Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD).

PURPOSE: Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. METHODS: This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. RESULTS: A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. CONCLUSION: DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03984734.

Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial).

BACKGROUND: Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. METHODS: This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. RESULTS: A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. CONCLUSION: The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).

SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer. / Guía SEOM-SERAM-SEMNIM sobre el empleo de las técnicas de imagen funcional y molecular en el cáncer de pulmón no microcítico avanzado.

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.

SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer.

Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision-making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.

Enlarged lymph nodes in the upper abdomen after liver transplantation: imaging features and clinical significance.

PURPOSE: Our aim was to review our single-centre experience regarding imaging features and pathological conditions arising from enlarged lymph nodes following orthotopic liver transplantation (OLD) and identify imaging features that may allow narrowing the differential diagnosis. MATERIALS AND METHODS: Between January 1997 and September 2008, 715 OLTs were performed at our Institution in 585 patients. In 19 patients (2.6 %) ultrasound (US) showed enlarged lymph nodes in the upper abdomen, and abdominal computed tomography (CT) was performed RESULTS: Histological results showed posttransplantation lymphoproliferative disorder (PTLD) in six patients (31.5 %), hepatic tumoral disease in six (31.5 %), disseminated systemic tuberculosis in one (5.2%) and sarcoidosis in one (5.2%). Histological results showed nonspecific reactive lymph node hyperplasia in five patients (26%). CONCLUSIONS: Detecting enlarged lymph nodes in the upper abdomen after liver transplantation is and infrequent occurrence; however, thorough imaging is required to detect and characterise a wide variety of disorders. Most of the time, enlarged lymph nodes will be related to posttransplantation lymphoproliferative disorder or tumoral recurrence.

[MRI evaluation of a supernumerary kidney fused with a horseshoe kidney]. / Riñón supernumerario fusionado con riñón en herradura. Valoración por RM.

We present the case of a patient in whom a horseshoe kidney was discovered during US examination performed for abdominal pain. MRI confirmed this finding and also revealed a supernumerary kidney. The three kidneys were fused, with the supernumerary kidney forming the isthmus of the horseshoe kidney. Whereas horseshoe kidney is a relatively common renal malformation, a supernumerary kidney is one of the rarest renal malformations. The coexistence of these two malformations and especially the particular disposition of the supernumerary kidney is very rare. Knowledge of this malformation is interesting because it can lead to complications such as lithiasis, hydronephrosis, infections, and neoplasms and because it has important implications for surgical planning.

A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis.

BACKGROUND: The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial. METHODS: Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo). RESULTS: Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays. CONCLUSION: The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

[Initial experience with Arndt-type bronchial blockers in thoracic surgery]. / Experiencia inicial con los bloqueadores bronquiales tipo Arndt en cirugía torácica.

OBJECTIVES: The aim of the present study was to consider the feasibility of Arndt-type bronchial blockers in thoracic surgery. PATIENTS AND METHODS: We enrolled the first 11 patients undergoing uncomplicated thoracic surgery expected to be of short duration. The following variables were recorded: age, weight, height, diagnosis, type of surgery, side where the blocker was used, time needed for positioning, the number of times the blocker was malpositioned according to fiberoptic bronchoscopy, time of lung isolation, duration of surgery, and effectiveness of lung collapse. RESULTS: Eleven blockers were placed in 5 women and 6 men aged between 25 and 81 years old (mean +/- SD, 52.73 +/- 22.12 years). Weight ranged from 45 to 88 Kg (mean 65.82 +/- 11.86 Kg). Height ranged from 157 to 175 cm (mean 166 +/- 5.76 cm). Time needed for positioning the blocker ranged from 2 to 30 minutes (median 5 minutes, interquartile range 1-12). According to fiberoptic bronchoscopy, the bronchial cuff was malpositioned, with herniation into the carina, in 1 case. Duration of surgery ranged from 30 minutes to 4 hours (median 70 minutes, interquartile range 50-210 minutes). Lung collapse was excellent in 9 cases and acceptable in 2 according to the surgeon. CONCLUSIONS: Our initial experience with bronchial blockers in elective surgery has shown that time for initial positioning is acceptably short and that surgical conditions are excellent in most cases.

Clinicopathologic characteristics of head and neck squamous cell carcinoma in Puerto Ricans

OBJECTIVE: The purpose of this study is to characterize head and neck squamous cell carcinoma (HNSCC) in the Puerto Rican population. This is a follow-up to our initial published report on the first 134 patients. Specifically, demographic characteristics, stage at presentation, initial treatment given, and rate of recurrence were studied. METHODS: Relevant data was obtained from 445 histologically confirmed HNSCC cases identified through the University of Puerto Rico School of Medicine Otolaryngology Department Head and Neck Cancer Clinics between August 1993 and January 2003. Data collected after informed consent included demographic factors (sex, age, areas of residence, income); risk factors (occupation, alcohol intake, cigarette usage); and pathological variables (tumor location, histopathology, stage at presentation, current disease status, tumor recurrence). RESULTS: The average age at diagnosis was 64.0 years (range 18-98); 84.5 per cent of the patients were male, 16 per cent were females. The most frequent anatomical sites of the primary tumor were the larynx (36.4 per cent) and the oral cavity (29.9 per cent). The majority of patients (61.1 per cent) presented with advanced stage (III-IV) disease at the time of diagnosis and over half (55.5 per cent) had moderately-differentiated tumors. Most patients had less than 12 years of formal education (81.2 per cent). Prolonged use of tobacco and alcohol identified in 88.1 per cent and 79.8 per cent of patients, respectively. The most frequent therapeutic modality used was radiation therapy followed by the combination of radiation and surgery. Twenty five percent of the cases experienced a recurrence of disease during the follow-up period. CONCLUSIONS: These findings emphasize the need for early detection programs for HNSCC in Puerto Rican patients given the high rate of advanced-stage disease at time of diagnosis. The key role of heavy alcohol intake and tobacco use as risk factors in the development of HNSCC is once again highlighted.

The value of endorectal MRI in the early diagnosis of prostate cancer.

OBJECTIVE: Assess the value of endorectal MR imaging (EMRI) in the early diagnosis of prostate cancer (PCa) and compare this test to prostate specific antigen (PSA) and digital rectal examination (DRE) in the prediction of negative biopsies. MATERIAL AND METHODS: 92 patients with elevated PSA (>4 ng/ml) and/or abnormal DRE were studied. All patients underwent an EMRI previous to transrectal ultrasound guided needle sextant biopsies (3 cores in each peripheral zone), and were followed up. We performed a total of 184 biopsies: 92 patients underwent 1 biopsy; out of them, 61 patients underwent 2 biopsies, 27 patients 3 biopsies, 3 patients 4 biopsies and 1 patient 5 biopsies. 67 patients had a final negative biopsy and 25 had a final positive biopsy. Mean PSA was 10.44 ng/ml, and the mean % fPSA/tPSA was 0.20. Uni- and multivariate analysis and ROC curves were used to compare the accuracy of the different tests. The probability of positive biopsy with each technique was also assessed. RESULTS: EMRI had a high negative predictive value (91.07%) and the highest accuracy (77%) of all tests, higher than PSA (62%). Mean PSA was not statistically different in patients with negative biopsies (9.44 ng/ml) and positive biopsies (11.8 ng/ml) (p=0.064). The association of EMRI-DRE-PSA had the highest accuracy (83%) significantly higher than DRE-PSA (70%). The probability of positive biopsy in patients with negative DRE and EMRI, and PSA values between 5 and 15 ng/ml was 5-10% at first and second biopsies, but decreased progressively on subsequent biopsies (<8% at third biopsy, <5% at fourth biopsy and <3% at fifth biopsy). CONCLUSION: In patients with elevated PSA and/or abnormal DRE with two previous negative biopsies, an EMRI is a useful test to rule out PCa, when negative, and avoid subsequent biopsies, as they have a low chance of positive biopsy.

[Hemodynamics of the cirrhotic patient during liver transplantation. Influence of the preservation of portal and vena cava flow]. / Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava.

OBJECTIVE: To describe the hemodynamic pattern of patients undergoing liver transplantation with preservation of portocaval flow. PATIENTS AND METHODS: A prospective study of 20 cirrhotic patients who had not previously undergone surgery for portal hypertension or had porto-systemic bypass, both of which have hemodynamic effects in the cirrhotic patient. The patients were transplanted with preservation of inferior vena cava flow and temporary portocaval shunt. RESULTS: The decrease in cardiac output during the anhepatic phase was only 10% and mean blood pressure (77.6 +/- 11 versus 76 +/- 10 mm Hg) and supply pressures (central venous pressure 9.1 +/- 5.5 versus 8.4 +/- 5.3 mm Hg; pulmonary capillary pressure 11.4 +/- 6.1 versus 11.3 +/- 7.4 mm Hg) remained stable. Likewise, no significant increase in systemic vascular resistance (614 +/- 223 versus 676 +/- 306 dyne-sec/cm5) or heart rate (90 +/- 14 versus 97 +/- 17 beats/min). The number of units of packed red cells was 2.7 +/- 2.5 and 35% of the patients required no transfusions. Diuresis was stable throughout the procedure (total diuresis 3.6 +/- 2.4 mL/Kg/h; anhepatic phase 1.3 +/- 1.5 mL/Kg/h). CONCLUSIONS: Creation of a portocaval shunt during the anhepatic phase of liver transplantation allows hemodynamic vital signs to be held stable, decreases the need for transfusion and maintains diuresis.

Influence of donor post-reperfusion changes on graft evolution after liver transplant.

INTRODUCTION: The increase in indications for liver transplantation has meant that waiting lists are growing ever longer. For this reason, broadening the donor pool is a priority for most groups. OBJECTIVE: The objective of this study was to analyze the predictive value of post-reperfusion biopsy in the evolution of graft function after liver transplantation. PATIENTS: One hundred and forty-eight liver biopsies, obtained after graft reperfusion, were analyzed. Eight pathological variables and thirty-seven clinical variables of the donors were recorded. Risk factors for presenting primary graft non-function or dysfunction were studied with logistic regression models. Factors associated to the long-term graft failure were studied using Cox analysis and actuarial survival curves. RESULTS: Microvesicular steatosis greater than 50% was the only risk factor associated to graft dysfunction in the multivariate logistic regression model. Microvesicular steatosis greater than 30%, severe hepatocyte necrosis and presence of abundant neutrophilic leukocytes were risk factors associated to graft failure in the univariate study. Only steatosis remained as an independent risk factor in the multivariate study. These grafts also presented poorer long-term survival. Abundant polymorphonuclear infiltrate was associated to a higher frequency of biliary complications. CONCLUSIONS: Microvesicular steatosis implies a better evolution than macrovesicular steatosis. Neutrophilic infiltrate and hepatocellular necrosis lead to poorer initial graft function and reduced long-term survival.

[Clinical study of 437 consecutive hepatectomies]. / Estudio clínico de 437 hepatectomías consecutivas.

BACKGROUND: The aim of this prospective study was to analyze the risk of liver resection in unselected patients. PATIENTS AND METHOD: From 1990 to 2000, 437 consecutive hepatectomies were performed in our center. Most frequent indications were liver metastases (n = 288), hepatocellular carcinoma (n = 62), Klatskin tumor (n = 17), gallblader carcinoma (n = 139) and other malignant tumors (n = 6). The indication was a benign tumor in 51 patients. In 357 cases the liver parenchyma was normal, 51 patients had an underlying cirrhosis and 17 patients had an obstructive jaundice. RESULTS: Overall mortality was 3.6% (15 cases). Mortality in benign tumors was lacking. The prevalence of postoperative complications was 43.9%, which was mainly influenced by malignancy (46.9% vs 21.6%, p = 0.001) and type of tumor (Klastkin tumor, p # 0.001). Major liver resection (p < 0.001), blood transfusion (p < 0.001), age over 60 years (p = 0.001) and the type of hepatectomy (p < 0.001) also increased significantly the morbidity. The prevalence of biliary fistula was 11.2%, which was mainly related to the type of hepatectomy (major hepatectomy; p = 0.002) and a biliary-enteric anastomosis (p < 0.001). The prevalence of hepatic insufficiency was 3.6%, and chief risk factors for its development were underlying liver disease and major liver resection (p = 0.017). CONCLUSIONS: Mortality after hepatectomy in experienced centers is low. Morbidity is mainly related to the amount of parenchyma resected, type of hepatectomy, underlying liver disease and associated procedures. Liver resection should be performed preferentially in centers with high volume by specialized surgeons.

Postreperfusion biopsies are useful in predicting complications after liver transplantation.

Biliary complications after orthotopic liver transplantation (OLT) may occur because of preservation injury (PI). In this study, we examine findings on routine reperfusion biopsy specimens in relation to the occurrence of biliary complications and graft outcome. From 1997 to 2000, a total of 193 OLTs were performed in our center. Postreperfusion biopsy specimens were analyzed and histological lesions were graded. For analysis, grafts were grouped into 2 categories: the presence or absence of PI (severe to moderate lesions versus mild or no lesions). Histological evidence of PI was present in 17% of the biopsy specimens. The incidence of grafts with PI and ischemia time longer than 12 hours was 38% compared with 14% in PI and short ischemia time (P =.02). Biliary complications were also more frequent in the PI group (28% v 14%; P =.03). Study of risk factors by means of logistic regression analysis confirmed that the PI group had a greater risk for biliary complications (relative risk, 2.8; 95% confidence interval, 1 to 7.4; P =.03). Moreover, moderate macrovesicular steatosis was found in 6% of the grafts, resulting in a 40% graft loss rate. We found that an increased presence of neutrophilic infiltrates in the postreperfusion biopsy specimen, indicating PI, was related to an increased incidence of biliary complications. Moreover, moderate macrovesicular steatosis was associated with increased graft loss. Therefore, postreperfusion biopsies are useful in anticipating post-OLT complications.