Neutrophil elastase:From mechanisms to therapeutic potential

Neutrophil elastase(NE),a major protease in the primary granules of neutrophils,is involved in microbicidal activity.NE is an important factor promoting inflammation,has bactericidal effects,and shortens the inflammatory process.NE also regulates tumor growth by promoting metastasis and tumor microenvironment remodeling.However,NE plays a role in killing tumors under certain conditions and promotes other diseases such as pulmonary ventilation dysfunction.Additionally,it plays a complex role in various physiological processes and mediates several diseases.Sivelestat,a specific NE inhibitor,has strong potential for clinical application,particularly in the treatment of coronavirus disease 2019(COVID-19).This review discusses the pathophysiological processes associated with NE and the potential clinical applications of sivelestat.

Potential Application of a Wine Extract in Skin Care: How to Benefit from the Antibacterial, Antioxidant and Elastase Inhibiting Properties

Since plant polyphenols have many beneficial properties on health, the aim of this study was to evaluate the potential use of a phenolic wine extract, a by-product of wine production, for skin care on HaCaT cells. In these studies, a significant reduction of reactive oxygen species formation in HaCaT cells and severe elastase inhibition was observed. In contrast, the wine extract caused a major increase in lipase activity. The extract showed no influence on cell proliferation, but an immunomodulatory effect on the release of the interleukins IL-6 and IL-8 was found. The phenolic wine extract demonstrated a strong activity against gram-positive and gram-negative pathogens, yeasts, and fungi. Overall, our results show that the investigated phenolic wine extract is a promising ingredient for anti-aging skin care, could contribute to the improvement of skin appearance and health, and may positively affect cellulite.

Age-related changes in seminal polymorphonuclear elastase in men with asymptomatic inflammation of the genital tract

Aim： To investigate age-related inflammatory events in the male genital tract. Methods： In a total of 4 265 randomly collected patients attending the andrological outpatient clinic of the Center for Dermatology and Andrology, University of Giessen, Germany, ejaculate volume, pH-value, sperm concentration, total and progressive sperm motility, concentration of polymorphonuclear （PMN） elastase, number of peroxidase-positive cells and fructose were measured and correlated with patient＇s age. Results： While ejaculate volume, motility and fructose all correlated negatively with age, sperm concentration, PMN elastase and the pH-value showed a positive correlation. The prevalence of male genital tract inflammation （as defined by PMN elastase 〉 250 ng/mL） and its severity increased significantly. PMN elastase did not correlate with sperm motility. Fructose as a marker of seminal vesicle function showed a significant negative relationship with the PMN elastase levels, the number of peroxidase-positive cells and sperm motility. Conclusion： The significant increases of PMN elastase levels as marker of male genital tract inflammation in older men appear to be indicative of age-related changes in local immunoregulatory mechanisms. Because there is no association of PMN elastase with sperm motility, a direct inhibitory effect of this enzyme can be excluded.

Effects of neutrophil elastase inhibitor in patients undergoing esophagectomy:A systematic review and meta-analysis

AIM: To evaluate the benefit and safety of sivelestat(a neutrophil elastase inhibitor) administration in patients undergoing esophagectomy. METHODS: Online databases including Pub Med, EMBASE, the Cochrane Library, Web of Knowledge, and Chinese databases(Wanfang database, VIP and CNKI) were searched systematically up to November 2013. Randomized controlled trials and high-qualitycomparative studies were considered eligible for inclusion. Three reviewers evaluated the methodological quality of the included studies, and Stata 12.0 software was used to analyze the extracted data. The risk ratio(RR) was used to express the effect size of dichotomous outcomes, and mean difference(MD) or standardized mean difference was used to express the effect size of continuous outcomes.RESULTS: Thirteen studies were included in this systematic review and nine studies were included in the meta-analysis. The duration of mechanical ventilation was significantly decreased in the sivelestat group on postoperative day 5 [I2 = 76.3%, SMD =-1.41, 95%CI:-2.63-(-0.19)]. Sivelestat greatly lowered the incidence of acute lung injury in patients after surgery(I2 = 0%, RR = 0.27, 95%CI: 0.08-0.93). However, it did not decrease the incidence of pneumonia, intensive care unit stay or postoperative hospital stay, and did not increase the incidence of complications such as anastomotic leakage, recurrent nerve palsy, wound infection, sepsis and catheter-related fever. CONCLUSION: A neutrophil elastase inhibitor is beneficial in patients undergoing esophagectomy. More high quality, large sample, multi-center and randomized controlled trials are needed to validate this effect.

A novel arterial pouch model of saccular aneurysm by concomitant elastase and collagenase digestion

Background: An ideal aneurysm model of cerebral aneurysm is of great importance for studying the pathogenesis of the lesion and testing new techniques for diagnosis and treatment. Several models have been created in rabbits and are now widely used in experimental studies; however, every model has certain intrinsic limitations. Here we report the development of a novel saccular aneurysm model in rabbits using an arterial pouch that is subject to in vitro pre-digestion with combined elastase and collagenase. Methods: A segment of right common carotid artery (CCA) was dissected out and treated with elastase (60 U/ml, 20 min) followed by type I collagenase (1 mg/ml, 15 min) in vitro. The graft was anastomosed to an arterial arch built with the left CCA and the remaining right CCA, while the other end of the graft was ligated. The dimension and tissue structure of the pouch were analysed immediately, 2 or 8 weeks after operation. Findings: Ten terminal aneurysms were produced. The gross mor-phology of the aneurysm resembles the human cerebral terminal aneurysms. We have observed the following pathological changes: (1) growth of the aneurysm (mean diameter increased from (2.0±0.1) to (3.2±0.3) mm at 2 weeks, P【0.001, n=7~10); (2) thinning of the aneurysmal wall (the mean wall thickness decreased to 44% at 2 weeks), which was accompanied by significant losses of elastic fibres, collagen and the cellular component; and (3) spontaneous rupture (3 out of 9, one aneurysm ruptured 24 h after operation with the other two at 2 and 4 weeks respectively). Conclusion: This rabbit arterial pouch model mimics human cerebral aneurysms in relation to morphology and histology. In particular, this model exhibited an increased tendency of spontaneous rupture.

Destabilization of acrosome and elastase influence mediate the release of secretory phospholipase A2 from human spermatozoa

Aim： To determine the cellular distribution of secretory phospholipase A2 （sPLA2） in dependence on the acrosomal state and under the action of elastase released under inflammatory processes from leukocytes. Methods： Acrosome reaction of spermatozoa was triggered by calcimycin. Human leukocyte elastase was used to simulate inflammatory conditions. To visualize the distribution of sPLA2 and to determine the acrosomal state, immunofluorescence techniques and lectin binding combined with confocal laser scanning fluorescence microscopy and flow cytometry were used. Results： Although sPLA2 was detected at the acrosome and tail regions in intact spermatozoa, it disappeared from the head region after triggering the acrosome reaction. This release of sPLA2 was associated with enhanced binding of annexin V-fluoroscein isothiocyanate （FITC） to spermatozoa surfaces, intercalation of ethidium-homodimer I, and binding of FITC-labelled concanavalin A at the acrosomal region. Spermatozoa from healthy subjects treated with elastase were characterized by release of sPLA2, disturbance of acrosome structure, and loss of vitality. Conclusion： The ability of spermatozoa to release secretory phospholipase A2 is related to the acrosomal state. Premature destabi- lization of the acrosome and loss of sPLA2 can occur during silent inflammations in the male genital tract. The distribution pattern of sPLA2 in intact spermatozoa might be an additional parameter for evaluating sperm quality.

Comparing acid steatocrit and faecal elastase estimations for use in M-ANNHEIM staging for pancreatitis

AIM To compare two tests for exocrine pancreatic function(EPF) for use in M-ANNHEIM staging for pancreatitis. METHODS One hundred and ninety four consecutive patients with acute pancreatitis(AP; n = 13), recurrent acute pancreatitis(RAP; n = 65) and chronic pancreatitis(CP; n = 116) were enrolled. EPF was assessed by faecal elastase-1(FE-1) estimation and stool fat excretion by the acid steatocrit method. Patients were classified as per M-ANNHEIM stages separately based on the results of the two tests for comparison. Independent Student's t-test, χ~2 test, Kruskal-Wallis test, Mann-Whitney U test and Mc Nemar's test were used as appropriate. RESULTS Sixty-one(52.5%) patients with CP had steatorrhoea when assessed by the acid steatocrit method; 79 (68.1%) with CP had exocrine insufficiency by the FE-1 test(χ~2 test, P < 0.001). The results of acid steatocrit and FE-1 showed a significant negative correlation(Spearman's rho =-0.376, P < 0.001). A statistically significant difference was seen between the M-ANNHEIM stages as classified separately by acid steatocrit and the FE-1. Thirteen(6.7%), 87(44.8%), 89(45.8%) and 5(2.5%) patients were placed in M-ANNHEIM stages 0,?Ⅰ, Ⅱ, and Ⅲ respectively, with the use of acid steatocrit as against 13(6.7%), 85(43.8%), 75(38.6%), and 21(10.8%) respectively by FE-1 in stages 0,?Ⅰ, Ⅱ, and Ⅲ thereby altering the stage in 28(14.4%) patients(P < 0.001, Mc Nemar's test). CONCLUSION FE-1 estimation performed better than the acid steatocrit test for use in the staging of pancreatitis by the M-ANNHEIM classification since it diagnosed a higher proportion of patients with exocrine insufficiency.

Nanocellulose-Based Biosensors: Design, Preparation, and Activity of Peptide-Linked Cotton Cellulose Nanocrystals Having Fluorimetric and Colorimetric Elastase Detection Sensitivity

Nanocrystalline cellulose is an amphiphilic, high surface area material that can be easily functionalized and is biocompatible and eco-friendly. It has been used singularly and in combination with other nanomaterials to optimize biosensor design. The attachment of peptides and proteins to nanocrystalline cellulose and their proven retention of activity provide a route to bioactive conjugates useful in designs for point of care biosensors. Elastase is a biomarker for a number of inflammatory diseases including chronic wounds, and its rapid sensitive detection with a facile approach to sensing is of interest. An increased interest in the use of elastase sensors for point of care diagnosis is resulting in a variety of approaches to elsastase sensors utilizing different detection technologies. Here elastase substrate peptide-celluose conjugates synthesized as colorimetric and fluorescent sensors on cotton cellulose nanocrystals are compared. The structure of the sensor peptide-nanocellulose crystals when modeled with computational crystal structure parameters demonstrates the spatio-stoichiometric features of the nanocrystalline surface that allows ligand to active site protease interacttion. An understanding of the structure/function relations of enzyme and conjugate substrate of the peptides covalently attached to nancellulose has implications for enhancing the biomolecular transducer. The potential applications of both fluorescent and colorimetric detection to markers like elastase using peptide cotton cellulose nanocrystals as a transducer surface to model point of care biosensors for protease detection are discussed.

The activities of endothelial elastase and cathepsin G in rats at oxidative stress caused by heavy metals salts

CoCl2 introduction increased cathepsin G activity in the heart and liver as well as endothelial elastase (EEl) in kidney that indicated the development of destructive processes. CoCl2 introduction decreased EEl and cathepsin G activities in blood serum and cathepsin G in lungs. HgCl2 injection decreased EEl in blood serum, heart, liver, kidney and cathepsin G in blood serum. These decreasing of proteinases activities may be caused by cytotoxic effects of heavy metals and/or the inclusion of these proteases in the destructive processes and absence of their synthesis and/or release.

Characterization of a novel variant of the second domain of bikunin with increased leukocyte elastase inhibitory activity

The light chain of inter-α inhibitor, also known as bikunin or urinary trypsin inhibitor, is composed of two tandemly arranged Kunitz-type protease inhibitor domains. The second domain of bikunin has factor Xa inhibitory activity which previously was enhanced by mutating two amino acids, glutamine 19 and tyrosine 46 to lysine and aspartate, respectively. In this study, we tried to potentiate its inhibitory activity against leukocyte elastase. A molecular docking model of the second domain of bikunin with leukocyte elastase revealed that P5 arginine 11 was a candidate residue for a third substitution. We generated six triple point mutants using site-directed mutagenesis, compared their leukocyte elastase-inhibitory activities, and selected the most potent variant with arginine 11 substituted to serine. The IC50 values for factor XIa, factor Xa, and leukocyte elastase were 182, 302, and 273 nM, respectively. Moreover, this triple point mutant prolonged the activated partial thromboplastin time and moderately reduced leukocyte elastase-induced endothelial injury. Additionally, favorable conformations created by these mutations were speculated using the structure of the Kunitz protease inhibitor domain of protease nexin 2 complexed with factor XIa as a reference. We discovered a novel triple point mutant of the second domain of bikunin that has potent inhibitory activities against factor XIa, factor Xa, and leukocyte elastase. This variant exhibited anticoagulant activity in plasma and suppressed endothelial cell injury.

Pterostilbene supresses inflammation-induced melanoma metastasis by impeding neutrophil elastase-mediated thrombospondin-1 degradation

Objective: Chronic inflammation plays a fatal role in tumor metastasis. Pterostilbene(PTE) is a natural dimethylated analogue of resveratrol with anticancer and anti-inflammatory activities. This study aimed to investigate the inhibitory effect of PTE on inflammation-associated metastasis and explore the underlying mechanisms.Methods: Lipopolysaccharide(LPS)-induced lung inflammation and melanoma metastasis models were established in mice. After PTE treatment for four weeks, the organ index, histological changes, proinflammatory cytokines, and the expression and activity of neutrophil elastase(NE), a biomarker of neutrophil influx in the lungs, were analysed. Additionally, direct effects of PTE on NE-induced B16 cell migration were explored in wound healing and Transwell assays, and the expression of thrombospondin-1(TSP-1) and epithelial-mesenchymal transition(EMT) markers were also detected.Results: PTE obviously attenuated the LPS-induced metastasis of circulatory B16 cells to lungs by reducing the number of metastatic nodules on the lung surfaces and the lung weight/body weight ratio. PTE treatment also significantly reduced LPS-activated increase levels of tumor necrosis factor(TNF)-a and interleukin(IL)-6 in the lungs of tumor-bearing mice. In addition, increased expression and enzyme activity of NE and decreased expression of TSP-1 were observed, and these were blocked by PTE. In vitro, PTE at concentrations without cytotoxicity also markedly suppressed NE-triggered B16 cell migration, prevented NE-induced TSP-1 proteolysis and reversed the expression of vimentin, N-cadherin and Ecadherin.Conclusion: PTE could block inflammation-enhanced tumor metastasis, and the underlying mechanism might be associated with the inhibition of NE-mediated TSP-1 degradation.

Identification and characterization of a novel elastase inhibitor from Hirudinaria manillensis

A large number of protease inhibitors have been found from leeches,which are essential in various physiological and biological processes.In the curret study,a novel elastase inhibitor was purified and characterized from the leech of Hirudinaria manillensis,which was named HMEI-A.Primary structure analysis showed that HMEI-A belonged to a new family of proteins.HMEI-A exerted inhibitory effects on elastase and showed potent abilities to inhibit elastase with an inhibition constant(Ki)of 1.69×10^(−8) mol·L^(−1).Further study showed that HMEI-A inhibited the formation of neutrophil extracellular trap(NET).These results suggested that HMEIA from the leech of H.manillensis is a novel elastase inhibitor which can suppress NET formation.It may play a significant role in blood-sucking of leeches and is a potential candidate as an anti-inflammatory agent.

miRNA-141-5p Affects the Levels of Neutrophil Elastase in Preeclampsia by Regulating MAPK1

Objective:The objective of this study was to investigate the expression levels of microRNA-141-5p(miRNA-141-5p),MAPK1 and neutrophil elastase in patients with and without preeclampsia(PE),and the relationship between miRNA-141-5p and MAPK1 with respect to the secretion of elastase by neutrophils in patients with PE.Methods:Thirty patients with PE and 30 healthy pregnant(HP)women were recruited from The Second Hospital of Shanxi Medical University,Taiyuan,China,between February 2017 and July 2018.Neutrophils were isolated from 8 mL peripheral blood samples and cultured.We recorded neutrophil count and morphology during culture.Apoptosis was detected by flow cytometry in different groups at 0,24,and 48 h.The expression levels of elastase were detected in neutrophils by enzyme-linked immunosorbent assay,whereas the expression levels of miRNA-141-5p in peripheral blood neutrophils were detected by real-time polymerase chain reaction.We used TargetScanHuman Release 7.2 to analyze the target genes of miRNA-141-5p.The expression of MAPK1 in peripheral blood neutrophils was detected by western blotting.Data were analyzed by SPSS version 21.0 software,and comparisons between groups were carried out with the Studentt test.Results:There was no significant difference between the PE and HP groups(P>0.050)with regard to age or body mass index.The weight of newborns in the PE group(2846.00±600.00 g)was significantly lower than that in the HP group(3055.00±230.68 g).The number of neutrophilic granulocytes(NGs)in blood samples from the PE group was significantly higher than that in the HP group(P=0.003).There was no significant difference between the groups with regard to morphology.Apoptosis in the PE group was delayed when compared with the HP group at different time points.TheP value of apoptosis in the PE and HP groups were respectively 0.790,<0.001 and 0.030 at 0 h,24 h and 48 h.The expression levels of miRNA-141-5p in the PE group were significantly lower than those in the HP group(P<0.050).The expression levels of MAPK1 in neutrophils from the PE group were significantly higher than those in the HP group(P<0.050)by western blot.The expression levels of elastase in neutrophils from the PE group were significantly higher than those in the HP group(P<0.050).Furthermore,the number of NGs in peripheral blood from the PE group was higher than that of the HP group;however,the levels of apoptosis were lower.The expression levels of miRNA-141-5p in NGs decreased,the expression of MAPK1 increased,and the secretion of neutrophil elastase in the NG medium increased in the PE group than those in the HP group.Conclusion:Collectively,our analysis suggested that miRNA-141-5p may be involved in the pathogenesis of PE by regulating the MAPK1 signaling pathway to activate neutrophils and increase the secretion of elastase.

Which factors determine exocrine pancreatic dysfunction in diabetes mellitus?

The exocrine structure is significantly affected by diabetes because of endocrine structure-function disorder within the pancreas. Exocrine pancreatic dysfunction (EPD) is the general name of the malabsorption process resulting from inadequate production, release, decreased activation, and/or insufficient degradation of enzymes required for digestion from pancreatic acinar cells. It is important to diagnose patients early and correctly, since there may be both macro- and micro-nutrient deficiency in EPD. In this paper, EPD, the diabetes- EPD relationship, and the predictive, effective factors affecting the emergence of EPD are briefly explained and summarized with contemporary literature and our experienced based on clinical, lab, and radiological findings.

Diagnostic utility of faecal biomarkers in patients with irritable bowel syndrome

Irritable bowel syndrome(IBS)is a common functional gastrointestinal(GI)disorder characterized by unspecific symptoms.In clinical practice it is crucial to distinguish between non-inflammatory functional problems and inflammatory,malignant or infectious diseases of the GI tract.Differentiation between these involves the use of clinical,radiological,endoscopic,histological and serological techniques,which are invasive,expensive,time-consuming and/or hindered by inaccuracies arising from subjective components.A range of faecal markers now appears to have the potential to greatly assist in the differentiation of inflammatory bowel disease(IBD)and IBS.Faecal markers of neutrophil influx into the mucosa are reliable indicators of intestinal inflammation and their role has been mainly studied in discriminating IBD from non-IBD conditions(including IBS)rather than organic from non-organic diseases.Phagocytespecific proteins of the S100 family(S100A12,calprotectin)are amongst the most promising faecal biomarkers of inflammation.Faecal leukocyte degranulation markers(lactoferrin,polymorphonuclear elastase and myeloperoxidase)have also been suggested as diagnostic tools for the differentiation of IBD and IBS.More recently,additional proteins,including granins,defensins and matrix-metalloproteases,have been discussed as differential diagnostic markers in IBD and IBS.In this review,some of the most promising faecal markers,which have the potential to differentiate IBD and IBS and to advance diagnostic practices,will be discussed.

Skin whitening and anti-corrugation activities of glycoprotein fractions from liquid extracts of boiled sea cucumber

Objective: To determine skin whitening and wrinkle improvement efficacy, glycoprotein fractions were extracted from liquid extracts of boiled sea cucumber and their effects on tyrosine and elastase inhibitory activities were assayed. Methods: Fractions above and below 50 k Da(>50 kD a and <50 kD a) were extracted via a series of steps invovling: boiling, filtering, desalting and freeze drying. Cytotoxicity, skin whitening and wrinkle-removing effects of boiled liquid were determined. Results: Our MTT data showed that neither glycoprotein fraction of boiled liquid induces cellular cytotoxicity up to a concentration of 10 mg/m L treatment of the mouse melanoma cell line, B16F10, with 10 mg/m L >50 kDa enhanced tyrosinase and elastase inhibitory activities by 50.84% and 28.78%, respectively. Correlations of the >50 kD a concentration with tyrosinase inhibitory(R^2=0.968) and elastase inhibitory(R2=0.983) efficacy were significant. Conclusions: >50 kD a glycoprotein fraction isolated from liquid extracts of boiled sea cucumber, which can serve as a functional cosmetic ingredient for whitening and wrinkle improvement of skin.

Exocrine pancreatic function during the early recovery phase of acute pancreatitis

BACKGROUND:Exocrine pancreatic dysfunction has been reported in humans in the convalescent period after acute pancreatitis,but the data are scarce and conflicting.This study aimed to prospectively assess the exocrine pancreatic function in patients with acute pancreatitis at the time of their refeeding. METHODS:Fecal elastase-1 was determined on the day of refeeding in all consecutive acute pancreatitis patients with their first episode of the disease.They were 75 patients including 60(80.0%)patients with mild acute pancreatitis and 15(20.0%)patients with severe acute pancreatitis. Etiologically 61 patients(81.3%)had biliary disease,1(1.3%) had alcoholic disease and 3(4.0%)had hypertriglyceridemia. No causes of acute pancreatitis were found in the remaining 10 patients(13.3%).The mean(±SD)refeeding time after the attack of acute panereatitis was 11.2±10.2 days. RESULTS:Pathological values of FE-1 were found in 9 of the 75 patients(12.0%):7(9.3%)patients with mild pancreatitis and 2(2.7%)patients with severe pancreatitis(P=1.000). The frequency of the pathological values of fecal elastase-1 was significantly different from that of various etiologies of the disease(P=0.030).It was significantly lower in patients with biliary pancreatitis(9.8%;P=0.035)than in one patient with alcoholic pancreatitis(P=0.126),one patient with hypertriglyceridemia-induced pancreatitis(33.3%; P=0.708),and one patient with idiopathic pancreatitis (10.0%;P=0.227).Pathological fecal elastase-1 was not significantly related to sex,age or day of refeeding.CONCLUSION:Exocrine pancreatic function should be routinely assessed in patients with acute pancreatitis at the time of refeeding in order to supplement their diet with pancreatic extracts.

Effects of the Syzygium aromaticum L. extract on antioxidation and inhibition of matrix metalloproteinase in human dermal fibroblast

Objective: To investigate cosmetic potential of Syzygium aromaticum L.(S. aromaticum L.) and to determine its antioxidant and anti-wrinkling effects. Methods: Using highperformance liquid chromatography, eugenol component was quantitated. The antioxidant activity of S. aromaticum L. was analyzed by 2,2-diphenyl-1-picrylhydrazyl radical scavenging and superoxide dismutase like activities. To determine cell viability, elastase and matrix metalloproteinase-1(MMP-1) activity, human dermal fibroblasts(HS68) were treated with S. aromaticum L. The inhibitory effect of S. aromaticum L. on tumor necrosis factor alpha induced MMPs expression in HS68 was analyzed by realtime-PCR. Results: The eugenol content was confirmed in S. aromaticum L. S. aromaticum L. was observed to have high 2,2-diphenyl-1-picrylhydrazyl radical scavenging activity and superoxide dismutase like activity. S. aromaticum L. had no cytotoxicity against the HS68 and dose-dependently increased elastase inhibition. Moreover, S. aromaticum L. significantly decreased MMP-1 content and inhibited gene levels of MMP-1, MMP-2, MMP-3 and MMP-9. Conclusions: The findings suggest that S. aromaticum L. has great potential as a cosmeceutical ingredient with antioxidant and antiwrinkling effects.

Considerations on pancreatic exocrine function after pancreaticoduodenectomy

The pancreaticoduodenectomy(PD) procedure may lead to pancreatic exocrine and endocrine insufficiency.There are several types of reconstruction for this kind of operation.Pancreaticogastrostomy(PG) was introduced to reduce the rate of postoperative pancreatic fistula.Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy(PJ),recently some reports reveal benefits from the PG over the PJ.Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice,and the detrimental results over the exocrine pancreatic function.The pancreatic exocrine function can be measured with direct and indirect tests.Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement.Among the tubeless indirect tests,the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption.The patient compliance and time consuming makes it not so suitable for its clinical use.Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency,is not cumbersome,and has been used to study pancreatic function after resection.We analyze the FE1 levels in our patients after the PD with two types of reconstruction,PG and PJ,and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.

Associations with pancreatic exocrine insufficiency:An United Kingdom single-centre study

BACKGROUND Pancreatic exocrine insufficiency(PEI)is said to be associated with numerous conditions both within and outside the gastrointestinal(GI)system.The majority of research has been concerned with conditions that reduce the volume of functioning pancreatic tissue or prevent adequate drainage to the small bowel,such as chronic pancreatitis,cystic fibrosis,pancreatic cancer and pancreatic resection.However,the evidence base supporting an association with extrapancreatic conditions,such as coeliac disease,diabetes mellitus and congestive cardiac failure,is heterogeneous.AIM To strengthen the evidence base by studying all previously reported associations with PEI in a large cohort of outpatients.METHODS A single-centre retrospective study was performed.General gastroenterology outpatients tested for PEI with faecal elastase-1(FE1)were identified and information retrieved from the electronic patient record.PEI was defined as FE1<200μg/g.Patients already taking pancreatic enzyme replacement therapy were excluded.Multiple imputation was used to handle missing data.Univariable logistic regression was used to study which presenting symptoms predicted PEI.Multivariable logistic regression was used to explore the relationship between all previously reported associations and PEI.RESULTS Of 1027 patients were included.182 patients(17.7%)were diagnosed with PEI.Steatorrhoea[odds ratios(OR):2.51,95%confidence intervals(CI):1.58-3.98]and weight loss(OR:1.49,95%CI:1.08-2.06)were the only presenting symptoms that predicted PEI.Chronic pancreatitis(OR:7.98,95%CI:3.95-16.15),pancreatic cancer(OR:6.58,95%CI:1.67-25.98),upper GI surgery(OR:2.62,95%CI:1.32-5.19),type 2 diabetes(OR:1.84,95%CI:1.18-2.87),proton pump inhibitor therapy(OR:1.87,95%CI:1.25-2.80)and Asian ethnicity(OR:2.11,95%CI:1.30-3.42)were significantly associated with PEI in the multivariable analysis.None of the other historically reported associations with PEI were significant after adjustment for the other variables included in our multivariable analysis.CONCLUSION PEI is common in patients with chronic pancreatitis,pancreatic cancer,upper GI surgery and type 2 diabetes.Proton pump inhibitor therapy may also be associated with PEI or a false positive FE1.