Pancreas transplantation: review.

Pancreas transplant (PTx) is the only treatment that establishes normal glucose levels for patients diagnosed with diabetes types 1 and 2. The paper aims to review and analyze graft survival, patient survival, and the impact on diabetic complications. We describe that the graft survival was 82-98% at 1 year, 90% at 5 years, and 75-54% at 10 years for simultaneous pancreas-kidney recipient; 71% pancreas after kidney (PAK), and 62% PTx alone at 1 year. Patient survival: At 1 year for recipients was 96.9% simultaneous pancreas-kidney transplantation (SPK); for PAK transplantation recipients, 96.3%; and for PTx alone recipients, 98.3%. In general, the pancreas transplantation improves and reverses diabetic complications. Finally, the pancreatic transplant is a morbid procedure and emerges as a significant alternative in diabetes management, directly competing with conventional insulin therapies. Results so far suggest that the most effective transplant model is the SPK. While more patients could benefit from this procedure, surgical complications and the need for immunosuppression pose significant challenges.

El trasplante de páncreas es el único tratamiento que estabiliza los niveles normales de glucosa en los pacientes diagnosticados con diabetes tipo 1 o tipo 2. En esta revisión se analizan la supervivencia del injerto, la supervivencia del paciente y el impacto en las complicaciones diabéticas. Se describe la supervivencia del injerto: 82-98% al año para los receptores de trasplante simultáneo de páncreas y riñón, 71% para trasplante páncreas después de riñón y 62% para trasplante de páncreas solitario al año. Supervivencia de los pacientes a 1 año: 96.9% para los receptores de trasplante simultáneo de páncreas y riñón, 96.3% para los receptores de trasplante de páncreas después de riñón y 98.3% para los receptores de páncreas solitario. En general, el trasplante de páncreas mejora y revierte las complicaciones diabéticas. Finalmente, el trasplante de páncreas, un procedimiento mórbido, surge como una alternativa significativa en el manejo de la diabetes, compitiendo directamente con las terapias convencionales de insulina. Hasta ahora, los resultados indican que el modelo de trasplante más efectivo es el simultáneo de páncreas y riñón. Aunque más pacientes podrían beneficiarse de este procedimiento, las complicaciones quirúrgicas y la necesidad de inmunosupresión plantean desafíos significativos.

Current status of pancreatic cancer with oligometastasis.

BACKGROUND: Pancreatic cancer is the seventh leading cause of death worldwide, with ductal adenocarcinoma as the most frequent neoplasm. Half of the patients who are diagnosed have metastases at the time of diagnosis. OBJECTIVE: A review of the treatment of resectable pancreatic adenocarcinoma with oligometastatic disease was carried out in order to present an overview of the existing evidence. METHOD: A bibliographic search was carried in PubMed/Medline, Clinical Key and Index Medicus vhith MESH terms, from the year 1993 to 2022. RESULTS: Patients with liver or lung metastases due to pancreatic ductal adenocarcinoma who undergo surgery and chemotherapy have a longer survival in carefully selected patients. CONCLUSIONS: The evidence regarding surgery in patients with pancreatic ductal adenocarcinoma and oligometastasis is limited and further randomized controlled trials are needed for both scenarios. As well as established criteria that help the selection of patients who can receive this type of treatment.

ANTECEDENTES: El cáncer pancreático es la séptima causa de muerte en el mundo, siendo el adenocarcinoma ductal del páncreas la neoplasia más frecuente. La mitad de los pacientes que son diagnosticados presentan metástasis al momento del diagnóstico. OBJETIVO: Se realizó una revisión sobre el tratamiento del adenocarcinoma pancreático resecable con enfermedad oligometastásica con el fin de presentar un panorama sobre la evidencia existente. MÉTODO: Se realizó una búsqueda bibliográfica en PubMed/Medline, Clinical Key e Index Medicus con términos MESH desde 1993 hasta 2022. RESULTADOS: Los pacientes con metástasis hepáticas o pulmonares por adenocarcinoma ductal de páncreas que son sometidos a cirugía y quimioterapia tienen una mayor sobrevida en casos cuidadosamente seleccionados. CONCLUSIONES: La evidencia respecto a la cirugía en pacientes con adenocarcinoma ductal de páncreas y oligometástasis es limitada y se necesitan ensayos controlados aleatorizados adicionales para ambos escenarios, así como criterios bien establecidos que ayuden a la selección de los pacientes que pueden recibir este tipo de tratamiento.

The Age-AST-D Dimer (AAD) Regression Model Predicts Severe COVID-19 Disease.

AIM: Coronavirus disease (COVID-19) ranges from mild clinical phenotypes to life-threatening conditions like severe acute respiratory syndrome (SARS). It has been suggested that early liver injury in these patients could be a risk factor for poor outcome. We aimed to identify early biochemical predictive factors related to severe disease development with intensive care requirements in patients with COVID-19. METHODS: Data from COVID-19 patients were collected at admission time to our hospital. Differential biochemical factors were identified between seriously ill patients requiring intensive care unit (ICU) admission (ICU patients) versus stable patients without the need for ICU admission (non-ICU patients). Multiple linear regression was applied, then a predictive model of severity called Age-AST-D dimer (AAD) was constructed (n = 166) and validated (n = 170). RESULTS: Derivation cohort: from 166 patients included, there were 27 (16.3%) ICU patients that showed higher levels of liver injury markers (P < 0.01) compared with non-ICU patients: alanine aminotrasnferase (ALT) 225.4 ± 341.2 vs. 41.3 ± 41.1, aspartate aminotransferase (AST) 325.3 ± 382.4 vs. 52.8 ± 47.1, lactic dehydrogenase (LDH) 764.6 ± 401.9 vs. 461.0 ± 185.6, D-dimer (DD) 7765 ± 9109 vs. 1871 ± 4146, and age 58.6 ± 12.7 vs. 49.1 ± 12.8. With these finding, a model called Age-AST-DD (AAD), with a cut-point of <2.75 (sensitivity = 0.797 and specificity = 0.391, c - statistic = 0.74; 95%IC: 0.62-0.86, P < 0.001), to predict the risk of need admission to ICU (OR = 5.8; 95% CI: 2.2-15.4, P = 0.001), was constructed. Validation cohort: in 170 different patients, the AAD model < 2.75 (c - statistic = 0.80 (95% CI: 0.70-0.91, P < 0.001) adequately predicted the risk (OR = 8.8, 95% CI: 3.4-22.6, P < 0.001) to be admitted in the ICU (27 patients, 15.95%). CONCLUSIONS: The elevation of AST (a possible marker of early liver injury) along with DD and age efficiently predict early (at admission time) probability of ICU admission during the clinical course of COVID-19. The AAD model can improve the comprehensive management of COVID-19 patients, and it could be useful as a triage tool to early classify patients with a high risk of developing a severe clinical course of the disease.

Impact of liver enzymes on SARS-CoV-2 infection and the severity of clinical course of COVID-19.

BACKGROUND AND AIM: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the current pandemic, can have multi-organ impact. Recent studies show that liver injury could be a manifestation of the disease, and that liver disease could also be related to a worse prognosis. Our aim was to compare the characteristics of patients with severe coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 who required intubation versus stable hospitalized patients to identify the early biochemical predictive factors of a severe course of COVID-19 and subsequent requirement for intubation, specifically in Mexican. METHODS: This was an observational case-control study nested in a cohort study. Complete medical records of patients admitted for confirmed COVID-19 at a tertiary level center in Mexico City were reviewed. Clinical and biochemical data were collected, and the characteristics of patients who required invasive mechanical ventilation (IMV) (cases) were compared with stable hospitalized patients without ventilation (controls). RESULTS: We evaluated 166 patients with COVID-19 due to SARS-CoV-2 infection; 114 (68.7%) were men, the mean age was 50.6 ± 13.3 years, and 27 (16.3%) required IMV. The comparative analysis between cases and controls showed (respectively) significantly lower blood oxygen saturation (SpO2) (73.5 ± 12.0% vs. 83.0 ± 6.8%, P < 0.0001) and elevated alanine aminotransferase (ALT) (128 (14-1123) IU/L vs. 33 (8-453) IU/L, P = 0.003), aspartate aminotransferase (AST) (214 (17-1247) vs. 44 (12-498) IU/L, P = 0.001), lactic dehydrogenase (LDH) (764.6 ± 401.9 IU/L vs. 461.0 ± 185.6 IU/L, P = 0.001), and D-dimer (3463 (524-34,227) ng/mL vs. 829 (152-41,923) ng/mL, P = 0.003) concentrations. Patients in the cases group were older (58.6 ± 12.7 years vs. 49.1 ± 12.8 years, P=0.001). Multivariate analysis showed that important factors at admission predicting the requirement for IMV during hospitalization for COVID-19 were AST ≥250 IU/L (odds ratio (OR) = 64.8, 95% confidence interval (CI) 7.5-560.3, P < 0.0001) and D-dimer ≥ 3500 ng/mL (OR = 4.1, 95% CI 1.2-13.7, P=0.02). CONCLUSIONS: Our study confirms the importance of monitoring liver enzymes in hospitalized patients with COVID-19; seriously ill patients have significantly elevated AST and D-dimer concentrations, which have prognostic implications in the SARS-CoV-2 disease course.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Bile duct injuries after cholecystectomy, analysis of constant risk.

BACKGROUNDS/AIMS: The bile duct injuries are the most severe complications that occur after the surgical manipulation of the bile duct. The hepaticojejunostomy remained as the best treatment. Several factors identified that affect the result. This study aimed to analyze and identify risk factors that affected the evolution of these patients. METHODS: A retrospective, observational study was conducted from February 1998 to June 2017. We included all patients with bile duct injuries who required surgical treatment. RESULTS: We found 79 patients. The majority had a Bismuth type III in 35.4% (n=28). The morbidity of the Hepaticojejunostomy was 19% (n=15). In short-term follow-up, the main complications were cholangitis 11.4% (n=9) and bile leak 10% (n=8). In the long-term follow-up, in 2.5% (n=2) stricture was presented. On the comparison between postoperative and preoperative parameters, biliary peritonitis after a cholecystectomy (p=0.02) was an independent predictor of postoperative morbidity (p<0.05). CONCLUSIONS: In the treatment of bile duct injuries, different factors affect their outcomes. Our results show that infectious complications continue to affect the results of the treatment of bile duct lesions.

Retroperitoneal fibrosis associated with immunoglobulin IgG4-related disease in the differential diagnosis in retroperitoneal tumors. Case report. / Fibrosis retroperitoneal nodular asociada a IgG4 como diagnóstico diferencial en tumores retroperitoneales. Reporte de un caso.

The patient was a 55-year-old woman with a 4-month history of pain in left flank that irradiated to the lumbar region. Computed tomography revealed a cystic tumor in the retroperitoneal region that compresses the ureter and left renal pelvis in contact with pancreatic body and tail. Surgery was performed and the definitive pathological report diagnosed nodular retroperitoneal fibrosis associated with IgG4; Ki67-positive in germinal centers (5%) and IgG4-positive (40 plasma cells in 3 fields of 40x) by immunohistochemistry. Retroperitoneal fibrosis is a rare disease, that develops gradually and has an excellent response to steroid management. Surgical treatment is reserved for cases that compromise adjacent structures. Thus, identifying it when studying a retroperitoneal tumor leads to better prognosis and survival.

Quality of Life in Patients with Background of Iatrogenic Bile Duct Injury.

BACKGROUND: There are only a few reports regarding the quality of life of patients who underwent a complicated cholecystectomy with an iatrogenic bile duct injury (IBDI); the results have been heterogeneous and realized with unspecific measures. METHODS: The objective was to determine whether the quality of life of the subjects with a history of IBDI repaired with bilioenteric derivation is modified in the long term with respect to a control group, for which a group of patients with a history of IBDI (group A) was compared with a group of patients with a history of uncomplicated cholecystectomy (group B). Two different measures were used: on the one hand, the SF-12 questionnaire and on the other hand, a questionnaire was implemented where the patient could determine by himself which variables define his quality of life. RESULTS: A total of 46 patients were included in group A and 51 in group B. The analysis of the SF-12 questionnaire showed a statistical significant reduction in 4 of 8 of the evaluated parameters (general health, physical functioning, physical role and social functioning) in group A in comparison with group B. If a more specific questionnaire is used, the results are similar, with a statistically significant reduction in the quality of life within the group A (0.03). CONCLUSIONS: We conclude that the quality of life of patients with a history of bilioenteric derivation due to an IBDI decreases significantly compared to patients with uncomplicated cholecystectomy.

[Totally laparoscopic pancreaticoduodenectomy. First case reported in México]. / Pancreatoduodenectomía totalmente laparoscópica. Primer caso reportado en México.

BACKGROUND: Approximately 48,960 people in the USA will be diagnosed with pancreatic cancer in 2015 and 40,560 will die for this reason; in Mexico, the new cases of pancreatic cancer in 2012 were 4,274, with 4,133 deaths; survival rate at 5 years goes from 1% to15%. Less than 20% of cases were considered resectable at the time of diagnosis. The Whipple procedure is currently the only curative treatment option for periampullary cancers since the first communication by Whipple in 1935, and up until now is a common procedure in several reference centres around the world. In 1994, Gagner reported the first totally laparoscopic pancreaticoduodenectomy. Some groups have currently demonstrated the safety and efficacy of this technique. OBJECTIVE: To report our initial experience with totally laparoscopic pancreaticoduodenectomy in the Hospital General de México. CLINICAL CASE: The case concerns a 58 year-old women with jaundice and loss of weight of 3 months onset. Her biopsy reported adenocarcinoma of Váter's ampulla, and as it was considered resectable, she underwent a laparoscopic pancreaticoduodenectomy. CONCLUSIONS: This procedure must be performed in centres with experience in open pancreatic surgery and training in advanced laparoscopic surgery. The main advantages are lower blood loss and shorter hospital stay.

Sensibilidad y especificidad del CA 19-9 para el diagnóstico de neoplasias pancreatobiliares en pacientes con ictericia de origen obstructivo / Sensitivity and specificity of CA-19-9 for the diagnosis of pancreatobiliary neoplasms in patients with obstructive-origin jaundice

Objetivo: Describir el comportamiento biológico del CA 19-9 en colestasis para determinar su utilidad para el diagnóstico de cáncer pancreatobiliar en pacientes con ictericia de origen obstructivo. Sede: Hospital General de México, O.D. Diseño: Prospectivo, longitudinal y comparativo. Análisis estadístico: prueba t y Kolmogorov-Smirnov para muestras independientes; prueba de valor diagnóstico (sensibilidad, especificidad y valor global). Se realizó análisis con curvas ROC para identificar sensibilidad y especificidad con los diferentes puntos de corte. Pacientes y métodos: Se incluyeron 54 pacientes con diagnóstico de ictericia de origen obstructivo. Se dividieron en dos grupos de acuerdo al diagnóstico final, enfermedad maligna vs enfermedad benigna. Se realizó determinación sérica de CA 19-9 al ingreso y al resolver la colestasis y se correlacionaron los niveles con el diagnóstico final. Resultados: En pacientes ictéricos, con un punto de corte de 60 U/mL para distinguir entre enfermedad maligna y benigna, el CA 19-9 tiene una sensibilidad de 80% y una especificidad de 90%. Una vez resuelta la colestasis con punto de corte de 39 U/mL se obtiene una sensibilidad de 71% con una especificidad de 96%. La normalización del marcador después del drenaje biliar es altamente sugerente de patología benigna. La persistencia de niveles elevados (mayores de 60 U/mL) es altamente sugerente de malignidad con una sensibilidad de 58% y especificidad de 100%. Conclusiones: La colestasis sí modifica la sensibilidad y especificidad del CA 19-9 para el diagnóstico de neoplasias malignas pancreatobiliares, por lo que en presencia de ictericia de origen obstructivo el punto de corte de 60 U/mL ofrece una sensibilidad de 80% con una especificidad de 90% para distinguir entre enfermedad benigna y maligna. Una vez resuelta la colestasis, la persistencia de niveles elevados es altamente sugerente de malignidad.

Objective: To describe the biological behavior of the tumor marker CA 19-9 in cholestasis to determine its usefulness for the diagnosis of pancreatobiliary cancer in patients with obstructive-origin jaundice. Sede: General Hospital of Mexico, third level health care center. Mexico City. Design: Prospective, longitudinal, and comparative study. Statistical analysis: T and Kolmogorov Smirnov tests for independent samples; diagnostic value test (sensitivity, specificity, and global value). Analysis with ROC curves was performed to identify sensitivity and specificity at the different cutting points. Patients and methods: We included 54 patients with a diagnosis of obstructive-origin jaundice. They were divided in two groups according to the final diagnosis, malignant disease vs. benign disease. Serum CA 19-9 was determined at admittance and once cholestasis had been resolved, and the levels were correlated with the final diagnosis. Results: In jaundice patients, with a cut point of 60 U/mL to distinguish between malignant and benign disease, the CA 19-9 marker has a sensitivity of 80% and a specificity of 90%. Once cholestasis had been resolved with a cut point of 39 U/mL, sensitivity was of 71% with a 96% specificity. Normalization of the marker after bile drainage is highly suggestive of benign pathology. The persistence of high levels (higher than 60 U/mL) is highly suggestive of malignancy with a sensitivity of 58% and specificity of 100%. Conclusions: Cholestasis does modify the sensitivity and specificity of the CA 19-9 marker for the diagnosis of pancreatobiliary malignant neoplasms; therefore, in the presence of obstructive-origin jaundice, the 60 U/mL cut point offers a sensitivity of 80% with a specificity of 90% to be able to distinguish between malignant and benign disease. Once cholestasis has been resolved, persistence of high levels is highly suggestive of malignancy.

Gallstones play a significant role in Salmonella spp. gallbladder colonization and carriage.

Salmonella enterica serovar Typhi can colonize the gallbladder and persist in an asymptomatic carrier state that is frequently associated with the presence of gallstones. We have shown that salmonellae form bile-mediated biofilms on human gallstones and cholesterol-coated surfaces in vitro. Here, we test the hypothesis that biofilms on cholesterol gallbladder stones facilitate typhoid carriage in mice and men. Naturally resistant (Nramp1(+/+)) mice fed a lithogenic diet developed cholesterol gallstones that supported biofilm formation during persistent serovar Typhimurium infection and, as a result, demonstrated enhanced fecal shedding and enhanced colonization of gallbladder tissue and bile. In typhoid endemic Mexico City, 5% of enrolled cholelithiasis patients carried serovar Typhi, and bacterial biofilms could be visualized on gallstones from these carriers whereas significant biofilms were not detected on gallstones from Escherichia coli infected gallbladders. These findings offer direct evidence that gallstone biofilms occur in humans and mice, which facilitate gallbladder colonization and shedding.

[Frequency of organic failure in acute necrotic pancreatitis]. / Frecuencia de falla orgánica en la pancreatitis aguda necrótica.

INTRODUCTION: Theacute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. MATERIAL AND METHODS: A study retrospective, traverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. RESULTS: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory, and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn't present it. The SIRPA and irreversible shock were the causes of death. DISCUSSION: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

Frecuencia de falla orgánica en la pancreatitis aguda necrótica / Frecuency of organic failure in acute necrosis pancreatitis

Introducción: La pancreatitis aguda se clasifica como severa por la presencia de necrosis glandular o falla orgánica. Sin embargo, ambas condiciones no son simultáneas. En este estudio determinamos la frecuencia de falla orgánica en pacientes con necrosis pancreática por pancreatitis aguda. Material y Métodos: Se realizó un estudio retrospectivo, transversal, descriptivo y observacional. Se incluyeron los casos de necrosis pancreática por pancreatitis aguda presentados del 1 de enero de 1996 al 31 de diciembre de 2000. Se determinó la presencia de falla orgánica, así como edades, sexo, etiología, estado nutricional, criterios de Ranson, cirugías realizadas y mortalidad. Resultados: De los pacientes con necrosis pancreática, 45% desarrolló falla orgánica. En ellos predominó el sexo masculino y la realización de alguna cirugía. De los pacientes con falla orgánica, 92% la presentó al ingreso; el sistema afectado más frecuente fue el circulatorio, seguido por el pulmonar y el renal. Los pacientes con falla orgánica tuvieron mortalidad de 88%. Las causas de muerte fueron SIRPA y choque irreversible. Discusión: La relación entre necrosis y falla orgánica no es clara. Existen factores a considerar tales como la muerte de tejido pancreático por apoptosis, que limita el daño y la necrosis que lo favorece. La hipoperfusión tisular puede ser determinante entre estas dos formas de lesión.

Introduction: The acute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. Material and Methods: A study retrospective, transverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. Results: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn 't present it. The SIRPA and irreversible shock were the causes of death. Discussion: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

[Use of base deficit as a prognosis factor for acute pancreatitis]. / Utilidad del déficit de base como factor pronóstico en la pancreatitis aguda.

INTRODUCTION: Acute pancreatitis (AP) severe is accompanied by important morbidity and mortality. Tissular hypoperfusion has been suggested as a severity determinant. Base deficit (BD) demonstrated to be a good indicator of hypo-perfusion. We established predictive value in AP. MATERIAL AND METHODS: A retrospective, longitudinal, descriptive, and observational study was carried out. We included hospitalized patients from January 1996 to December 2000 with confirmed diagnosis of AP for laboratory, tomography and/or surgery; and with determination of BD on admission. Patients were divided into groups with or without BD and were compared with certain severity and mortality. RESULTS: We study 104 patients, 40(38%) without BD and 64 (62%) with BD. The mortality belonged to 22 patients (21.2%), all of the group with BD. The BD had a sensibility of 71.4% to predict severity and of 100% for the motility DISCUSSION: BD allows predicting severity and mortality in AP. These points out the role that carried out tissular hip perfusion; in addition, it can serve as guide for appropriate treatment.

[Etiology on determining the severity of acute pancreatitis]. / Etiología como determinante de severidad en la pancreatitis aguda.

INTRODUCTION: There exist contradictory results regarding the role of etiology in severity and mortality of acute pancreatitis. In the population of "Hospital General de México" we stablished their importance. MATERIAL AND METHODS: We carried out a retrospective, comparative, longitudinal, and observational study. We determined sex, age, time of evolution, and subjective nutritional state of patients with diagnosis of acute pancreatitis from January 1, of 1996 to December 31, 2000. We compared days of hospitalization, severity, and mortality according to etiology. RESULTS: Ninety five patients were studied, 54% with biliarY and 41% with alcoholic etiology. Differences did not exist in ages and times of symptom evolution, but did in distribution by sex and nutritional state. There were no differences in days of hospitalization but there were differences in severity and mortality when comparing groups of different etiologies. DISCUSSION: In acute pancreatitis, etiology is the decisive factor of severity and mortality, although this can be conditioned by sex of patient and nutritional state.

[Superior mesenteric artery syndrome as a cause of chronic partial intolerance to oral feeding. Report of a case and review of the subject]. / Síndrome de la arteria mesentérica superior como causa de intolerancia parcial crónica a la alimentación oral. Reporte de un caso y revisión del tema.

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is the obstruction of the duodenum in the third portion due to this artery. We present a case of chronic oral feeding intolerance due to this problem. CLINICAL CASE: A 24 year-old woman, with a time of evolution of 1 year and a half of postprandial epigastric pain with nausea, vomiting, and loss of 30 kg managed as acid-peptic disease. The patient was studied with gastrointestinal contrast study and endoscopy without conclusive results. The patient was admitted for unstoppable vomiting, malnutrition, and severe dehydration. A laparotomy was performed and SMAS was identified. We performed Treitz's ligament section and gastrojejunoanastomosis. Her clinical outcome was satisfactory and the patient was discharged without complications. DISCUSSION: SMAS is also called Wilkie's syndrome. SMAS is more frequent in women between the 10 and 39 years. The disease due to the decrease of the angle between the superior mesenteric artery and the aorta, to the anomalous origin of this artery, or to the shortening of Treitz's ligament. SMAS may appear as a sudden weight loss. Food intolerance is a predominant symptom. Diagnosis can be made with x-ray studies. Treatment is medical or surgical, with Treitz's ligament section, duodenojejunoanastomosis, and in some cases gastrojejunoanastomosis. CONCLUSIONS: SMAS should be considered as no the differential diagnosis of chronic oral feeding intolerance.