United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU)

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

Efficacy and safety of continuous glucose monitoring on glycaemic control in patients with chronic pancreatitis and insulin-treated diabetes: A randomised, open-label, crossover trial

AIMS

Continuous glucose monitoring (CGM) improves glycaemic control and reduces hypoglycaemia in type 1 and 2 diabetes, but its role in managing diabetes in chronic pancreatitis is unknown. We aimed to investigate the effect of CGM compared to self-monitoring of blood glucose (SMBG) on hypoglycaemia and glycaemic control in patients with chronic pancreatitis and insulin-treated diabetes.

MATERIALS AND METHODS

In a randomised, open-label, crossover trial, 30 participants with chronic pancreatitis and insulin-treated diabetes were randomised to 50 days of CGM or SMBG, separated by a 20-day washout period. The primary endpoint was time in level 2 hypoglycaemia (<3.0 mmol/L). Secondary endpoints included additional CGM metrics, HbA1c, daily insulin dose, questionnaires, and safety outcomes.

RESULTS

Twenty-nine participants completed the trial (mean age 64.4 ± 8.8 years; 22 men [75.9%]). There was a numerical reduction in time spent in level 2 hypoglycaemia with CGM compared to SMBG (mean difference -0.36%, 95% confidence interval (CI) -0.78% to 0.06%; p = 0.09). CGM improved time in range (3.9-10.0 mmol/L; mean difference 7.46%, 95% CI 1.67% to 13.25%; p = 0.01), reduced time above range (>10.0 mmol/L; mean difference -6.55%, 95% CI -12.59% to -0.51%; p = 0.04), and reduced time below range (<3.9 mmol/L; mean difference -0.91%, 95% CI -1.79% to -0.03%; p = 0.04) compared to SMBG. No differences were observed for the safety endpoints.

CONCLUSIONS

In patients with chronic pancreatitis and insulin-treated diabetes, CGM increased time in range and reduced time above and below range. These findings highlight the potential of CGM in improving glycaemic control.

Italian Chronic Pancreatitis Registry (ITARECIPE): protocol for a nationwide cohort study

INTRODUCTION

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas leading to permanent damage, resulting in both exocrine and endocrine insufficiency. Understanding the management of patients with CP and their outcomes is critical for improving patient care. CP is relatively rare in Italy and is characterised by various aetiologies and clinical progression requiring personalised treatment options. This registry (ITARECIPE) aims to prospectively collect and analyse data on patients with newly diagnosed CP to gain insights into its epidemiology, presentation, disease progression, and treatment outcomes.

METHODS AND ANALYSIS

This is a multicentre, observational, non-interventional incident cohort study supported by the Italian Association for the Study of the Pancreas and endorsed by relevant Italian gastroenterological societies. ITARECIPE is the first registry in Italy focusing on newly diagnosed CP patients, leading to a comprehensive understanding of disease onset and progression. The study plans to enrol ≥300 patients annually over a minimum of 5 years. Data are recorded in a pseudo-anonymous electronic Case Report Form (eCRF) at baseline and follow-up visits, covering patient demographics, comorbidities, chronic medications, CP aetiology, pancreatic function (exocrine and endocrine), pain, complications, imaging, laboratory tests and treatments. It will track epidemiology, clinical history and treatment outcomes, potentially improving adherence to best practices and informing health policy decisions. The ITARECIPE registry will contribute significantly to the understanding of CP by providing detailed epidemiological, clinical and examinations data into disease management, which could help the development of future clinical practice and guidelines.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee (EC) of the promoter centre (San Raffaele Hospital, Milan, Italy; approval code 178/2022) and subsequently by the EC of each participating centre. All patients will be included after signing written informed consent and will be recorded in a pseudo-anonymous manner in a specific eCRF, in accordance with international principles and recommendations for observational studies. The ongoing results may be presented at national or international conferences and will be reported in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05733130.

Diagnosis and staging of chronic pancreatitis-Diagnostic accuracy and agreement between endoscopic ultrasound and transabdominal ultrasound shear wave elastography

BACKGROUND

Diagnosis of chronic pancreatitis (CP) is invasive and depending on endoscopic ultrasound (EUS) evaluation using Rosemont Criteria (RC). Non invasive ultrasound (US) based tests are necessary to detect CP.

AIM

We compared transabdominal 2D Shear Wave Elastography (SWE) of the pancreas and the Gemelli Ultrasound Chronic Pancreatitis Score to EUS/RC for the diagnosis of chronic pancreatitis.

METHODS

We conducted a single center prospective case-control study. EUS with RC defined cohorts with (n = 51) and without CP (n = 51). Patients underwent US evaluation of the pancreas using 2D SWE and USCP.

RESULTS

Median SWE values were different between groups (no CP 1.45m/s; IQR 1.34-1.60 and with CP 1.72m/s; IQR 1.63-1.96; p < 0.0001) and different between RC subgroups (RC indeterminate for CP 1.67m/s, IQR 1.52-1.72 vs. RC suggestive 1.72m/s, IQR 1.62-1.97 vs. RC consistent with CP 1.90 m/s, IQR 1.72-2.12 m/s; p < 0.0001). Median USCP was different between groups. 2D SWE correlated with USCP (p < 0.0001) and RC (p < 0.0001). We defined a cut off SWE value of <1.42m/s to rule out CP (Sensitivity 96 %; NPV 92 %) and a SWE cut off >1.87m/s to diagnose CP (Specifity 96 %;PPV 90 %).

CONCLUSION

Pancreatic US evaluation with 2D SWE is a widely applicable and unexpensive tool for the diagnosis of CP. Larger studies are needed to confirm these results.

Management of IgG4-related cholangitis: diagnosis, therapy, and long-term surveillance

IgG4-related cholangitis (IRC) is a chronic cholestatic liver disease that often occurs concomitantly with autoimmune pancreatitis type 1. Both conditions are manifestations of IgG4-related disease, a systemic autoimmune-mediated fibroinflammatory disorder. Patients often present with jaundice and weight loss, mimicking hepatobiliary malignancies, such as cholangiocarcinoma, primary sclerosing cholangitis, and pancreatic cancer. Accurate diagnosis is challenging due to the absence of pathognomonic findings but can be achieved using the HISORt criteria (histology, imaging, serology, other organ involvement, and response to immunosuppressive therapy). Early diagnosis is critical to avoid unnecessary surgery and prevent progression to liver fibrosis or cirrhosis. IRC responds well to corticosteroid therapy, though relapses are common, necessitating long-term immunosuppressive treatment in many cases. Steroid-sparing agents for remission induction and maintenance therapy comprise immunomodulators, such as azathioprine, as well as B-cell depletion therapies, such as rituximab. This review provides a structured clinical overview of the diagnosis, differential diagnosis, and therapy, including novel therapeutic options, such as inebilizumab, for this rare yet severe condition. A key focus is on long-term surveillance strategies, which include laboratory tests, imaging (contrast-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography, ultrasound, endosonography), and, particularly in patients with fibrotic bile duct strictures, endoscopy (endoscopic retrograde cholangiopancreatography, cholangioscopy).

16. Pain in chronic pancreatitis

INTRODUCTION

Chronic pancreatitis is defined as a disease of the pancreas in which recurrent inflammatory episodes result in replacement of the pancreatic parenchyma by fibrous connective tissue in individuals with genetic, environmental, and other risk factors. Pain is one of the most important symptoms of chronic pancreatitis and, in many cases, has chronic visceral nociceptive, nociplastic, and even neuropathic components, with evidence of both central and peripheral sensitization, neuroplasticity, and neurogenic inflammation.

METHODS

The literature on the diagnosis and treatment of pain in chronic pancreatitis was reviewed and summarized.

RESULTS

Treatment of abdominal pain in chronic pancreatitis is guided by pancreatic morphology on imaging, although the correlation between pain symptoms and pathoanatomical changes is not always straightforward. Patients with pancreatic duct obstruction are initially offered endoscopic or surgical therapies, while non-obstructive disease is mostly managed medically. Lifestyle changes and psychological support are of particular importance for all chronic pancreatitis patients. Analgesic options range from non-opioid medications to opioids and adjuvant agents. Interventional pain management may consist of radiofrequency treatment of the splanchnic nerves and spinal cord stimulation. To date, there are no randomized trials supporting their efficacy in the treatment of chronic pancreatitis pain, and the recommendation to consider these treatment options is justified by evidence from observational studies. Possible opioid-sparing effects of interventional pain treatments are important to consider because opioid use and dependency are common in chronic pancreatitis patients and associated with worse outcomes. Celiac plexus block is not generally recommended for chronic pancreatitis due to the limited quality of evidence, overall short duration of effect, and invasiveness of the procedure. Central sensitization can impact the effectiveness of invasive treatments.

CONCLUSIONS

Managing pain in chronic pancreatitis is a complex task that requires a multidimensional and individualized approach. Due to the lack of randomized trials, treatment decisions are often guided by expert opinion. Integrating pharmacological and non-pharmacological interventions and collaborating with a multidisciplinary team are key components of effective chronic pancreatitis pain management.

Pancreatic Enzyme Replacement Therapy in Pancreatic Exocrine Insufficiency-Real-World's Dosing and Effectiveness: A Systematic Review

BACKGROUND

Pancreatic exocrine insufficiency (PEI) results from impaired exocrine function of the pancreas, causing distressing symptoms like steatorrhea, diarrhea, abdominal distention, bloating, and pain. Treatment involves pancreatic enzyme replacement therapy (PERT), yet compliance with clinical guidelines and its real-world effectiveness are unclear. This systematic review aimed to assess the concordance between real-world PERT doses and clinical guidelines and to evaluate the effectiveness of PERT doses, considering their average administration.

METHODS

A systematic search of MEDLINE and EMBASE up to June 2023 identified observational studies reporting PERT doses and their effects on diarrhea and nutrition in PEI patients. Studies were classified based on adherence to current clinical guidelines for PERT dosing.

RESULTS

Twenty-five observational studies involving 3818 patients met the inclusion criteria. In 40% of the studies, average PERT doses were lower than the recommended 40,000-50,000 lipase units (LU) per meal. Significant alleviation of diarrhea was observed in nearly all studies with lower-than-recommended doses, but none showed benefits in nutritional status. PERT doses compliant with guidelines helped reduce diarrhea in most studies and improved or maintained nutritional status.

CONCLUSIONS

This review revealed that real-world PERT doses were lower than European guidelines in 40% of studies. While lower doses alleviated gastrointestinal symptoms, they were insufficient for maintaining normal nutritional status. Therefore, PERT dosing should aim for nutritional improvement by adhering to guideline-recommended doses. Individualized dosing, considering both symptom management and nutritional status, is essential due to varying responses to treatment.

Patients Receive Care for Chronic Pancreatitis in a VA System with Low Diagnostic Confidence

BACKGROUND AND AIMS

With the exception of late-stage disease, making an accurate diagnosis of chronic pancreatitis remains a significant clinical challenge. Using established diagnostic criteria, a retrospective review from a VA cohort was performed to determine the level of confidence with which this diagnosis is applied. Evaluation for clinical factors associated with diagnostic confidence was performed.

METHODS

Among 832 patient charts reviewed, 245 met inclusion criteria. Applying described diagnostic criteria, patients with a presumed diagnosis of chronic pancreatitis were evaluated for diagnostic confidence level at the time of diagnosis and again over time. Regression analysis was performed to determine clinical factors that were independently associated with a low-confidence diagnosis as well as change in diagnostic confidence over time.

RESULTS

57% of patients (n = 140) received a low-confidence diagnosis of chronic pancreatitis, with a more likely diagnosis identified in 67% of those cases, including underlying neoplasia (n = 12, 13%). Over 7.3 years of follow-up, 49% (n = 120) of patients maintained a low-confidence diagnosis. Alcohol use (OR 14.0; CI 1.3-111.1) and a history of acute pancreatitis (OR 12.8; CI 1.4-113.7) were associated with a change from low- to high-confidence diagnosis over time. PERT was prescribed frequently (60%, n = 148), despite low diagnostic confidence and infrequent objective testing for exocrine insufficiency (20%, n = 48).

CONCLUSION

Approximately, 50% of patients in a VA population clinically managed with a working diagnosis of chronic pancreatitis have low clinical confidence in that diagnosis. Increased diagnostic scrutiny and wider adoption of applicable diagnostic approaches are of the utmost importance.

Surgery for chronic pancreatitis across Europe (ESCOPA): prospective multicentre study

BACKGROUND

Randomized trials have demonstrated the superiority of surgery over endoscopy in patients with symptomatic chronic pancreatitis. However, large international studies quantifying the impact of surgery on chronic pancreatitis are lacking. The aim of this study was to evaluate current practice across Europe regarding indications, surgical techniques, and outcomes of surgery for chronic pancreatitis.

METHODS

A prospective multicentre study of consecutive patients undergoing surgery for symptomatic chronic pancreatitis from 22 centres in 13 countries from 1 June 2021 to 30 November 2022 was conducted. The outcome of interest in patients with pain as an indication was the Izbicki pain score at 6-month follow-up, with complete pain relief defined as an Izbicki pain score ≤10 and partial pain relief defined as an Izbicki pain score >10, but with a >50% decrease compared with the baseline score. Quality of life was assessed using Pancreatitis Quality of Life Instrument (PANQOLI) and 12-Item Short-Form (SF-12) surveys. Predictors of pain relief were analysed using multivariable analysis.

RESULTS

Overall, 207 patients underwent surgery (24.6% underwent surgical drainage procedures, 29.5% underwent duodenum-preserving head resections, and 45.9% underwent formal pancreatic resections). Before surgery, 48.8% used opioids and 51.2% had undergone prior endoscopic treatment. Major morbidity occurred in 14.0% and the 90-day mortality rate was 1.4%. Among 113 patients operated on for pain, the median Izbicki pain score decreased from 61.3 to 19.0 at 6 months (P < 0.001). Pain relief was achieved in 72.6% (43 patients reported complete pain relief and 39 patients reported partial pain relief). PANQOLI and SF-12 Physical Component Summary scores improved significantly (P < 0.001). Longer symptom duration (OR 0.95 (95% c.i. 0.90 to 1.00), P = 0.045) and use of opioids before surgery (OR 3.16 (95% c.i. 1.04 to 9.64), P = 0.043) predicted less pain relief.

CONCLUSION

Surgery for chronic pancreatitis across Europe was performed with low morbidity. Patients reported good pain relief and improvements in quality-of-life scores. Multidisciplinary consultation is recommended for all patients with chronic pancreatitis before undergoing any intervention.

[Prevalence and risk of malnutrition in patients with chronic pancreatitis: A systematic review and meta-analysis]

AIM

To systematize data on the prevalence and risk of malnutrition in patients with chronic pancreatitis (CP).

MATERIALS AND METHODS

MEDLINE/PubMed, EMBASE, Cochrane, Google Scholar, Scopus, and the Russian Science Citation Index were searched for studies published between January 1, 1985, and October 23, 2024 (inclusive) based on an analysis of the titles and abstracts of articles in these databases. The study included relevant publications in peer-reviewed periodicals in English or Russian, publications with data on the prevalence of malnutrition in patients with CP and control subjects (if any), studies on adult patients with CP, and publications with detailed descriptive statistics that allow using the data in the meta-analysis.

RESULTS

The final analysis included 13 studies involving 3,812 subjects (3,401 patients with CP and 411 controls). The overall prevalence of malnutrition in patients with CP was 43.43% (95% confidence interval [CI] 32.419-54.780), whereas in controls, it was 10.843% (95% CI 1.360-27.698). When analyzing the association in the overall pool of studies, a significant risk of malnutrition in CP patients compared to controls was shown (relative risk [RR] 3.635, 95% CI 1.409-9.373; p=0.008). The analysis used a random effect model, as there was high heterogeneity between the groups (I2=88.09%, 95% CI 74.76-94.38). A review of studies that used only validated instrumental methods for the diagnosis of malnutrition (criteria of the Global Leadership Initiative on Malnutrition) showed a total prevalence of malnutrition of 38.348% (95% CI 14.975-65.047) in patients with CP and 12.22% (95% CI 5.985-67.238) in control subjects.

CONCLUSION

This meta-analysis demonstrated that malnutrition is a common complication of CP and occurs in approximately 40% of CP patients. A modern clinician should promptly assess malnutrition markers in a CP patient and correct them using enzyme replacement therapy if detected.

Etiologies of exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a major cause of maldigestion and malnutrition, resulting from primary pancreatic diseases or other conditions. As the prevalence of EPI continues to rise, accurate identification of its etiology has become critical for the diagnosis and treatment of pancreatic secretory insufficiency. EPI can result from both pancreatic and non-pancreatic disorders. Pancreatic disorders include acute and chronic pancreatitis, pancreatic tumors, cystic fibrosis, procedures that involve pancreatic resection, and other rare causes. Non-pancreatic disorders of EPI include diabetes mellitus, celiac disease, inflammatory bowel disease, gastrointestinal and esophagectomy surgery, as well as advanced patient age. This review aims to provide a comprehensive analysis of the literature on EPI etiology, with a thorough overview to support its consideration as a potential diagnosis.

Pathophysiology, Assessment, and Management of Pain Associated with Chronic Pancreatitis

Chronic pancreatitis (CP) is a fibroinflammatory disease, with pain as its most prominent symptom. This article provides a comprehensive review of the pathophysiology, assessment methodologies, and management strategies pertaining to pain in CP. Pathophysiological mechanisms include inflammatory and neuropathic components, including peripheral and central sensitization. Pain assessment can include unidimensional and multidimensional pain assessment scales, neurophysiological assessments, and advanced imaging techniques. Management strategies include a spectrum from lifestyle modifications, pharmacologic interventions, and interventional procedures to neuromodulatory techniques and other experimental treatments.

Updates in the Diagnosis of Chronic Pancreatitis: Current Approaches and New Possibilities

This review provides a comprehensive update on the diagnostic approaches to chronic pancreatitis (CP), emphasizing recent advancements in imaging techniques, biomarker research, and multivariable scoring systems. Despite substantial progress in these areas, current diagnostic algorithms have limitations, particularly for early and non-calcific CP. Traditional criteria have focused on classic diagnostic signs, but "minimal change" CP is increasingly recognized through advanced imaging and function tests. This article aims to guide clinicians in applying current methods and available strategies for CP diagnosis and outline research efforts in the field.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Advances in research of metabolic bone disease secondary to chronic pancreatitis

Chronic pancreatitis (CP) is a progressive chronic inflammatory disease that can cause irreversible damage to pancreatic tissue, ultimately leading to pancreatic endocrine and exocrine insufficiency. Metabolic bone disease (MBD) is one of the systemic complications of CP, which includes osteopenia and osteoporosis, characterized by degradation of bone microstructure and an increased risk of fragility fracture. Nearly half of the patients with CP suffer from MBD, which is affected by a number of factors. Pancreatic exocrine insufficiency and pancreatic diabetes mellitus, which are also systemic complications of CP, can affect bone mineral density by lowering serum calcium, and increased levels of inflammatory factors in chronic inflammatory states, as well as the use of opioids to alleviate the pain of CP, can disrupt the balance between bone formation and resorption and promote the development of MBD. In addition, known risk factors for osteoporosis, such as smoking, alcohol abuse, aging, and low body mass index, account for a higher proportion of CP cases than in the general population and contribute to the high prevalence of MBD in CP patients. Foreign guidelines recommend that CP patients be regularly screened for fat-soluble vitamin deficiency, tested for bone mineral density, and evaluated for fracture risk, and encourage all CP patients to actively take preventive measures. In this article, we present a review on the research progress of CP-related metabolic bone disease, discussing the prevalence, related risk factors, and prevention and management of MBD, which will provide a reference for clinical workers.

Recommendations from the European guidelines for the diagnosis and therapy of pancreatic exocrine insufficiency

BACKGROUND

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below a level that allows normal digestion of nutrients. Pancreatic disease and pancreatic surgery are the main causes of PEI, but other conditions can affect the digestive function of the pancreas.

METHODS

In collaboration with European Digestive Surgery (EDS), European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society for Clinical Nutrition and Metabolism (ESPEN), European Society of Digestive Oncology (ESDO), and European Society of Primary Care Gastroenterology (ESPCG) the working group developed European guidelines for the diagnosis and therapy of PEI. United European Gastroenterology (UEG) provided both endorsement and financial support for the development of the guidelines.

RESULTS

Recommendations covered topics related to the clinical management of PEI: concept, pathogenesis, clinical relevance, general diagnostic approach, general therapeutic approach, PEI secondary to chronic pancreatitis, PEI after acute pancreatitis, PEI associated with pancreatic cancer, PEI secondary to cystic fibrosis, PEI after pancreatic surgery, PEI after esophageal, gastric, and bariatric surgery, PEI in patients with type 1 and type 2 diabetes, and PEI in other conditions.

CONCLUSIONS

The European guidelines for the diagnosis and therapy of PEI provide evidence-based recommendations concerning key aspects of the etiology, diagnosis, therapy, and follow-up, based on current available evidence. These recommendations should serve as a reference standard for existing management of PEI and as a guide for future clinical research. This article summarizes the recommendations and statements.

Treatment Strategies for Chronic Pancreatitis (CP)

Chronic pancreatitis (CP) and autoimmune pancreatitis (AIP) are diseases with overlapping features, both requiring complex management strategies. CP is characterized by pancreatic exocrine insufficiency (PEI) and pain, with treatment focused on symptom relief through pancreatic enzyme replacement therapy (PERT), pain control, and lifestyle and nutritional changes. However, the standard therapy does not address the underlying inflammation or fibrosis, which drives disease progression. AIP, on the other hand, presents with obstructive jaundice and fibrosis and is classified into two subtypes: Type 1 (AIP-1), linked to IgG4-related disease, and Type 2 (AIP-2), associated with inflammatory bowel disease. Treatment for AIP typically involves oral steroids. Immunomodulators and rituximab are used for recurrent or refractory cases. Novel therapies targeting the inflammation and fibrotic components of CP are being explored. A multidisciplinary approach is essential to optimize care and improve patients' outcomes.

The 12-Year Experience of the Hungarian Pancreatic Study Group

The Hungarian Pancreatic Study Group (HPSG) was established with the aim of advancing pancreatology. Our summary outlines the methodologies, key results, and future directions of the HPSG. Methodological elements included, the formation of strategic national and international collaborations, the establishment of patient registries and biobanks, and a strong focus on education and guideline development. Key results encompassed, pioneering research on pancreatic ductal function and the role of cystic fibrosis transmembrane conductance regulator (CFTR) in inflammation, significant advancements in understanding acute and chronic pancreatitis, and the execution of numerous clinical trials to explore new therapeutic approaches. Despite challenges, such as securing funding and translating research into clinical practice, the HPSG's commitment to patient care and scientific innovation has been unwavering. The group aims to deepen research into pancreatic cancer and chronic pancreatitis, conduct more randomized controlled trials (RCTs), and expand its efforts internationally by involving global staff and patients. The authors hope that this summary inspires others to undertake similar initiatives and contribute to the global advancement of medical research and patient care in pancreatology.

Long-Term Outcomes of Early Surgery vs Endoscopy First in Chronic Pancreatitis: Follow-Up Analysis of the ESCAPE Randomized Clinical Trial

Importance

Patients with painful chronic pancreatitis and a dilated pancreatic duct can be treated by early surgery or an endoscopy-first approach.

Objective

To compare long-term clinical outcomes of early surgery vs an endoscopy-first approach using follow-up data from the ESCAPE randomized clinical trial.

Design, Setting, and Participants

Between April 2011 and September 2018, 88 patients with painful chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach in 30 hospitals in the Netherlands collaborating in the Dutch Pancreatitis Study Group as part of the ESCAPE randomized clinical trial. For the present cohort study, long-term clinical data were collected after the initial 18-month follow-up. Follow-up was completed in June 2022, and data analysis was performed in June 2023.

Exposure

Patients with chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach.

Main Outcomes and Measures

The primary end point was pain, assessed by the Izbicki pain score; secondary end points included patient-reported complete pain relief and satisfaction. Predefined subgroups included patients who progressed from endoscopy to surgery and those with ductal clearance obtained by endoscopy. Analysis was performed according to the intention-to-treat principle.

Results

In this cohort study, 86 of 88 overall patients could be evaluated, with a mean (SD) follow-up period of 98 (16) months. Of 88 initial patients, 21 patients (24%) were female, and mean (SD) patient age was 61 (10) years. At the end of long-term follow-up, the mean (SD) Izbicki pain score was significant lower (33 [31] vs 51 [31]) in the early surgery group, as was the rate of patient-reported complete pain relief (14 of 31 patients [45%] vs 6 of 30 patients [20%]), compared to the endoscopy-first group. After the initial 18-month follow-up, 11 of 43 patients in the early surgery group (26%) underwent reinterventions vs 19 of 43 patients in the endoscopy-first group (44%). At the end of follow-up, more patients in the early surgery group were "very satisfied" with their treatment (22 of 31 patients [71%] vs 10 of 30 patients [33%]). Patients who progressed from endoscopy to surgery (22 of 43 patients [51%]) had significantly worse mean (SD) Izbicki pain scores (33 [31] vs 52 [24]) compared to the early surgery group and had a lower rate of complete pain relief (55% for early surgery vs 12% for endoscopy first). In the endoscopy-first group, patients with endoscopic ductal clearance had similar mean (SD) Izbicki pain scores as the remaining patients (49 [34] vs 53 [28]).

Conclusions and Relevance

In this cohort study evaluating long-term outcomes of the ESCAPE randomized clinical trial, after approximately 8 years of follow-up, early surgery was superior to an endoscopy-first approach in patients with painful chronic pancreatitis and a dilated main pancreatic duct in pain scores and patient satisfaction. Notably, patients who progressed from endoscopy to surgery had worse outcomes compared to patients undergoing early surgery, and obtaining endoscopic ductal clearance did not improve outcomes.

Surgical management of chronic pancreatitis: A narrative review

Chronic pancreatitis is a severe disabling disease with persistent pain as the most prominent symptom often leading to significant quality of life (QoL) reduction. Current international guidelines propagate a step-up approach in which surgery should only be considered as a last resort in patients with failure of both medical and endoscopic interventions. Accumulating evidence, however, suggests that surgery is superior to endoscopic therapy and that early surgical intervention is beneficial in terms of pain relief, pancreatic function and QoL. Several surgical procedures are available with low morbidity and mortality rates, providing excellent long-term results. The purpose of this review was to present an overview of the surgical treatment options for chronic pancreatitis with a focus on the timing of surgery.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Chronic and Idiopathic Pancreatitis-A Personalized Treatment Approach

Chronic pancreatitis is a fibroinflammatory disease of the pancreas with heterogeneous clinical features and a significant socioeconomic burden. Assessing its aetiology and early diagnosis of associated complications remain challenging. Personalized therapy necessitates precise knowledge of the genetic, biological, and clinical differences within a patient population. In this context, the identification of the underlying aetiology represents an essential cornerstone. This review elucidates current standards for identifying underlying aetiologies and the diagnostic work-up for idiopathic cases. It provides an overview of general therapeutic approaches and highlights individual treatment options. Additionally, the follow-up management of pancreatitis-associated complications, namely exocrine pancreatic insufficiency, post-pancreatitis diabetes mellitus, pain management, pancreatic fluid collections, and pancreatic cancer risk, is summarized.

Chronic Pancreatitis: One Patient, Multiple Etiologies

Pancreatitis, by definition, is an acute inflammation of the pancreas. Acute and chronic pancreatitis can be seen as a spectrum of the same disease rather than two different entities. Here, the authors report the diagnostic and therapeutic approach to a case of a 44-year-old male patient with multiple episodes of acute pancreatitis, leading to the development of chronic pancreatitis. An extended study revealed multiple causes for chronic pancreatitis, such as tobacco, alcohol, and genetics. Pain management and risk factor control were challenging in this case.

Minimally invasive versus open lateral pancreaticojejunostomy in patients with painful chronic pancreatitis: systematic review

BACKGROUND

Patients with painful chronic pancreatitis combined with a dilated main pancreatic duct and a normal size pancreatic head are treated according to guidelines by lateral pancreaticojejunostomy (LPJ). This systematic review compared outcomes of minimally invasive LPJ and open LPJ.

METHODS

From 1 January 2000 until 13 November 2023, series reporting on minimally invasive LPJ and open LPJ in patients with symptomatic chronic pancreatitis were included. This study was structured in accordance with the PRISMA guidelines. The primary outcome was intraoperative and postoperative complications. Secondary outcomes included long-term clinical outcomes.

RESULTS

Overall, 19 retrospective studies were included. Morbidity rate ranged from 0% to 57% after minimally invasive LPJ versus 4% to 68% after open LPJ (median: 25, i.q.r.: 23). Length of hospital stay ranged from 5 to 7 days after minimally invasive LPJ and from 6 to 16 days after open LPJ. The rate of pain relief ranged from 62% to 91% after open LPJ (median: 78.5, i.q.r.: 23) and from 71% to 100% (median: 82.5, i.q.r.: 12.5) after minimally invasive LPJ respectively. New-onset endocrine insufficiency ranged from 21% to 22% in minimally invasive LPJ and 19% to 26% after open LPJ. New-onset exocrine insufficiency was shown in 11% to 27% in minimally invasive LPJ versus 8% to 26% after open LPJ. Weight gain ranged from 60% to 100% (median: 97, i.q.r.: 23) after minimally invasive LPJ.

DISCUSSION

This systematic review suggested that minimally invasive LPJ can be performed safely in selected patients with symptomatic chronic pancreatitis. Phase 2 randomized trials should assess potential short-term benefits such as postoperative pain and length of hospital stay after minimally invasive LPJ.

Exocrine pancreatic inflammation in canine diabetes mellitus - An active offender?

The purpose of this review is to examine the current scientific literature regarding the interplay between the exocrine and endocrine pancreas, specifically the role of the exocrine pancreas in the pathogenesis of canine diabetes mellitus. β-cell death caused by exocrine pancreatic inflammation is thought to be an under-recognised contributor to diabetes mellitus in dogs, with up to 30 % of canine diabetic patients with concurrent evidence of pancreatitis at post-mortem examination. Current diagnostics for pancreatitis are imprecise, and treatments for both diseases individually have their own limitations: diabetes through daily insulin injections, which has both welfare and financial implications for the stakeholders, and pancreatitis through treatment of clinical signs, such as analgesia and anti-emetics, rather than targeted treatment of the underlying cause. This review will consider the evidence for exocrine pancreatic inflammation making an active contribution to pancreatic β-cell loss and insulin-deficiency diabetes in the dog and explore current and potential future diagnostic and treatment avenues to improve outcomes for these patients.

Pancreatic atrophy is a predictor for exocrine pancreatic dysfunction: Data from a large cohort of patients with chronic pancreatitis

OBJECTIVES

Pancreatic atrophy is commonly observed in end-stage chronic pancreatitis (CP). Diagnostic standards for pancreatic atrophy not well established. The present cross-sectional observation study explored two-point pancreatic size measurements in a large CP cohort from the Scandinavian Baltic Pancreatic Club (SBPC) database to validate clinically relevant cutoffs for pancreatic atrophy and explore associations to etiological factors and disease outcomes.

METHODS

Patients with CP according to M-ANNHEIM diagnostic criteria were included. We measured maximal axial dimension of the pancreatic head and body and recorded presence of calcifications and pancreatic duct changes on cross-sectional imaging. We calculated cutoffs for clinically relevant atrophy related to exocrine pancreatic dysfunction (EPD) defined as fecal elastase (FE) < 200. Associations between pancreatic atrophy and smoke, alcohol, sex, body size and disease outcomes were analysed using multivariate logistic regression.

RESULTS

We included 539 CP patients (356 male) from four centres in the SBPC study group. Small pancreatic size represented by sum of two-point maximal axial dimension less than 31 mm for females and 37.5 mm for males predicted EPD with good specificity (males: 0.89 (95 % CI, 0.81, 0.95), females: 0.96 (95 % CI, 0.85, 0.99)) but poor sensitivity (males: 0.38 (95 % CI, 0.31, 0.45), females 0.25 (95 % CI, 0.18, 0.35). Male sex, increasing age and long duration of CP were clearly associated with pancreatic atrophy. Corrected for other factors reducing exocrine capacity, pancreatic atrophy was still strongly associated to EPD.

CONCLUSION

We conclude that following the suggested cutoffs, pancreatic atrophy in CP is independently associated with EPD.

The chronic pancreatitis (CP) Type Cambridge 2 as a cause of unclear upper abdominal pain: a radiologically underestimated diagnosis

The time interval from symptom onset to the diagnosis of chronic pancreatitis (CP) remains disproportionately long today due to nonspecific symptoms and the absence of a definitive laboratory marker. Nevertheless, mortality is increased by 3.6 times compared to the general population. Additionally, the risk of developing pancreatic carcinoma is 16 times higher in the presence of CP. According to the current S3 guideline, the morphological staging of CP should be based on the Cambridge Classification for CT/MRCP. Most radiologists morphologically associate CP with Cambridge Stage 4, which is characterized by classic calcifications. The subtle morphologies of earlier Cambridge Stages are often unrecognized, leading to delayed diagnosis. The aim of this study was to diagnose CP at Cambridge Stage 2 as the cause of unexplained upper abdominal discomfort.A retrospective analysis was conducted on 266 patients with unexplained upper abdominal pain who underwent outpatient MRI with MRCP between January 1, 2021, and October 1, 2023. The criteria for Cambridge Stage 2 were evaluated: pancreatic duct in the corpus measuring between 2 and 4 mm, pancreatic hypertrophy, cystic changes < 10 mm, irregularities in the duct, or > 3 pathological side branches. Patients with known tumors or other leading diagnoses, which explained the discomfort, were excluded.25 patients (15 female, 10 male) met the criteria for CP Stage 2 (9%). Ductal dilation between 2 and 4 mm was visible in 21 cases. Pancreatic hypertrophy was observed in six cases. Cystic changes < 10 mm were identified in three cases. Irregularities in the duct ("wavy duct") were diagnosed in 19 patients. Dilation of > 3 side branches was recognized in 17 cases. Lipase levels were additionally determined, with 13 patients showing pathologically elevated levels (> 60 U/l).CP at Cambridge Stage 2 is an important and underestimated diagnosis in patients with unexplained upper abdominal pain in the outpatient setting. Radiologists should pay attention not only to common signs like calcifications, large cysts, or duct strictures but also to subtle changes such as duct irregularities ("wavy duct configuration") and pathologically dilated side branches, which could lead to a significantly earlier diagnosis of CP. Lipase determination may be an additional indication of chronic pancreatitis in this context. · Early-stage Cambridge 2 CP is an important and underestimated diagnosis in patients with unexplained upper abdominal pain in the outpatient setting.. · Radiologists should pay attention to subtle signs of early CP.. · Additional information about lipase levels can be helpful in the diagnostic process..

S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

Comparison of the efficacy and safety of basket catheters and balloon catheters for endoscopic pancreatic duct stone clearance

BACKGROUND

The choice of a basket or a balloon catheter during endoscopic retrograde cholangiopancreatography (ERCP) for the clearance of pancreatic duct stones in patients with chronic pancreatitis (CP) remains controversial. This study compared the efficacy and safety of these two devices for pancreatic duct stone extractions.

METHODS

We compared the efficacy and safety of basket and balloon catheters for pancreatic stone extractions. We enrolled CP patients who underwent ERCP for the first time at Changhai Hospital, Naval Medical University between February 2012 and December 2021. After propensity score matching (1:1), 101 patients were included in each group. The primary outcome was the rate of pancreatic stone clearance. Secondary outcomes included the rate of adverse events during hospitalization, long-term pain relief, and quality of life after one year follow-up period.

RESULTS

The rate of complete clearance was comparable between the two groups (86.1 % vs. 84.2 %, P = 0.692). In patients with stones ≥ 2 cm before extracorporeal shock wave lithotripsy (ESWL), the rate of complete clearance was significantly higher in the balloon catheter group when compared to the basket catheter group [100 % (19/19) vs. 70.0 % (14/20), P = 0.031]. In the multivariate analysis, ESWL prior to stone extraction was the only independent predictor of complete clearance [with ESWL 58.4 % (264/452) vs. without ESWL 41.6 % (188/452), odds ratio = 2.3, 95 % confidence interval: 1.2-4.3; P = 0.013]. No significant differences between groups were found regarding the rates of adverse events during hospitalization, quality of life, and pain relief after one year of follow-up.

CONCLUSIONS

Basket and balloon catheters showed similar efficacy and safety for pancreatic stone extractions. However, the balloon catheter was superior to the basket catheter if the pancreatic stone size was ≥ 2 cm before ESWL.

Role of enzyme replacement therapy for exocrine and nutritional insufficiency in patients with malignancies: A review

Exocrine pancreatic insufficiency (EPI) is a condition in which the amount of secreted pancreatic enzymes is insufficient to maintain normal digestion. EPI is a frequent complication of pancreatic or other malignancies. The presence of EPI in a cancer patient may be suggested by symptoms of maldigestion, malabsorption, and alteration of nutritional markers; however, it is important to note that the EPI symptoms may be subtle. In the early stages, EPI may be latent and manifested by malnutrition. However, even in the later stages, the symptoms of EPI may be similar to those of cancer or be masked by the condition after chemoradiation therapy. Antitumor therapy itself may also cause EPI. Enzyme replacement therapy (ERT) is the standard of care for EPI, but it is rarely prescribed to cancer patients. However, supportive therapy plays an essential role in treating cancer patients because the quality of life and life expectancy of patients largely depend on the adequacy of the complex treatment. The review discusses the possible causes of EPI and its diagnosis and treatment in cancer patients. Special attention is paid to ERT regimens, including those for improving digestion and the drug's dosage form. It is shown that pancreatin in minimicrospheres is the drug of choice for ERT, since the minimum particle size facilitates the most physiological digestion process.

Predictive analysis of osteoarthritis and chronic pancreatitis comorbidity: complications and risk factors

Background

The comorbidity of chronic pancreatitis (CP) in patients with osteoarthritis (OA) is insufficiently studied, and the reciprocal impact of these conditions remains poorly understood. This study aimed to investigate potential predictors for the development of CP in OA patients, as well as associated complications.

Methods

A cohort of 181 patients was categorized into four groups: a control group (n=30), patients with OA (n=68), patients with CP (n=31), and patients with OA and comorbid CP (n=52). All four groups had no statistical differences in age and gender. The study utilized the WOMAC index, Visual Analog Scale (VAS), Lequesne index, biochemical assays, and advanced statistical methods to assess joint status in OA patients with comorbid CP. It explored potential predictors of comorbidity development and associated complications.

Results

The study revealed that concurrent CP in OA exacerbates progression and contributes to malnutrition. Body Mass Index (BMI) emerged as a potential predictor for CP comorbidity development in OA patients. Factors such as the WOMAC total score, fecal elastase-1, C-reactive protein (CRP), ferritin, retinol, tocopherol, 25-hydroxyvitamin D3, and BMI were found to influence the development of comorbidity of CP in OA. Additionally, Gastrointestinal Symptom Rating Scale-Diarrhea Syndrome (GSRS-DS), Gastrointestinal Symptom Rating Scale-Constipation Syndrome (GSRS-CS), Qualitative Assessment of the Symptoms and Impact of Pancreatic Exocrine Insufficiency Domain A (PEI-Q-A), retinol, tocopherol, and iron were identified as potential predictors comorbidity CP with exocrine pancreatic insufficiency in OA patients.

Conclusion

The presence of CP in OA patients exacerbates disease progression and complications, necessitating further investigation.

Complete extraction of main pancreatic duct residual and microstones using an 8-wire basket catheter

Background and study aims Extracorporeal shock wave lithotripsy (ESWL), pancreatoscopy-guided electrohydraulic lithotripsy (EHL), and endoscopic retrograde cholangiopancreatography (ERCP) are primary treatments for symptomatic main pancreatic duct (MPD) stones. However, incomplete clearance of residual/microstones post-treatment may cause symptom recurrence. We hypothesized that the 8-wire biliary basket catheter could be suitable for MPD stone extraction and aimed to analyze its ability to achieve more complete clearance of MPD residual/microstones. Patients and methods Patients suspected of having MPD residual/microstones ≤ 5 mm because of abdominal symptoms, computed tomography examination results, and pancreatography results after previous therapy, including ERCP, EHL, and extracorporeal shock wave lithotripsy, were retrospectively enrolled. Patients with severe MPD stenosis/biliary obstruction requiring ERCP drainage were excluded. Extraction of residual/microstones was attempted using an 8-wire basket that is widely expandable in the narrow pancreatic duct and can capture and sweep stones in the narrow pancreatic duct. Technical success was defined as extraction of residual/microstones. The primary outcome was the technical success rate. Secondary outcomes were therapeutic details of stone extraction using the 8-wire basket catheter, including symptom improvements. Results The technical success rate was 100% for seven patients; 1 to 8 residual/microstones were extracted. An improvement was observed in five patients with symptoms after the previous therapy. Three patients underwent residual stone extraction after extraction using a dedicated basket. No patient experienced symptom recurrence during the 270-day follow-up period. Conclusions The 8-wire basket resulted in successful MPD residual/microstone extraction and pancreatic symptom improvement. This method may prevent symptom recurrence caused by incomplete residual/microstone clearance.

An intensified trans-sectoral nutritional intervention in malnourished patients with chronic pancreatitis improves diseases prognosis and identifies potential biomarkers of nutritional status

Background

Malnutrition is a common complication in chronic pancreatitis and associated with reduced quality of life and life expectancy. Nutritional support is considered mandatory in malnourished patients with chronic pancreatitis but there is only scarce evidence on optimal treatment modalities and the efficacy of nutrition therapy. Here, we investigated the feasibility and efficacy of an intensified nutritional intervention in malnourished patients with chronic pancreatitis and aimed to identify suitable indicators for monitoring nutritional status.

Methods

We performed a single-arm feasibility study, in which malnourished patients with chronic pancreatitis received an intensified trans-sectoral nutritional intervention for 6 months. Multimodal treatment comprised face-to-face dietary counseling, oral nutritional supplementation, and a complementary telephone-based nutrition and exercise coaching. Patients underwent follow-up examinations after 28, 90, and 180 days, when we assessed changes in anthropometric and body composition measures, muscle function, Chronic Pancreatitis Prognosis Score (COPPS), as well as blood parameters and intestinal microbiota composition.

Results

Eleven out of 73 patients initially screened for study participation were enrolled in the trial of which 9 subjects (age (mean ± SD): 56.2 (±14.8) years; male: 67%; alcoholic etiology: 44%) underwent the complete intervention. Patients gained a median of 5.3 kg (8.6%) body weight, including 1.6 kg skeletal muscle mass, and significantly increased gait speed (p < 0.001). Ameliorated nutritional status and muscle function were associated with increased blood levels of IGF-1 and cholinesterase as well as altered gut microbiota composition on the phyla and genera level. Moreover, significant improvements in COPPS indicated reduced disease severity after 90 and 180 days.

Conclusion

Malnourished patients with chronic pancreatitis benefit from intensified nutritional therapy. Besides ameliorated nutritional status, a multimodal intervention can improve muscle function as well disease prognosis. Future studies are needed to prove superiority to standard-of-care and to validate potential biomarkers for prospective monitoring of nutritional status.

Clinical trial registration

https://clinicaltrials.gov/study/NCT04476056, NCT04476056.

Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures.

METHODS

A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated.

RESULTS

A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively.

CONCLUSIONS

FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.

Glycemic Variability in Pancreatogenic Diabetes Mellitus: characteristics, Risks, Potential Mechanisms, and Treatment Possibilities

In recent years, pancreatogenic diabetes mellitus has garnered significant attention due to its high incidence, complications, and mortality rates. Glycemic variability (GV) can increase the risk of pancreatogenic diabetes mellitus and its associated complications; however, the precise mechanism remains unclear. The effective control of GV is crucial for preventing the onset of pancreatic diabetes mellitus and improving prognosis. Both diet and antidiabetic medications have substantial effects on GV. However, many patients are prescribed suboptimal or even harmful drugs. Therefore, to provide a comprehensive treatment basis for clinicians to prevent and treat pancreatogenic diabetes mellitus, this study aimed to elucidate the relationship between GV and pancreatogenic diabetes mellitus; investigate the potential mechanisms (such as oxidative stress, inflammatory response, insulin resistance, and lipid metabolism disorders); provide lifestyle guidance; and recommend drug selections to reduce the GV in patients with pancreatogenic diabetes mellitus.

[Possibilities of post-processing of multislice computed tomography results in non-invasive diagnosis of pancreatic fibrosis]

AIM

To evaluate the possibilities of post-processing of multidetector computed tomography (CT) results in the non-invasive diagnosis of pancreatic fibrosis (PF).

MATERIALS AND METHODS

The study included 165 patients aged 57.91±13.5 years who underwent preoperative CT during surgical treatment for chronic pancreatitis and pancreatic cancer from April 2022 to February 2024. The normalized contrast ratios of pancreatic tissue in the pancreatic (NCPP) and venous (NCVP) phases, as well as the contrast ratio (CR) were measured. Pathomorphological assessment of PF performed in tissues outside neoplasm or desmoplastic reaction by the Kloppel and Maillet scale.

RESULTS

The values of post-processing CT results were compared in groups with different degrees of PF. Mean CR values were significantly higher (p=0.001) in patients with severe PF (CR 1.16±0.65 HU) than in patients with mild PF (CR 0.78±0.31 HU). CR value significant increase (p=0.03) was found in patients with signs of inflammatory changes in the pancreas tissue (CR 1.14±0.6 HU) than in those without them (CR 0.81±0.3 HU). There were no significant differences between the values of NCPP and NCVP, and the degree of PF.

CONCLUSION

The CR value increased in patients with severe degree of PF. There was a relationship between CR value increase and the radiological density of pancreatic tissue in non-contrast phase and presence of early signs of pancreatic inflammatory changes. Thus, there was a relationship between CT postprocessing results and morphological signs of PF, which can be used for pancreatic fibrosis non-invasive diagnosis and identification of additional signs of early chronic pancreatitis.

The reliability of virtual non-contrast reconstructions of photon-counting detector CT scans in assessing abdominal organs

BACKGROUND

Spectral imaging of photon-counting detector CT (PCD-CT) scanners allows for generating virtual non-contrast (VNC) reconstruction. By analyzing 12 abdominal organs, we aimed to test the reliability of VNC reconstructions in preserving HU values compared to real unenhanced CT images.

METHODS

Our study included 34 patients with pancreatic cystic neoplasm (PCN). The VNC reconstructions were generated from unenhanced, arterial, portal, and venous phase PCD-CT scans using the Liver-VNC algorithm. The observed 11 abdominal organs were segmented by the TotalSegmentator algorithm, the PCNs were segmented manually. Average densities were extracted from unenhanced scans (HUunenhanced), postcontrast (HUpostcontrast) scans, and VNC reconstructions (HUVNC). The error was calculated as HUerror=HUVNC-HUunenhanced. Pearson's or Spearman's correlation was used to assess the association. Reproducibility was evaluated by intraclass correlation coefficients (ICC).

RESULTS

Significant differences between HUunenhanced and HUVNC[unenhanced] were found in vertebrae, paraspinal muscles, liver, and spleen. HUVNC[unenhanced] showed a strong correlation with HUunenhanced in all organs except spleen (r = 0.45) and kidneys (r = 0.78 and 0.73). In all postcontrast phases, the HUVNC had strong correlations with HUunenhanced in all organs except the spleen and kidneys. The HUerror had significant correlations with HUunenhanced in the muscles and vertebrae; and with HUpostcontrast in the spleen, vertebrae, and paraspinal muscles in all postcontrast phases. All organs had at least one postcontrast VNC reconstruction that showed good-to-excellent agreement with HUunenhanced during ICC analysis except the vertebrae (ICC: 0.17), paraspinal muscles (ICC: 0.64-0.79), spleen (ICC: 0.21-0.47), and kidneys (ICC: 0.10-0.31).

CONCLUSIONS

VNC reconstructions are reliable in at least one postcontrast phase for most organs, but further improvement is needed before VNC can be utilized to examine the spleen, kidneys, and vertebrae.

Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis

Background:

Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures.

Methods:

A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated.

Results:

A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively.

Conclusions:

FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.

Correlation between endoscopic ultrasound features and exocrine pancreatic function in chronic pancreatitis

BACKGROUND

Endoscopic ultrasound (EUS) is the most sensitive method for diagnosing chronic pancreatitis (CP) in its early stages, and Rosemont Classification (RC) is used for its evaluation. Data on the correlation between EUS features and pancreatic exocrine insufficiency (PEI) are limited. We investigated the correlation between the EUS findings and PEI.

METHODS

This was a retrospective, monocentric cohort study involving patients prospectively enrolled from 2018 to 2022, with definite or probable CP according to the M-ANNHEIM criteria. All the patients underwent EUS and exocrine function investigations within 12 months of diagnosis. PEI was diagnosed using fecal elastase (FE) or when overt steatorrhea was reversed by pancreatic enzyme replacement therapy. Logistic regression analyses, rank correlation, ROC curve, and area under the curve (AUROC) were performed to evaluate the association between EUS features and PEI, and the accuracy of RC in predicting PEI.

RESULTS

Among 128 patients examined (63.3 % male; mean age, 47 years), 69.5 % were diagnosed with PEI. In multivariate logistic regression among all the RC criteria, only lithiasis in the main pancreatic duct (MPD) was associated with increased risk of PEI (OR 2.92, 95 % CI 1.29-6.61; p = 0.01). Rank analysis showed a weak inverse correlation between RC and FE (Spearman's rho = -0.02; p = 0.03). The accuracy of RC was moderate (AUROC 0.62, p = 0.014).

CONCLUSIONS

Among RC EUS features, lithiasis in the MPD is helpful for predicting the risk of PEI, while other findings are of limited utility in evaluating exocrine function.

Diagnostics and Management of Pancreatic Cystic Lesions-New Techniques and Guidelines

Pancreatic cystic lesions (PCLs) are increasingly diagnosed owing to the wide use of cross-sectional imaging techniques. Accurate identification of PCL categories is critical for determining the indications for surgical intervention or surveillance. The classification and management of PCLs rely on a comprehensive and interdisciplinary evaluation, integrating clinical data, imaging findings, and cyst fluid markers. EUS (endoscopic ultrasound) has become the widely used diagnostic tool for the differentiation of pancreatic cystic lesions, offering detailed evaluation of even small pancreatic lesions with high sensitivity and specificity. Additionally, endoscopic ultrasound-fine-needle aspiration enhances diagnostic capabilities through cytological analysis and the assessment of fluid viscosity, tumor glycoprotein concentration, amylase levels, and molecular scrutiny. These detailed insights play a pivotal role in improving the clinical prognosis and management of pancreatic neoplasms. This review will focus mainly on the latest recommendations for the differentiation, management, and treatment of pancreatic cystic lesions, highlighting their clinical significance.

Pancreas 2000. My journey with the central organ

The European Pancreatic Club Lifetime Achievement Award is a distinction awarded for research on the pancreas and service to European Pancreatology. It comes with the obligation to submit a review article to our society's journal, Pancreatology. It was awarded to me 2023 and I take this opportunity to highlight my journey with the central organ AKA the pancreas, that is inseparatable from "Pancreas 2000" - an educational program for future pancreatologists, inaugurated by Karolinska Institutet.

Canadian Association of Radiologists Gastrointestinal Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion.

The role of EUS in the diagnosis of early chronic pancreatitis

The diagnosis of early chronic pancreatitis (ECP) is challenging due to the lack of standardized diagnostic criteria. EUS has been considered a sensitive diagnostic modality for chronic pancreatitis (CP), with advancements in technique such as EUS-guided fine needle aspiration and biopsy (EUS-FNA/FNB) being developed. However, their role in the diagnosis of ECP remains unelucidated. This review thereby aimed to provide an overview of the clinical landscape of EUS in the field of ECP.

Surgical Treatment for Chronic Pancreatitis With a Normal-Sized Pancreatic Head and a Dilated Duct: Frey or Extended Partington Procedure?

BACKGROUND

Surgical drainage for chronic pancreatitis patients with a normal-sized pancreatic head remains controversial. Both Frey and extended Partington procedures could be used, but the level of evidence is weak.

METHOD

The object of this prospective cohort study was to assess the mid-term results concerning pain, quality of life, and pancreatic function of surgical drainage (Frey or extended Partington procedure) in patients with painful chronic pancreatitis and a normal-sized pancreatic head.

RESULTS

Fifty-nine patients (Frey procedure: 14 cases; extended Partington procedure: 45 cases) were enrolled in the study with a median length of follow-up of 16 months. The effective and complete pain relief rate was 85% and 58%, respectively. The Izbicki score decreased from 53.4 preoperatively to 8.8 postoperatively. The general 12-Item Short Form Health Survey (SF-12) score increased from 45.2 to 75.4. The pancreatic insufficiency did not change significantly postoperatively. At three months after surgery, the complete pain relief and Izbicki score were more favorable in the Frey group than in the extended Partington group.

CONCLUSION

Both Frey and extended Partington procedures resulted in excellent pain relief and quality of life improvement and did not worsen pancreatic function. The Frey procedure could yield a more favorable result in the early postoperative period.

Bone loss over time and risk of osteoporosis in advanced pancreatic cancer

BACKGROUND

Pancreatic cancer has a high risk of developing osteoporosis. However, the impact of osteoporosis has not been well-studied. This study aimed to evaluate bone loss over time and risk of osteoporosis in patients with advanced pancreatic cancer.

METHODS

We retrospectively examined consecutive patients with unresectable pancreatic cancer who had evaluable computed tomography before treatment and at 1-year follow-up. Bone mineral density at the first lumbar vertebra was measured on computed tomography, and osteoporosis was defined as bone mineral density < 135 Hounsfield units. The prevalence and risk factors for osteoporosis, changes in bone mineral density over time and incidence of bone fractures were analyzed.

RESULTS

Three hundred eighty patients were included. Osteoporosis was associated with older age, female sex, low body mass index and poor performance status at baseline. A consistent decrease in bone mineral density was observed over time regardless of age, sex or disease status, resulting in an increase in the prevalence of osteoporosis over time (47% at baseline, 79% at 1 year, 88% at 2 years, 89% at 3 years, 95% at 4 years and 100% at 5 years). Changes in bone mineral density from baseline were greater in patients with locally-advanced pancreatic cancer, in those who received modified FOLFIRINOX or S-IROX for more than 3 months, and in those who received radiation therapy. Incident fractures developed in 45 patients (12%) during follow-up.

CONCLUSIONS

Osteoporosis and osteoporotic fractures were highly prevalent in patients with advanced pancreatic cancer. This study highlights the importance of screening for osteoporosis in such patients.

Clinical and Analytical Comparison of Monoclonal and Polyclonal Immunoassays for Fecal Pancreatic Elastase

BACKGROUND

Numerous immunoassays have been commercialized to determine pancreatic elastase (PE) in feces in screening for exocrine pancreatic insufficiency (EPI), but how the different assays compare to one another is controversial, especially in the context that all methods use the same cut-off values for interpreting the results obtained on the presence or absence of EPI or the degree of insufficiency if it is present. Our aim was to analytically verify a new method for determining PE, compare the results with a previous method, and verify the declared cut-off values for interpretation of the results.

METHODS

PE in the stool was assayed using a previous monoclonal enzyme-linked immunosorbent assay ("ScheBo ELISA") and a new polyclonal particle-enhanced turbidimetric immunoassay ("Bühlmann PETIA"). The direct method comparison of two immunoassays was performed in 40 samples. Clinical comparisons were conducted against each other for the binary determination of "abnormal/normal" elastase levels and the three-way determination of "severe/moderate/no" EPI in 56 samples. The indirect comparison method used external quality assessment (EQA) data to compare the monoclonal and polyclonal immunoassays for PE, and additionally compare the monoclonal ScheBo ELISA to a monoclonal chemiluminescence immunoassay ("DiaSorin CLIA").

RESULTS

Precision in the series and intra-laboratory precision for Bühlmann PETIA met the manufacturer's specifications for the concentration range of limit/lower values and the range of normal values. The Bühlmann PETIA immunoassay on different analytical platforms yielded comparable results and nearly perfect agreement in the case of three-way classification (kappa = 0.89 with 95%CI from 0.79 to 1.00. ScheBo ELISA tends to generate higher values of pancreatic elastase than the Bühlmann PETIA; agreement between the methods was moderate in the case of binary classification (kappa = 0.43; 95% CI 0.25 to 0.62), and substantial in the case of three-way classification (kappa = 0.62; 95% CI 0.50 to 0.75). EQA data analysis showed a statistically significant difference between ScheBo ELISA and Bühlmann PETIA peer groups (p = 0.031), as well as the DiaSorin CLIA and ScheBo ELISA peer groups (p = 0.010).

CONCLUSION

The ScheBo ELISA and Bühlmann PETIA do not appear to be commutable in the analytical and clinical context. Our data address a discordance between different mono- and polyclonal immunoassays for pancreatic elastase and the potential of misclassification using its universal cut-off values in screening suspected patients for exocrine pancreatic insufficiency.

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.