Early and Long-Term Morbidity and Mortality Following Pancreaticoduodenectomy for Periampullary Tumors in Elderly Patients.

AIM: The growing elderly population is facing an increasing risk of cancers, consequently raising the pancreatic cancer surgery rate. This study aimed to determine whether advanced age is a risk factor for morbidity and mortality following pancreaticoduodenectomy (PD) for periampullary tumors. MATERIALS AND METHODS: The present study included 90 patients who underwent PD for periampullary tumors. Patients were divided into two age-related groups, including those aged 60-74 years (n = 60) (Group 1) and those aged ≥75 years (n = 30) (Group 2). Each patient's characteristics, perioperative features, morbidity, and long-term results were evaluated retrospectively. RESULTS: In both univariate and multivariate logistic regression analyses, old age (≥75 years) was not a risk factor for morbidity and hospital mortality. The multivariate analysis demonstrated that male gender (p = 0.008), pancreatic duct diameter (<3 mm) (p < 0.001), and length of hospital stay (p = 0.005) were independent risk factors for pancreatic fistula post-operation and reoperation. Additionally, hospital mortality was significantly associated with reoperation (p = 0.011). The overall median survival was 27 ± 4.1 (18.8-35.1) months. Lymph node positivity (p < 0.001), neural tumor invasion (p = 0.026), and age ≥75 years (p = 0.045) were risk factors affecting the overall survival rate. Moreover, there was no statistically significant difference in terms of PD rates during the Coronavirus disease-19 (COVID-19) period among groups, and PD during this period was not related to the occurrence of pancreatic fistula. CONCLUSION: PD can be performed effectively in selected elderly patients with tolerable morbidity and mortality rates.

Acute pancreatitis in Turkey: Results of a nationwide multicenter study.

BACKGROUND: Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management. METHODS: All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria. RESULTS: The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically. CONCLUSIONS: This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

Electronic Alert System Significantly Increases HBV Screening Rates Before Immunosuppressive Treatments.

BACKGROUND: Hepatitis B Virus (HBV) screening rates before starting immunosuppressive treatments are suboptimal. The aim of the study was to evaluate the efficacy of a new electronic alert system in increasing HBV screening rates. METHODS: The electronic alert system, HBVision2, identifies patients at risk of HBV reactivation when a pre-determined International Classification of Diseases (ICD)-10 code is entered into the hospital's database or immunosuppressive treatment is prescribed. The system evaluates the prior Hepatitis B Surfage Antigen (HBsAg) and anti-Hepatitis B Core Immunglobulin G (HBc IgG) results and sends an alert code to the clinician for screening if serology is not completely available or consult a specialist in case of positive serology. The HBV screening and consultation rates of patients before (control group) and after HBVision2 were retrospectively compared. The clinical course of unscreened and/or unconsulted patients was determined, and the clinical efficacy of HBVision2 in preventing HBVr was predicted. RESULTS: Control group included 815 patients (52.6% male, mean age: 60 ± 12, 82.5% with oncologic malignancy) and study group included 504 patients (56% male, mean age: 60 ± 13, 91.4% with oncologic malignancy). Groups were similar with respect to gender, mean age, and HBVr risk profile of the immunosuppressive treatment protocols. Overall, both HBsAg (from 55.1% to 93.1%) and anti- HBc IgG screening rates significantly increased (from 4.3% to 79.4%) after the electronic alert system (P < .001, for both). Consultation rates of anti-HBc IgG-positive patients significantly increased from 40% to 72.7% (P = .012). HBVr developed in 2 patients (2.6%) who were not screened and/or consulted after the alert system. Alert program prevented the development of HBVr in 10 patients (1.9%) of the study group and decreased the development of HBVr by 80%. CONCLUSION: Electronic alert system significantly improved HBsAg and anti-HBc IgG screening rates before starting immunosuppressive treatment and prevented the development of HBVr to a great extent. However, screening rates are still below optimal and need to be improved.

Higher Complications During the Waiting Period for Interval Cholecystectomy in Patients With Mild Biliary Pancreatitis.

BACKGROUND: Although current guidelines recommend cholecystectomy during the same admission in patients with mild acute biliary pancreatitis (ABP), it involves a waiting list most of the time. We aimed to assess the risk of complications and determine predictors during the waiting period for cholecystectomy after the first episode of ABP. METHODS: A prospective observational study was conducted in patients with mild ABP. Follow-ups were done by phone calls or using electronic health records for a maximum of 6 months after discharge or until cholecystectomy. RESULTS: A total of 194 patients were included in the study. Although all patients were referred to surgeons, only 81 (41.8%) underwent cholecystectomy within 6 months after discharge. During the observation period, gallstone-related biliary events (GRBEs) developed in 68 (35.1%) patients, which included biliary colic, recurrent ABP, acute cholecystitis, choledocholithiasis, gallbladder perforation, cholangitis, and liver abscess. The overall readmission rate was 25.2%, with 44.8% occurred within 4 weeks after discharge. The odds ratio of any complication was 1.58 (95% CI, 1.42 to 1.76, P =0.028) and 1.59 (95% CI, 1.42 to 1.78, P =0.009) in the patients who did not have surgery within 2 to 7 days and 8 to 15 days, respectively. A 4-fold increased risk of readmission was detected (95% CI, 1.16 to 13.70, P =0.019) if cholecystectomy was not performed within 31 to 90 days. The patients who developed complications had significantly higher C-reactive protein at admission, longer waiting time, and had 3 or more gallstones on imaging. CONCLUSIONS: Interval cholecystectomy was associated with a high risk of complications during the waiting period in patients with mild ABP.

Clinical Features and Outcomes of Coronavirus Disease 2019 in Patients with Inflammatory Bowel Disease and Spondyloarthropathies.

BACKGROUND: We aimed to determine the clinical features, predictive factors associated with severe disease, and outcomes of coronavirus disease 2019 in patients with immune-mediated inflammatory diseases and report data on the comparison of coronavirus disease 2019 between patients with inflammatory bowel disease and spondyloarthropathies. METHODS: A total of 101 patients with inflammatory bowel disease and spondyloarthropathies who had confirmed diagnosis of coronavirus disease 2019 were retrospectively analyzed. Demographics, comorbidities, immunosuppressive treatments, and the impact of immunosuppression on negative outcomes were assessed. RESULTS: The median age of the patients was 47 (38-57) years. The most common rheumatologic diagnosis was ankylosing spondylitis (n = 24), psoriatic arthritis (n = 17), and reactive arthritis (n = 1). In the inflammatory bowel disease group, 47 patients had ulcerative colitis, 11 Crohn's disease, and 1 unclassified. The most commonly used treatments were biologics (55%) in the spondyloarthropathies group and aminosalicylates (66.1%) in the inflammatory bowel disease group. Overall, 18.8% of the patients required hospitalization, 5% developed severe complications, and 2% died. There were no significant differences in coronavirus disease 2019-related negative outcomes between spondyloarthropathies and inflammatory bowel disease patients. The median age was higher in the patients who required hospitalization [57 (46-66) vs 47 (38-57) years, P=.008]. Bilateral opacities on chest radiographs were more common in the patients who required hospitalization in the spondyloarthropathies group [88.9% vs 14.3%, P=.016]. Comorbidity was significantly associated with hospitalization in the inflammatory bowel disease group (P ≤ .05). Baseline therapy with biologics or immunosuppressives was not associated with severe coronavirus disease 2019 outcomes. CONCLUSION: Older age, comorbidities, and bilateral ground-glass opacities were associated with adverse outcomes, whereas specific immune-mediated inflammatory disease diagnoses or immunosuppressive treatments were not.

Morbidity and long-term results in patients with wild and mutant type Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations undergoing colorectal cancer surgery.

BACKGROUND: In colorectal cancer (CRC), the mutation of the K(N)RAS gene has a significant impact on the clinical course, and is associated with a negative prognosis. We aim to present the morbidity and long-term results in patients with wild/mut-K(N)RAS, undergoing CRC surgery. METHODS: A total of 116 patients who underwent surgery for colorectal cancers with wild/mut-K(N)RAS were included in this retrospective study. The patients were divided into two groups: wild-K(N)RAS patients (Group 1) and mutant- K(N)RAS patients (Group 2). Results were evaluated for clinical, operative, morbidity and long-term survival outcomes. MATERIALS AND METHODS: The highest surgical site infection (SSI) rate (OR=140.339)(4.303-4581.307)(P=0.005) was seen in patients given Bevacizumab during neoadjuvant treatment. Meanwhile, the SSI site infection rate was at its lowest in cases where minimally invasive surgery was preferred (OR=0.062)(0.006-0.628)(P=0.019). In addition, the overall median survival rate for the total cohort was 38±3.1 (31-44) months. Multivariate analysis showed that CEA (>5ng/mL)(HR 2.94)(1.337-6.492))(P=0.007); tumor stage (P=0.034), T(T4) stage (HR 1.91)(1.605-252.6)(P=0.02); metastasectomy/ablation (HR 0.19)(0.077-0.520)(P=0.001); the number of removed metastatic lymph nodes (HR 1.08)(1.010-1.155)(P=0.025); tumor implant or nodule (HR 2.71)(1.102-6.706)(P=0.03); curative resection (HR 2.40)(0.878-6.580)(P=0.042) to be factors affecting the overall survival rate. CONCLUSION: Treatment with Bevacizumab during the neoadjuvant period in mut-K(N)RAS cases, surgical technique and complications of Grade 3 or higher are risk factors for SSI on morbidity in patients with mut/wild-K(N)RAS undergoing colorectal cancer surgery. Moreover, CEA (>5ng/mL), tumor stage, T stage, metastasectomy/ablation, the number of removed metastatic lymph nodes, tumor implant/nodule and curative resection are risk factors on the overall survival rate. KEY WORDS: Bevacizumab, Colorectal cancer, K(N)RAS mutation, Morbidity, Mortality.

Hepatitis B reactivation after oral capecitabine treatment in a rectum cancer patient with isolated anti-HBc IgG positivity.

INTRODUCTION: Hepatitis B virus (HBV) reactivation in the setting of chemotherapy and immunosuppressive therapy is associated with significant morbidity and mortality. Herein we present a case of HBV reactivation after oral capecitabine treatment in a patient with rectum cancer and isolated anti-HBc IgG positivity. CASE REPORT: A 57-year-old man was consulted from the oncology clinic because of increased serum liver tests after chemotherapy. He underwent surgery for early-stage rectal cancer and received adjuvant chemotherapy with oral capecitabine. After cessation of chemotherapy, his laboratory tests revealed severe liver dysfunction. HBV markers showed positivity for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc). HBV DNA level was markedly elevated. MANAGEMENT AND OUTCOME: A review of medical records revealed that, before chemotherapy, the patient was positive for anti-HBc IgG but negative for HBsAg, and serum aminotransferases were within the normal limits. A diagnosis of HBV-related hepatitis due to capecitabine use was made, and the patient was put on tenofovir treatment. Six months later, HBV DNA decreased, and liver function tests were normalized. DISCUSSION: To the best of our knowledge, this is the first case report describing HBV reactivation after chemotherapy with capecitabine for rectal cancer in a patient with isolated anti-HBc IgG positivity. Our case shows that HBV reactivation may develop in a low-risk patient with a low degree of immunosuppression.

Dilemma in post-IBD patients with IBS-D symptoms: A 2020 overview.

INTRODUCTION: Inflammatory bowel disease (IBD) patients in apparent clinical remission who present with irritable bowel syndrome (IBS)-like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD IBS. When associated with a diarrheal IBS presentation, this clinical syndrome is known as post-IBD IBS-D. AREAS COVERED: We review and describe the literature regarding the clinical overlap of IBD and IBS. We discuss prevalent theories regarding the pathophysiology of post-IBD IBS-D and whether this presentation represents coincident inherent IBS-D, IBS-D triggered by IBD, or an even more subtle level of IBD activity that is unrecognized by available laboratory modalities. We also discuss observations that post-IBD IBS-D patients harbor significantly increased colon mucosal eosinophils and appear to respond to a GI-hypoallergenic diet and budesonide therapy. EXPERT OPINION: The symptoms overlap between IBD and IBS complicates diagnosis and subsequent management of patients with post-IBD IBS-D. In addition to current theories regarding the pathophysiology of this condition such as alterations in mucosal inflammation, the microbiota, mucosal permeability, and gut-brain interactions. This new avenue of eosinophilic colopathy and therapy directed toward food-derived immune response in patients with post-IBD IBS-D deserves additional investigation.

Comparison of Tenofovir Disoproxil Fumarate and Entecavir in the Prophylaxis of HBV Reactivation.

INTRODUCTION: Current guidelines recommend starting antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in patients receiving immunosuppressive treatments (IST). The aim of this study was to compare the efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) for prophylaxis. METHODS: Patients, who were HBsAg and/or anti-HBc IgG positive and scheduled to receive IST for oncologic and hematologic diseases, were enrolled into the study. Those who were already receiving an antiviral treatment for HBV or had an associated HIV, hepatitis C, D were excluded. The remaining patients with a prophylaxis indication according to the AGA guideline were randomized to receive either ETV (0.5 mg/day) or TDF (245 mg/day). Prophylaxis was continued for 6-12 months after completion of IST. Patients were followed up for 1 year after completion of prophylaxis. The HBV reactivation rates and side effects of the drugs were compared. RESULTS: The study group included 120 patients. There was no significant difference between the demographic data, viral serologic parameters and reactivation risk profiles of the ETV (n = 60) and TDF (n = 60) groups. Forty-one patients in the ETV and 36 in the TDF group completed the antiviral prophylaxis, and no HBV reactivation was observed. HBV reactivation was observed in 4 of 37 patients (10.8%) in the ETV group and 5 of 35 (14.3%) patients in the TDF group (including one with flare) during the follow-up after completion of prophylaxis. Ten patients in the ETV group (16.7%) and 14 patients (23.3%) in the TDF group experienced side effects (p = 0.77). One patient in the TDF group had to switch to ETV due to severe itchy, maculopapular rash-like lesions. CONCLUSIONS: ETV and TDF had a similar efficacy in the prophylaxis of HBV reactivation in patients undergoing IST, with none of the patients experiencing reactivation.

The Importance of Eosinopenia for Predicting Treatment Response in Patients with Cholangitis.

OBJECTIVE: To compare recovery of eosinopenia, C-reactive protein (CRP) and procalcitonin levels in predicting the response to treatment in patients with cholangitis. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Department of Gastroenterology, Sakarya Training and Research Hospital, Turkey between September 2018 and February 2019. METHODOLOGY:  Patients with cholangitis, who underwent endoscopic retrograde cholangiopancreatography (ERCP), were inducted. Those with choledocholic thiasis alone were considered controls. Eosinophil count above 100.5 cells/µL was the limit value accepted as improvement. ERCP repeat was decided according to eosinophil count below 100.5 and not clinically improving. Relationship between inflammatory markers such as CRP, procalcitonin and eosinopenia values in patients with stone-associated cholangitis was investigated. RESULTS: The cholangitis group was comprised of 62 patients [mean age 67±14.57 years; 26 (41.9%) female], while control group was comprised  of 57 patients [mean age 57.4±18.10 years; 39 (68.4%) females, p=0.004]. At time of admission, median eosinophils was significantly lower in cholangitis group at 17.50 [9.82-84] ×103/µL compared to control group at 168 [100.11-270] ×103/µL (p=0.001). ERCP were repeated on two patients as their clinical conditions and unremitting eosinophil counts worsened. Eosinophil and CRP markers and clinical improvement were observed after  second ERCP procedure. CONCLUSION: Eosinopenia may be used as inflammatory marker in  evaluation of response to treatment and for predicting the need to repeat ERCP during clinical follow-up of patients who undergo cholangitis treatment. Key Words: Cholangitis, C-reactive protein, Endoscopic retrograde cholangiopancreatography, Eosinopenia, Procalcitonin.

Experience of the Endoscopists Matters in Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients.

BACKGROUND/AIMS: Altered anatomy is a challenge in endoscopic retrograde cholangiopancreatography (ERCP) for patients with Billroth II anastomosis. In this study, we investigated the overall success and role of endoscopist experience. METHODS: Data of patients who underwent ERCP between 2014 and 2018 after a previous Billroth II operation were retrieved retrospectively from 2 tertiary ERCP centers. The procedures were performed by 2 endoscopists with different levels of experience. Clinical success was defined as extraction of the stone, placement of a stent through a malignant stricture, and clinical and laboratory improvements in patients. RESULTS: Seventy-five patients were included. The technical success rate was 83% for the experienced endoscopist and 75% for the inexperienced endoscopist (p=0.46). The mean (±standard deviation) procedure time was 23.8±5.7 min for the experienced endoscopist and 40.68±6.07 min for the inexperienced endoscopist (p<0.001). In total, 3 perforations (4%) were found. The rate of afferent loop perforation was 6.25% (1/16) for the inexperienced endoscopist and 0% (0/59) for the experienced endoscopist (p=0.053). CONCLUSION: ERCP in patients who had undergone Billroth II gastrectomy was time consuming for the inexperienced endoscopist who should beware of the unique adverse events related to ERCP in patients with altered anatomy.

Rheumatologists' awareness of hepatitis B reactivation before immunosuppressive therapy.

HBV reactivation (HBVr) is a well-known complication of immunosuppressive (IS) treatment. The aim of this study was to evaluate the awareness of rheumatologists about the risk of HBVr. A survey was sent via e-mail to 270 members of the Turkish Society for Rheumatology. It consisted of fourteen questions on their awareness of the major society guidelines, approach to hepatitis B virus (HBV) screening according to different IS regimens, decision process in screening patients for HBV, knowledge of antiviral treatments for HBV, follow-up strategies, experience and postgraduate training on HBVr. Forty-eight (17.8%) rheumatologists responded to the survey. Of the respondents, 93.8% reported that they screened all patients before IS treatment, while 6.2% screened patients with a high risk of HBV infection only. The screening rate was 95.8% (46/48) in patients undergoing high-risk IS treatment and 35.4% (17/48) in those undergoing low-risk treatment. All respondents screened for HBsAg, and 83.3% (40/48) screened for anti-HBc IgG and anti-HBs. Forty-four (91.7%) rheumatologists had previously initiated antiviral prophylaxis, and 14 (29.2%) had detected HBVr in at least one patient. Rheumatologists had a high awareness of the necessity for HBV screening before IS treatment. However, the screening rates were still lower than desired, especially in patients receiving IS treatments with moderate or low risk of reactivation.

Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit.

BACKGROUND: While acute pancreatitis (AP) resolves spontaneously with supportive treatment in most patients, it may be life-threatening. Predicting the disease severity at onset dictates the management strategy. We aimed to define the patients with mild pancreatitis who may be considered for outpatient management with significant cost-savings. MATERIALS AND METHODS: This prospective observational study included 180 patients with mild AP according to the harmless acute pancreatitis score (HAPS) and Imrie score. The relationships of biochemical parameters with the changes in the Balthazar score and clinical course were examined. RESULTS: The study included 180 patients (111 females, 69 males; mean age: 53.9 ± 17.2 years; range: 17-92 years). The etiology was biliary in 118 (65%) patients and remained undetermined in 38 (21.1%) patients. Computed tomography (CT) performed within the first 12 h revealed mild and moderate AP in 159 (88.3%) and 21 (11.7%) patients, respectively. CT repeated at 72 h revealed mild, moderate, and severe AP in 155 (86.1%), 24 (13.3%), and 1 (0.6%) patients, respectively. Comparisons between stages A + B + C and D + E showed significant differences in the amylase levels on day 1 and 3, and in C-reactive protein on day 3. Also, in stage D and E disease, narcotic analgesic intake, oral intake onset time, and pain were significantly higher. CONCLUSION: There were no significant changes in the CT findings of patients with mild AP at 12 and 72 h. Most patients (n = 179; 99.4%) recovered uneventfully. Patients with mild pancreatitis according to the HAPS and Imrie scores can be considered for outpatient management. The recovery is longer in stage D and E disease.

INTRODUÇÃO: Apesar da pancreatite aguda resolver espontaneamente com medidas de suporte na maioria dos doentes, esta também pode ser grave e fatal. A prediçãoinicial da gravidade da doença orienta a estratégia terapêutica.O nosso objetivo foi definir os doentes com pancreatite ligeira que podem ser considerados para terapêutica em ambulatório com redução dos custos. MATERIAL E MÉTODOS: Estudo prospetivo observacional com 180 doentes com pancreatite aguda ligeira segundo os scores de HAPS e Imrie. As relações entre os parâmetros bioquímicos, as alterações no score de Balthazar e o curso clinico foram examinadas. RESULTADOS: Este estudo incluiu 180 doentes (111 mulheres, 69 homens; idade média 53.9±17.2 anos). A etiologia foi biliar em 118 (65%) e permaneceu indeterminada em 38 (21.1%) doentes, respetivamente. A tomografia computorizada (TC) realizada nas primeiras 12 h revelou pancreatite ligeira e moderada em 159 (88.3%) e 21 (11.7%) doentes, respetivamente. A TC repetida às 72h revelou pancreatite aguda, moderada e grave em 155 (86.1%), 24 (13.3%), e 1 (0.6%) dos doentes, respetivamente. As comparações entre os estadios A+B+C e D+E mostraram diferenças significativas nos níveis de amílase nos dias 1 e 3, e na PCR no dia 3. Também nos estadios D e E, a toma de narcóticos, tempo de inicio da dieta oral e a dor foram significativamente superiores. CONCLUSÃO: Não se verificaram alterações significativas na TC dos doentes com pancreatite ligeira nem às 12 nem às 72h. A maioria dos doentes (99.4%) recuperou sem complicações.Doentes com pancreatite ligeira segundos os scores de HAPS e Imrie podem ser considerados para orientação em ambulatório. A recuperação é mais longa nos estadios D e E da doença.

Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled,open-label study.

BACKGROUND/AIMS: Acute pancreatitis (AP) runs a moderately severe and severe course in 20%-30% of cases. The purpose of the present study was to determine the effect of low molecular weight heparin (LMWH) for the prevention of pancreatic necrosis (PN) in moderately severe and severe AP (MSAP). MATERIALS AND METHODS: A total of 100 patients with MSAP were randomized to receive either standard care (SC) or SC plus LMWH. LMWH was administered at 1 mg/kg via subcutaneous injection twice a day between days 1 and 7. The revised Atlanta criteria were used in the diagnosis of MSAP. Patients with a Harmless AP Score of >1 and a Balthazar computed tomography (CT) score of D and E were included in the study. RESULTS: The mean age±SD of the patients (46 male and 54 female) was 52±19 years (range, 17-100). There were 50 patients in each group. On admission, clinical and laboratory parameters and Balthazar CT scores were similar between the groups. Initially, PN was present in one patient in the LMWH group and two in the SC group. Over the course, PN developed in 3 (6.1%) patients in the LMWH group and 11 (22.9%) in the SC group (p<0.05). Local and systemic complications were significantly lower in the LMWH group (p<0.05). No hemorrhagic complication occurred. Mortality was not significantly different between the groups (p=0.056). CONCLUSION: Low molecular weight heparin treatment is safe and provides better prognosis in MSAP.

Helicobacter pylori is undetectable in intraductal papillary mucinous neoplasm.

BACKGROUND: About half of the world population is infected with Helicobacter pylori (H. pylori), a bacterium associated with gastric cancer and considered to be a risk factor for pancreatic ductal adenocarcinoma. Whether the bacterium is associated with intraductal papillary mucinous neoplasm, believed to be a precursor of pancreatic ductal adenocarcinoma, is unknown. The aim of this study was to investigate the presence of H. pylori DNA in tissue sections of intraductal papillary mucinous neoplasm. METHODS: The presence of H. pylori DNA was tested in a retrospective controlled study of formalin-fixed, paraffin-embedded pancreatic tissues from 24 patients who underwent surgery for intraductal papillary mucinous neoplasm. Histologically normal tissues surrounding neoplasms were used as control. H. pylori DNA was evaluated after deparaffinization, DNA extraction, and purification, and results were evaluated statistically. RESULTS: Samples were collected from 13 males and 11 females with mean age 59 years (range 44-77), and consisted of 19 cases of main-duct and three cases of branched-duct intraductal papillary mucinous neoplasm. Two patients were diagnosed with pancreatic cancer and main-duct intraductal papillary mucinous neoplasm. H. pylori DNA was not detected either in intraductal papillary mucinous neoplasm tissue, or in surrounding normal tissue. CONCLUSIONS: Although H. pylori has been implicated in pancreatic ductal adenocarcinoma, it may not play a key role in the development of intraductal papillary mucinous neoplasm.

Effect of pantoprazole and Helicobacter pylori therapy on uninvestigated dyspeptic patients.

BACKGROUND/AIMS: This study aimed to test the efficacy of empirical proton pump inhibitor use and Helicobacter pylori therapy for uninvestigated dyspepsia in a population with a high prevalence of H. pylori. MATERIAL AND METHODS: The study had a two-stage design. In the first stage, the efficacy of 4-week pantoprazole treatment was compared with placebo in patients with uninvestigated dyspepsia. In the second stage, the efficacies of 2-week treatment with pantoprazole in H. pylori-negative patients and H. pylori eradication therapy (pantoprazole + amoxicillin + clarithromycin) in H. pylori-positive patients were compared. The primary endpoint was sufficient overall symptom relief (Global Overall Symptom score ≤2; no or minimal symptoms) at the end of treatment. RESULTS: In the first stage, sufficient overall symptom relief was achieved by 25.2% of patients in the pantoprazole group and 15.5% of patients in the placebo group, a difference that was not statistically significant (p=0.06). In the second stage, the rate of sufficient overall symptom relief was higher in the H. pylori therapy group than in the pantoprazole group (37.1% vs. 23.4%; p=0.02). After untreated follow-up, sufficient overall symptom relief remained significantly higher in the H. pylori therapy group than in the pantoprazole group (39.7% vs. 18%; p<0.001). Almost all patients receiving pantoprazole experienced symptom relapse after treatment. CONCLUSIONS: This study validated the use of a test-and-treat strategy against H. pylori in uninvestigated dyspepsia, which may be an advisable treatment approach for uninvestigated dyspeptic patients in countries with a high prevalence of H. pylori.

Yields of dual therapy containing high-dose proton pump inhibitor in eradication of H. pylori positive dyspeptic patients.

UNLABELLED: BACKGROUND/AIMs: H. pylori eradication has been recommended for dyspeptic patients in high prevalance regions. Triple therapies are still prescribed mostly because culture and antibiotic susceptibility tests aren't widely available in the world. Dual therapy with high-dose proton pump inhibitors reported to have higher eradication rates. Our objective was to determine eradication success and cost-effectivity of dual therapy in dyspeptic patients. METHODOLOGY: Patients were treated orally with either dual (n:74,omeprazole 20mg q.i.d and amoxicillin 1g b.i.d) or triple therapy (n:116,omeprazole 20mg b.i.d and amoxicillin 1g b.i.d and clarithromycin 500mg b.i.d) for 14 days. HpSA was requested 3 months later. The results were evaluated statistically, p values ˂0,05 were considered significant. RESULTS: Patients (n:190) were included the study((80 female,110 male, mean age: 35.6±11year(p<0.001)). Alcohol/smoking, endoscopic findings and H. pylori rates with pathological examinations were not significantly different between groups whereas there was a significant difference in HpFast tests(p<0.01). When examined with HpSA tests 3 months after the treatment, eradication rate was 81.1% in the dual therapy group versus 63.8% in the triple therapy group (p:0.011). Dual therapy was economic than triple therapy (144USDvs.107USD,p<0.001). CONCLUSIONS: Dual therapy seems more successful, cost-effective and is less risky in terms of side effects compared to standard triple therapy in patients with dyspepsia.

Role of serum myeloperoxidase, CPK, CK-MB, and cTnI tests in early diagnosis of myocardial ischemia during ERCP.

BACKGROUND/AIMS: Some patients may experience retrosternal pain during ERCP, which may be a pioneer of a serious myocardial problem, and early diagnosis is very important for the prognosis and management. In the study, we aimed to investigate the role of serum cardiac biomarkers, such as myeloperoxidase (MPO), creatine phospokinase (CPK), creatine kinase- myocardial band (CK-MB), and cTnI, on early diagnosis of myocardial ischemia during endoscopic retrograde cholangio pancreaticograpy (ERCP) procedures. MATERIALS AND METHODS: In this prospective observational study, ERCP patients were separated into ischemic cardiac (n:48) and non-ischemic (n:76) groups. Serious cardiac, kidney, and liver disease patients were excluded from the study. Changes in electrocardigrapy (ECG), blood pressure, pulse rate, oxygen saturation, and serum MPO, CPK, CK-MB, and cTnI levels were investigated before and after the ERCP. Results were evaluated statistically (p<0.05). RESULTS: Mean age was 59.76±16.62 (55♀, 69♂). Only one patient had clinically unimportant retrosternal pain (0.8%). ST-elevation was detected in 10.4% (n:5), ST-depression in 12.5% (n:6), and negative-T in 31.3% (n:15) of ischemic patients during ERCP. Systolic and diastolic blood pressure and pulse rates in both groups and oxygen saturations in the ischemic group were reduced after ERCP. Significance was not detected with MPO and CPK tests. CK-MB levels showed an increase after the ERCP in the non-ischemic group (p<0.001). cTnI means were higher among the ischemics when pre- and post-ERCP periods (p:0.001) were compared. CONCLUSION: Clinically unimportant retrosternal pain, T negativity, and ST segment changes as well as reduced systolic, diastolic blood pressure, and heart rates can be seen during ERCP. MPO and CPK levels remain insignificant if myocardial injury does not develop. Increased CK-MB levels in non-ischemic patients and increased cTnI levels in ischemics may be seen.