Experience in the resection of the uncinate process of the pancreas: Indications and results. Literature review.

INTRODUCTION: The aim of our study is to assess the accumulated experience in the use of uncinatectomy (UC) as a parenchymal-sparing pancreatectomy technique. METHOD: We have carried out a observational and descriptive study including restrospectively all the patients undergoing UC at Hospital Universitary de Bellvitge (HUB) and an exhaustive review of the cases described in the english literature. RESULTS: From 2003 to 2019, seven patients have been operated by UC in the HUB with a diagnostic orientation of pancreatic lesion considered premalignant. All patients have presented morbidity, mainly in the form of postoperative pancreatic fistula, and none of them have presented endocrine or exocrine pancreatic insufficiency. Currently, all patients are alive and without recurrence of neoplastic disease. Another 29 cases have been described in the literature. Of all the cases (36 patients), the approach was minimally invasive (laparoscopic or robotic) in 6 patients (16.7%), leading to a shorter hospital stay. The global incidence of pancreatic fistula is 50%, with a re-admission rate of less than 10%, but without requiring re-intervention. CONCLUSIONS: UC is an infrequent and poorly standardized technique for the resection of benign lesions or those with low potential for malignancy located in the uncinate process of the pancreas. Although it is associated with equal or greater morbidity than standardized resection techniques, it offers excellent preservation of endocrine and exocrine pancreatic function, with the consequent long-term benefit in the patients life quality.

The Global End-Diastolic Volume (GEDV) Could Be More Appropiate to Fluid Management Than Central Venous Pressure (CVP) During Closed Hyperthermic Intrabdominal Chemotherapy with CO2 Circulation.

BACKGROUND: Closed hyperthermic intraperitoneal chemotherapy (HIPEC) may increase abdominal pressure and effects of hemodynamic changes due to maintenance hyperthermia. Our aim was to analyze the safety and effectiveness of our closed technique with CO2 circulation in management fluid status and hemodynamic parameters by means of cardiac preload control measured by Global End Diastolic Values (GEDV) and a gas exchanger. MATERIAL AND METHODS: A Pilot Clinical Study that included 18 advanced ovarian cancer patients undergoing citoreductive surgery and HIPEC. We used a closed-perfusion system (PRS Combat®) that includes CO2 circulation and a gas exchanger. Transpulmonary thermodilutions and hemodynamic measurements (PiCCO2®) were performed after citoreductive surgery (Pre-HIPEC); At half time of the HIPEC (Intra-HIPEC); After HIPEC (Post-HIPEC). RESULTS: No significant hemodynamic measurements changes in the three thermodilutions values of Cardiac Index (CI) (p = 0.227), Global End Diastolic Values (GEVD) (p = 0.966), Stroke Volume Variation (SVV) (p = 0,884) and Systemic Vascular Resistance Index (SVRI) (p = 0.082). No correlation between central venous pressure (CVP) and GEDV (Pre-HIPEC: r = 0.164, p = 0.211; Intra-HIPEC: r = 0.015, p = 0.900; Post-HIPEC: r = 0.018, p = 0.890). There was better correlation between GEDV and CI (Pre-HIPEC: r = 0.432, p = 0.071; Intra-HIPEC: r = 0.418, p = 0.074; Post-HIPEC: r = 0.411, p = 0.080). CONCLUSIONS: Closed intrabdominal chemotherapy with CO2 circulation model may be a safe model for HIPEC by means of a gas exchanger. GEDV and its changes significantly correlated to CI, and not observed for CVP. GEDV values may be more appropriate for monitoring cardiac preload, blood loss limitation and to predict changes in intravascular volume status during intraperitoneal chemotherapy.

Intra-abdominal pressure as a prognostic factor for tolerance of enteral nutrition in critical patients.

BACKGROUND: The purpose of this study is to establish a relationship between tolerance of enteral nutrition (EN) and intra-abdominal pressure (IAP) in critical patients, establish an objective measure for monitoring tolerance, and determine a threshold value for IAP. MATERIALS AND METHODS: Prospective and observational study at the critical care unit. Seventy-two patients were recruited with an expected stay of more than 72 hours and scheduled to receive EN. We recorded IAP and clinical and laboratory variables to describe predictive ones for tolerance of EN at the start of nutrition. RESULTS: The largest group was polytrauma patients (41.7%). Of the patients, 40.3% had undergone surgery prior to inclusion in the study. Most patients (87.5%) were fed via nasogastric tube. Physiological POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) on admission was 26.4 ± 7.6, and surgical POSSUM was 22.4 ± 8.0. The mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 13.6 ± 6.0. Mortality was 31.9%. In all, 70.8% tolerated EN. The univariate analysis revealed a statistically significant relation between tolerance of EN and surgical POSSUM, APACHE II, and baseline IAP. The multivariate analysis showed a relationship between APACHE II score, baseline IAP, and the tolerance of EN. So, on the basis of these 2 variables, logistic regression analysis can predict whether a patient will tolerate the diet with an overall precision of 80.3%. CONCLUSIONS: In critically ill patients, there is a relation between IAP values and the tolerance of EN. The baseline IAP with the APACHE II score can predict the tolerance of EN.

Cutaneous metastasis from hepatocellular carcinoma as the first clinical sign.

Hepatocellular carcinoma (HCC) is a tumor whose incidence has been increasing in recent years. The occurrence of cutaneous metastases from HCC, as the first sign of onset, is very unusual. We report a case of cutaneous metastasis from HCC appearing as a shoulder abscess and being the first clinical sign of the disease. We also examined the few published cases, and the diagnosis, treatment, and survival rate for this disease. Metastases of HCC should be included in the differential diagnosis of growing lesions in unusual localizations. Biopsies are required to confirm the diagnosis. The diagnosis of HCC from a cutaneous lesion is very uncommon and is associated with a poor prognosis.