What to do with an intraductal papilary mucinous pancreatic neoplasm? Our experience. / ¿Qué hacer ante una neoplasia mucinosa papilar intraductal de páncreas? Nuestra experiencia.

INTRODUCTION: Cystic pancreatic neoplasms are a heterogeneous group of pathology, and intraductal papillary mucinous neoplasia is becoming more common. The aim of this study is to review our series of cystic pancreatic neoplasms that underwent surgery and to evaluate the similarities with Fukuoka recommendations. METHODS: Retrospective review of our experience analyzing clinical and radiological data, indication for surgery and pathology study of 11 patients operated on in our centre from july 2011 to july 2015, aiming to evaluate the degree of agreement with the current consensus. RESULTS: In our series the majority of cases (7/11) had symptoms at diagnosis. Preoperative diagnosis was achieved in 10 patients using radiology and/or endoscopy. Indications for surgery were the presence of symptoms, radiological data suspicious of malignancy, and secondary branch neoplasia over 30mm. Pathological findings were malignancy in 6/11 cases (2 invasive neoplasia, 4 high grade dysplasia), moderate dysplasia in 2/11, low-grade dysplasia in 2/11 and no dysplasia in one patient. CONCLUSIONS: Surgical indication of intraductal mucinous pancreatic neoplasms depends on the associated symptoms, size, location, risk and suspicion of malignancy.

Short- and long-term outcomes after distal pancreatectomy with radiologic infiltration of splenic vessels for pancreatic ductal adenocarcinoma.

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.

Distal pancreatectomy with multivisceral resection: A retrospective multicenter study - Case series.

BACKGROUND: Multivisceral resection (MVR) is sometimes necessary to achieve disease-free margins in cancer surgery. In certain patients with pancreatic tumors that invade neighboring organs these must be removed to perform an appropriate oncological surgery. In addition, there is an increasing need to perform resections of other organs like liver not directly invaded by the tumor but which require synchronous removal. The results of MVR in pancreatic surgery are controversial. MATERIAL AND METHODS: A distal pancreatectomy retrospective multicenter observational study using prospectively compiled data carried out at seven HPB Units. The period study was January 2008 to December 2018. We excluded DP with celiac trunk resection. RESULTS: 435 DP were performed. In 62 (14.25%) an extra organ was resected (82 organs). Comparison of the preoperative data of MVR and non-MVR patients showed that patients with MVR had lower BMI, higher ASA and larger tumor size. In the MVR group, the approach was mostly laparotomic and spleen preservation was performed only in 8% of the cases, Blood loss and the percentage of intraoperative transfusion were higher in MVR group. Major morbidity rates (Clavien > IIIa) and mortality (0.8vs.4.8%) were higher in the MVR group. Pancreatic fistula rates were practically the same in both groups. Mean hospital stay was twice as long in the MVR group and the readmission rate was higher in the MVR group. Histology study confirmed a much higher rate of malignant tumors in MVR group. CONCLUSIONS: In order to obtain free margins or treat pathologies in several organs we think that DP + MVR is a feasible technique in selected patients; the results obtained are not as good as those of DP without MVR but are acceptable nonetheless. CLINICALTRIALS. GOV IDENTIFIER: NCT04317352.

Case report: Diverticulitis complicating a giant Meckel's divertuculum.

INTRODUCTION: In this paper, we discuss a unique case of diverticulitis in which the patient presented a giant Meckel's diverticulum. PRESENTATION OF CASE: The patient was a 44 year old male whose medical history included a laparoscopic gastric bypass four years before the finding, and chronical high blood pressure. The patient came to the emergency department with an abdominal pain and elevated acute-phase reactants. An abdominal CT revealed a 17 cm long Meckel's diverticulum with signs of severe inflammation. The patient was then taken to the operating room, and subjected to a 4 cm ileum resection, including the entire diverticulum, with a manual end-to-end anastomosis. DISCUSSION: Although Meckel's diverticulum is the most common congenital abnormality of the intestinal tract, it is unusual for it to cause symptoms in adults. However, when a patient arrives at the emergency department with a complicated Meckel's diverticulum, an early diagnosis is essential to prevent serious complications, such as perforation of the diverticulum and subsequent peritonitis. The presence of a giant diverticulum is an extremely rare condition. There are few publications to date, but these diverticula are associated with more complications, presenting a higher risk of torsion, volvulus or intestinal obstruction. This paper include a bibliographic review of existing studies on etiopathogenesis, and the diagnosis and treatment of complicated Meckel's diverticulum, particularly in its giant variant. CONCLUSION: Although Meckel's diverticulitis is a rare entity, it can appear as an acute abdomen. An early diagnosis and treatment to prevent subsequent complications is essential to ensure an optimal recovery.

De Garengeot's hernia: Case report and literature review.

INTRODUCTION: De Garengeot's Hernia is a rare type of femoral hernia in which the appendix is located inside the herniated sac. Diagnosis of the condition is challenging and its treatment must be performed without delay. PRESENTATION OF CASE: We present the case of a 75-year-old patient with a femoral hernia in which an appendix with signs of inflammation was found. An appendectomy followed by hernia repair was performed under an open preperitoneal approach according to Nyhus technique. The patient did not present any complications and was discharged on the second postoperative day. DISCUSSION: This type of hernia is often unexpected and its preoperative diagnosis is difficult to perform. In most cases the clinical picture is indistinguishable from a common incarcerated hernia. Contrast-enhanced CT is the most useful complementary test, although it is not as accurate as desirable, so the diagnosis is frequently found intraoperatively. There is a wide variety of surgical options and there is no consensus on the most appropriate one. The preperitoneal approach enables the performance of an appendectomy and subsequent hernia reparation. The use of prosthesis should be considered if there are no signs of perforation or abscess. CONCLUSION: De Garengeot's hernia is a very rare entity. The diagnosis and subsequent surgical treatment must be early to prevent the disease progression. The preperitoneal approach should be considered as the first choice technique, as it allows the exploration of the herniated sac and the performance of surgical procedures on its content.

[Obstructive jaundice caused by duodenal amyloidosis succesfully treated with surgery]. / Ictericia obstructiva. Inicio clínico de una amiloidosis duodenal tratada quirúrgicamente.

We present a case of obstructive jaundice due to duodenal amyloidosis presenting as a bulbar pseudotumor (amyloidoma). The duodenal and biliary obstruction were treated by double bypass, hepatojejunostomy and gastroenterostomy. Our case suggests that surgical palliative treatment may be effective, and that anastomosis is probably safe, allowing the patient a good quality of life.

Lesión pancreática aislada tras traumatismo abdominal cerrado: a propósito de un caso / Isolated pancreatic injury after blunt abdominal trauma: a case report

Introducción. La incidencia de lesiones traumáticas del páncreas es baja debido a su localización retroperitoneal, y las lesiones aisladas son excepcionales debido a la proximidad del páncreas a otros órganos y estructuras vasculares. Caso clínico. Presentamos el caso de un varón de 21 años con lesión aislada del páncreas tras traumatismo abdominal cerrado, que precisó manejo quirúrgico. Discusión. Las lesiones pancreáticas aisladas secundarias a traumatismo son raras, pero debemos tenerlas en cuenta en un paciente politraumatizado. Su diagnóstico precoz y manejo adecuado son cruciales para evitar el desarrollo de complicaciones

Introduction. The incidence of traumatic injuries to the pancreas is low due to its retroperitoneal location, and isolated injuries are rare due to the proximity of the pancreas to other vascular organs and structures. Clinical case. We present the case of a 21-year-old man with an isolated lesion of the pancreas after blunt abdominal trauma, which required surgical management.Discussion. Isolated pancreatic injuries secondary to trauma are rare but must be taken into account in a multiple trauma patient. Its early diagnosis and proper management are crucial to avoid the development of complications

[Complex surgical techniques to control bleeding]. / Técnicas quirúrgicas complejas para el control de la hemorragia.

Massive bleeding is a major cause of intraoperative death or death in the immediate postoperative period as a result of surgery. The present article describes the basic principles for the control of surgical bleeding as well as temporary and definitive maneuvers. Temporary control of bleeding can often be achieved with simple maneuvers, which may not be definitive, in which case damage control or planned reoperation are required. The surgeon's aim should always be to control the bleeding. If simple maneuvers fail, more complex procedures are required. The present article also describes these maneuvers to control bleeding (Pringle's maneuver, total vascular exclusion, atrial caval shunt, Mattox's maneuver, Cattel Braasch maneuver, Kocher's maneuver and aortic control maneuvers).

[Intestinal linitis plastica: late metastasis from gastric signet ring cell adenocarcinoma]. / Linitis plástica intestinal: metástasis tardía de adenocarcinoma gástrico en anillo de sello.

Linitis plastica is a malignant disease that usually occurs in the stomach, although it can affect any segment of the alimentary tract. Typically, this entity shows slow progression and insidious clinical course. We present the case of a patient with a previous diagnosis of signet ring cell cancer of the stomach that had been treated with curative intent 12 years before the clinical onset of small and large bowel linitis plastica. The diagnosis was obtained as an incidental pathological finding after urgent surgery for intestinal obstruction. No gastric mass was found. Linitis plastica should be considered in the differential diagnosis of patients with symptoms of obstruction after resection of a gastric carcinoma, especially if there are macroscopic surgical findings of circumferential narrowing. A long interval after diagnosis and treatment of the primary disease does not allow malignancy to be ruled out.