Introduction

Hypertriglyceridemia is a well-established cause of acute pancreatitis, representing up to 35% of all etiologies. The risk of developing acute pancreatitis increases progressively with serum triglyceride (TG) levels over 500 mg/dL. The degree of TG elevation is also associated to the severity of hypertriglyceridemia-induced pancreatitis (HTGP). Besides general measures, it has been suggested from observation studies that, in selected patients, insulin and plasmapheresis may have a role in the management of this condition.

Aims & Methods

We present an observational retrospective study of patients diagnosed with severe HTGP treated with plasmapheresis (PX) in an Intensive Care Unit (ICU) between January 2013 and March 2023.

Results

Of the 19 patients included in this study, 89% were men (n=17) and the mean age of presentation was 41 ± 7 years. Around 90% of patients were obese with a mean body mass index (BMI) of 29 ± 3 kg/m². The average APACHE II score was 9±7 and most patients did not require organ support (n=16, 84%). All the selected patients had severe hypertriglyceridemia at admission (1225 to 4700 mg/dL) and underwent PX within 48h of ICU admission. Levels of TG were measured before and after each plasmapheresis. 68% of patients needed only one treatment to reduce TG to a value below 500 mg/dL (n=13), 26% needed two treatments (n=5) and 5% needed four (n=1). A total of 27 PX were conducted. The average decrease in TG levels per treatment was 67% and 74% with the first treatment. The mean volume exchanged was 3683 mL ± 859 mL, and the most used replacement solutions were albumin/crystalloid (n=12, 44%) and albumin alone (n=11, 41%). The technique was interrupted mainly due to elevated transmembrane pressure (n=11, 40%). There were no PX interruptions due to complications related to the patient. Although heparin was used in all patients for anticoagulation, no hemorrhagic complications were associated to the technique. Hypotension occurred in 7% of plasmapheresis and was solved with crystalloid administration . The mean ICU length of stay was 7+11 days and the mean hospital length of stay was 17+21 days. The hospital mortality was 5% (n=1).

Conclusion

PX proved to be successful in lowering TG levels in HTGP. One to two plasma exchanges effectively reduced the serum TG level. There was a low rate of procedure-related complications. However, having no comparison with standard treatments, the impact of this technique on the patients’ clinical outcomes is still uncertain. Further prospective randomized clinical studies are needed to outline an efficient treatment for the management of HTGP.

References

Padmanabhan, A et al, “Guidelines on the Use of Therapeutic Apheresis in Clinical Practice”, J Clin Apher. 2019;34:171–354.
Banks PA, “Practice guidelines in acute pancreatitis.”, Am J Gastroenterol. 2006;101(10):2379)
Rawla, P. “Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies”, Clin J Gastroenterol. 2018 Dec;11(6):441-448.
Faria, R. et al, “Therapeutic Plasmapheresis: Seven Year Experience of an Intensive Care Unit in Portugal”, Acta Med Port 2022 Mar;35(3):176-183
Stefanutti, C. et al, “Severe Hypertriglyceridemia-Related Acute Pancreatitis”, Therapeutic Apheresis and Dialysis 2013; 17(2):130–137

Introduction

Pancreatic cysts are a common finding in imaging studies, and, considering the different malignant potentials of mucinous and non-mucinous cysts, it is necessary to develop accurate methods and algorithms to differentiate between them. We conducted this study to compare the diagnostic performance of glucose levels and CEA levels in the diagnosis of mucinous pancreatic cysts.

Aims & Methods

We conducted a retrospective study of patients who underwent EUS-FNA of pancreatic cystic lesions between September 2020 and March 2023 at a tertiary referral center. We included patients whose glucose and CEA levels had been measured. Indicators of mucinous cysts include glucose levels less than 2.7 mmol/l and CEA levels greater than 192 ng/ml. It was compared to the final pathology (obtained after surgery or by EUS-FNB) result to determine their accuracy.

Results

	Non-mucinous	Mucinous
Gender (%male)	47.3%	33.3%
Age ( Median)	50.2	58.3
Cyst location
head	9	3
body	2	5
tail	8	4

A total of 31 patients were included in the study, 13 males and 18 females. The mean age was 55.7 years. Of the 31 patients, 12 (38.7%) were diagnosed with mucinous cysts (6 mucinous cystic neoplasms, 6 intraductal papillary mucinous neoplasms), and 19 (61.2%) were diagnosed with non-mucinous cysts (9 serous cystic neoplasm, 8 pseudocysts, 1 solid pseudopapillary neoplasm, and 1 lymphoepithelial cyst). There was a female prevalence in patients with mucinous cysts (8 females and 4 males) with a mean age of 59,6 years. From the cyst fluid analysis, the sensitivity, specificity, and accuracy of glucose in diagnosing mucinous cysts were 91.7%, 89.5%, and 90.3%, respectively. CEA’s sensitivity, specificity, and accuracy were 81.8%, 85.0%, and 83.9%, respectively.

Conclusion

In the diagnosis of pancreatic cystic lesions, glucose levels have high diagnostic performance with high sensitivity and accuracy. In contrast, CEA levels have a lower diagnostic performance. The findings of our study support the use of EUS-FNA and glucose levels in the diagnosis of pancreatic cystic lesions, as well as EUS-FNB to obtain histological specimens for a more accurate diagnosis of pancreatic cysts. Further studies are needed to validate these findings and explore the potential of other biomarkers in diagnosing and managing pancreatic cystic lesions.