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Modulation of exocrine pancreatic secretion by afferent nerves and calcitonine-gene related peptide (CGRP)
A362
AGA ABSTRACTS
Drainage combined with local excisionof the head of the pancreas vs. duodenompreserving resection of the head of the pancre~a prospective randomized trial J. R. hbicki. W. T. Knoefel,C. BI0chle,T. Kiichler,C. E. Brcelsch Depamuem of Stwgery,Universityof Hamburg, Germany Dept of MedicalPsychology,Universityof Hamburg Objective: A drainagepronecktrc(longitudinalpancrcalmojganostc~y)combined~ith I~.,al excision of the head of the pancreas (Frcy-proccdure) was compared *~4th duodentlm-pr~Ang resectlco of the head of the pancreas (Beget procedure) hi a prospc~ve ~ trial. The technicalfeasibilityand effects on qtmJityof life were assessed. Summary Background Data: D ~ e and resecOonare the principlesof surge6' in chronicpancresfitis.The techniquesof duodenum-preservingresectionof the head of the pancreasas describedby Beget and Frey conabineboth to differentdegrees.The efl]cacy of bah procedureshas so far not beenconapmed. Methods: 42 patientswere mndorrdyallocatedto either Bcger's(n=25) or Frey's (n=23) group. In addition to routine pancreatic diagnostic wonk-up a multidimensional ps)chometric qualit)~of-litbquesfionnatreand a pain score v,ere used. Ass~sment of endocrine and exocrine fimction included oral glucose tolerance test, serum concenWafi~s of insulin, C-pepfide, and HbAlc, as v,ell as fecal chymotrypsinand pancroolaluyltest. "Ihe intervalbetv~ee~as?rnptomsand surge~, ranged from 12 m(xghs to 12 yearswith a meanof 5.7 )eats~The mean follow-upx~as 1.5 ),ears. Results: There v,as no mortality.Overall morbidity,was 14% (20%Beger, 9% Fr~'). Compfications from adjacent organs ~ere definitivelyresolved in 94% (90% Beger_ 100% Frey").A decreme of 95% and 94% of the pain score after Begees and Fr~% procedure, respeclavely,and an increaseof 67% of the overall quality-of-lifeindex in both groups were oiSsen,ed. Endocrineand exocrmefimctiondid net differbevmen both groups. Condusinns:. Both techniquesof duodenum preserving resection of the head of the pancreasare equaUysafe arideffectivewith regardto pare relief,tmproven~ntof quality of life.and &~finifivcconlrolof complicationsaffec'nr,gadjace~ organs. Both proccdur~ do not leadto fitrflaerdcteriomfionof endocrine and exccnne pancreaticfimction.We conclude that a drainage procedure combincd xfith local excision of the head of the pancreasis sufficientfor adcquatepain ~ t r o l in patientsvdth chronic pancreafitJs.
• MODULATION OF EXOCRINE PANCREATIC SECRETION BY AFFERENT NERVES AND CALCITONINE-GENE RELATED PEPTIDE ICGRP). ~. Jaworek, A. Szlacheic, S.J. Konturek. Inst. Physiol., Univ. Med; Sch., Krakow, Poland. In the pancreas, CGRP has been demonstrated in sensory nerves and its receptors were fou~gd in pancreatic acini. This study was designed to compaz'e the exocrine pancreatic enzyme secretion in response to CGRP and capsaicin ICAP) In rats with intact and denervated (by CAP) seasory nerves. For the in vivo tests, rats were equipped with chronic pancreatico-duodenal fistula. Sensory nerves were stimulated by intradyodenal lid) application of low doses of CAP (0.2~-I mE/kg) , whereas deactivation of these nerves was obtained by prior injections of CAP (12S mg/kg s.c.). For in vitro studies, pancreatic slices and acini were prepared from normal and CAp-denervated animals. In conscious rats, CGRP (1-I0 ~g/kg s.c.) suppressed dosedependently pancreatic enzyme secretion. CAP given id at lower doses was ineffective but at higher dose (I mg/kg id.) it "stimulated this secretion. In in vitro studies, CGRP (lO-a°-10-eM increased basal and augmented CCK- or urecholine-induced amylase release both from the acini and slices {containing nerves). The pancreatic slices [but not acin~ were stimulated dose-dependently by CAP (I0[ I-IO-eM} and this was dimished by atropine [lo-SM) but not L-NNA (10 -4) (an inhibitor of NO synthase). CAPdenervated slices and acini were insensitive ~o CAP stimulation, while showing secretory responses to CGRP, CCK or Urecholine as those with intact sensory innervation. In Contrast, CAp-denervation in vivo reduced basal secretion by about 50Z and attenuated the responses to CCK and Urecholine as well as feeding and pancreatic juice diversion IPJDI. We conclude that I. Stimulation of sensory nerves by CAP produced secretory effects dependin~ in part upon the release of CGRP; 2. CAP-inactivation of sensory nerves did not affect the secretory response Of pancreatic acini and slices to CGRP and pancreatic secretagogues but eliminated the stimulation by CAP itself; and 3. In COnsCiOUS rats, CAP-deactivation reduced secretory responses to mea] and PJD.
GASTROENTEROLOGY,Vol. 108, NO. 4
• PREVENTION OF PANCREATITIS IN PATIENTS WITH IDIOPATHIC RECURRENT PANCREATITIS (IRP); A PROSPECTIVE RANDOMIZED STUDY USING ENDOSCOPIC STENTS. L Jacob, JE Geenen, MJ Schmalz, MF Catalano, GK Johnson, DJ Geenen, WJ Hogan, St Lukes, Racine, Pancreatic Biliary Center, St Lukes Medical Center, Milwaukee, WI There is no current therapy available to prevent attacks of pancreatitis in IRP patients. AIM: To evaluate the effectiveness of pancreatic duct (PD) stants in preventing attacks ofpancreatitis in IRP. METHOD: During a 5 year period, 34 patients met the diagnostic criteria for IRP (2 or more episodes of pancreatitls; twice normal serum amylase). No etiology of pancreatitis was found despite a detailed history, lab test, US, CT scan, ERCP, CBD and PD manometry. 20 of these patients had prior eholecyst~tomy, 3 other patients had no evidence of bile crystals. Patients were randomly assigned to 2 groups; 19 (14 women, 5 men, mean age 44 yrs) to the panereatic stent group; 15 patients (10 women, 5 men, mean age 47 yrs) to the control group. The stem group received at least 3 PD stents Over a period of 1 year. The control group had selective pancreatograms but no stent. Both groups were followed at 3 month intervals for 1 year and subsequently by standardized telephone interviews. Episodes of pancreatitis and/or pancreatic pain requiring ER visits or hospitalizations were recorded. Mean follow up was 33 and 35 months in the stent and control groups respectively. RESULTS: STENT VS. CONTROL; RECURRENCE OF SYMPTOMS Group Stent Con.t[bl
Pt (n)
Pancreatitis Pt(n) (%)
Pancreatic pain pt(n) (%)
19
2
6÷
[
I
11%*
[
32%
I
15 8 53% 6 40% nt occlusion in 5 of these patients. Two patients'in the control group who had recurrence of pancreatltis were crossed over to stent therapy and had no further pancreatitis. During follow up pancreatic ductal alterations occurred in 5 patients in the stent group but were also demonstrated in 4 patients in the control group. Complications included 3 episodes of ERCP-induced mild pancreatitis in the stent group and 1 in the contro! group. During the study period 17 stents were occluded; 14 had migrated out. CONCLUSION: The results of this study suggest that pancreatic duct stenting may prevent recurrent attacks of pancreatitis in IRP patients. Intermittent pancreatic duct sphincter dysfunction or relative outlet obstruction may be the underlying cause for the recurrent attacks of pancreatitis.
S E P A R A T I O N AND C H A R A C T E R I Z A T I O N O F D I S T I N C T PANCREATIC ACINAR CELL SUBTYPES IN THE RAT. Teres¢ L. Ieraldo, Jessica A. Coutu, Aijaz Ahmed, Joel W. Adelson. Depts. of Pediatrics and Physiology, Brown Univ. School of Medicine, Rhode Island Hospital., Providence, R.I., USA. We have recently shown that pancreatic aeinar cells of the rabbit and rat are highly heterogeneous with respect to their capacities to bind lectins, which label glycosyl residues in cellular proteins with a high degree of specificity. Twenty lectins were employed in the rat; 16 stained homogeneously. In contrast, with lectins ECA, UEA, DBA and PHA distinct patterns of specific cellular labeling emerged: UEA and ECA labeled specific individual acinar ceils distributed in. acini throughout the gland (diffuse tele-insular pattern); acinar cells surrounding the islets of Langerhans (peri-insular "halos"); and individual ceils within selected pancreatic lobules (lobular pattern). Electron microscopy showed that all zymogen granules in adjacent singles cells were either labeled or unlabeled. We now report the isolation of specific subpopulations of acinar cells in ~jtro. Methods: Pancreatic tissue was excised from fasted male S.D. 200 gin. rats, minced, digested sequentially with collagenase and trypsin, and chelated by modifications of standard methods. After filtration through 20g nylon mesh; the cells were examined by light microscopy; cell viability exceeded 90% by trypan blue exclusion, 85-90% were single cells with a fe w pairs and triplets. A single gland yielded 10 - 15x106 cells. The cells were fixed with 4% paraformaldehyde, perrneabilized with saponin, labeled with specific biotinylated lectins and treated with streptavidin-FITC. The mixed single cell population was examined by phase and fluorescence microscopy and flow Cytometry; cell sorting was also performed. Results: Flow cytometry revealed a wide distribution of eel1 sizes and granularity for ECA- and UEA- labeled cells; both populations distributed over a 7 to 21g size range as expected for acinar cells. The mixed single cell population readily showed ECA or UEA positive and negative ceils. Cell sorting, based on fluorescence, yielded two highly purified and distinct cell populations. Lectin fluorescence w a s primarily localized over the zymogen granule region. Double labeling with ECA and UEA preliminarily indicated that nearly all ceils which bound UEA also bound ECA; numerous ECA positive cells were, however, UEA negative; indicating subsets of cells within a particular group of lecfin binding cells. Conclusion: These studies represent the first isolation of unique subpopulations of pancreatic acinar cells; further functional characterization and analysis of cell specific m-RNA is in progress.
AGA ABSTRACTS
Drainage combined with local excisionof the head of the pancreas vs. duodenompreserving resection of the head of the pancre~a prospective randomized trial J. R. hbicki. W. T. Knoefel,C. BI0chle,T. Kiichler,C. E. Brcelsch Depamuem of Stwgery,Universityof Hamburg, Germany Dept of MedicalPsychology,Universityof Hamburg Objective: A drainagepronecktrc(longitudinalpancrcalmojganostc~y)combined~ith I~.,al excision of the head of the pancreas (Frcy-proccdure) was compared *~4th duodentlm-pr~Ang resectlco of the head of the pancreas (Beget procedure) hi a prospc~ve ~ trial. The technicalfeasibilityand effects on qtmJityof life were assessed. Summary Background Data: D ~ e and resecOonare the principlesof surge6' in chronicpancresfitis.The techniquesof duodenum-preservingresectionof the head of the pancreasas describedby Beget and Frey conabineboth to differentdegrees.The efl]cacy of bah procedureshas so far not beenconapmed. Methods: 42 patientswere mndorrdyallocatedto either Bcger's(n=25) or Frey's (n=23) group. In addition to routine pancreatic diagnostic wonk-up a multidimensional ps)chometric qualit)~of-litbquesfionnatreand a pain score v,ere used. Ass~sment of endocrine and exocrine fimction included oral glucose tolerance test, serum concenWafi~s of insulin, C-pepfide, and HbAlc, as v,ell as fecal chymotrypsinand pancroolaluyltest. "Ihe intervalbetv~ee~as?rnptomsand surge~, ranged from 12 m(xghs to 12 yearswith a meanof 5.7 )eats~The mean follow-upx~as 1.5 ),ears. Results: There v,as no mortality.Overall morbidity,was 14% (20%Beger, 9% Fr~'). Compfications from adjacent organs ~ere definitivelyresolved in 94% (90% Beger_ 100% Frey").A decreme of 95% and 94% of the pain score after Begees and Fr~% procedure, respeclavely,and an increaseof 67% of the overall quality-of-lifeindex in both groups were oiSsen,ed. Endocrineand exocrmefimctiondid net differbevmen both groups. Condusinns:. Both techniquesof duodenum preserving resection of the head of the pancreasare equaUysafe arideffectivewith regardto pare relief,tmproven~ntof quality of life.and &~finifivcconlrolof complicationsaffec'nr,gadjace~ organs. Both proccdur~ do not leadto fitrflaerdcteriomfionof endocrine and exccnne pancreaticfimction.We conclude that a drainage procedure combincd xfith local excision of the head of the pancreasis sufficientfor adcquatepain ~ t r o l in patientsvdth chronic pancreafitJs.
• MODULATION OF EXOCRINE PANCREATIC SECRETION BY AFFERENT NERVES AND CALCITONINE-GENE RELATED PEPTIDE ICGRP). ~. Jaworek, A. Szlacheic, S.J. Konturek. Inst. Physiol., Univ. Med; Sch., Krakow, Poland. In the pancreas, CGRP has been demonstrated in sensory nerves and its receptors were fou~gd in pancreatic acini. This study was designed to compaz'e the exocrine pancreatic enzyme secretion in response to CGRP and capsaicin ICAP) In rats with intact and denervated (by CAP) seasory nerves. For the in vivo tests, rats were equipped with chronic pancreatico-duodenal fistula. Sensory nerves were stimulated by intradyodenal lid) application of low doses of CAP (0.2~-I mE/kg) , whereas deactivation of these nerves was obtained by prior injections of CAP (12S mg/kg s.c.). For in vitro studies, pancreatic slices and acini were prepared from normal and CAp-denervated animals. In conscious rats, CGRP (1-I0 ~g/kg s.c.) suppressed dosedependently pancreatic enzyme secretion. CAP given id at lower doses was ineffective but at higher dose (I mg/kg id.) it "stimulated this secretion. In in vitro studies, CGRP (lO-a°-10-eM increased basal and augmented CCK- or urecholine-induced amylase release both from the acini and slices {containing nerves). The pancreatic slices [but not acin~ were stimulated dose-dependently by CAP (I0[ I-IO-eM} and this was dimished by atropine [lo-SM) but not L-NNA (10 -4) (an inhibitor of NO synthase). CAPdenervated slices and acini were insensitive ~o CAP stimulation, while showing secretory responses to CGRP, CCK or Urecholine as those with intact sensory innervation. In Contrast, CAp-denervation in vivo reduced basal secretion by about 50Z and attenuated the responses to CCK and Urecholine as well as feeding and pancreatic juice diversion IPJDI. We conclude that I. Stimulation of sensory nerves by CAP produced secretory effects dependin~ in part upon the release of CGRP; 2. CAP-inactivation of sensory nerves did not affect the secretory response Of pancreatic acini and slices to CGRP and pancreatic secretagogues but eliminated the stimulation by CAP itself; and 3. In COnsCiOUS rats, CAP-deactivation reduced secretory responses to mea] and PJD.
GASTROENTEROLOGY,Vol. 108, NO. 4
• PREVENTION OF PANCREATITIS IN PATIENTS WITH IDIOPATHIC RECURRENT PANCREATITIS (IRP); A PROSPECTIVE RANDOMIZED STUDY USING ENDOSCOPIC STENTS. L Jacob, JE Geenen, MJ Schmalz, MF Catalano, GK Johnson, DJ Geenen, WJ Hogan, St Lukes, Racine, Pancreatic Biliary Center, St Lukes Medical Center, Milwaukee, WI There is no current therapy available to prevent attacks of pancreatitis in IRP patients. AIM: To evaluate the effectiveness of pancreatic duct (PD) stants in preventing attacks ofpancreatitis in IRP. METHOD: During a 5 year period, 34 patients met the diagnostic criteria for IRP (2 or more episodes of pancreatitls; twice normal serum amylase). No etiology of pancreatitis was found despite a detailed history, lab test, US, CT scan, ERCP, CBD and PD manometry. 20 of these patients had prior eholecyst~tomy, 3 other patients had no evidence of bile crystals. Patients were randomly assigned to 2 groups; 19 (14 women, 5 men, mean age 44 yrs) to the panereatic stent group; 15 patients (10 women, 5 men, mean age 47 yrs) to the control group. The stem group received at least 3 PD stents Over a period of 1 year. The control group had selective pancreatograms but no stent. Both groups were followed at 3 month intervals for 1 year and subsequently by standardized telephone interviews. Episodes of pancreatitis and/or pancreatic pain requiring ER visits or hospitalizations were recorded. Mean follow up was 33 and 35 months in the stent and control groups respectively. RESULTS: STENT VS. CONTROL; RECURRENCE OF SYMPTOMS Group Stent Con.t[bl
Pt (n)
Pancreatitis Pt(n) (%)
Pancreatic pain pt(n) (%)
19
2
6÷
[
I
11%*
[
32%
I
15 8 53% 6 40% nt occlusion in 5 of these patients. Two patients'in the control group who had recurrence of pancreatltis were crossed over to stent therapy and had no further pancreatitis. During follow up pancreatic ductal alterations occurred in 5 patients in the stent group but were also demonstrated in 4 patients in the control group. Complications included 3 episodes of ERCP-induced mild pancreatitis in the stent group and 1 in the contro! group. During the study period 17 stents were occluded; 14 had migrated out. CONCLUSION: The results of this study suggest that pancreatic duct stenting may prevent recurrent attacks of pancreatitis in IRP patients. Intermittent pancreatic duct sphincter dysfunction or relative outlet obstruction may be the underlying cause for the recurrent attacks of pancreatitis.
S E P A R A T I O N AND C H A R A C T E R I Z A T I O N O F D I S T I N C T PANCREATIC ACINAR CELL SUBTYPES IN THE RAT. Teres¢ L. Ieraldo, Jessica A. Coutu, Aijaz Ahmed, Joel W. Adelson. Depts. of Pediatrics and Physiology, Brown Univ. School of Medicine, Rhode Island Hospital., Providence, R.I., USA. We have recently shown that pancreatic aeinar cells of the rabbit and rat are highly heterogeneous with respect to their capacities to bind lectins, which label glycosyl residues in cellular proteins with a high degree of specificity. Twenty lectins were employed in the rat; 16 stained homogeneously. In contrast, with lectins ECA, UEA, DBA and PHA distinct patterns of specific cellular labeling emerged: UEA and ECA labeled specific individual acinar ceils distributed in. acini throughout the gland (diffuse tele-insular pattern); acinar cells surrounding the islets of Langerhans (peri-insular "halos"); and individual ceils within selected pancreatic lobules (lobular pattern). Electron microscopy showed that all zymogen granules in adjacent singles cells were either labeled or unlabeled. We now report the isolation of specific subpopulations of acinar cells in ~jtro. Methods: Pancreatic tissue was excised from fasted male S.D. 200 gin. rats, minced, digested sequentially with collagenase and trypsin, and chelated by modifications of standard methods. After filtration through 20g nylon mesh; the cells were examined by light microscopy; cell viability exceeded 90% by trypan blue exclusion, 85-90% were single cells with a fe w pairs and triplets. A single gland yielded 10 - 15x106 cells. The cells were fixed with 4% paraformaldehyde, perrneabilized with saponin, labeled with specific biotinylated lectins and treated with streptavidin-FITC. The mixed single cell population was examined by phase and fluorescence microscopy and flow Cytometry; cell sorting was also performed. Results: Flow cytometry revealed a wide distribution of eel1 sizes and granularity for ECA- and UEA- labeled cells; both populations distributed over a 7 to 21g size range as expected for acinar cells. The mixed single cell population readily showed ECA or UEA positive and negative ceils. Cell sorting, based on fluorescence, yielded two highly purified and distinct cell populations. Lectin fluorescence w a s primarily localized over the zymogen granule region. Double labeling with ECA and UEA preliminarily indicated that nearly all ceils which bound UEA also bound ECA; numerous ECA positive cells were, however, UEA negative; indicating subsets of cells within a particular group of lecfin binding cells. Conclusion: These studies represent the first isolation of unique subpopulations of pancreatic acinar cells; further functional characterization and analysis of cell specific m-RNA is in progress.