Drainage after distal pancreatectomy: Still an unsolved problem.

BACKGROUND: The use of intraperitoneal drainage after distal pancreatectomy is still controversial. Its use increases fistula risk, but its absence increases the severity of the fistula. Therefore, since 2014, we have systematically used two drains. METHODS: This study examined consecutive patients undergoing distal pancreatectomy with splenectomy. Two drains were routinely used. One closed-suction-type drain is placed in the left subphrenic space with the aim to avoid the accumulation of any fluid coming from the pancreatic stump. The second is a tubulo-laminar drain placed near the pancreatic stump. These patients were compared with a cohort of patients (n = 94) before the adoption of this strategy (control group). RESULTS: 127 patients underwent distal pancreatectomy. 48 patients presented no POPF, 60 patients presented biochemical leak and in 19 patients (14.9%), drain amylase level was high and the drain was removed at 4 weeks, classified as grade-B according to the Revised 2016 ISGPS or B1 according to grade-B subclass. No grade-C was observed. The comparison with the 94 patients in the control group with single drainage, the occurrence of POPF was not different. However, in the control group, POPF severity was statistically higher (grade-B 14.9% vs 33%; grade-C 0% vs 3,2%; P = 0.00026). CONCLUSIONS: Since changing the drainage strategy, we have observed a dramatic decrease in pancreatic abscess formation and fluid collections needing percutaneous drainage. The results of this study show that the strategy of double drainage after distal pancreatectomy may reduce the severity of POPF, thus avoiding reoperation or further interventions.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy procedure using ischemic bipartition: Two case reports.

RATIONALE: The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure is a recently introduced treatment strategy for patients with advanced primary or metastatic liver tumors and small future liver remnants. ALPPS procedure using ischemic bipartition of the liver is a modified technique that may reduce complications compared to classical ALPPS. PATIENT CONCERNS: Two patients with multiple colorectal liver metastasis with extensive involvement of the liver were considered unresectable before treatment because of small future liver remnant (FLR). DIAGNOSES: Two patients were diagnosed by imaging examination with volumetry of the liver. INTERVENTIONS: In the first stage, ischemic bipartition of the liver is achieved using radiofrequency ablation. The Glissonian pedicles from Segment 4 are identified and ablated, the FLR is cleared, and the right portal vein is ligated. In the second stage, the typical procedure is performed, and an extended liver resection is performed. OUTCOMES: The procedure was feasible with acceptable hypertrophy of FLRs. Blood transfusions were unnecessary, and severe postoperative complications were avoided. LESSONS: The ALPPS procedure with ischemic bipartition is safe and feasible and can produce results that are the same as those of the classical ALPPS procedure while reducing invasiveness during the first stage.

Effects of diazoxide in experimental acute necrotizing pancreatitis.

OBJECTIVE:: We aimed to assess the effects of diazoxide on the mortality, pancreatic injury, and inflammatory response in an experimental model of acute pancreatitis. METHODS:: Male Wistar rats (200-400 g) were divided randomly into two groups. Fifteen minutes before surgery, animals received physiological (0.9%) saline (3 mL/kg) (control group) or 45 mg/kg diazoxide (treatment group) via the intravenous route. Acute pancreatitis was induced by injection of 2.5% sodium taurocholate via the biliopancreatic duct. Mortality (n=38) was observed for 72 h and analyzed by the Mantel-Cox Log-rank test. To study pancreatic lesions and systemic inflammation, rats (10 from each group) were killed 3 h after acute pancreatitis induction; ascites volume was measured and blood as well as pancreases were collected. Pancreatic injury was assessed according to Schmidt's scale. Cytokine expression in plasma was evaluated by the multiplex method. RESULTS:: Mortality at 72 h was 33% in the control group and 60% in the treatment group (p=0.07). Ascites volumes and plasma levels of cytokines between groups were similar. No difference was observed in edema or infiltration of inflammatory cells in pancreatic tissues from either group. However, necrosis of acinar cells was lower in the treatment group compared to the control group (3.5 vs. 3.75, p=0.015). CONCLUSIONS:: Treatment with diazoxide can reduce necrosis of acinar cells in an experimental model of acute pancreatitis, but does not affect the inflammatory response or mortality after 72 h.

Effects of diazoxide in experimental acute necrotizing pancreatitis

OBJECTIVE: We aimed to assess the effects of diazoxide on the mortality, pancreatic injury, and inflammatory response in an experimental model of acute pancreatitis. METHODS: Male Wistar rats (200-400 g) were divided randomly into two groups. Fifteen minutes before surgery, animals received physiological (0.9%) saline (3 mL/kg) (control group) or 45 mg/kg diazoxide (treatment group) via the intravenous route. Acute pancreatitis was induced by injection of 2.5% sodium taurocholate via the biliopancreatic duct. Mortality (n=38) was observed for 72 h and analyzed by the Mantel-Cox Log-rank test. To study pancreatic lesions and systemic inflammation, rats (10 from each group) were killed 3 h after acute pancreatitis induction; ascites volume was measured and blood as well as pancreases were collected. Pancreatic injury was assessed according to Schmidt's scale. Cytokine expression in plasma was evaluated by the multiplex method. RESULTS: Mortality at 72 h was 33% in the control group and 60% in the treatment group (p=0.07). Ascites volumes and plasma levels of cytokines between groups were similar. No difference was observed in edema or infiltration of inflammatory cells in pancreatic tissues from either group. However, necrosis of acinar cells was lower in the treatment group compared to the control group (3.5 vs. 3.75, p=0.015). CONCLUSIONS: Treatment with diazoxide can reduce necrosis of acinar cells in an experimental model of acute pancreatitis, but does not affect the inflammatory response or mortality after 72 h.

Effect of parenteral infusion of fish oil-based lipid emulsion on systemic inflammatory cytokines and lung eicosanoid levels in experimental acute pancreatitis.

Parenteral fish oil lipid emulsion (FOLE) might mitigate inflammation after injury. Acute pancreatitis (AP) can occur following major surgery and is characterized by tissue and systemic release of inflammatory mediators that contributes to the systemic inflammatory response syndrome and multiple organ failure. AIM: We evaluated the effect of short-term FOLE infusion before experimental induction of AP on systemic cytokine and lung eicosanoid profiles. METHODS: Lewis rats (n = 72) received parenteral infusion of FOLE (FO group) or saline (SS group), or remained without parenteral infusion (CG group) for 48 h. Thereafter, AP was induced by retrograde injection of sodium taurocholate into the pancreatic duct. Animals were sacrificed after 2, 12 and 24 h. Blood and lung samples were collected to assess serum inflammatory cytokines (Luminex) and tissue eicosanoids (ELISA), respectively. RESULTS: Serum TNF-α increased over time and serum IL-10 decreased from 12 to 24 h in CG group. In SS group serum TNF-α increased from 12 to 24 h (p = 0.039) and serum IL-10 decreased over time. Both CG and SS groups exhibited increased IL-6/IL-10 ratio (p = 0.040). From 12 to 24 h animals from FO group showed decreased serum IL-1 (p < 0.001), IL-4 (p < 0.002) and IL-6 (p = 0.050), and a trend towards increased IL-10 (p = 0.060). All experimental groups showed a trend towards increased PGE2 and decreased LTB4 in the lung at 24 compared with 12 h CONCLUSION: Parenteral infusion of FOLE for 48 h before the induction of experimental AP appears to favorably influence the cytokine response without affecting lung eicosanoids at the time points measured. The use of FOLE to prevent and treat AP following major surgery needs to be further explored.

Pentoxifylline enhances the protective effects of hypertonic saline solution on liver ischemia reperfusion injury through inhibition of oxidative stress.

BACKGROUND: Liver ischemia reperfusion (IR) injury triggers a systemic inflammatory response and is the main cause of organ dysfunction and adverse postoperative outcomes after liver surgery. Pentoxifylline (PTX) and hypertonic saline solution (HTS) have been identified to have beneficial effects against IR injury. This study aimed to investigate if the addition of PTX to HTS is superior to HTS alone for the prevention of liver IR injury. METHODS: Male Wistar rats were allocated into three groups. Control rats underwent 60 minutes of partial liver ischemia, HTS rats were treated with 0.4 mL/kg of intravenous 7.5% NaCl 15 minutes before reperfusion, and HPTX group were treated with 7.5% NaCl plus 25 mg/kg of PTX 15 minutes before reperfusion. Samples were collected after reperfusion for determination of ALT, AST, TNF-alpha, IL-6, IL-10, mitochondrial respiration, lipid peroxidation, pulmonary permeability and myeloperoxidase. RESULTS: HPTX significantly decreased TNF-alpha 30 minutes after reperfusion. HPTX and HTS significantly decreased ALT, AST, IL-6, mitochondrial dysfunction and pulmonary myeloperoxidase 4 hours after reperfusion. Compared with HTS only, HPTX significantly decreased hepatic oxidative stress 4 hours after reperfusion and pulmonary permeability 4 and 12 hours after reperfusion. CONCLUSION: This study showed that PTX added the beneficial effects of HTS on liver IR injury through decreases of hepatic oxidative stress and pulmonary permeability.

Severe acute pancreatitis: a possible role of intramyocardial cytokine production.

CONTEXT: Several mechanisms are involved in the development of the local and systemic response in acute pancreatitis. Cardiovascular system may be affected throughout the clinical course of acute pancreatitis. The aim was to evaluate local myocardial cytokine production, as well as, functional and histological myocardial alterations in severe acute pancreatitis. METHODS: The animals were divided into three groups: Group 1: control; Group 2: sham; Group 3: severe acute pancreatitis. Echocardiographic assessment of cardiac function, serum levels of amylase and cytokines (TNF-α, IL-6 and IL-10), and mRNA expression of TNF-α, IL-6 and TGF-ß were measured. Myocardial tissue alterations were analysed by histological examination. RESULTS: The serum TNF-α and IL-10 levels were significant higher in AP 2h group. The mRNA IL-6 levels from group AP 2h were statistically higher. The mRNA TNF-α level from sham group and AP 2h were statistically lower. Significant changes in the left ventricular diameter were found in AP 2h and AP 12h groups. There were statistical changes for vacuolar degeneration, picnosis and loss of nucleus, and lymphocytes. CONCLUSION: We found cardiac and histological changes compatible with the inflammatory process triggered by SAP with the promotion of local myocardial cytokine production.

PGC-1α expression is increased in leukocytes in experimental acute pancreatitis.

Severe acute pancreatitis (AP) induces a systemic inflammatory disease that is responsible for high mortality rates, particularly when it is complicated by infection. Therefore, differentiating sepsis from the systemic inflammation caused by AP is a serious clinical challenge. Considering the high metabolic rates of leukocytes in response to stress induced by infection, we hypothesized that the transcription coactivator peroxisome proliferator-activated receptor gamma coactivator 1 (PGC-1α), a master regulator of mitochondrial biogenesis and function, would be distinctly expressed during inflammation or infection and, therefore, could constitute a useful marker to differentiate between these two conditions. Rats were subjected to injection of taurocholate into the main pancreatic duct, which caused a severe AP with high amylase levels and white blood cell counts. In these animals, a marked increase in PGC-1α mRNA levels in circulating leukocytes was observed 48 h after the surgical procedure, a time when bacteremia is present. Antibiotic treatment abolished PGC-1α up-regulation. Moreover, PGC-1α expression was higher in peritoneal macrophages from animals subjected to a bacterial insult (cecal ligation and puncture) than in animals with AP. In isolated macrophages, we also observed that PGC-1α expression is more prominent in the presence of a phagocytic stimulus (zymosan) when compared to lipopolysaccharide-induced aseptic inflammation. Moreover, abolishing PGC-1α expression with antisense oligos impaired zymosan phagocytosis. Together, these findings suggest that PGC-1α is differentially expressed during aseptic inflammation and infection and that it is necessary for adequate phagocytosis. These results could be useful in developing new tests for differentiating infection from inflammation for clinical purposes in patients with AP.

Penetrance of functioning and nonfunctioning pancreatic neuroendocrine tumors in multiple endocrine neoplasia type 1 in the second decade of life.

CONTEXT: Data are scarce on the penetrance of multiple endocrine neoplasia type 1 (MEN1)-related nonfunctioning pancreatic neuroendocrine tumors (NF-PETs) and insulinomas in young MEN1 patients. A potential positive correlation between tumor size and malignancy (2-3 cm, 18%; >3 cm, 43%) has greatly influenced the management of MEN1 adults with NF-PETs. OBJECTIVE: The aim of the study was to estimate the penetrance of NF-PETs, insulinomas, and gastrinomas in young MEN1 carriers. DESIGN: The data were obtained from a screening program (1996-2012) involving 113 MEN1 patients in a tertiary academic reference center. PATIENTS: Nineteen MEN1 patients (aged 12-20 y; 16 patients aged 15-20 y and 3 patients aged 12-14 y) were screened for NF-PETs, insulinomas, and gastrinomas. METHODS: Magnetic resonance imaging/computed tomography and endoscopic ultrasound (EUS) were performed on 10 MEN1 carriers, magnetic resonance imaging/computed tomography was performed on five patients, and four other patients underwent an EUS. RESULTS: The overall penetrance of PETs during the second decade of life was 42% (8 of 19). All eight PET patients had NF-PETs, and half of those tumors were multicentric. One-fifth of the screened patients (21%; 4 of 19) harbored at least one large tumor (>2.0 cm). Insulinoma was detected in two NF-PET patients (11%) at the initial screening; gastrinoma was not present in any cases. Six of the 11 (54%) screened patients aged 15-20 years who underwent an EUS had NF-PETs. Potential false-positive EUS results were excluded based on EUS-guided biopsy results, the reproducibility of the NF-PET findings, or the observation of increased tumor size during follow-up. Distal pancreatectomy and the nodule enucleation of pancreatic head tumors were conducted on three patients with large tumors (>2.0 cm; T2N0M0) that were classified as grade 1 neuroendocrine tumors (Ki-67<2%). CONCLUSIONS: Our data demonstrated high penetrance of NF-PETs in 15- to 20-year-old MEN1 patients. The high percentage of the patients presenting consensus criteria for surgery for NF-PET alone or NF-PET/insulinoma suggests a potential benefit for the periodic surveillance of these tumors in this age group.

Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction: an old trick for a new dog.

BACKGROUND: Pancreatoduodenectomy is an established procedure for the treatment of benign and malignant diseases located at the pancreatic head and periampullary region. In order to decrease morbidity and mortality, we devised a unique technique using two different jejunal loops to avoid activation of pancreatic juice by biliary secretion and therefore reduce the severity of pancreatic fistula. This technique has been used for open pancreatoduodenectomy worldwide but to date has never been described for laparoscopic pancreatoduodenectomy. This article reports the technique of laparoscopic pylorus-preserving pancreatoduodenectomy with two jejunal loops for reconstruction of the alimentary tract. MATERIALS AND METHODS: After pancreatic head resection, retrocolic end-to-side pancreaticojejunostomy with duct-to-mucosa anastomosis is performed. The jejunal loop is divided with a stapler, and side-to-side jejunojejunostomy is performed with the stapler, leaving a 40-cm jejunal loop for retrocolic hepaticojejunostomy. Finally, end-to-side duodenojejunostomy is performed in an antecolic fashion. RESULTS: This technique has been successfully used in 3 consecutive patients with pancreatic head tumors: 2 patients underwent hand-assisted laparoscopic pylorus-preserving pancreatoduodenectomy, and 1 patient underwent totally laparoscopic pylorus-preserving pancreatoduodenectomy. One patient presented a Grade A pancreatic fistula that was managed conservatively. One patient received blood transfusion. Mean operative time was 9 hours. Mean hospital stay was 7 days. No postoperative mortality was observed. CONCLUSIONS: Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction is feasible and may be useful to decrease morbidity and mortality after pancreatoduodenectomy. This operation is challenging and may be reserved for highly skilled laparoscopic surgeons.

Long noncoding intronic RNAs are differentially expressed in primary and metastatic pancreatic cancer.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is known by its aggressiveness and lack of effective therapeutic options. Thus, improvement in current knowledge of molecular changes associated with pancreatic cancer is urgently needed to explore novel venues of diagnostics and treatment of this dismal disease. While there is mounting evidence that long noncoding RNAs (lncRNAs) transcribed from intronic and intergenic regions of the human genome may play different roles in the regulation of gene expression in normal and cancer cells, their expression pattern and biological relevance in pancreatic cancer is currently unknown. In the present work we investigated the relative abundance of a collection of lncRNAs in patients' pancreatic tissue samples aiming at identifying gene expression profiles correlated to pancreatic cancer and metastasis. METHODS: Custom 3,355-element spotted cDNA microarray interrogating protein-coding genes and putative lncRNA were used to obtain expression profiles from 38 clinical samples of tumor and non-tumor pancreatic tissues. Bioinformatics analyses were performed to characterize structure and conservation of lncRNAs expressed in pancreatic tissues, as well as to identify expression signatures correlated to tissue histology. Strand-specific reverse transcription followed by PCR and qRT-PCR were employed to determine strandedness of lncRNAs and to validate microarray results, respectively. RESULTS: We show that subsets of intronic/intergenic lncRNAs are expressed across tumor and non-tumor pancreatic tissue samples. Enrichment of promoter-associated chromatin marks and over-representation of conserved DNA elements and stable secondary structure predictions suggest that these transcripts are generated from independent transcriptional units and that at least a fraction is under evolutionary selection, and thus potentially functional.Statistically significant expression signatures comprising protein-coding mRNAs and lncRNAs that correlate to PDAC or to pancreatic cancer metastasis were identified. Interestingly, loci harboring intronic lncRNAs differentially expressed in PDAC metastases were enriched in genes associated to the MAPK pathway. Orientation-specific RT-PCR documented that intronic transcripts are expressed in sense, antisense or both orientations relative to protein-coding mRNAs. Differential expression of a subset of intronic lncRNAs (PPP3CB, MAP3K14 and DAPK1 loci) in metastatic samples was confirmed by Real-Time PCR. CONCLUSION: Our findings reveal sets of intronic lncRNAs expressed in pancreatic tissues whose abundance is correlated to PDAC or metastasis, thus pointing to the potential relevance of this class of transcripts in biological processes related to malignant transformation and metastasis in pancreatic cancer.

Cognitive performance and mood in patients on the waiting list for liver transplantation and their relation to the model for end-stage liver disease / Desempenho cognitivo e humor em pacientes em lista de espera de transplante de fígado e suas relações com modelo para doença hepática e fase terminal

Objective: To investigate the links between depression and cognitive functioning in patients with Hepatitis C and other chronic liver diseases with and without the use of alcohol on the waiting list for liver transplantation and their associations with the MELD classification. Method: 40 patients were evaluated on a waiting list for liver transplant by a battery of neuropsychological tests, depression scales and interview at the Liver Transplant Service, of the Hospital das Clínicas University of São Paulo Medical School. Results: After splitting the sample according to the education, the results showed statistical significance in the comparisons between groups of MELD > 15 and <15 in the following functions: estimated IQ, visual-spatial delayed recall and recognition as part of episodic memory and short term memory. Conclusion: These findings, usually found in hepatic encephalopathy, corroborated with the literature and emphasized the need to investigate in more detail the cognitive functions of these patients in order to facilitate the adoption of different conducts.

Objetivo: Investigar as relações entre depressão e funcionamento cognitivo em pacientes portadores de hepatite C e demais doenças hepáticas crônicas com e sem uso de álcool em fila de espera para transplante hepático e suas relações com a classificação MELD. Método: Foram avaliados 40 pacientes em lista de espera para transplante hepático por bateria de testes neuropsicológicos, escalas de depressão e entrevista no Serviço de Transplante do Fígado do HC-FMUSP. Resultados: Após divisão da amostra por escolaridade os resultados mostraram significância estatística nas comparações entre grupos de MELD > 15 e <15 nas funções: QI estimado, memória episódica de evocação tardia e de reconhecimento visuo-espacial e memória de curto prazo. Conclusão: As dificuldades encontradas, comuns ao quadro de encefalopatia hepática, corroboram a literatura pesquisada e enfatizam a necessidade de se investigar de maneira mais detalhada o funcionamento cognitivo destes pacientes, uma vez que diferentes condutas podem ser adotadas.

Generation and characterization of human insulin-releasing cell lines.

BACKGROUND: The in vitro culture of insulinomas provides an attractive tool to study cell proliferation and insulin synthesis and secretion. However, only a few human beta cell lines have been described, with long-term passage resulting in loss of insulin secretion. Therefore, we set out to establish and characterize human insulin-releasing cell lines. RESULTS: We generated ex-vivo primary cultures from two independent human insulinomas and from a human nesidioblastosis, all of which were cultured up to passage number 20. All cell lines secreted human insulin and C-peptide. These cell lines expressed neuroendocrine and islets markers, confirming the expression profile found in the biopsies. Although all beta cell lineages survived an anchorage independent culture, none of them were able to invade an extracellular matrix substrate. CONCLUSION: We have established three human insulin-releasing cell lines which maintain antigenic characteristics and insulin secretion profiles of the original tumors. These cell lines represent valuable tools for the study of molecular events underlying beta cell function and dysfunction.

Hepatectomia laparoscópica no tratamento das metástases hepáticas / Laparoscopic hepatectomy for liver metastasis

Descreve-se experiência inicial e resultados imediatos da hepatectomia laparoscópica no tratamento de metástases hepáticas em quatro pacientes. Uma paciente foi submetida a hepatectomia direita e três foram submetidas a bissegmentectomia 6-7. O tempo médio cirúrgico foi de 360 minutos e 4 dias de internação. Uma paciente apresentou fístula biliar autolimitada. Mortalidade operatória foi nula. Conclui-se que hepatectomia maior laparoscópica é factível, segura e apresenta excelentes resultados imediatos, com retorno precoce às atividades profissionais. Entretanto, ainda são necessários estudos com maior número de casos e trabalhos comparativos para se estabelecer limites e indicações deste procedimento em metástases hepáticas.

The authors describe their initial experience and immediate results with laparoscopic liver resection in the treatment of four patients with liver metastasis. Three patients underwent laparoscopic anatomic bisegmentectomy 6-7 and one laparoscopic right hemihepatectomy. Mean operation time was 360 minutes and median hospital stay was 4 days. One patient developed bile leakage that was treated conservatively. No postoperative mortality was observed. This initial experience demonstrates that laparoscopic liver resection can be safely done with excellent immediate results. However larger and comparative studies are still needed to establish indications and limits for laparoscopy in the treatment of liver metastasis.

Double-dose hepatitis B vaccination in cirrhotic patients on a liver transplant waiting list

Development of immunity to hepatitis B virus in cirrhotic patients waiting for liver transplantation is highly desirable. Though a double-dose regimen is available, little is know about its effectiveness. We examined the efficacy of double-dose hepatitis B virus vaccination in cirrhotic patients waiting for liver transplantation. We studied 43 patients who were waiting for liver transplantation. They were vaccinated with three doses of 40 mg hepatitis B vaccine at 0, 1 and 6 months; the normal dose is 20 mg. Efficacy was measured based on seroconversion of anti-HBs. Global response to the primary vaccination scheme was 67.5 percent (29 patients). Forty-one per cent of responders had anti-HBs titers above 1,000 IU/mL. No factors were associated with response, based on multivariate analysis. The vaccination scheme of 40 mg at 0, 1 and 6 months was superior to conventional vaccination doses (20 mg) for cirrhotic patients on a waiting list for liver transplantation.

Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.

BACKGROUND: Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection. However, laparoscopic liver resection has not been widely developed and anatomical segmental liver resection is not currently performed due to difficulty to control segmental Glissonean pedicles laparoscopically. METHODS: Seven consecutive patients underwent laparoscopic liver resection using an intrahepatic Glissonian approach from April 2007 to September 2007. Three patients underwent laparoscopic bisegmentectomy 6-7 and 4 patients underwent laparoscopic right hemihepatectomy. RESULTS: Blood transfusion was required in 1 patient. Mean operation time was 460 minutes (range 300-630 minutes). The median hospital stay was 5 days (range 3-8 days). One patient developed bile leakage that was treated conservatively. No patient had postoperative signs of liver failure. No postoperative mortality was observed. CONCLUSIONS: The main advantage over other techniques is the possibility to gain a rapid and precise access to the right posterior and anterior sheaths facilitating right hemihepatectomy, and right anterior and posterior sectionectomies. We believe that the described technique facilitates laparoscopic liver resection by reducing the technical difficulties in pedicle control and may increase the development of segment-based laparoscopic liver resections.

Solid pseudopapillary neoplasm of the pancreas: distinct patterns of onset, diagnosis, and prognosis for male versus female patients.

BACKGROUND: Solid pseudopapillary neoplasm of the pancreas is a distinctive pancreatic neoplasm with low metastatic potential. This study examines clinical differences and prognosis between male and female patients. METHODS: The medical records of 34 consecutive patients with pancreatic solid pseudopapillary neoplasms between 1990 and 2006 were reviewed. Whenever feasible, organ-preserving operation was performed. Statistical analysis was performed using chi-square and Student t test. RESULTS: There were 27 women (79%) and seven men (21%) with median age of 23 years. Mean diameter of the tumor was 7 cm. Tumor size tended to be smaller in patients treated in more recent years. Conservative surgery was possible in 11 patients including spleen-preserving distal pancreatectomy in 3, central pancreatectomy in 5, and enucleation in 3 patients. Median hospital stay was 11 days, morbidity rate was 62%, including 17 patients with grade A pancreatic fistula, and there was no operative mortality. Mean follow-up time was 84 months. Tumor recurred in 2 patients (6%). Overall late morbidity rate was 12%. At the time of diagnosis, age was (x +/- SD) higher among male patients (25 +/- 2 years vs 37 +/- 7 years; P <.05) with no difference in tumor size. The neoplasms were more aggressive in male patients; therefore, conservative surgery was less likely. There was no correlation between tumor aggressiveness and age of the patient or size of tumor. CONCLUSION: This is the first single center study to demonstrate that solid pseudopapillary neoplasms in male patients have distinct patterns of onset and aggressiveness when compared with female patients. Although valid prognostic criteria are still lacking, it appears that male patients may be best treated by more radical operation and should be observed more closely during follow-up.

[Laparoscopic hepatectomy for liver metastasis]. / Hepatectomia laparoscópica no tratamento das metástases hepáticas.

The authors describe their initial experience and immediate results with laparoscopic liver resection in the treatment of four patients with liver metastasis. Three patients underwent laparoscopic anatomic bisegmentectomy 6-7 and one laparoscopic right hemihepatectomy. Mean operation time was 360 minutes and median hospital stay was 4 days. One patient developed bile leakage that was treated conservatively. No postoperative mortality was observed. This initial experience demonstrates that laparoscopic liver resection can be safely done with excellent immediate results. However larger and comparative studies are still needed to establish indications and limits for laparoscopy in the treatment of liver metastasis.