Gastric perforation as a complication of Wilkie's syndrome.

Wilkie's syndrome, also known as Superior mesenteric artery (SMA) syndrome, is characterized by intestinal obstruction due to aortomesenteric duodenal compression caused by the reduction of the normal angle between (38-65º) to <25º or to a distance <8mm. The clinical presentation is usually non-specific (dyspepsia, postprandial abdominal pain) but sometimes presented as an acute intestinal obstruction syndrome (nausea, vomiting, gastric dilatation and abdominal distention). In this study, we report the case of a 22-year-old patient with a BMI of 16.5 who presented to the emergency room with acute intestinal obstruction caused by SAMS. He presented with massive gastric dilation that caused ischaemic necrosis of the gastric mucosa with subsequent perforation. It should be noted that only one case associated with Wilkie syndrome has been described in the literature. Therefore, given the rare incidence of complications associated with this syndrome and the favourable prognosis with conservative management, surgery is usually the last line of treatment. However, we must not forget that when necrosis appears, it is often extensive and requires urgent surgical treatment in most cases.

Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study.

INTRODUCTION: Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS: Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS: Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS: Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.

Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study.

BACKGROUND: The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors. AIM: To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years. METHODS: Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups. RESULTS: Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor. CONCLUSION: The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

Capsule endoscopy diagnosis of gastrointestinal melanoma.

Melanoma is a cancer that frequently metastasises to the small bowel, but most cases are asymptomatic and are diagnosed postmortem. Therefore, CT and PET CT cannot detect all lesions and conventional endoscopic study only detects 10-20% of lesions. In this study, we present the case of a 68-year-old patient with a history of cutaneous melanoma and a diagnosis of intestinal melanoma. Thanks to capsule endoscopy, two lesions compatible with cutaneous melanoma metastasis to the small bowel were detected, allowing a much more effective surgical planning. Capsule endoscopy is an innovative technique that improves preoperative diagnosis, as it is able to detect bowel segments that cannot be inspected by conventional endoscopy. It also has a better resolution than conventional CT, improving sensitivity in the detection of lesions.

Cephalic pancreatoduodenectomy in octogenarian patients with pancreatic tumors.

INTRODUCTION: Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (≥80 years) patients as well as younger patients. METHODS: This is a retrospective and comparative trial, comparing results for CPD performed on 30 patients ≥80 years with PC and 159 patients <80 years. RESULTS: The patients in the octogenarian group showed a significantly higher rate of preoperative cardiovascular morbidity and a more aggressive tumoral behaviour, including more significant preoperative anemia, jaundice and levels of CA 19-9, higher vascular and neural invasion, and a lower rate of R0 resection despite using the same surgical technique. There were no significant differences in terms of postoperative complications. Postoperative mortality was similar in both groups (3.3% in octogenarians vs 3.1% in patients <80 years). Mortality during follow-up was mainly due to tumour recurrence, cardiovascular complications and COVID-19 in 2 elderly patients. Actuarial survival at 1, 3 and 5 years was significantly larger for patients <80 years old, as compared to octogenarians (85.9%, 61.1% and 39.2% versus 72.7%, 28.9% and 9.6%, respectively; P = 0.001). The presence of a pancreatic fistula and not using external Wirsung stenting were significantly associated with 90-day postoperative mortality after a CPD. CONCLUSIONS: Morbidity and mortality post-CPD is similar in octogenarians and patients younger than 80, although long-term survival is shorter due to more aggressive tumours and comorbidities associated with older age.

"Long-term follow-up of liver transplantation in incidental intrahepatic cholangiocarcinoma and mixed hepatocellular-cholangiocarcinoma".

INTRODUCTION: The standard treatment for intrahepatic cholangiocarcinoma (iCCA) and mixed hepatocellular-cholangiocarcinoma (HCC-CC) is surgical resection, nevertheless, recent studies show adequate survival rates in selected patients with iCCA or HCC-CC undergoing liver transplantation (LT). METHODS: A retrospective cohort study was design including all patients undergoing LT at our center between January, 2006 and December, 2019 with incidentally diagnosed iCCA or HCC-CC after pathological examination of the explanted liver (n = 13). RESULTS: There were no iCCA or HCC-CC recurrences during the follow-up, and hence, there were no tumor related deaths. Global and disease-free survival were the same. The 1, 3 and 5-years patient survival were 92.3%, 76.9% and 76.9%, respectively. Survival rates in the "early-stage tumor group" at 1, 3 and 5 years were 100%, 83.3% and 83.3%, respectively, with no significant differences as compared to the "advanced-stage tumors group". No statistically significant differences in terms of 5-year survival were found when comparing tumor histology (85.7% for iCCA and 66.7% for HCC-CC). CONCLUSIONS: These results suggest that LT could be an option in patients with chronic liver disease who develop an iCCA or HCC-CC, even in highly selected advanced tumors, but we must be cautious when analyzing these results because of the small sample size of the series and its retrospective nature.

Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases.

INTRODUCTION: There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS: A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS: Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively. CONCLUSIONS: Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Anastomotic reconstruction and external drainage of Wirsung's duct as treatment for pancreaticojejunal stenosis following pancreaticoduodenectomy. / Reconstrucción anastomótica y drenaje externo del conducto de Wirsung como tratamiento de la estenosis pancreato-yeyunal posduodenopancreatectomía cefálica.

Stenosis of the pancreaticodigestive anastomosis (pancreaticogastrostomy and pancreaticojejunostomy) is a very rare complication that usually develops several years after pancreaticoduodenectomy (PD). Only a few cases have been previously reported. We have reviewed the literature and present 2 more cases of pancreaticojejunostomy stenosis that started with episodes of recurrent acute pancreatitis 6 years and 1 year after PD, respectively. Diagnosis was based on symptoms of pancreatitis (12-15 episodes between 5 and 20 months after PD) and CT and MRI scans. Both patients were treated by resection of the pancreaticojejunostomy stenosis, including a 1-cm slice of pancreatic parenchyma in contact with the jejunum, followed by a new well-vascularized two-layer end-to-side PJ with external drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both cases, and after a follow-up period of 3 and 2.5 years, respectively, the patients remain asymptomatic but with endocrine and exocrine insufficiency. Resection of the PJ and construction of a new PJ with external stent drainage of the Wirsung duct is our preferred surgical option in the rare cases of PJ stenosis after a Whipple procedure.

Tumor recurrence after liver transplantation for diffuse biliary papillomatosis in the absence of invasive carcinoma.

Intraductal papillary neoplasm of the bile duct (IPNB) or biliary papillomatosis (BP) is a premalignant entity with high risk of malignant transformation. When the disease extends widely from the intrahepatic to the extrahepatic biliary tree, liver transplantation (LT) is the only option available. We present the case of a 43-year-old male who was admitted in our hospital with an acute cholangitis. He was diagnosed of diffuse biliary and pancreatic papillomatosis. Firstly, we performed a cephalic pancreaticoduodenectomy, then we completed a total pancreatectomy, and finally, after confirming the absence of foci of carcinoma infiltration or lymph nodes involvement, a LT was performed. Foci of carcinoma infiltration or lymph nodes involvement in the liver were not found. After a two-year follow-up the patient developed liver recurrence and the biopsy showed a biliary adenocarcinoma. In 2010, Vibert et al. published a series of three cases concluding that in the absence of invasive carcinoma and positive lymph nodes, LT can be performed with success. The present case is the first to describe recurrence of the disease after LT in the absence of invasive carcinoma and positive lymph nodes in the literature. When the disease affects widely the entire biliary duct, small micro-invasive foci may not be detected. Nevertheless, although we know that it is a recurrent entity, the pathogenesis is unknown, and we do not know if it is possible that papillomatosis recurs over the new liver.

Candidiasis intraabdominal masiva secundaria a cirugías digestivas en pacientes inmunocompetentes. A propósito de 2 casos / Massive intra-abdominal candida infection secondary to digestive surgery in inmunocompetent patients: A report on 2 cases

La perforación asociada a infección intraabdominal difusa por Candida spp. es excepcional. Suele asociarse a pacientes inmunodeprimidos o con enfermedad tumoral avanzada. Presentamos 2 casos de perforación digestiva secundaria a candidiasis invasiva. En el primer caso, una mujer de 68 años con una perforación duodenal secundaria a Candida spp., se realiza laparotomía exploradora y reparación de la perforación duodenal. Sin embargo, la paciente requiere más de 2 intervenciones, observándose Candida spp. macroscópica diseminada por toda la cavidad abdominal. El segundo caso es el de un varón de 60 años que presenta un postoperatorio complicado de una hemicolectomía derecha, que se asocia con pancretitis, y con posterior diseminación fúngica abdominal secundaria a Candida parapsilopsis, con múltiples complicaciones infecciosas. En ambos casos se intentó un tratamiento basado en resección quirúrgica y cambio de anti-fúngicos, sin éxito. El tratamiento antifúngico precoz evita la diseminación hematógena y el shock séptico, disminuyendo la morbimortalidad de estos pacientes.

Candida spp. as cause of diffuse intraabdominal infection is very rare. Often associated with immunocompromised or patients with advanced tumor disease. We are reporting 2 cases of gastrointestinal perforation secondary to invasive candidiasis. The first case, a 68 years old female with a Candida spp. duodenal perforation. An emergency exploratory laparotomy was performed and a duodenal perforation repair was done. However, the patient required 2 more reoperation due to Candida spp. macroscopic intra-abdominal disemination. The second case, is presented in the context of a postoperative period of a right hemicolectomy, pancreatitis associating abdominal spread and subsequent secondary fungal Candida parapsilopsis with multiple infectious complications. In both cases there were unsuccessful surgical resection and antifungal change. The early antifungal treatment prevents hematogenous dissemination and septic shock, reducing the morbidity and mortality of these patients.

Incidence, risk factors and outcome of de novo tumors in liver transplant recipients focusing on alcoholic cirrhosis.

Orthotopic liver transplantation (OLT) is an established life-saving procedure for alcoholic cirrhotic (AC) patients, but the incidence of de novo tumors ranges between 2.6% and 15.7% and is significantly increased in comparison with patients who undergo OLT for other etiologies. Tobacco, a known carcinogen, has been reported to be between 52% and 83.3% in AC patients before OLT. Other risk factors that contribute to the development of malignancies are dose-dependent immunosuppression, advanced age, viral infections, sun exposure, and premalignant lesions (inflammatory bowel disease, Barrett's esophagus). A significantly more frequent incidence of upper aerodigestive (UAD) tract, lung, skin, and kidney-bladder tumors has been found in OLT recipients for AC in comparison with other etiologies. Liver transplant recipients who develop de novo non-skin tumors have a decreased long-term survival rate compared with controls. This significantly lower survival rate is more evident in AC recipients who develop UAD tract or lung tumors after OLT mainly because the diagnosis is usually performed at an advanced stage. All transplant candidates, especially AC patients, should be encouraged to cease smoking and alcohol consumption in the pre- and post-OLT periods, use skin protection, avoid sun exposure and over-immunosuppression, and have a yearly otopharyngolaryngeal exploration and chest computed tomography scan in order to prevent or reduce the incidence of de novo malignancies. Although still under investigation, substitution of calcineurin inhibitors for sirolimus or everolimus may reduce the incidence of de novo tumors after OLT.