Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Hyperplasia of parathyroid gland in a five-year old child affected by MEN 2A

Primary hyperparathyroidism (HPT) is observed in 20-30% of patients with multiple endocrine neoplasia type 2A (MEN 2A). The age of diagnosis ranges from seven to seventy one year old (with median of thirty eight years) in patients affected by HPT in MEN 2A. We diagnosed primary HPT in a 5 year old boy carrier of RET gene mutation associated with MEN 2A,submitted to prophylactic total thyroidectomy (TT). The RET mutated gene carriers are submitted to prophylactic TT at different ages. Recent studies demonstrated that based on the type of RET gene mutation the timing of TT varies, as the transforming potential of RET-mutations are codon-dependentwith significant correlations between genotype and clinical phenotype in MEN 2A patients. In particular, the medullary thyroid carcinoma (MTC) occurs earlier in the patients with codon 634 mutations than in those with other mutations, and these patients have also a higher frequency of pheochromocytoma and hyperparathyroidism. This genotype-phenotype correlation is confirmed in the patient described in this report, who was carrier of a germline mutation in the 634 codon (Cys→Trp) and showed early expression of MTC and parathyroid pathology. The young age of this patient represents an exception, as other Authors report the absence of parathyroid pathology in children or in adolescents submitted to prophylactic TT. The patient underwent a partial parathyroidectomy in agreement with the preferred surgical treatment of HPT in MEN 2A, which consists in removing only the parathyroid(s) with increased volume. Indeed, the experiences with subtotal or total parathyroidectomy associated to autograft are very limited, with results supporting lack of major differences and, therefore, suggesting a more conservative surgical approach HPT in MEN 2A. We diagnosed primary HPT in a 5 year old boy carrier of RET gene mutation associated with MEN 2A, submitted to prophylactic total thyroidectomy (TT). The RET mutated gene carriers are submitted to prophylactic TT at different ages. Recent studies demonstrated that based on the type of RET gene mutation the timing of TT varies, as the transforming potential of RET-mutations are codon-dependent with significant correlations between genotype and clinical phenotype in MEN 2A patients. In particular, the medullary thyroid carcinoma (MTC) occurs earlier in the patients with codon 634 mutations than in those with other mutations, and these patients have also a higher frequency of pheochromocytoma and hyperparathyroidism. This genotype-phenotype correlation is confirmed in the patient described in this report, who was carrier of a germline mutation in the 634 codon (Cys→Trp) and showed early expression of MTC and parathyroid pathology. The young age of this patient represents an exception, as other Authors report the absence of parathyroid pathology in children or in adolescents submitted to prophylactic TT. The patient underwent a partial parathyroidectomy in agreement with the preferred surgical treatment of HPT in MEN 2A, which consists in removing only the parathyroid(s) with increased volume. Indeed, the experiences with subtotal or total parathyroidectomy associated to autograft are very limited, with results supporting lack of major differences and, therefore, suggesting a more conservative surgical approac

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

IMPORTANCE Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.OBJECTIVE To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.DESIGN, SETTINGS, AND PARTICIPANTS This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.MAIN OUTCOMES Mortality and morbidity after EC.RESULTS Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P <.001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).CONCLUSIONS AND RELEVANCE This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC