IS THERE A ROLE FOR BILIODIGESTIVE BYPASS SURGERY IN TREATING CHOLESTASIS IN ADVANCED PANCREATIC CANCER?

BACKGROUND: The unresectable pancreatic head tumors develop obstructive jaundice and cholestasis during follow-up. Cholestasis is associated with complications and treatment options are endoscopic stenting (ES) and biliary bypass surgery (BBS). AIMS: The aim of the current study was to compare the safety and efficacy of biliary bypass surgery (BBS) and endoscopic stenting (ES) for cholestasis in advanced pancreas cancer. METHODS: This is a retrospective cohort of patients with cholestasis and unresectable or metastatic pancreas cancer, treated with BBS or ES. Short and long-term outcomes were evaluated. We considered the need for hospital readmission due to biliary complications as treatment failure. RESULTS: A total of 93 patients (BBS=43; ES=50) were included in the study. BBS was associated with a higher demand for postoperative intensive care (37 vs.10%; p=0.002, p<0.050), longer intensive care unit stay (1.44 standard deviation±2.47 vs. 0.66±2.24 days; p=0.004, p<0.050), and longer length of hospital stay (7.95±2.99 vs. 4.29±5.50 days; p<0.001, p<0.050). BBS had a higher risk for procedure-related complications (23 vs. 8%; p=0.049, p<0.050). There was no difference in overall survival between BBS and ES (p=0.089, p>0.050). ES was independently associated with a higher risk for treatment failure than BBS on multivariate analysis (hazard ratio 3.97; p=0.009, p<0.050). CONCLUSIONS: BBS is associated with longer efficacy than ES for treating cholestasis in advanced pancreatic cancer. However, the BBS is associated with prolonged intensive care unit and hospital stays and higher demand for intensive care.

Choledocoduodenal Biliary Bypass for Recurrent Choledocholithiasis in a Patient with Gastric Bypass: An Old Trick to Solve a Modern Problem.

Bariatric patients are at risk for developing biliary stones. Choledocholithiasis poses a significant challenge in Roux-en-Y gastric bypass patients due to anatomical changes, complicating the treatment. We present a case of a 71-year-old female with recurrent choledocholithiasis post-bariatric surgery. After failed endoscopic attempts, a biliodigestive bypass with choledocoduodenal anastomosis was performed successfully using the Da Vinci robotic platform. This technique offers a single anastomosis, excluding the duodenum from transit, preventing food reflux. The patient had an uneventful recovery with no recurrence after 1 year. The choledocoduodenal anastomosis is a viable option for biliary diversion in patients with challenging endoscopic access post-gastric bypass, offering favorable outcomes.

ROBOTIC ASSISTED VERSUS LAPAROSCOPIC DISTAL PANCREATECTOMY: A RETROSPECTIVE STUDY.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown. AIMS: To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias. METHODS: This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS). RESULTS: Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP - 72,4% versus LDP - 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP). CONCLUSIONS: The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher.

Robotic assisted versus laparoscopic distal pancreatectomy: a retrospective study / Pancreatectomia distal robótica versus laparoscópica: um estudo retrospectivo

ABSTRACT BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown. AIMS: To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias. METHODS: This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS). RESULTS: Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP - 72,4% versus LDP - 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP). CONCLUSIONS: The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher.

RESUMO RACIONAL: A pancreatectomia distal minimamente invasiva (PDMI) está associada a menos perda sanguínea e recuperação funcional mais rápida, no entanto, os benefícios da pancreatectomia distal robótica (PDR) são desconhecidos quando comparada a pancreatectomia distal laparoscópica (PDL). OBJETIVOS: Comparar PDR versus PDL no tratamento cirúrgico de lesões benignas, neoplasias pancreáticas malignas, pré-malignas e limítrofes. MÉTODOS: Estudo retrospectivo comparando PDL com PDR. Os desfechos primários avaliados foram morbidade e custos hospitalares. Os desfechos secundários foram fístula pancreática (FP), complicações infecciosas, readmissão, tempo cirúrgico e tempo de internação hospitalar (TIH). RESULTADOS: Trinta pacientes submetidos a PDL e 29 submetidos a PDR foram incluídos no estudo. Não houve diferença em relação às características pré-operatórias. Não houve diferença em relação às complicações gerais (PDL - 72,4% versus PRD - 80%, p=0,49). Os custos foram superiores para PDR (PDR=US$ 6688 versus PDL=US$ 6149, p=0,02), principalmente devido aos custos mais elevados de materiais cirúrgicos (PDR=US$ 2364 versus PDL=1421, p=0,00005). Vinte e um pacientes submetidos a PDR e 24 submetidos a PDL desenvolveram fístula pancreática (PF), no entanto, apenas 4 submetidos PDR e 7 a PDL apresentaram complicações infecciosas associadas a FP. O tempo cirúrgico (PDR=224 min. versus PDL=213 min., p=0,36) e a conversão para cirurgia aberta (1 PDR e 2 PDL) não tiveram diferença estatística. CONCLUSÕES: A morbidade pós operatória da pancreatectomia distal robótica é comparável à pancreatectomia distal laparoscópica. Entretando, os custos da pancreatectomia distal robótica são mais elevados.

Insights of Outcome after Resection of Small Nonfunctioning Neuroendocrine Pancreatic Tumors.

BACKGROUND: The incidence of small nonfunctioning neuroendocrine pancreatic tumors (NF-PNETs) has been increasing systematically in the last few decades. Surgical resection was once considered the treatment of choice but has been questioned in the direction of a more conservative approach for selected patients. Our aim was to analyze the outcome of surgical resection of small (≤3cm) NF-PNETs. METHODS: We retrospectively evaluated 14 patients with sporadic NF-PNETs who underwent pancreatic resection. Data were collected from patients' medical records. RESULTS: Of the 14 patients included, 35.71% were men, and the average age was 52.36 ± 20.36 years. Comorbidities were present in 92.86% of the cases. The incidence of postoperative complications was 42.86%, the 30-day mortality was zero, and the length of follow-up was 3.31 ± 3.0 years. The results of pathological evaluations revealed WHO grade I in 42.86% of cases, II in 21.43%, and neuroendocrine carcinoma in 35.71%. The median tumor size was 1.85cm (range, 0.5-3cm), and 2 cases had synchronous metastasis. The median TNM stage was IIa (range, I-IV). The disease-free and patient survival rates were 87.5% and 100% at 3 years and 43.75% and 75% at 10 years, respectively. The tumor pathological grade was significantly higher in head tumors than body-tail tumors, but there were no differences with respect to tumor size and TNM staging. CONCLUSION: A surgical approach to treat small sporadic NF-PNETs is safe with low mortality and high patient survival. Based on these data, small pancreatic head tumors can be more aggressive, suggesting that surgical resection is still the best option to treat small nonfunctioning PNETS. Thus, conservative treatment should be indicated very cautiously for only cases with absolute contraindications for surgery.

Advanced age does not increase morbidity in pancreaticoduodenectomy.

BACKGROUND: Due to rising life expectancy of population, very complex surgical procedures such as pancreaticoduodenectomy (PD), are more commonly being performed in elderly patients. The objective of this study was to evaluate the safety of PD in patients older than 75 years old and the risk factors associated with severe complications. METHODS: Patients who underwent PD for periampullary tumors were retrospectively reviewed and divided into two groups, A (<75 years) and B (>75 years). The primary endpoint was severe postoperative complications (Clavien 3 or greater). Secondary endpoints were mortality and any complications. RESULTS: Ninety consecutive patients underwent PD for periampullary tumors in the studied period, 70 in group A and 20 in group B. Clinical and pathological characteristics of both groups were equivalents except for age. There were no difference regarding the incidence of severe complications (17% vs. 10%, P=0.72) or all complications (50% vs. 50%, P>0.999). Although mortality was greater in group A (8.6% vs. 0%), it was not statistically significant (P=0.333). On multivariate analyses, only male sex, obesity and American Society of Anesthesiology Score of 3 or 4 were associated with severe postoperative complications. CONCLUSIONS: Poor clinical status, obesity and male gender are associated with severe complications in PD, but not age greater than 75 years, therefore PD can be considered safe in elderly patients and age itself should not be a contraindication for PD.

MINIMALLY INVASIVE SURGERY FOR PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS.

BACKGROUND: Solid pseudopapillary pancreatic neoplasia is usually a large well-circumscribed pancreatic mass, with cystic and solid areas more frequently found in young women. It is a benign pancreatic neoplasia in most cases, therefore minimally invasive surgery could be an interesting approach. AIM: Evaluate the results of minimally invasive surgery for this neoplasia. METHODS: Patients with this tumor who underwent minimally invasive pancreatectomies between 2009 and 2015 in a single institution, were analyzed regarding demographic, clinical-pathological futures, post-operative morbidity and disease-free survival. RESULTS: All were women, and their median age was 39 (18-54) years. Two patients with tumor in the head of the pancreas underwent laparoscopic pancreaticoduodenectomy, and another one underwent laparoscopic enucleation. Two patients with tumor in the neck underwent central pancreatectomy. Distal pancreatectomies were performed in the other five, one with splenic preservation. None required blood transfusion or conversion to open surgery. Two (20%) developed clinical relevant pancreatic fistulas, requiring readmission. Median length of postoperative hospital stay was five days (2-8). All resection margins were negative. Patients were followed for a median of 38 months (14-71), and there was no recurrence. CONCLUSIONS: Minimally invasive surgery for solid pseudopapillary pancreatic neoplasia is feasible for tumors in different locations in the pancreas. It was associated with acceptable morbidity and respected the oncologic principles for treatment.

RACIONAL: Tumores sólidos pseudopapilíferos do pâncreas são em geral massas circunscritas, com componentes sólidos e císticos, mais frequentemente encontrados em mulheres jovens. Na maioria dos casos, são neoplasias benignas e portanto, a abordagem minimamente invasiva pode ser considerada vantajosa. OBJETIVO: Avaliar os resultados das pancreatectomias laparoscópicas em pacientes com esses tumores. MÉTODOS: Foram avaliados pacientes submetidos à pancreatectomias minimamente invasivas em um única instituição. Foram analisadas variáveis demográficas, clinicopatológicas, complicações pós-operatórias e sobrevida. RESULTADOS: Todos os pacientes eram mulheres e a idade mediana foi de 39 (18-54) anos. Duas pacientes com tumores na cabeça do pâncreas foram submetidas à duodenopancreatectomia e outra à enucleação. Duas pacientes com tumores no colo do pâncreas realizaram pancreatectomia central. Outras cinco com neoplasias no corpo e cauda foram submetidas à pancreatectomia distal, uma delas com preservação do baço. Nenhuma necessitou de conversão para laparotomia. Houve duas fístulas pancreáticas clinicamente relevantes (20%). O tempo mediano de internação foi de cinco (2 a 8) dias e duas pacientes foram reinternadas (20%). Todas as margens de ressecção foram negativas e após seguimento mediano de 38 (14-71) semanas, todas estavam livres de doença. CONCLUSÃO: As ressecções pancreáticas minimamente invasivas de tumores sólidos pseudopapilíferos são factíveis para tumores em diferentes localizações no pâncreas, com morbidade aceitável obedecendo-se os princípios oncológicos para o tratamento dessas neoplasias.

Evaluation of microvessel density and p53 expression in pancreatic adenocarcinoma.

OBJECTIVE: To evaluate the prognostic significance of microvessel density and p53 expression in pancreatic cancer. METHODS: Between 2008 and 2012, 49 patients with pancreatic adenocarcinoma underwent resection with curative intention. The resected specimens were immunohistochemically stained with anti-p53 and anti-CD34 antibodies. Microvessel density was assessed by counting vessels within ten areas of each tumoral section a highpower microscope. RESULTS: The microvessel density ranged from 21.2 to 54.2 vessels/mm2. Positive nuclear staining for p53 was found in 20 patients (40.6%). The overall median survival rate after resection was 24.1 months and there were no differences in survival rates related to microvessel density or p53 positivity. Microvessel density was associated with tumor diameter greater than 3.0 cm and with R0 resection failure. CONCLUSIONS: Microvessel density was associated with R1 resection and with larger tumors. p53 expression was not correlated with intratumoral microvessel density in pancreatic adenocarcinoma.

Evaluation of microvessel density and p53 expression in pancreatic adenocarcinoma

OBJECTIVE: To evaluate the prognostic significance of microvessel density and p53 expression in pancreatic cancer. METHODS: Between 2008 and 2012, 49 patients with pancreatic adenocarcinoma underwent resection with curative intention. The resected specimens were immunohistochemically stained with anti-p53 and anti-CD34 antibodies. Microvessel density was assessed by counting vessels within ten areas of each tumoral section a highpower microscope. RESULTS: The microvessel density ranged from 21.2 to 54.2 vessels/mm2. Positive nuclear staining for p53 was found in 20 patients (40.6%). The overall median survival rate after resection was 24.1 months and there were no differences in survival rates related to microvessel density or p53 positivity. Microvessel density was associated with tumor diameter greater than 3.0 cm and with R0 resection failure. CONCLUSIONS: Microvessel density was associated with R1 resection and with larger tumors. p53 expression was not correlated with intratumoral microvessel density in pancreatic adenocarcinoma.

Minimally invasive surgery for pseudopapillary neoplasm of the pancreas / Cirurgia minimamente invasiva para tratamento da neoplasia pseudopapilar do pâncreas

ABSTRACT Background: Solid pseudopapillary pancreatic neoplasia is usually a large well-circumscribed pancreatic mass, with cystic and solid areas more frequently found in young women. It is a benign pancreatic neoplasia in most cases, therefore minimally invasive surgery could be an interesting approach. Aim: Evaluate the results of minimally invasive surgery for this neoplasia. Methods: Patients with this tumor who underwent minimally invasive pancreatectomies between 2009 and 2015 in a single institution, were analyzed regarding demographic, clinical-pathological futures, post-operative morbidity and disease-free survival. Results: All were women, and their median age was 39 (18-54) years. Two patients with tumor in the head of the pancreas underwent laparoscopic pancreaticoduodenectomy, and another one underwent laparoscopic enucleation. Two patients with tumor in the neck underwent central pancreatectomy. Distal pancreatectomies were performed in the other five, one with splenic preservation. None required blood transfusion or conversion to open surgery. Two (20%) developed clinical relevant pancreatic fistulas, requiring readmission. Median length of postoperative hospital stay was five days (2-8). All resection margins were negative. Patients were followed for a median of 38 months (14-71), and there was no recurrence. Conclusions: Minimally invasive surgery for solid pseudopapillary pancreatic neoplasia is feasible for tumors in different locations in the pancreas. It was associated with acceptable morbidity and respected the oncologic principles for treatment.

RESUMO Racional: Tumores sólidos pseudopapilíferos do pâncreas são em geral massas circunscritas, com componentes sólidos e císticos, mais frequentemente encontrados em mulheres jovens. Na maioria dos casos, são neoplasias benignas e portanto, a abordagem minimamente invasiva pode ser considerada vantajosa. Objetivo: Avaliar os resultados das pancreatectomias laparoscópicas em pacientes com esses tumores. Métodos: Foram avaliados pacientes submetidos à pancreatectomias minimamente invasivas em um única instituição. Foram analisadas variáveis demográficas, clinicopatológicas, complicações pós-operatórias e sobrevida. Resultados: Todos os pacientes eram mulheres e a idade mediana foi de 39 (18-54) anos. Duas pacientes com tumores na cabeça do pâncreas foram submetidas à duodenopancreatectomia e outra à enucleação. Duas pacientes com tumores no colo do pâncreas realizaram pancreatectomia central. Outras cinco com neoplasias no corpo e cauda foram submetidas à pancreatectomia distal, uma delas com preservação do baço. Nenhuma necessitou de conversão para laparotomia. Houve duas fístulas pancreáticas clinicamente relevantes (20%). O tempo mediano de internação foi de cinco (2 a 8) dias e duas pacientes foram reinternadas (20%). Todas as margens de ressecção foram negativas e após seguimento mediano de 38 (14-71) semanas, todas estavam livres de doença. Conclusão: As ressecções pancreáticas minimamente invasivas de tumores sólidos pseudopapilíferos são factíveis para tumores em diferentes localizações no pâncreas, com morbidade aceitável obedecendo-se os princípios oncológicos para o tratamento dessas neoplasias.