RESUMEN
We present the case of a 76-year-old male with a history of acute cholecystitis who underwent a scheduled laparoscopic cholecystectomy. Chronic cholecystitis with a thickened cystic duct was observed intraoperatively. The anatomic pathology report found high-grade dysplasia that affected the distal edge of the cystic duct. In view of these findings, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with SpyGlass® and an excrescent lesion suggestive of malignancy adjacent to the cystic-common bile duct junction was observed. A resection of the extrahepatic bile duct was performed with lymphadenectomy of the hepatic hilum and hepaticojejunostomy in a subsequent procedure. The definitive pathology report confirmed pancreaticobiliary intraductal papillary mucinous neoplasia with high-grade dysplasia and free margins.
Asunto(s)
Neoplasias de los Conductos Biliares , Conductos Biliares Extrahepáticos , Neoplasias Pancreáticas , Anciano , Neoplasias de los Conductos Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Hepatectomía , Humanos , Masculino , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/cirugíaRESUMEN
BACKGROUND: Parastomal evisceration is a very uncommon complication of stomas with only few cases reported in the literature. This complication can be developed in the early postoperative period due to technical aspects of stoma creation, but late parastomal evisceration appearing after 6 months from surgery is an exceptional condition. Herein, we present a rare case of a patient with late parastomal evisceration. CASE PRESENTATION: A 44-year-old man with sigmoid volvulus underwent a temporary end-terminal colostomy. The ostomy was complicated by a parastomal hernia and stoma prolapse 5 months postoperatively. He was brought into our emergency department having been found collapsed in the street. On physical examination, the patient presented signs of shock and evisceration of small bowel through the colostomy. Intraoperatively, a perforation of prolapsed colon was assessed as the point for intestinal evisceration. We discuss this case and all similar cases reported in the literature. CONCLUSION: Parastomal evisceration is a potentially life-threatening complication. Patients with parastomal hernia and stoma prolapse must be considered for surgical treatment to avoid this complication.
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Hernia Incisional , Enfermedades Intestinales , Vólvulo Intestinal , Estomas Quirúrgicos , Adulto , Colostomía/efectos adversos , Humanos , Masculino , Mallas Quirúrgicas , Estomas Quirúrgicos/efectos adversosRESUMEN
OBJECTIVE: To compare the rates of R0 resection in pancreatoduodenectomy (PD) for pancreatic and periampullary malignant tumors by means of standard (ST-PD) versus artery-first approach (AFA-PD). BACKGROUND: Standardized histological examination of PD specimens has shown that most pancreatic resections thought to be R0 resections are R1. "Artery-first approach" is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. To date, studies comparing AFA-PD versus ST-PD are retrospective cohort or case-control studies. METHODS: A multicenter, randomized, controlled trial was conducted in 10 University Hospitals (NCT02803814, ClinicalTrials.gov). Eligible patients were those who presented with pancreatic head adenocarcinoma and periampullary tumors (ampulloma, distal cholangiocarcinoma, duodenal adenocarcinoma). Assignment to each group (ST-PD or AFA-PD) was randomized by blocks and stratified by centers. The primary end-point was the rate of tumor-free resection margins (R0); secondary end-points were postoperative complications and mortality. RESULTS: One hundred seventy-nine patients were assessed for eligibility and 176 randomized. After exclusions, the final analysis included 75 ST-PD and 78 AFA-PD. R0 resection rates were 77.3% (95% CI: 68.4-87.4) with ST-PD and 67.9% (95% CI: 58.3-79.1) with AFA-PD, P=0.194. There were no significant differences in postoperative complication rates, overall 73.3% versus 67.9%, and perioperative mortality 4% versus 6.4%. CONCLUSIONS: Despite theoretical oncological advantages associated with AFA-PD and evidence coming from low-level studies, this multicenter, randomized, controlled trial has found no difference neither in R0 resection rates nor in postoperative complications in patients undergoing ST-PD versus AFA-PD for pancreatic head adenocarcinoma and other periampullary tumors.
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Adenocarcinoma/patología , Adenocarcinoma/cirugía , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Adenocarcinoma/mortalidad , Adulto , Anciano , Arterias/cirugía , Supervivencia sin Enfermedad , Femenino , Hospitales Universitarios , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/efectos adversos , Pronóstico , Medición de Riesgo , Estadísticas no Paramétricas , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Pancreatic neuroendocrine tumors represent less than 5% of all pancreatic tumors. They are a heterogeneous group of neoplasms with a diverse behavior and prognosis. Pancreatic vasoactive intestinal polypeptide tumor (VIPoma) is an exceptional tumor within this group due to its low incidence. The presence of pancreatic VIPoma should be clinically suspected in all patients with watery diarrhea, particularly when accompanied by a loss of potassium and bicarbonate and a pancreatic mass on imaging. There are other pathologies with similar symptoms; therefore, a correct differential diagnosis with an adequate treatment is essential for its management. We present the case of a 46-year-old patient who developed a prerenal kidney failure secondary to severe watery diarrhea after a diagnosis of pancreatic VIPoma. Thus, a resection was performed as the patient was rapidly deteriorating and required an intervention.
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Lesión Renal Aguda/etiología , Diarrea/etiología , Neoplasias Pancreáticas/complicaciones , Vipoma/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Tomografía Computarizada por Rayos X , Vipoma/diagnóstico por imagen , Vipoma/patología , Vipoma/cirugíaRESUMEN
INTRODUCTION: iatrogenic bile duct injury (IBDI) is a complication with a high morbidity after cholecystectomy. In recent years, endoscopy has acquired a fundamental role in the management of this pathology. METHODS: a retrospective study of IBDI after open cholecystectomy (OC) or laparoscopic cholecystectomy (LC) of patients treated in our center between 1993 and 2017 was performed. Clinical characteristics, type of injury according to the Strasberg-Bismuth classification, diagnosis, repair techniques and follow-up were analyzed. RESULTS: 46 patients were studied and IBDI incidence was 0.48%, 0.61% for LC and 0.24% for OC. A diagnosis was made intraoperatively in 12 cases (26%) and by endoscopic retrograde cholangiopancreatography (ERCP) in 10 (21.7%) cases. The most common IBDI patient characteristics were acute cholecystitis (20/46, 43.5%), previous admission due to biliary pathology (16/46, 43.2%) and ERCP prior to cholecystectomy (7/46, 18.9%). The most frequent types of IBDI were D (17/46, 36.9%) and A (15/46, 32.6%). The most commonly used treatment was primary suture (13/46, 28.3%) followed by ERCP (11/46, 23.9%) with sphincterotomy and/or stents. In addition, ERCP was performed during the immediate postoperative period in 6 (13%) patients with a surgical IBDI repair in order to resolve immediate complications. CONCLUSION: ERCP is useful in the management of IBDI that is not diagnosed intraoperatively. This procedure facilitates the localization of the injured area of the bile duct, therapeutic maneuvers and successful outcomes in postoperative complications.
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Conductos Biliares/lesiones , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía/efectos adversos , Complicaciones Posoperatorias/terapia , Adulto , Anciano , Anciano de 80 o más Años , Conductos Biliares/diagnóstico por imagen , Colecistectomía Laparoscópica/efectos adversos , Femenino , Humanos , Enfermedad Iatrogénica/epidemiología , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Estudios Retrospectivos , Esfinterotomía Endoscópica , Stents , Técnicas de Sutura , Adulto JovenAsunto(s)
Neoplasias Duodenales , Duodeno , Tomografía Computarizada por Rayos X , Anciano , Neoplasias Duodenales/diagnóstico por imagen , Neoplasias Duodenales/patología , Neoplasias Duodenales/cirugía , Duodeno/diagnóstico por imagen , Duodeno/patología , Duodeno/cirugía , Resultado Fatal , Femenino , Humanos , Neoplasias Intestinales/diagnóstico por imagen , Neoplasias Intestinales/patología , Neoplasias Intestinales/cirugía , Perforación Intestinal/diagnóstico por imagen , Perforación Intestinal/patología , Perforación Intestinal/cirugía , Linfoma Extranodal de Células NK-T/diagnóstico , Linfoma Extranodal de Células NK-T/patología , Linfoma Extranodal de Células NK-T/cirugíaRESUMEN
INTRODUCTION: Involvement of surgical resection margins is a fundamental prognostic factor in pancreatic oncological surgery. However, there is a lack of standardized histopathology definition. The aims of this study are to investigate the real rate of R1 resections when surgical specimens are evaluated according to a standardized protocol and to study its survival implications. PATIENTS Y METHODS: One hundred consecutive surgically resected patients with pancreatic ductal adenocarcinoma were included in the study. They were further divided in 2 groups: pre-protocol, evaluated before the introduction of the standardized protocol and post-protocol, analyzed with the standardized protocol. RESULTS: R0 resection rate in the pre-protocol group was 78%, falling to 47% after the introduction of the standardized protocol (p=0,003). The posterior retroperitoneal margin was the most frequently involved margin. In cases with tumors located at the pancreatic head and analyzed according to the standardized protocol R1 involvement negatively affected survival. Median survival in the R0 group was 22 months versus 16 in those with the margin involved (HR: 2.044; IC 95% 1,00-4,16; P=.043). CONCLUSIONS: Standardized evaluation of the retroperitoneal margins in pancreatic cancer increases the rate of R1 patients. In cases with pancreatic cancer located at the pancreatic head involvement of posterior retroperitoneal margin significantly decreases survival.
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Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosRESUMEN
Activated hepatic stellate cells (aHSCs), the main perpetrators of liver fibrosis, are a promising therapeutic target in the treatment of chronic liver disease. During liver injury, HSCs transcend from a quiescent to a fibrotic phenotype, a process which involves major metabolic reprogramming with altered mitochondrial function. The antiretroviral drug Rilpivirine (RPV) has demonstrated a hepatoprotective and specifically antifibrotic effect in several animal models of chronic liver injury, as well as in vitro. Herein, we use HSCs activated with the profibrogenic cytokine TGF-ß to explore whether mitochondrial function is implicated in this effect. The mitochondrial bioenergetic profile, morphology and dynamics of TGF-ß-treated cells (48â¯h) were altered and these effects were prevented by co-treatment with clinically relevant concentrations of RPV. A MitoStress Test (Seahorse Analyzer) revealed that TGF-ß increased both oxygen consumption rate (basal respiration, maximal respiration and spare respiratory capacity) and extracellular acidification rate (indicative of increased glycolysis). Cells exposed to TGF-ß also displayed diminished mitochondrial membrane potential and enhanced mitochondrial fission. All of these effects were rescued with RPV. RNA sequencing analysis of cells exposed to TGF-ß revealed the presence of 338 differentially expressed genes that encode mitochondrial proteins (mito-DEGs), of which 139 and 199 were significantly up- and down-regulated (adjusted p<0.05). This alteration in 15 (10.79â¯%) and 31 (22.03â¯%) of the up-regulated and 16 (8.04â¯%) and 49 (24.62â¯%) of the down-regulated mitoDEGs was prevented with co-exposure to RPV 4µM or 8µM, respectively. In conclusion, alterations in mitochondrial function are implicated in the antifibrogenic action of RPV, pointing to potential novel antifibrotic targets.
Asunto(s)
Células Estrelladas Hepáticas , Mitocondrias , Rilpivirina , Factor de Crecimiento Transformador beta , Células Estrelladas Hepáticas/efectos de los fármacos , Células Estrelladas Hepáticas/metabolismo , Rilpivirina/farmacología , Factor de Crecimiento Transformador beta/metabolismo , Mitocondrias/efectos de los fármacos , Mitocondrias/metabolismo , Cirrosis Hepática/tratamiento farmacológico , Cirrosis Hepática/patología , Cirrosis Hepática/metabolismo , Potencial de la Membrana Mitocondrial/efectos de los fármacos , Humanos , Animales , Consumo de Oxígeno/efectos de los fármacos , Dinámicas Mitocondriales/efectos de los fármacos , Antifibróticos/farmacologíaRESUMEN
BACKGROUND: Textbook outcome is an interesting quality metrics tool. Information on textbook outcomes in distal pancreatectomy is very scarce. In this study we determined textbook outcome in a distal pancreatectomy multicenter database and propose a specific definition of textbook outcome-distal pancreatectomy that includes pancreatic fistula. METHODS: Retrospective multicenter observational study of distal pancreatectomy performed at 8 hepatopancreatobiliary surgery units from January 1, 2008, to December 31, 2018. The inclusion criteria were any scheduled distal pancreatectomy performed for any diagnosis and age > 18 years. Specific textbook outcome-distal pancreatectomy was defined as hospital stay P < 75, no Clavien-Dindo complications (≥ III), no hospital mortality, and no readmission recorded at 90 days, and the absence of pancreatic fistula (B/C). RESULTS: Of the 450 patients included, 262 (58.2%) obtained textbook outcomes. Prolonged stay was the parameter most frequently associated with failure to achieve textbook outcomes. The textbook outcome group presented the following results. Preoperative: lower American Society of Anesthesiologists score < III, a lower percentage of smokers, and less frequent tumor invasion of neighboring organs or vascular invasion; operative: major laparoscopic approach, and less resection of neighboring organs and less operative transfusion; postoperative: lower percentage of delayed gastric emptying and pancreatic fistula B/C, and diagnosis other an adenocarcinoma. In the multivariate study, the American Society of Anesthesiologists score > II, resection of neighboring organs, B/C pancreatic fistula, and delayed gastric emptying were associated with failure to achieve textbook outcomes. CONCLUSION: The textbook outcome rate in our 450 pancreaticoduodenectomies was 58.2%. In the multivariate analysis, the causes of failure to achieve textbook outcomes were American Society of Anesthesiologists score > II, resection of neighboring organs, pancreatic fistula B/C, and delayed gastric emptying. We believe that pancreatic fistula should be added to the specific definition of textbook outcome-distal pancreatectomy because it is the most frequent complication of this procedure.
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Gastroparesia , Laparoscopía , Neoplasias Pancreáticas , Humanos , Adulto , Persona de Mediana Edad , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Fístula Pancreática/cirugía , Pancreatectomía/métodos , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico , Resultado del Tratamiento , Laparoscopía/efectos adversosRESUMEN
Understanding progression mechanisms and developing new targeted therapies is imperative in pancreatic ductal adenocarcinoma (PDAC). In this study, 80 metastatic PDAC patients were prospectively recruited and divided into discovery (n=37) and validation (n=43) cohorts. Tumor and plasma samples taken at diagnosis were pair analyzed using whole exome sequencing (WES) in patients belonging to the discovery cohort alone. The variant allele frequency (VAF) of KRAS mutations was measured by ddPCR in plasma at baseline and response assessment in all patients. Plasma WES identified at least one pathogenic variant across the cohort, uncovering oncogenic mechanisms, DNA repair, microsatellite instability, and alterations in the TGFb pathway. Interestingly, actionable mutations were mostly found in plasma rather than tissue. Patients with shorter survival showed enrichment in cellular organization regulatory pathways. Through WES we could identify a specific molecular profile of patients with liver metastasis, which exhibited exclusive mutations in genes related to the adaptive immune response pathway, highlighting the importance of the immune system in liver metastasis development. Moreover, KRAS mutations in plasma (both at diagnosis and persistent at follow-up) correlated with shorter progression free survival (PFS). Patients presenting a reduction of over 84.75 % in KRAS VAF at response assessment had similar PFS to KRAS-negative patients. Overall, plasma WES reveals molecular profiles indicative of rapid progression, potentially actionable targets, and associations between adaptive immune response pathway alterations and liver tropism.
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Carcinoma Ductal Pancreático , ADN Tumoral Circulante , Progresión de la Enfermedad , Secuenciación del Exoma , Neoplasias Pancreáticas , Humanos , Carcinoma Ductal Pancreático/genética , Carcinoma Ductal Pancreático/patología , Carcinoma Ductal Pancreático/secundario , Carcinoma Ductal Pancreático/mortalidad , Masculino , Femenino , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/patología , Persona de Mediana Edad , Anciano , ADN Tumoral Circulante/genética , ADN Tumoral Circulante/sangre , Mutación , Metástasis de la Neoplasia , Proteínas Proto-Oncogénicas p21(ras)/genética , AdultoRESUMEN
BACKGROUND: The effect of radiologic splenic vessels involvement (RSVI) on the survival of patients with pancreatic adenocarcinoma (PAC) located in the body and tail of the pancreas is controversial, and its influence on postoperative morbidity after distal pancreatectomy (DP) is unknown. This study aimed to determine the influence of RSVI on postoperative complications, overall survival (OS), and disease-free survival (DFS) in patients undergoing DP for PAC. METHODS: A multicenter retrospective study of DP was conducted at 7 hepatopancreatobiliary units between January 2008 and December 2018. Patients were classified according to the presence of RSVI. A Clavien-Dindo grade of >II was considered to represent a major complication. RESULTS: A total of 95 patients were included in the analysis. Moreover, 47 patients had vascular infiltration: 4 had arterial involvement, 10 had venous involvement, and 33 had both arterial and venous involvements. The rates of major complications were 20.8% in patients without RSVI, 40.0% in those with venous RSVI, 25.0% in those with arterial RSVI, and 30.3% in those with both arterial and venous RSVIs (P = .024). The DFS rates at 3 years were 56% in the group without RSVI, 50% in the group with arterial RSVI, and 16% in the group with both arterial and venous RSVIs (P = .003). The OS rates at 3 years were 66% in the group without RSVI, 50% in the group with arterial RSVI, and 29% in the group with both arterial and venous RSVIs (P < .0001). CONCLUSION: RSVI increased the major complication rates after DP and reduced the OS and DFS. Therefore, it may be a useful prognostic marker in patients with PAC scheduled to undergo DP and may help to select patients likely to benefit from neoadjuvant treatment.
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Adenocarcinoma , Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/cirugía , Pancreatectomía/efectos adversos , Estudios Retrospectivos , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/cirugía , Carcinoma Ductal Pancreático/diagnóstico por imagen , Carcinoma Ductal Pancreático/cirugía , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND AND OBJECTIVES: Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival. METHODS: Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected. RESULTS: The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895). CONCLUSION: Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.
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Carcinoma de Células Renales , Neoplasias Renales , Neoplasias Pancreáticas , Humanos , Carcinoma de Células Renales/cirugía , Carcinoma de Células Renales/patología , Estudios Retrospectivos , Pancreatectomía/métodos , Neoplasias Pancreáticas/patología , Neoplasias Renales/cirugía , Neoplasias Renales/patología , RecurrenciaRESUMEN
Background: Mucinous cysts of the pancreas (MCN) are infrequent, usually unilocular tumors which occur in postmenopausal women and are located in the pancreatic body/tail. The risk of malignancy is low. The objective is to define preoperative risk factors of malignancy in pancreatic MCN and to assess the feasibility of the laparoscopic approach. Methods: Retrospective multicenter observational study of prospectively recorded data regarding distal pancreatectomies was carried out at seven hepatopancreatobiliary (HPB) Units between 01/01/08 and 31/12/18 (the ERPANDIS Project). Results: Four hundred and forty-four distal pancreatectomies were recorded including 47 MCN (10.6%). Thirty-five were non-invasive tumors (74.5%). In all, 93% of patients were female, and 60% were ASA (American Society of Anaesthesiology) II. The mean preoperative size was 46 mm. Patients with invasive tumors were older (54 vs. 63 years). Invasive tumors were larger (6 vs. 4 cm), although the difference was not significant (P=0.287). Sixty percent was operated via laparoscopic approach, which was used in 74.6% of non-invasive tumors and in 16.7% of the invasive ones. The spleen was not preserved in 93.6% of the patients. R0 resection was obtained in all patients. Two patients with invasive tumors died. Conclusions: In our surgical series of MCN, patients with malignancy were older and presented larger tumors, although the difference was not statistically significant. Laparoscopy is a safe and feasible approach for MCN. Prospective studies are now needed to define risk factors that can guide the decision whether to administer conservative treatment or to operate.
RESUMEN
BACKGROUND: Renal Cell Carcinoma (RCC) occasionally spreads to the pancreas. The purpose of our study is to evaluate the short and long-term results of a multicenter series in order to determine the effect of surgical treatment on the prognosis of these patients. METHODS: Multicenter retrospective study of patients undergoing surgery for RCC pancreatic metastases, from January 2010 to May 2020. Variables related to the primary tumor, demographics, clinical characteristics of metastasis, location in the pancreas, type of pancreatic resection performed and data on short and long-term evolution after pancreatic resection were collected. RESULTS: The study included 116 patients. The mean time between nephrectomy and pancreatic metastases' resection was 87.35 months (ICR: 1.51-332.55). Distal pancreatectomy was the most performed technique employed (50 %). Postoperative morbidity was observed in 60.9 % of cases (Clavien-Dindo greater than IIIa in 14 %). The median follow-up time was 43 months (13-78). Overall survival (OS) rates at 1, 3, and 5 years were 96 %, 88 %, and 83 %, respectively. The disease-free survival (DFS) rate at 1, 3, and 5 years was 73 %, 49 %, and 35 %, respectively. Significant prognostic factors of relapse were a disease free interval of less than 10 years (2.05 [1.13-3.72], p 0.02) and a history of previous extrapancreatic metastasis (2.44 [1.22-4.86], p 0.01). CONCLUSIONS: Pancreatic resection if metastatic RCC is found in the pancreas is warranted to achieve higher overall survival and disease-free survival, even if extrapancreatic metastases were previously removed. The existence of intrapancreatic multifocal compromise does not always warrant the performance of a total pancreatectomy in order to improve survival.
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Carcinoma de Células Renales/cirugía , Neoplasias Renales/patología , Metastasectomía , Pancreatectomía , Neoplasias Pancreáticas/cirugía , Complicaciones Posoperatorias/epidemiología , Anciano , Carcinoma de Células Renales/secundario , Femenino , Humanos , Neoplasias Renales/cirugía , Masculino , Persona de Mediana Edad , Nefrectomía , Neoplasias Pancreáticas/secundario , España/epidemiología , Resultado del TratamientoRESUMEN
CONTEXT: Foregut cystic malformations are common lesions in the mediastinum but are rarely found in subdiaphragmatic locations. Only a few cases have been described within the pancreas where they can easily be misdiagnosed as cystic neoplasms. CASE REPORT: We herein present the case of a 37-year-old female with acute cholangitis in whom a diagnostic work-up revealed a 1 cm solid-cystic heterogeneous lesion located at the head of the pancreas. The patient underwent a pancreaticoduodenectomy. Pathological evaluation demonstrated a cystic cavity lined by pseudostratified tall columnar ciliated epithelium with goblet cells, but lacking cartilage or smooth muscle bundles. Thus, the final diagnosis of the lesion was a ciliated foregut cyst of the pancreas. CONCLUSIONS: A review of the cases published regarding these lesions shows great variability in the taxonomy and a lack of accuracy in the definitions of each different subtype. An easy to use algorithm for the diagnosis of foregut cystic malformations subtypes, based on epithelial lining and wall features, is presented.
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Páncreas/anomalías , Quiste Pancreático/diagnóstico , Adulto , Colangitis/diagnóstico , Colangitis/etiología , Colangitis/patología , Diagnóstico Diferencial , Femenino , Humanos , Páncreas/patología , Quiste Pancreático/complicaciones , Quiste Pancreático/patologíaRESUMEN
The possibility of modelling diagnostic images in three dimensions (3D) in pancreatic surgery is a novelty that provides us multiple advantages. A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases. We present the case study of a borderline pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery. The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection. The use of this tool could translate into: shorter operative time, fewer intraoperative complications or an increase in R0 resections. The usability of the program used in our case, agile and intuitive, was an added advantage.
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Adenocarcinoma , Procedimientos Quirúrgicos del Sistema Digestivo , Neoplasias Pancreáticas , Adenocarcinoma/diagnóstico por imagen , Humanos , Imagenología Tridimensional , Páncreas/diagnóstico por imagen , Neoplasias Pancreáticas/diagnóstico por imagenRESUMEN
The possibility of modelling diagnostic images in three dimensions (3D) in pancreatic surgery is a novelty that provides us multiple advantages. A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases. We present the case study of a borderline pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery. The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection. The use of this tool could translate into: shorter operative time, fewer intraoperative complications or an increase in R0 resections. The usability of the program used in our case, agile and intuitive, was an added advantage.
RESUMEN
OBJECTIVE: To investigate whether percutaneous cholecystostomy (PC) for the treatment of acute calculous cholecystitis (ACC) has better results than emergency cholecystectomy (EC) in elderly and high-risk surgical patients. METHODS: Patients ≥ 70 years and/or ≥ ASA-PS 3 with ACC treated with PC or EC between 2005 and 2016 were retrospectively reviewed. Both techniques were compared regarding morbi-mortality, hospital stay, complications and readmissions. A subgroup analysis in higher risk patients (≥ 70 years plus ≥ ASA-PS 3) was also performed. A binary logistic regression analysis for outcome variables to calculate the OR was carried out. RESULTS: A total of 461 patients were included in the study. The results of PC were worse compared to EC: 30-day mortality (8.6 vs. 1.7%, OR 18.4), 90-day mortality (10.4 vs. 2.1%, OR 10.3), length of stay (days) (13.21 ± 8.2 vs. 7.48 ± 7.67, OR 8.7) and readmission rate (35.1 vs. 12.6%, OR 4.7). Complications were lower for PC (14 vs. 22.6%, OR 0.41), but there were no significant differences in the number of severe complications (Clavien-Dindo ≥ III). Higher-risk subgroup analysis (n = 193; PC = 128, EC = 65) showed similar results to the whole series. Patients with ACC for more than 3 days had more risk of severe complications in both groups (OR 2.26; OR 2.76). CONCLUSION: PC was associated with an increased risk of mortality at 30 and 90 days, more readmissions and longer hospital stay. Although PC presents a lower risk of complications, the percentage of severe complications (Clavien-Dindo ≥ III) does not show significant differences.
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Colecistitis Aguda , Colecistostomía , Anciano , Colecistectomía , Colecistitis Aguda/cirugía , Colecistostomía/efectos adversos , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.