality of SAP. Whether early prophylactic use of antibiotics in the treatment of SAP can reduce the incidence of secondary infection is still controversial. This paper reviews the research progress of prophylactic use of antibiotics in the treatment of secondary infection of SAP in recent years.
Collapse
Affiliation(s)
- Lin He
- Department of Critical Care Medicine, the Second Affiliated Hospital, Hefei 230601, Anhui Province, China
| | - Yun Sun
- Department of Critical Care Medicine, the Second Affiliated Hospital, Hefei 230601, Anhui Province, China
| |
Collapse
|
8
|
Zhang W, Zhang K, Zhang P, Zheng J, Min C, Li X. Research Progress of Pancreas-Related Microorganisms and Pancreatic Cancer. Front Oncol 2021; 10:604531. [PMID: 33520714 PMCID: PMC7841623 DOI: 10.3389/fonc.2020.604531] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
Pancreatic cancer is one of the most common digestive system cancers. Early diagnosis is difficult owing to the lack of specific symptoms and reliable biomarkers. The cause of pancreatic cancer remains ambiguous. Smoking, drinking, new-onset diabetes, and chronic pancreatitis have been proven to be associated with the occurrence of pancreatic cancer. In recent years, a large number of studies have clarified that a variety of microorganisms colonized in pancreatic cancer tissues are also closely related to the occurrence and development of pancreatic cancer, and the specific mechanisms include inflammatory induction, immune regulation, metabolism, and microenvironment changes caused by microorganism. The mechanism of action of the pancreatic colonized microbiome in the tumor microenvironment, as well as immunotherapy approaches require further study in order to find more evidence to explain the complex relationship between the pancreatic colonized microbiome and PDAC. Relevant studies targeting the microbiome may provide insight into the mechanisms of PDAC development and progression, improving treatment effectiveness and overall patient prognosis. In this article, we focus on the research relating to the microorganisms colonized in pancreatic cancer tissues, including viruses, bacteria, and fungi. We also highlight the microbial diversity in the occurrence, invasion, metastasis, treatment, and prognosis of pancreatic cancer in order to elucidate its significance in the early diagnosis and new therapeutic treatment of pancreatic cancer, which urgently need to be improved in clinical practice. The elimination or increase in diversity of the pancreatic microbiome is beneficial for prolonging the survival of PDAC patients, improving the response to chemotherapy drugs, and reducing tumor burden. The colonization of microorganisms in the pancreas may become a new hotspot in the diagnosis and treatment of pancreatic cancer.
Collapse
Affiliation(s)
| | | | | | | | | | - Xiaoyu Li
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
9
|
Bivand JM, Nygaard RM, Kommedal Ø. Characterization of abscesses from liver, pancreas and kidney using deep sequencing of the 16S rRNA gene. Diagn Microbiol Infect Dis 2020; 99:115277. [PMID: 33454607 DOI: 10.1016/j.diagmicrobio.2020.115277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/30/2020] [Accepted: 11/17/2020] [Indexed: 11/16/2022]
Abstract
To characterize the microbial communities in abscess material from liver, pancreas, and kidneys, we performed deep sequencing of the 16S rRNA gene, in addition to cultivation and Sanger based 16S rRNA gene sequencing directly from the samples. Fifty-nine abscess samples were investigated, 38 from liver, 11 from pancreas, 10 from kidney. Using deep sequencing we made 227 bacterial identifications in 52 specimens, as compared to 69 identifications from the 44 specimens positive by culture. Escherichia coli, Enterococcus sp., Klebsiella sp. and Streptococcus sp. were the most common findings, but various anaerobe bacteria also constituted a large part of the microflora and those were frequently not detected by culture. Culture-independent methods like 16S deep sequencing can significantly improve microbiological diagnostics of clinical specimens. They are particularly valuable for complex purulent infections like abdominal abscesses. Therefore, deep sequencing approaches should be considered as a part of the available repertoire in diagnostic hospital laboratories.
Collapse
Affiliation(s)
| | | | - Øyvind Kommedal
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
10
|
Černá P, Kilpatrick S, Gunn-Moore DA. Feline comorbidities: What do we really know about feline triaditis? J Feline Med Surg 2020; 22:1047-1067. [PMID: 33100169 PMCID: PMC10814216 DOI: 10.1177/1098612x20965831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PRACTICAL RELEVANCE Feline triaditis describes concurrent pancreatitis, cholangitis and inflammatory bowel disease (IBD). The reported prevalence is 17-39% in ill referral patients. While the aetiology is poorly understood, it is known to include infectious, autoimmune and physical components. What is not known is whether different organs are affected by different diseases, or the same process; indeed, triaditis may be part of a multiorgan inflammatory disease. Feline gastrointestinal tract anatomy plays its role too. Specifically, the short small intestine, high bacterial load and anatomic feature whereby the pancreatic duct joins the common bile duct before entering the duodenal papilla all increase the risk of bacterial reflux and parenchymal inflammation. Inflammation may also be a sequela of bowel bacterial translocation and systemic bacteraemia. DIAGNOSTIC CHALLENGES Cholangitis, pancreatitis and IBD manifest with overlapping, vague and non-specific clinical signs. Cholangitis may be accompanied by increased serum liver enzymes, total bilirubin and bile acid concentrations, and variable ultrasonographic changes. A presumptive diagnosis of pancreatitis is based on increased serum pancreatic lipase immunoreactivity or feline pancreas-specific lipase, and/or abnormal pancreatic changes on ultrasonography, though these tests have low sensitivity. Diagnosis of IBD is challenging without histopathology; ultrasound findings vary from normal to mucosal thickening or loss of layering. Triaditis may cause decreased serum folate or cobalamin (B12) concentrations due to intestinal disease and/or pancreatitis. Triaditis can only be confirmed with histopathology; hence, it remains a presumptive diagnosis in most cases. EVIDENCE BASE The literature on feline triaditis, pancreatitis, cholangitis and IBD is reviewed, focusing on histopathology, clinical significance and diagnostic challenges. Current management recommendations are provided. Further studies are needed to understand the complex pathophysiology, and in turn improve diagnosis and treatment.
Collapse
Affiliation(s)
- Petra Černá
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, and Small Animal Clinic, The University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | | | - Danielle A Gunn-Moore
- The Royal (Dick) School of Veterinary Studies, and The Roslin Institute, University of Edinburgh, UK
| |
Collapse
|
11
|
Pancreatolithiasis in a cat with chronic pancreatitis. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2020-001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
12
|
Regulation and modulation of antitumor immunity in pancreatic cancer. Nat Immunol 2020; 21:1152-1159. [PMID: 32807942 DOI: 10.1038/s41590-020-0761-y] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma carries a dismal prognosis, and outcomes have improved little with modern therapeutics. Checkpoint-based immunotherapy has failed to elicit responses in the vast majority of patients with pancreatic cancer. Alongside tumor cell-intrinsic mechanisms associated with oncogenic KRAS-induced inflammation, the tolerogenic myeloid cell infiltrate has emerged as a critical impediment to adaptive antitumor immune responses. Furthermore, the discovery of an intratumoral microbiome and the elucidation of host-microbe interactions that curtail antitumor immunity also present opportunities for intervention. Here we review the mechanisms of immunotherapy resistance in pancreatic ductal adenocarcinoma and discuss strategies to directly augment T cell responses in parallel with myeloid cell- and microbiome-targeted approaches that may enable immune-mediated control of this malignancy.
Collapse
|
13
|
Abstract
Clinical findings with triaditis and individual disease components overlap and may include hyporexia, weight loss, lethargy, vomiting, diarrhea, dehydration, icterus, abdominal pain, thickened bowel loops, pyrexia, dyspnea, and shock. A definitive diagnosis of triaditis requires histologic confirmation of inflammation in each organ, but this may not be possible because of financial or patient-related constraints. Evidence-based data indicate that histologic lesions of triaditis are present in 30% to 50% of cats diagnosed with pancreatitis and cholangitis/inflammatory liver disease. Treatment of triaditis is based on the overall health status of the patient and the type and severity of disease in component organs.
Collapse
|
14
|
Abstract
In recent years, increased awareness of feline pancreatitis by the veterinary profession and improved diagnostic modalities have led to an increased frequency of diagnosis of pancreatitis in this species. Consequently, pancreatic diseases, especially chronic pancreatitis, are considered highly prevalent, even in populations of apparently healthy individuals. This prevalence has led to the suspicion that the condition may be overdiagnosed. This article summarizes the difficulties of diagnosis of acute and chronic pancreatitis, assesses the reasons why this is a challenging disease to recognize, and considers whether these difficulties could result in either overdiagnosis or underdiagnosis.
Collapse
|
15
|
Sun J, Tang Q, Yu S, Xie M, Xie Y, Chen G, Chen L. Role of the oral microbiota in cancer evolution and progression. Cancer Med 2020; 9:6306-6321. [PMID: 32638533 PMCID: PMC7476822 DOI: 10.1002/cam4.3206] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/14/2022] Open
Abstract
Bacteria identified in the oral cavity are highly complicated. They include approximately 1000 species with a diverse variety of commensal microbes that play crucial roles in the health status of individuals. Epidemiological studies related to molecular pathology have revealed that there is a close relationship between oral microbiota and tumor occurrence. Oral microbiota has attracted considerable attention for its role in in‐situ or distant tumor progression. Anaerobic oral bacteria with potential pathogenic abilities, especially Fusobacterium nucleatum and Porphyromonas gingivalis, are well studied and have close relationships with various types of carcinomas. Some aerobic bacteria such as Parvimonas are also linked to tumorigenesis. Moreover, human papillomavirus, oral fungi, and parasites are closely associated with oropharyngeal carcinoma. Microbial dysbiosis, colonization, and translocation of oral microbiota are necessary for implementation of carcinogenic functions. Various underlying mechanisms of oral microbiota‐induced carcinogenesis have been reported including excessive inflammatory reaction, immunosuppression of host, promotion of malignant transformation, antiapoptotic activity, and secretion of carcinogens. In this review, we have systemically described the impact of oral microbial abnormalities on carcinogenesis and the future directions in this field for bringing in new ideas for effective prevention of tumors.
Collapse
Affiliation(s)
- Jiwei Sun
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Qingming Tang
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Shaoling Yu
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Mengru Xie
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Yanling Xie
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Guangjin Chen
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| | - Lili Chen
- Department of Stomatology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, China
| |
Collapse
|
16
|
Ryu KH. [Gut Microbiota and Pancreatobiliary System]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 75:231-239. [PMID: 32448854 DOI: 10.4166/kjg.2020.75.5.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/03/2022]
Abstract
The gut microbiota is part of the human body that is involved in body metabolism and the occurrence of various diseases. Detecting and analyzing their genetic information (microbiome) is as important as analyzing human genes. The core microbiome, the key functional genes shared by all humans, helps better understand the physiology of the human body. Information on the gut microbiome of a diseased person can help diagnose and treat disease. The pancreatobiliary system releases functional antimicrobial substances, such as bile acids and antimicrobial peptides, which affect the gut microbiota directly. In response, the gut microbiota influences pancreatobiliary secretion by controlling the generation and emission of substances through indirect signaling. This crosstalk maintains homeostasis of the pancreatobiliary system secretion and microbiota. Dysbiosis and disease can occur if this fails to work properly. Bile acid therapy has been used widely and may affect the microbial environment in the intestine. An association of the gut microbiota has been reported in many cases of pancreatobiliary diseases, including malignant tumors. Traditionally, most pancreatobiliary diseases are accompanied by infections from the gut microbiota, which is an important target for treatment. The pancreatobiliary system can control its function through physical and drug therapy. This may be a new pioneering field in the study or treatment of the gut microbiota.
Collapse
Affiliation(s)
- Ki-Hyun Ryu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| |
Collapse
|
17
|
Thomas RM, Jobin C. Microbiota in pancreatic health and disease: the next frontier in microbiome research. Nat Rev Gastroenterol Hepatol 2020; 17:53-64. [PMID: 31811279 DOI: 10.1038/s41575-019-0242-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
Diseases intrinsic to the pancreas such as pancreatitis, pancreatic cancer and type 1 diabetes mellitus impart substantial health and financial burdens on society but identification of novel mechanisms contributing to these pathologies are slow to emerge. A novel area of research suggests that pancreatic-specific disorders might be modulated by the gut microbiota, either through a local (direct pancreatic influence) or in a remote (nonpancreatic) fashion. In this Perspectives, we examine literature implicating microorganisms in diseases of the pancreas, specifically pancreatitis, type 1 diabetes mellitus and pancreatic ductal adenocarcinoma. We also discuss evidence of an inherent pancreatic microbiota and the influence of the intestinal microbiota as it relates to disease association and development. In doing so, we address pitfalls in the current literature and areas of investigation that are needed to advance a developing field of research that has clinical potential to reduce the societal burden of pancreatic diseases.
Collapse
Affiliation(s)
- Ryan M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, USA
| | - Christian Jobin
- Department of Medicine, Division of Gastroenterology, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|
18
|
Abstract
Bacterial translocation is a phenomenon in which live bacteria or their products cross the intestinal barrier to other organs or the circulatory system. Gut translocation of bacteria has been reported in both animal models, and clinical trials often accompany acute pancreatitis and are believed to be linked to patient outcome, especially in severe acute pancreatitis. Therefore, the mechanisms of intestinal bacterial translocation in acute pancreatitis have become a topic of interest in recent years. This review discusses Bacterial translocation in acute pancreatitis, identifies possible mechanisms of action, and provides an overview of the methods used to detect Bacterial translocation in acute pancreatitis. This review also highlights areas that require further research.
Collapse
Affiliation(s)
- Jinbo Liu
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China.,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou,Sichuan, P.R. China
| | - Lin Huang
- Department of Paediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Ming Luo
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Xianming Xia
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China.,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou,Sichuan, P.R. China
| |
Collapse
|
19
|
Cen ME, Wang F, Su Y, Zhang WJ, Sun B, Wang G. Gastrointestinal microecology: a crucial and potential target in acute pancreatitis. Apoptosis 2019; 23:377-387. [PMID: 29926313 DOI: 10.1007/s10495-018-1464-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the early stage of acute pancreatitis (AP), abundant cytokines induced by local pancreatic inflammation enter the bloodstream, further cause systemic inflammatory response syndrome (SIRS) by "trigger effect", which eventually leads to multiple organ dysfunction syndrome (MODS). During SIRS and MODS, the intestinal barrier function was seriously damaged accompanied by the occurrence of gut-derived infection which forms a "second hit summit" by inflammatory overabundance. Gastrointestinal microecology, namely the biologic barrier, could be transformed into a pathogenic state, which is called microflora dysbiosis when interfered by the inflammatory stress during AP. More and more evidences indicate that gastrointestinal microflora dysbiosis plays a key role in "the second hit" induced by AP gut-derived infection. Therefore, the maintenance of gastrointestinal microecology balance is likely to provide an effective method in modulating systemic infection of AP. This article reviewed the progress of gastrointestinal microecology in AP to provide a reference for deeply understanding the pathogenic mechanisms of AP and identifying new therapeutic targets.
Collapse
Affiliation(s)
- Meng-Er Cen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, China.,Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
| | - Feng Wang
- Department of Ophthalmology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ying Su
- Department of Ophthalmology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Wang-Jun Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, China
| | - Gang Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang, China.
| |
Collapse
|
20
|
Nivy R, Kaplanov A, Kuzi S, Mazaki-Tovi M, Yas E, Segev G, Ben-Oz J, Lavy E, Aroch I. A retrospective study of 157 hospitalized cats with pancreatitis in a tertiary care center: Clinical, imaging and laboratory findings, potential prognostic markers and outcome. J Vet Intern Med 2018; 32:1874-1885. [PMID: 30315665 PMCID: PMC6271303 DOI: 10.1111/jvim.15317] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 08/03/2018] [Accepted: 08/09/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Pancreatitis in cats (FP) has been increasingly diagnosed in recent years, but clinical studies of large numbers of affected cats are scarce. OBJECTIVES To describe a large cohort of cats with FP requiring hospitalization. ANIMALS One hundred and fifty-seven client-owned cats. METHODS Retrospective study, including cats diagnosed with pancreatitis based on sonographic evidence, positive SNAP feline pancreatic lipase immunoreactivity test results, increased 1,2-o-dilauryl-rac-glycerol-glutaric Acid-(6'-methylresorufin ester)-lipase activity, histopathology, or some combination of these. RESULTS One-hundred and twenty-two cats (77.7%) survived to discharge. Median time from onset of clinical signs to presentation was longer (P = .003) in nonsurvivors. Causes of FP included recent general anesthesia, trauma, hemodynamic compromise, and organophosphate intoxication, but most cases (86.6%) were idiopathic. Ultrasonographic findings consistent with pancreatitis were documented in 134 cats, including pancreatomegaly (81.3%), decreased (31.3%), or increased (14.9%) pancreatic echogenicity, extra-hepatic biliary tract dilatation (24%), and increased peri-pancreatic echogenicity (13%). Lethargy (P = .003), pleural effusion (P = .003), hypoglycemia (P = .007), ionized hypocalcemia (P = .016), azotemia (P = .014), parenteral nutrition administration (P = .013), and persistent anorexia during hospitalization (P = .001) were more frequent in nonsurvivors, whereas antibiotics were more frequently administered to survivors (P = .023). Nevertheless, when Bonferroni's correction for multiple comparisons was applied, none of the variables was statistically significant. CONCLUSIONS AND CLINICAL IMPORTANCE Previously unreported, clinically relevant, potential prognostic factors, including hypoglycemia, azotemia, parenteral nutrition, and withholding antibacterial treatment were identified in this exploratory study. These preliminary results should be examined further in confirmatory studies.
Collapse
Affiliation(s)
- Ran Nivy
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Alina Kaplanov
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Sharon Kuzi
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Michal Mazaki-Tovi
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Einat Yas
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Gilad Segev
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Jennifer Ben-Oz
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Eran Lavy
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Itamar Aroch
- Department of Small Animal Internal Medicine, Koret School of Veterinary Medicine - Veterinary Teaching Hospital and Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Rehovot, Israel
| |
Collapse
|
21
|
Nemoto Y, Haraguchi T, Shimokawa Miyama T, Kobayashi K, Hama K, Kurogouchi Y, Fujiki N, Baba K, Okuda M, Mizuno T. Pancreatic Abscess in a cat due to Staphylococcus aureus infection. J Vet Med Sci 2017; 79:1146-1150. [PMID: 28529270 PMCID: PMC5559355 DOI: 10.1292/jvms.17-0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
A 16-year-old spayed female American Shorthair cat was presented with lethargy, anorexia, and wamble. Physical and blood examination did not reveal any remarkable findings. Abdominal ultrasonography identified the presence of a localized anechoic structure with a thick wall in contact with the small intestine and adjacent to the liver. Ultrasound-guided fine-needle aspiration of the structure revealed fluid containing numerous cocci and neutrophils. Two days after antibiotic treatment, exploratory laparotomy was performed and the content of the structure was removed before multiple lavages. The pathological and bacteriological examination results supported a confirmatory diagnosis of pancreatic abscess due to Staphylococcus aureus infection, making this the first such report in a cat. The cat remained healthy thereafter with no disease recurrence.
Collapse
Affiliation(s)
- Yuki Nemoto
- Laboratory of Molecular Diagnostics and Therapeutics, Department of Veterinary Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Tomoya Haraguchi
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Takako Shimokawa Miyama
- Laboratory of Veterinary Internal Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Kosuke Kobayashi
- Laboratory of Veterinary Internal Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Kaori Hama
- Laboratory of Veterinary Internal Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Yosuke Kurogouchi
- Laboratory of Molecular Diagnostics and Therapeutics, Department of Veterinary Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Noriyuki Fujiki
- Laboratory of Molecular Diagnostics and Therapeutics, Department of Veterinary Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Kenji Baba
- Laboratory of Veterinary Internal Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Masaru Okuda
- Laboratory of Veterinary Internal Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| | - Takuya Mizuno
- Laboratory of Molecular Diagnostics and Therapeutics, Department of Veterinary Medicine, Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677-1 Yoshida, Yamaguchi 753-8515, Japan
| |
Collapse
|
22
|
Rogers MB, Aveson V, Firek B, Yeh A, Brooks B, Brower-Sinning R, Steve J, Banfield JF, Zureikat A, Hogg M, Boone BA, Zeh HJ, Morowitz MJ. Disturbances of the Perioperative Microbiome Across Multiple Body Sites in Patients Undergoing Pancreaticoduodenectomy. Pancreas 2017; 46:260-267. [PMID: 27846140 PMCID: PMC5235958 DOI: 10.1097/mpa.0000000000000726] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The goals of this study were to characterize bacterial communities within fecal samples, pancreatic fluid, bile, and jejunal contents from patients undergoing pancreaticoduodenectomy (PD) and to identify associations between microbiome profiles and clinical variables. METHODS Fluid was collected from the pancreas, common bile duct, and proximal jejunum from 50 PD patients. Postoperative fecal samples were also collected. The microbial burden within samples was quantified with droplet digital polymerase chain reaction. Bacterial 16S ribosomal RNA gene sequences were amplified, sequenced, and analyzed. Data from fecal samples were compared with publicly available data obtained from volunteers. RESULTS Droplet digital polymerase chain reaction confirmed the presence of bacteria in all sample types, including pancreatic fluid. Relative to samples from the American Gut Project, fecal samples from PD patients were enriched with Klebsiella and Bacteroides and were depleted of anaerobic taxa (eg, Roseburia and Faecalibacterium). Similar patterns were observed within PD pancreas, bile, and jejunal samples. Postoperative fecal samples from patients with a pancreatic fistula contained increased abundance of Klebsiella and decreased abundance of commensal anaerobes, for example, Ruminococcus. CONCLUSIONS This study confirms the presence of altered bacterial populations within samples from PD patients. Future research must validate these findings and may evaluate targeted microbiome modifications to improve outcomes in PD patients.
Collapse
Affiliation(s)
| | - Victoria Aveson
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brian Firek
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Andrew Yeh
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandon Brooks
- Department of Earth and Planetary Sciences, University of California Berkeley, Berkeley, CA
| | | | - Jennifer Steve
- Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jillian F. Banfield
- Department of Earth and Planetary Sciences, University of California Berkeley, Berkeley, CA
| | - Amer Zureikat
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa Hogg
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian A. Boone
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Herbert J. Zeh
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael J. Morowitz
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Address Correspondence to: Michael J. Morowitz, MD, Division of Pediatric Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, 7th Floor Faculty Pavilion, Pittsburgh, PA 15244, , phone 412-692-7282, fax 412-692-8299
| |
Collapse
|
23
|
Lee M, Kang JH, Chang D, Na KJ, Yang MP. Pancreatic Abscess in a Cat with Diabetes Mellitus. J Am Anim Hosp Assoc 2015; 51:180-4. [DOI: 10.5326/jaaha-ms-6122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An 11 yr old spayed female Maine coon cat was referred with uncontrolled diabetes mellitus. The cat had a 2 mo history of weight loss and intermittent vomiting. An abdominal ultrasound identified the presence of a large cavity measuring a maximum of 4.6 cm in the pancreas that was filled with a homogeneous echogenic fluid. Cytological analysis and culture of the fluid obtained from the pancreatic mass indicated the presence of a bacterial abscess. The application of nonsurgical drainage and the administration of glargine insulin and antibiotics resolved the clinical signs. The size of the pancreatic abscess was reduced after 5 mo, and the cat achieved diabetic remission and remained healthy at the time this report was prepared. This case report describes the successful treatment of a pancreatic bacterial abscess concurrent with diabetes mellitus in a Maine coon cat.
Collapse
Affiliation(s)
- Minji Lee
- From the Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Ji-Houn Kang
- From the Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Dongwoo Chang
- From the Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Ki-Jeong Na
- From the Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Mhan-Pyo Yang
- From the Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| |
Collapse
|
24
|
Abstract
Only 30% of patients with a diagnosis of pancreatic cancer survive 1 year after the diagnosis. Progress in understanding the causes of pancreatic cancer has been made, including solidifying the associations with obesity and diabetes, and a proportion of cases should be preventable through lifestyle modifications. Unfortunately, identifying reliable biomarkers of early pancreatic cancer has been extremely challenging, and no effective screening modality is currently available for this devastating form of cancer. Recent data suggest that the microbiota may play a role in the disease process, but many questions remain. Future studies focusing on the human microbiome, both etiologically and as a marker of disease susceptibility, should shed light on how to better tackle prevention, early detection, and treatment of this highly fatal disease.
Collapse
Affiliation(s)
- Dominique S Michaud
- From the *Department of Epidemiology, School of Public Health, Brown University, Providence, RI; †Department of Epidemiology and Public Health, Imperial College, London, United Kingdom; ‡The Forsyth Institute, Cambridge MA; and §Harvard School of Dental Medicine, Boston MA
| | | |
Collapse
|
25
|
Simpson KW. Pancreatitis and triaditis in cats: causes and treatment. J Small Anim Pract 2015; 56:40-9. [DOI: 10.1111/jsap.12313] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 09/12/2014] [Accepted: 10/28/2014] [Indexed: 01/16/2023]
Affiliation(s)
- K. W. Simpson
- College of Veterinary Medicine; Cornell University; Ithaca NY 14850 USA
| |
Collapse
|
26
|
Plantefeve G, Hellmann R, Pajot O, Thirion M, Bleichner G, Mentec H. Abdominal compartment syndrome and intraabdominal sepsis: two of the same kind? Acta Clin Belg 2014; 62 Suppl 1:162-7. [PMID: 24881714 DOI: 10.1179/acb.2007.62.s1.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Abdominal compartment syndrome and intra-abdominal hypertension are frequently associated with peritonitis. The aim of this study is to establish the relationship between intra-abdominal hypertension and intra-abdominal sepsis especially in critically ill patients. METHODS Relevant information was identified through a Medline search (1966-October 2006). The terms used were "intra-abdominal sepsis", "peritonitis", "abdominal compartment syndrome", "intra-abdominal hypertension" and "relaparotomy for sepsis". The search was limited to English- and French-language publications. RESULTS Only a few clinical trials exist on this specific topic. Further investigations are required to define the incidence of intra-abdominal hypertension in intra-abdominal sepsis, and the prognostic impact of this setting and finally the potential specific treatment. Abdominal compartment syndrome is more likely linked to the abdominal surgery than to peritonitis itself. CONCLUSION Intra-abdominal pressure monitoring can be valuable in critically ill patients with suspicion of persisting intra-abdominal sepsis after surgical peritonitis treatment.
Collapse
|
27
|
Abstract
PRACTICAL RELEVANCE Pancreatitis is a frequent finding in cats, the chronic form being more common than the acute form. Despite the large number of diseases or conditions that may be associated with feline pancreatitis, in most cases no cause is diagnosed and the pancreatitis is said to be idiopathic. The chronic form can be mild and asymptomatic, and has a high prevalence in apparently healthy cats. This has generated debate concerning the clinical significance of chronic feline pancreatitis. However, several reports have demonstrated the severity of clinical signs in certain forms of acute feline pancreatitis, while other studies have reported a strong association between chronic pancreatitis and the development of comorbidities such as hepatic lipidosis, diabetes mellitus, inflammatory bowel disease or exocrine pancreatic insufficiency. This suggests that feline pancreatitis should not be overlooked. CLINICAL CHALLENGES Diagnosis of feline pancreatitis is complicated by the non-specific clinical signs and poor diagnostic value of basic biochemistry and haematology or imaging techniques. Development of a feline-specific pancreatic lipase immunoassay has improved our diagnostic ability in the past decade, but may have more limited application for mild and chronic forms of pancreatitis. Moreover, histopathology (the 'gold standard' diagnostic test) can be associated with false-negative results due to multifocal distribution of lesions or mild forms of the disease. With respect to treatment, it is important to take into account the idiosyncrasies of the feline species when considering medical therapies. EVIDENCE BASE This article reviews the literature on feline pancreatitis, focusing on the different forms and their relative clinical significance, while explaining difficulties inherent in the diagnosis of this disease. An overview of current recommendations for the management of cats with pancreatitis is also provided.
Collapse
Affiliation(s)
- Julien Bazelle
- Willows Veterinary Centre and Referral Service, Shirley, Solihull, West Midlands, B90 4NH, UK
| | - Penny Watson
- Queen’s Veterinary School Hospital, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK
| |
Collapse
|
28
|
Seifert GJ, Poxleitner PJ, Richter SC, Hopt UT, Wittel UA. Dissecting the effect of moxifloxacin in mice with infected necrosis in taurocholate induced necrotizing pancreatitis. Pancreatology 2014; 14:179-85. [PMID: 24854613 DOI: 10.1016/j.pan.2014.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/05/2014] [Accepted: 02/13/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To investigate the limited benefit of antibiotics in ameliorating the outcome of acute necrotizing pancreatitis, we analyzed antibiotic therapy in primarily infected necrotizing pancreatitis in mice with respect to the local pancreatic pathology as well as systemic, pancreatitis induced adverse events. METHODS Sterile pancreatic necrosis (SN) was induced by retrograde injection of 4% taurocholate in the common bile duct of Balb/c mice. Primarily infected pancreatic necrosis (IN) was induced by co-injecting 10(8) CFU/ml Escherichia coli. 10 mg/kg of moxifloxacin was administered prior to pancreatitis induction (AN). After 24 h, animals were sacrificed to examine serum as well as organs for signs of SIRS. RESULTS Moxifloxacin significantly reduced bacterial count in pancreatic lysates of animals with infected pancreatic necrosis (IN 4.1·10(7) ± 2.4·10(7) vs. AN 4.9·10(4) ± 2.6·10(4) CFU/g; p < 0.001). However, it did not alter pancreatic histology or pulmonary damage (Histology score: IN 23.8 ± 2.7 vs. AN 22.6 ± 1.7). Moxifloxacin reduced systemic immunoactivation (Serum IL-6: IN 330.5 ± 336.6 vs. 38.7 ± 25.5 pg/ml; p < 0.001), hypoglycemia (serum glucose: IN 105.8 ± 12.7 vs. AN 155.7 ± 39.5 mg/dl; p < 0.001), and serum aspartate aminotransferase (IN 606 ± 89.7 vs. AN 255 ± 52.1; p < 0.05). These parameters were significantly increased in animals with necrotizing pancreatitis. CONCLUSION In the experimental setting, initial antibiotic therapy with moxifloxacin in acute infected necrotizing pancreatitis in mice does not have a beneficial impact on pancreatic pathology or pulmonary damage. However, other systemic complications induced by infected necrosis in acute pancreatitis are reduced by the administration of moxifloxacin.
Collapse
Affiliation(s)
- Gabriel J Seifert
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Philipp J Poxleitner
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Sabine C Richter
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany.
| |
Collapse
|
29
|
Twedt DC, Cullen J, McCord K, Janeczko S, Dudak J, Simpson K. Evaluation of fluorescence in situ hybridization for the detection of bacteria in feline inflammatory liver disease. J Feline Med Surg 2014; 16:109-17. [PMID: 23884636 PMCID: PMC11383131 DOI: 10.1177/1098612x13498249] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
The etiopathogenesis of feline inflammatory liver disease (ILD) is unclear. Therefore, we sought to determine the presence and distribution of bacteria within the livers of cats with ILD using eubacterial fluorescence in situ hybridization (FISH). Histopathology from 39 cats with ILD and 19 with histologically normal livers (C) were classified using World Small Animal Veterinary Association guidelines. Hepatic sections were examined by 16 and 23S ribosomal RNA FISH. Antibodies against cytokeratins and factor VIIIa were used to distinguish bile ducts and vascular structures. Histopathologic findings included non-specific reactive hepatitis (12), neutrophilic cholangitis (NC; 12), lymphocytic cholangitis (seven), cholestasis/obstruction (three), probable lymphoma (three) and acute hepatitis (two). Bacteria were observed in 21/39 ILD and 3/19 C (P = 0.0054). In 8/39 ILD and 2/19 C bacteria were restricted to the outer liver capsule (P = 0.29) and may represent contaminants. The prevalence of intrahepatic bacteria was higher (P = 0.008) in ILD (13/31) than C (1/17). Bacteria in ILD were more frequently (P <0.0001) localized to portal vessels, venous sinusoids and parenchyma (12/13) than bile duct (1/13). Bacterial colonization was highest in Escherichia coli-positive NC cats. Concurrent non-hepatic disease, predominantly pancreatic and intestinal (8/10 cats biopsied), was present in all 13 cats with intrahepatic bacteria. Bacterial culture was positive (predominantly E coli and Enterococcus species) in 11/23 (48%) samples, and concurred with FISH in 15/23 cases. The presence of intrahepatic bacteria in 13/31 (41%) cats with ILD suggests a role in etiopathogenesis. The distribution of bacteria within the liver supports the possibility of colonization via either enteric translocation or hematogenous seeding.
Collapse
|
30
|
Huang HL, Nie X, Cai B, Tang JT, He Y, Miao Q, Song HL, Luo TX, Gao BX, Wang LL, Li GX. Procalcitonin levels predict acute kidney injury and prognosis in acute pancreatitis: a prospective study. PLoS One 2013; 8:e82250. [PMID: 24349237 PMCID: PMC3862675 DOI: 10.1371/journal.pone.0082250] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 10/21/2013] [Indexed: 02/05/2023] Open
Abstract
Background Acute kidney injury (AKI) has been proposed as a leading cause of mortality for acute pancreatitis (AP) patients admitted to the intensive care unit (ICU). This study investigated the predictive value of procalcitonin (PCT) for AKI development and relevant prognosis in patients with AP, and compared PCT’s predictive power with that of other inflammation-related variables. Methods Between January 2011 and March 2013, we enrolled 305 cases with acute pancreatitis admitted to ICU. Serum levels of PCT, serum amyloid A (SAA), interleukin-6 (IL-6), and C reactive protein (CRP) were determined on admission. Serum PCT was tested in patients who developed AKI on the day of AKI occurrence and on either day 28 after occurrence (for survivors) or on the day of death (for those who died within 28 days). Results Serum PCT levels were 100-fold higher in the AKI group than in the non-AKI group on the day of ICU admission (p<0.05). The area under the receiver-operating characteristic (ROC) curve of PCT for predicting AKI was 0.986, which was superior to SAA, CRP, and IL-6 (p<0.05). ROC analysis revealed all variables tested had lower predictive performance for AKI prognosis. The average serum PCT level on day 28 (2.67 (0.89, 7.99) ng/ml) was significantly (p<0.0001) lower than on the day of AKI occurrence (43.71 (19.24,65.69) ng/ml) in survivors, but the serum PCT level on death (63.73 (34.22,94.30) ng/ml) was higher than on the day of AKI occurrence (37.55 (18.70,74.12) ng/ml) in non-survivors, although there was no significant difference between the two days in the latter group (p = 0.1365). Conclusion Serum PCT is superior to CRP, IL-6, and SAA for predicting the development of AKI in patients with AP, and also can be used for dynamic evaluation of AKI prognosis.
Collapse
Affiliation(s)
- Hua-Lan Huang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Nie
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bei Cai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiang-Tao Tang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yong He
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Miao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hao-Lan Song
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tong-Xing Luo
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bao-Xiu Gao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- * E-mail: (LLW); (GXL)
| | - Gui-Xing Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
- * E-mail: (LLW); (GXL)
| |
Collapse
|
31
|
Sun X, Shao Y, Jin Y, Huai J, Zhou Q, Huang Z, Wu J. Melatonin reduces bacterial translocation by preventing damage to the intestinal mucosa in an experimental severe acute pancreatitis rat model. Exp Ther Med 2013; 6:1343-1349. [PMID: 24255660 PMCID: PMC3829749 DOI: 10.3892/etm.2013.1338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/27/2013] [Indexed: 01/26/2023] Open
Abstract
Recent studies have demonstrated that melatonin significantly decreased all studied acute pancreatitis-associated inflammatory parameters, in addition to reducing apoptosis and necrosis associated with pancreatic injury. However, the effect of melatonin on gut barrier dysfunction and bacterial translocation has not been fully elucidated. This study aimed to investigate the protective effects of melatonin on intestinal integrity in a rat model of severe acute pancreatitis (SAP) to evaluate whether melatonin prevented intestine barrier dysfunction and reduced bacterial translocation. Forty male Sprague Dawley (SD) rats were randomly divided into three groups, with 8 rats in the sham operation (SO) group, 18 rats in the SAP group and 14 SAP rats in the melatonin treatment (MT) group. SAP was induced by retrograde injection of 4% taurocholate into the biliopancreatic duct. Melatonin was administered 30 min prior to taurocholate injection in the melatonin-treated rats. All rats were sacrificed 24 h subsequent to pancreatitis induction. Real-time fluorescence quantitative polymerase chain reaction was used to detect and quantify Escherichia coli (E. coli) O157 in postcava blood. The microvilli structure was also analyzed with transmission electron microscopy. The level of E. coli DNA in the MT group was significantly lower than in rats in the SAP group. No E. coli DNA was detected in the control group. Villus height and crypt depth in the ileum were significantly higher in the MT and control groups compared to the SAP group, and were significantly higher in the MT group than in the SAP group. These results suggested that melatonin prevented gut barrier dysfunction and reduced bacterial translocation, resulting in reduced pancreatic-associated infections and decreased early mortality rates.
Collapse
Affiliation(s)
- Xuecheng Sun
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang 325000, P.R. China
| | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
|
34
|
The Effects of Total Colectomy on Bacterial Translocation in a Model of Acute Pancreatitis. Indian J Surg 2013; 77:412-8. [PMID: 26730036 DOI: 10.1007/s12262-013-0855-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/16/2013] [Indexed: 12/17/2022] Open
Abstract
Prevention of secondary infection is currently the main goal of treatment for acute necrotizing pancreatitis. Colon was considered as the main origin of secondary infection. Our aim was to investigate whether prophylactic total colectomy would reduce the rate of bacterial translocation and infection of pancreatic necrosis. Forty-two Sprague-Dawley rats were used. Pancreatitis was created by ductal infusion of sodium taurocholate. Rats were divided into four groups: group-1, laparotomy + pancreatic ductal infusion of saline; group-2, laparotomy + pancreatic ductal infusion of sodium taurocholate; group-3, total colectomy + pancreatic ductal infusion of saline; and group-4, total colectomy + pancreatic ductal infusion of sodium taurocholate. Forty-eight hours later, tissue and blood samples were collected for microbiological and histopathological analysis. Total colectomy caused small bowel bacterial overgrowth with gram-negative and gram-positive microorganisms. Bacterial count of gram-negative rods in the small intestine and pancreatic tissue in rats with colectomy and acute pancreatitis were significantly higher than in rats with acute pancreatitis only (group-2 versus group-4; small bowel, p = <0.001; pancreas, p = 0.002). Significant correlation was found between proximal small bowel bacterial overgrowth and pancreatic infection (r = 0,836, p = 0.001). In acute pancreatitis, prophylactic total colectomy (which can mimic colonic cleansing and reduction of colonic flora) induces small bowel bacterial overgrowth, which is associated with increased bacterial translocation to the pancreas.
Collapse
|
35
|
Ignatavicius P, Vitkauskiene A, Pundzius J, Dambrauskas Z, Barauskas G. Effects of prophylactic antibiotics in acute pancreatitis. HPB (Oxford) 2012; 14:396-402. [PMID: 22568416 PMCID: PMC3384864 DOI: 10.1111/j.1477-2574.2012.00464.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients. METHODS The study population consisted of 210 patients treated for SAP. In Group 1 (n= 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n= 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate. RESULTS Ultrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P= 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P= 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P= 0.206] were performed more frequently and earlier [at 16.6 ± 7.8 days vs. 17.2 ± 6.7 days (P= 0.723); at 19.5 ± 9.4 days vs. 24.5 ± 14.2 days (P= 0.498), and at 22.6 ± 13.5 days vs. 26.7 ± 18.1 days (P= 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit. CONCLUSIONS The results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.
Collapse
Affiliation(s)
- Povilas Ignatavicius
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Astra Vitkauskiene
- Department of Laboratory Medicine, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Juozas Pundzius
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Zilvinas Dambrauskas
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania,Department of Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Giedrius Barauskas
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| |
Collapse
|
36
|
Aydin S, Isik AT, Unal B, Comert B, Ozyurt M, Deveci S, Ozgur G, Cengiz O, Tasci I, Mas MR. Effects of infliximab on bacterial translocation in experimental acute necrotizing pancreatitis. Indian J Med Res 2012; 135:656-61. [PMID: 22771595 PMCID: PMC3401696 DOI: pmid/22771595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background & objectives: Translocation of bacteria from the gut is an important factor in the development of septic complications and mortality in acute pancreatitis (AP). The present study was designed to assess the effects of infliximab treatment on bacterial translocation (BT) in experimental acute necrotizing pancreatitis. Methods: Male Sprague-Dawley rats (n=45) were allocated into three groups. AP was induced in group II (positive control, n=15) and group III (Infliximab; n=15) by retrograde injection of taurocholate into the common biliopancreatic duct. Group I rats (Sham; n=15) received normal saline infusion into the common biliopancreatic duct as placebo. Groups I and II were treated by normal saline and group III was treated with infliximab intraperitoneally on 6, 30 and 54 h after induction of pancreatitis. All surviving animals were killed 60 h after the induction of pancreatitis, and specimens were collected for amylase measurement as well as histopathologic and microbiologic examinations. Results: Oedema, acinar cell necrosis, inflammatory infiltration, haemorrhage, fat necrosis and perivascular inflammation in group III rats were decreased with infliximab treatment when compared with group II (P<0.001). BT to mesentery lymph node in groups I, II and III were 20, 100 and 46 per cent, respectively. BT to peritoneum and pancreas in group III was lower than group II (P<0.05). Interpretation & conclusions: Infliximab administration resulted in beneficial effects on BT and histopathologic changes in the experimental necrotizing pancreatitis. Whether anti-TNF therapy has a role in prevention of complications of ANP needs to be established.
Collapse
Affiliation(s)
- Sezai Aydin
- Department of Surgery, Guven Hospital, A. Ayranci, Ankara, Turkey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Digestive System, Liver, and Abdominal Cavity. THE CAT 2012. [PMCID: PMC7158306 DOI: 10.1016/b978-1-4377-0660-4.00023-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
38
|
Abstract
Infections due to pancreatic necrosis and abscesses are observed in one third of patients with severe acute pancreatitis (SAP). Based on results of double-blind, randomized, placebo-controlled trials, antibiotic prophylaxis in SAP is ineffective for reducing the frequency of infected necrosis and to decrease hospital mortality. Antibiotic treatment using carbapenems and quinolones is indicated on demand in patients with SAP and multiorgan failure at admission and in those with hemodynamic shock. Patients with biliary acute pancreatitis (AP) and clinically acute cholecystitis and/or cholangitis benefit from antibiotic treatment. Patients with AP associated with bacteremia, positive bronchoalveolar lavage, and urinary tract infection should receive antibiotics. In necrotizing pancreatitis, evidence-based data do not support late use of antibiotic prophylaxis after onset. Further high-quality, randomized, controlled trials are needed to evaluate antibiotic prophylaxis in the first 24 to 48 hours after SAP onset.
Collapse
|
39
|
Ruben DS, Scorpio DG, Gabrielson KL, Simon BW, Buscaglia JM. Refinement of canine pancreatitis model: inducing pancreatitis by using endoscopic retrograde cholangiopancreatography. Comp Med 2009; 59:78-82. [PMID: 19295057 PMCID: PMC2703136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 09/02/2008] [Accepted: 12/13/2008] [Indexed: 05/27/2023]
Abstract
The causes and treatments of pancreatitis have been studied in diverse species, but the canine pancreatitis model has been used most often due to its similarities to the condition in humans. Although pancreatitis in dogs can be induced readily by numerous methods, managing these dogs can be difficult because they often develop severe abdominal pain, vomiting, inappetance, and lethargy. In an effort to study pancreatitis, we performed a pilot study to determine whether an endoscopic pancreatic procedure would be possible in a dog and whether, through various manipulations, a new method of inducing pancreatitis could be developed. The model uses endoscopic retrograde cholangiopancreatography (ERCP), a common procedure in human gastroenterology that has been associated with postprocedural pancreatitis. Although all 8 dogs used in developing the ERCP model had both biochemical and histologic changes consistent with pancreatitis, 7 of the 8 dogs remained free of classic clinical signs of the disease. This method is presented as a refinement of a canine model and presents an alternative method of inducing pancreatitis, with decreased risk of developing associated clinical signs.
Collapse
Affiliation(s)
- Dawn S Ruben
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | | | | | | | | |
Collapse
|
40
|
Abstract
OBJECTIVES A clinical study was made to test the hypothesis that gut mucosal damage happens and correlates with endotoxemia, systemic inflammation, severity of disease, septic complication, and outcome in acute pancreatitis (AP) patients. METHODS Patients were divided into 3 groups according to severity: grade 1 (n = 26, mild), grade 2 (n = 18, severe AP [SAP] without organ dysfunction), and grade 3 (n = 18, SAP with organ dysfunction). Twenty healthy volunteers were enrolled as control group. The intestinal lactulose and mannitol absorption ratio, d-xylose absorption, endotoxin, and tumor necrosis factor alpha were detected in parallel to clinical data collection. RESULTS Lactulose and mannitol absorption ratio increased in patients with AP, and the increase was more pronounced in SAP (grade 1: 0.044 +/- 0.017, grade 2: 0.39 +/- 0.16, grade 3: 0.48 +/- 0.22, control: 0.024 +/- 0.009; P < 0.01 between control and AP, P < 0.01 between mild and severe group). d-Xylose absorption decreased in pancreatitis groups (P < 0.01) especially in severe groups (P < 0.01 between mild and SAP). We also observed a significant positive correlation of mucosal permeability with endotoxin (r = 0.902, P < 0.001) and tumor necrosis factor alpha changes (r = 0.862, P < 0.001). The severity and septic complication in AP patients were different accompanied with severity of gut mucosal damage. CONCLUSIONS Intestinal mucosal function is injured in early phase of AP especially in patients with organ dysfunction, which may be a stimulus for development of multiple organ dysfunction and correlate with bad outcome in AP patients.
Collapse
|
41
|
Abstract
Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.
Collapse
|
42
|
Nakajima T, Ueda T, Takeyama Y, Yasuda T, Shinzeki M, Sawa H, Kuroda Y. Protective effects of vascular endothelial growth factor on intestinal epithelial apoptosis and bacterial translocation in experimental severe acute pancreatitis. Pancreas 2007; 34:410-6. [PMID: 17446839 DOI: 10.1097/mpa.0b013e3180335c64] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Bacterial translocation (BT) plays an important role in systemic complications in severe acute pancreatitis (SAP). We recently demonstrated that accelerated apoptosis of intestinal mucosa might have a role in BT. Effects of vascular endothelial growth factor (VEGF) on intestinal epithelial cell apoptosis and BT were investigated in SAP. METHODS Severe acute pancreatitis was induced by retrograde injection of sodium deoxycholate into the biliopancreatic duct in rats. Recombinant rat VEGF (2 microg) was injected, and SAP was immediately induced. Eight hours after the induction, serum amylase/lipase levels and apoptosis of ileal mucosa were evaluated. After 18 hours, the villous height of ileum was examined. After 22 hours, hematocrit, pancreatic water content, BT to the mesenteric lymph nodes, plasma plasminogen activator inhibitor 1 levels, and microvessel density in the small intestine were investigated. RESULTS Amylase/lipase levels were significantly elevated in SAP, but VEGF did not affect them. Apoptosis of ileal mucosa was accelerated in SAP, and VEGF significantly reduced the apoptosis. Villous height was significantly decreased in SAP, and VEGF significantly improved it. Vascular endothelial growth factor did not affect the hematocrit or pancreatic water content. Bacterial translocation occurred in the SAP group, and VEGF significantly prevented that. Plasminogen activator inhibitor 1 levels were significantly elevated in SAP, and VEGF significantly improved the elevation. Microvessel counts were significantly reduced in SAP, and VEGF significantly increased them. CONCLUSION These results suggest that VEGF inhibits intestinal epithelial cell apoptosis and subsequent BT in SAP.
Collapse
Affiliation(s)
- Takahiro Nakajima
- Department of Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, Kusunoki-cho, Chuo-ku, Kobe, Japan.
| | | | | | | | | | | | | |
Collapse
|
43
|
van Minnen LP, Blom M, Timmerman HM, Visser MR, Gooszen HG, Akkermans LMA. The use of animal models to study bacterial translocation during acute pancreatitis. J Gastrointest Surg 2007; 11:682-9. [PMID: 17468930 PMCID: PMC1915599 DOI: 10.1007/s11605-007-0088-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 11/29/2006] [Indexed: 01/31/2023]
Abstract
Infection of pancreatic necrosis with intestinal flora is accepted to be a main predictor of outcome during severe acute pancreatitis. Bacterial translocation is the process whereby luminal bacteria migrate to extraintestinal sites. Animal models were proven indispensable in detecting three major aspects of bacterial translocation: small bowel bacterial overgrowth, mucosal barrier failure, and disturbed immune responses. Despite the progress made in the knowledge of bacterial translocation, the exact mechanism, origin and route of bacteria, and the optimal prophylactic and treatment strategies remain unclear. Methodological restrictions of animal models are likely to be the cause of this uncertainty. A literature review of animal models used to study bacterial translocation during acute pancreatitis demonstrates that many experimental techniques per se interfere with intestinal flora, mucosal barrier function, or immune response. Interference with these major aspects of bacterial translocation complicates interpretation of study results. This paper addresses these and other issues of animal models most frequently used to study bacterial translocation during acute pancreatitis.
Collapse
Affiliation(s)
- L. P. van Minnen
- Department of Surgery, Gastrointestinal Research Unit, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. Blom
- Department of Surgery, Gastrointestinal Research Unit, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H. M. Timmerman
- Department of Surgery, Gastrointestinal Research Unit, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. R. Visser
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H. G. Gooszen
- Department of Surgery, Gastrointestinal Research Unit, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L. M. A. Akkermans
- Department of Surgery, Gastrointestinal Research Unit, University Medical Center Utrecht, P.O. Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
44
|
Isenmann R, Henne-Bruns D. Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now? Expert Rev Anti Infect Ther 2007; 3:393-401. [PMID: 15954856 DOI: 10.1586/14787210.3.3.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.
Collapse
Affiliation(s)
- Rainer Isenmann
- Department of Abdominal and Transplantation Surgery, University of Ulm, Steinhoevelstrasse 9, 89075 Ulm, Germany.
| | | |
Collapse
|
45
|
Yasuda T, Takeyama Y, Ueda T, Shinzeki M, Sawa H, Nakajima T, Kuroda Y. Breakdown of intestinal mucosa via accelerated apoptosis increases intestinal permeability in experimental severe acute pancreatitis. J Surg Res 2006; 135:18-26. [PMID: 16603187 DOI: 10.1016/j.jss.2006.02.050] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Revised: 02/03/2006] [Accepted: 02/21/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bacterial translocation plays an important role for infectious complications in severe acute pancreatitis (SAP). Breakdown of intestinal mucosal integrity may increase intestinal permeability and may be implicated in bacterial translocation. It is suggested that increase in intestinal permeability is correlated with the changes of tight junction and/or apoptosis in intestinal epithelial cells. The aim of this study was to investigate the changes of intestinal mucosa and its permeability in SAP. METHODS SAP was induced by injection of 3% sodium deoxycholate into the biliopancreatic ducts in rats. Permeability of intestinal wall was assayed ex vivo by measuring the leaked amount of FITC-dextran from the ileum pouch. Alteration of tight junction proteins such as zonula occludens (ZO)-1 and Occludin was evaluated by Western blotting and immunofluorescence staining. Apoptotic change of intestinal mucosa was detected by TUNEL staining and DNA fragmentation ELISA. In vitro, apoptosis-inducing effect of pancreatitis-associated ascitic fluid (PAAF) was examined using T84 cells. Integrity of monolayer cells was assessed by transepithelial electric resistance (TEER). RESULTS Permeability of ileum was significantly increased 6 h after induction of SAP. Blood endotoxin level was significantly elevated and bacterial translocation occurred 18 h after induction of SAP. Six hours after induction of SAP, expressions of ZO-1 and Occludin were not altered, but apoptosis of ileum mucosa was significantly accelerated. Addition of PAAF to T84 cells did not affect expressions of ZO-1 or Occludin, but significantly increased the apoptosis and significantly decreased TEER. CONCLUSIONS These results suggest that breakdown of intestinal mucosa via accelerated apoptosis may increase in intestinal permeability in SAP and that PAAF contains factor(s) that accelerates the apoptosis of intestinal epithelial cells.
Collapse
Affiliation(s)
- Takeo Yasuda
- Department of Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, Kobe, Japan.
| | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
The management of infected pancreatic necrosis is centered on image-guided fine needle aspiration followed by antibiotic therapy that is based on microbiologic culture results. The authors favor targeted antibiotic therapy rather than routine prophylactic antibiotic coverage. Prompt surgical debridement is recommended for patients who have infected necrosis who are suitable operative candidates. Newer surgical, percutaneous, and endoscopic techniques, as well as prolonged antibiotic therapy without intervention, are being evaluated as alternatives to operative debridement. Well-designed prospective trials will help to determine optimal treatment for patients who have infected pancreatic necrosis.
Collapse
Affiliation(s)
- Tyler M Berzin
- Department of Medicine, Division of Gastroenterology, Department of Radiology, and Center for Pancreatic Disease, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | | | | |
Collapse
|
47
|
van Minnen LP, Nieuwenhuijs VB, de Bruijn MT, Verheem A, Visser MR, van Dijk JE, Akkermans LMA, Gooszen HG. Effects of subtotal colectomy on bacterial translocation during experimental acute pancreatitis. Pancreas 2006; 32:110-4. [PMID: 16340752 DOI: 10.1097/01.mpa.0000191650.24796.89] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The colon is considered a major source of bacteria causing infection of pancreatic necrosis in acute pancreatitis (AP). Subtotal colectomy before AP in rats reduces mortality, but its role in affecting small bowel flora, bacterial translocation, and infection of pancreatic necrosis is unknown. Our aim was to study these phenomena in rats with AP. METHODS Fifty rats, allocated in 4 groups, underwent 2 laparotomies: group 1, sham laparotomy and saline biliopancreatic duct infusion; group 2, subtotal colectomy and saline infusion; group 3, sham laparotomy and AP (ductal infusion of glycodeoxycholic acid and intravenous cerulein); group 4, subtotal colectomy and AP. Seventy-two hours later, samples were collected for microbiological analysis. RESULTS Subtotal colectomy caused small bowel bacterial overgrowth with gram-positive cocci (group 1 versus group 2, duodenum: P = 0.030, ileum: P = 0.029). Bacterial counts of gram-negative rods/anaerobes in the duodenum and ileum and pancreatic bacterial counts of rats with colectomy and AP were significantly higher than in rats with AP only (group 3 versus group 4, duodenum: P = 0.040, ileum: P = 0.029, pancreas: P = 0.017). Duodenal bacterial overgrowth and pancreatic infection correlate significantly (r = 0.45, P = 0.004). CONCLUSIONS Subtotal colectomy induces small bowel bacterial overgrowth, which is associated with increased bacterial translocation to the pancreas.
Collapse
Affiliation(s)
- L Paul van Minnen
- Department of Surgery, University Medical Center, Utrecht, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Affiliation(s)
- H A Reber
- Gastrointestinal Surgery, UCLA School of Medicine, 10833 LeConte Ave, 72-215 CHS, Los Angeles, CA 90095-6904, USA
| |
Collapse
|
49
|
Affiliation(s)
- T Foitzik
- Department of Surgery, Benjamin Franklin Medical Center, Freie Universität Berlin, Germany.
| |
Collapse
|
50
|
Isenmann R, Beger HG. Bacterial infection of pancreatic necrosis: role of bacterial translocation, impact of antibiotic treatment. Pancreatology 2002; 1:79-89. [PMID: 12120191 DOI: 10.1159/000055798] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- R Isenmann
- Department of General Surgery, University of Ulm, Steinhoevelstrasse 9, D-89075 Ulm, Germany
| | | |
Collapse
|