Role of cyclooxygenase-2 gene polymorphisms in pancreatic carcinogenesis

AIM:To evaluate the clinical significance of-765G/C and-1195G/A cyclooxygenase-2 (COX-2) gene polymorphisms in patients with pancreatic cancer (PC).METHODS:The study included 201 patients:85 with PC and 116 healthy controls.-765G/C and-1195G/A COX-2 gene polymorphisms were studied in DNA isolated from blood samples.The associations of the analyzed genotypes and clinical data at diagnosis were evaluated.RESULTS:We found an increased frequency of the homozygous-1195AA COX-2 genotype in patients with PC (53.7%) compared with the control group (21%) (P < 0.01).In contrast,the distribution of genotypeand allele frequencies of the-765G/C COX-2 polymorphism in the PC patients were not different from those in control groups.A correlation between presence of homozygous-1195AA COX-2 genotype and tumor size > 3 cm was observed (P < 0.05).Analyzed polymorphisms were unrelated to the patients' sex and age,nor to the presence of regional or distant metastases.CONCLUSION:These preliminary results indicate that the-1195G/A COX-2 polymorphism may play an important role in PC prognosis and carcinogenesis.

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis?

Chronic pancreatitis(CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency.Abdominal pain and local complications(bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy.At the beginning,medical therapy is used.More invasive treatment is recommended for patients with pancreatic duct stones(PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient.Recently,Clarke et al assessed the long-term effectiveness of endoscopic therapy(ET) in CP patients.The authors compared ET with medical treatment.They reported that ET was clinically successful in 50% of patients with symptomatic CP.In this commentary,current CP treatment,including indications for ET and surgery in CP patients,is discussed.Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed.Different surgical methods used in the treatment of CP patients are also discussed.ET is the most useful in patients with large PDS,pancreatic duct obstruction and dilation.It should be the first-line option because it is less invasive than surgery.Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy.ET is a very effective and less invasive procedure,but it cannot be recommended as the treatment of choice in all CP patients.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Biliary cysts:Etiology,diagnosis and management

Biliary cysts(BC) are rare dilatations of different parts of a biliary tract.They account for approximately 1% of all benign biliary diseases.BC occur the most frequently in Asian and female populations.They are an important problem for pediatricians,gastroenterologists,radiologists and surgeons.Clinical presentation and management depend on the BC type.Cholangiocarcinoma is the most serious and dangerous BC complication.The other complications associated with BC involve cholelithiasis and hepatolithiasis,cholangitis,acute and chronic pancreatitis,portal hypertension,liver fibrosis and secondary liver cirrhosis and spontaneous cyst perforation.Different BC classifications have been described in the literature.Todani classification dividing BC into five types is the most useful in clinical practice.The early diagnosis and proper treatment are very important,because BC are associated with a risk of carcinogenesis.A malignancy risk increases with the age.Radiological investigations(ultrasonography,computed tomography,endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography) play an important role in BC diagnostics.Currently,prenatal diagnosis using ultrasonography is possible.It allows to differentiate biliary disorders in fetals and to perform the early surgical treatment that improves results.In most patients,total cyst excision with Roux-Y hepaticojejunostomy is the treatment of choice.Surgical treat-ment of BC is associated with high success rate and low morbidity and mortality.The early treatment is associated with a lower number of complications.Patients following BC surgery require permanent and careful postoperative observation using laboratory and imaging investigations because of possibility of biliary anastomosis stricture and biliary cancer in tissue remnant.

Pancreatic intraductal papillary mucinous neoplasms:Current diagnosis and management

Intraductal papillary mucinous neoplasms(IPMNs)represent approximately 1%of all pancreatic neoplasms and 25%of cystic neoplasms.They are divided into three types:main duct-IPMN(MD-IPPMN),branch duct-IPMN(BD-IPMN),and mixed type-IPMN.In this review,diagnostics,including clinical presentation and radiological investigations,were described.Magnetic resonance imaging is the most useful for most IPMNs.Management depends on the type and radiological features of IPMNs.Surgery is recommended for MD-IPMN.For BD-IPMN,management involves surgery or surveillance depending on the tumor size,cyst growth rate,solid components,main duct dilatation,high-grade dysplasia in cytology,the presence of symptoms(jaundice,new-onset diabetes,pancreatitis),and CA 19.9 serum level.The patient’s age and comorbidities should also be taken into consideration.Currently,there are different guidelines regarding the diagnosis and management of IPMNs.In this review,the following guidelines were presented:Sendai International Association of Pancreatology guidelines(2006),American Gastroenterological Association guidelines,revised international consensus Fukuoka guidelines(2012),revised international consensus Fukuoka guidelines(2017),and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas(2018).The Verona Evidence-Based Meeting 2020 was also presented and discussed.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries(IBDI)are still a challenge for surgeons.The most frequently,they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world.Endoscopic techniques are recommended as initial treatment of IBDI.When endoscopic treatment is not effective,surgery is considered.Different surgical biliary reconstructions are performed in most patients in IBDI.Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI.In some patients with complex IBDI,hepatectomy is required.Recently,Liet al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy(LC).Authors concluded that hepatectomy might be necessary to manage early or late complications after LC.The study showed that proximal IBDI(involving hepatic confluence)and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series.Authors distinguished two main groups of patients that require liver resection in IBDI:those with an injury-induced liver necrosis necessitating early intervention,and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis.In this commentary,indications for hepatectomy in patients with IBDI are discussed.Complex biliovascular injuries as indications for hepatectomy are presented.Short-and long-term results in patients following liver resection for IBDI are also discussed.Hepatectomy is not a standard procedure in surgical treatment of IBDI,but in some complex injuries it should be considered.

Association between acute pancreatitis and COVID-19 infection:What do we know?

The disease caused by severe acute respiratory syndrome coronavirus 2(SARSCoV-2),also called coronavirus disease 2019(COVID-19),first originated in Wuhan,China,displaying atypical pneumonia-like respiratory symptoms in affected patients.SARS-CoV-2 primarily attacks the respiratory system,and the most common symptoms include cough,shortness of breath,and fever.However,its impact on the digestive system has been shown,and various clinical gastrointestinal manifestations of this disease have been recognized.Some reports have shown acute pancreatitis(AP)as the initial symptom in patients with COVID-19.AP may be a consequence of direct pancreatic damage by the virus because pancreatic acinar cells contain angiotensin-converting enzyme 2 receptor proteins,and SARS-CoV-2 can bind to these receptors,causing pancreatic injury.Moreover,AP may be a secondary indicator of cytokine storms and altered inflammatory responses.Our review of the literature shows that SARS-CoV-2 appears to be a new etiological infectious factor related to AP.In this manuscript,a comprehensive review of case reports and case series of patients with AP and COVID-19 is presented.All reports on COVID-19-associated AP are summarized.All cases are thoroughly analyzed and discussed in-depth.

Pancreatic Anastomosis Healing

Background: Pancreatoduodenectomy (PD) is a complex procedure with a relatively high risk of complications. There is an increasing trend showing that the success of pancreato-enteral anastomosis depends on surgical skill and the material used. Methods: We present four cases of pancreato-enteral anastomosis resected 37 - 114 days after primary surgery and the analysis of the healing process, i.e., morphology of the pancreatic parenchyma, pancreatic duct, and digestive tract mucosa, as well as the pancreatic reaction to the sewing material by microscopic morphometry. Results: Evidence of regeneration in the columnar-lined mucosa of main pancreatic ducts in all cases of pancreato-enterostomy was observed. The inflammatory foreign-body reaction around monofilament stitch was present without an evident infection. There were no microscopic signs of pancreatic duct damage. Total foreign body reaction varied between 138.1 μm and 207.3 μm. Conclusions: This observation supports the beneficial use of thin monofilament threads for pancreato-enteral anastomosis. There was no evidence of harmful action from gastric or intestinal juices on pancreatic remnant or the Wirsung duct.