The consensus on liver autotransplantation from an international panel of experts

IntroductionMore than 1.0 million patients worldwide are diagnosed with space-occupying lesions in the liver every year, with the number approaching 0.5 million per year in China, and only 20% of the lesions are resectable Due to a lack of available donors, only a limited number of patients underwent allogeneic liver transplantation, the remaining patients simply receive palliative care. Therefore, discovering new options for treating these patients is a high priority. Liver autotransplantation （LAT） is a surgical technique that adopts liver transplantation skills to radically treat spaceoccupying hepatic lesions, benign or malignant,

Challenges for clinicians treating autoimmune pancreatitis:Current perspectives

Autoimmune pancreatitis(AIP)is a rare disease clinically characterized by obstructive jaundice,unintentional weight loss,acute pancreatitis,focal pancreatic mass,and diabetes.AIP is classified into two subtypes-type 1 and type 2-according to pathological findings,clinical features,and serology test results,but some cases may be defined as type not otherwise in the absence of pathological findings and inflammatory bowel disease.To address the differences in diagnostic criteria by country,standard diagnostic criteria for AIP were proposed in 2011 by an international consensus of expert opinions.Differential diagnosis of AIP from pancreatic ductal adenocarcinoma is important but remains challenging for clinicians.Fortunately,all subtypes of AIP show dramatic response to steroid treatment.This review discusses the current perspectives on the diagnosis and management of AIP in clinical practice.

Diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis(AIP) is a distinct form of chronic pancreatitis that is increasingly being reported. The presentation and clinical image findings of AIP sometimes resemble those of several pancreatic malignancies, but the therapeutic strategy differs appreciably. Therefore, accurate diagnosis is necessary for cases of AIP. To date, AIP is classified into two distinct subtypes from the viewpoints of etiology, serum markers, histology, other organ involvements, and frequency of relapse: type 1 is related to Ig G4(lymphoplasmacytic sclerosing pancreatitis) and type 2 is related to a granulocytic epithelial lesion(idiopathic duct-centric chronic pancreatitis). Both types of AIP are characterized by focal or diffuse pancreatic enlargement accompanied with a narrowing of the main pancreatic duct, and both show dramatic responses to corticosteroid. Unlike type 2, type 1 is characteristically associated with increasing levels of serum Ig G4 and positive serum autoantibodies, abundant infiltration of Ig G4-positive plasmacytes, frequent extrapancreatic lesions, and relapse. These findings have led several countries to propose diagnostic criteria for AIP, which consist of essentially similar diagnostic items; however, several differences exist for each country, mainly due to differences in the definition of AIP and the modalities used to diagnose this disease. An attempt to unite the diagnostic criteria worldwide was made with the publication in 2011 of the international consensus diagnostic criteria for AIP, established at the 2010 Congress of the International Association of Pancreatology(IAP).

Clinical significance of hypoechoic submandibular gland lesions in type 1 autoimmune pancreatitis

To assess the role of ultrasonography of submandibular glands (SGs) in the diagnosis of type 1 autoimmune pancreatitis (AIP).METHODSThirty-seven patients who were definitively diagnosed with type 1 AIP according to the international consensus diagnostic criteria (ICDC) for AIP at our institution between December 1990 and April 2016 were retrospectively reviewed. Findings by physical examination, ultrasonography, and scintigraphy of SGs were analyzed to reach a diagnosis based on the ICDC for AIP. The efficacy of corticosteroid treatment in the resolution of hypoechoic lesions in SGs was also evaluated by assessment with ultrasonography before and after treatment in 18 cases.RESULTSThe sensitivity of multiple hypoechoic lesions in SGs by ultrasonography for the diagnosis of sialadenitis in type 1 AIP (84%) was higher than that of physical examination (46%), scintigraphy (28%), and SGs thickness (49%). Ultrasonographic evidence of hypoechoic lesions in SGs improved the definitive diagnosis of sialadenitis and type 1 AIP by the ICDC criteria in 11 (30%) and 2 (5.4%) cases, respectively. Multiple hypoechoic lesions in SGs were resolved or disappear by corticosteroid administration in 14 of 16 cases with hypoechoic lesions in SGs, whereas the ultrasonographic findings in the remaining 2 cases with hypoechoic lesions in SGs and the 2 cases with homogenous SG parenchyma remained unchanged after corticosteroid administration.CONCLUSIONSG ultrasonography to detect multiple hypoechoic lesions might be useful for type 1 AIP diagnosis by improving diagnostic accuracy together with the ICDC sialadenitis criteria.

Endoscopic pancreatic necrosectomy in the United States-Mexico border:A cross sectional study

BACKGROUND A recent expert panel issued recommendations about the technical aspects of direct endoscopic necrosectomy(DEN) for pancreatic walled-off necrosis(WON).However, significant technical heterogeneity still exists among endoscopists.AIM To report the outcomes of our DEN technique and how it differs from a recent expert consensus statement and previous studies.METHODS Medical records of patients with WON who underwent DEN from September2016-May 2019 were queried for the following information: Age, gender,ethnicity, etiology of acute pancreatitis, WON location and size, DEN technical information, adverse events(AEs) and outcomes. Adverse events were graded according to the American Society of Gastrointestinal Endoscopy Lexicon grading system. Technical success was defined as adequate lumen apposing metal stent(LAMS) deployment plus removal of ≥ 90% of necrosum. Clinical success was defined as complete resolution of WON cavity by imaging and resolution of symptoms at ≤ 3 months(mo) after last DEN. Data analysis was performed using mean and standard deviation for continuous variables,frequency and proportion for categorical variables, and median and range for interval data.RESULTS A total of 21 patients underwent DEN. Most of them were Hispanic and their mean age was 51 ± 17 years. The majority of the collections were located in the body of the pancreas and the mean size was 13 cm ± 5 cm. The most common indication was persistent vomiting. Antibiotics were administered only in cases of infected necrosis. All LAMS were placed without radiological guidance,dilated the same day of deployment and removed after a mean of 27 ± 11 d.Routine cross-sectional imaging immediately after drainage was not performed.The mean interval between DEN sessions was 7 ± 4 d and the mean number of DEN/patient was 3 ± 2. Technical and clinical success rates were both 95%. AEs were seen in 5 patients and included: Sepsis(2), stent migration(1), stent maldeployment(1), perforation(1). The sensitivity and positive predictive value of an occluded LAMS leading to sepsis was 50% and 0.11 respectively. No fatalities were observed.CONCLUSION Our DEN technique differed significantly from the one recommended by a recent expert panel and the one published in previous studies. Despite these differences excellent clinical outcomes were obtained.