Preoperative hepatic artery embolization before distal pancreatectomy plus celiac axis resection does not improve surgical results: A Spanish multicentre study.

BACKGROUND: Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical procedure with high morbidity and mortality performed in patients with locally advanced pancreatic cancer. Preoperative embolization of hepatic artery (PHAE) has been postulated as a technical option to increase resection rate. OBJECTIVE: comparison of morbidity and mortality at 90 days, operative time, hospital stay and survival between patients that performed DP-CAR with and without PHAE. METHODS: Observational retrospective multicentre study. INCLUSION CRITERIA: patient operated in Spanish centers with DP-CAR for pancreatic cancer from April 2004 until 23 June 2018. Preoperative (PHAE, neodjuvant treatment), intraoperative (operative time and blood loss) and postoperative data (morbidity, hospital stay, R0 and survival) were studied. Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Data were analyzed using R version 3.1.3 (http://www.r-project.org). Level of significance was set at 0.05. RESULTS: 41 patients were studied. 26 patients were not embolized (NO-PHAE group) and 15 patients received PHAE. Preoperative BMI and percentage of neoadjuvant chemotherapy were the only preoperative variables different between both groups. The operative time in the PHAE group was shorter (343 min) than in the non-PHAE group (411 min) (p < 0.06). Major morbidity (Clavien > IIIa) and mortality at 90 days were higher in the PHAE group than in the non-PHAE group (60% vs 23% and 26.6% vs 11.6% respectively) (p < 0.004). No statistical difference in overall survival was observed between both groups (p = 0.14). CONCLUSION: In our study PHAE is not related with less postoperative morbidity. Even more, major morbidity (Clavien III-IV) and mortality was higher in PHAE group.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND: Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates. METHODS: Observational retrospective multicenter study. INCLUSION CRITERIA: patient undergoing TP, PD or DP plus CAR for a pancreatic cancer. RESULTS: Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups. CONCLUSION: It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

Extracellular volume, nutritional status, and refeeding changes.

ECW, and particularly its interstitial component, expands easily with malnutrition, sepsis, and trauma and after aggressive intravenous fluid therapy. In this scenario, hypoalbuminemia is usually the result of both an increased capillary escape rate due to leaky endothelium and increased distribution volume; this can be worsened by artificial intravenous nutrition with sodium, water, and glucose. Monitoring ECW is essential during TPN. Short-term changes in weight and serum albumin concentration are helpful to control ECW volume and prevent ECW expansion. Tetrapolar bioimpedance analysis is a promising technique for accurate bedside measurement of changes in body fluid compartments.

Disseminated and recurrent sarcoid-like granulomatous panniculitis due to bovine collagen injection.

Three to five percent of patients treated with injectable collagen implants have adverse local reactions. Systemic signs or symptoms are infrequent. We describe the case of a 53-year-old woman who developed local and general complaints 2 months after receiving two collagen injections in both nasolabial folds. She presented asthenia, malaise, polyarthralgia and inflammatory nodular panniculitis in the places of injection as well as on the forearms and lower extremities. Skin testing was compatible with hypersensitivity to collagen. This case raises the question as to whether the injection of animal-derived collagen induces manifestations similar to those observed in connective autoimmune diseases or human adjuvant disease.

[Silicone and autoimmune diseases]. / Silicona y enfermedades autoinmunes.

There exists controversy surrounding the potential relationship between silicone implants and autoimmune diseases. Indeed, silicone is not an inert substance and microparticles from the prosthesis can migrate causing localised or generalised reactions. Most notably, silicone has been associated with sclerodermia and human adjuvant disease. Sclerodermia has been observed within 50% patients suffering from autoimmune diseases linked with silicone. For patients with symptoms, the removal of the prosthesis achieves a favourable response in 50% of the cases. Before a patient undergoes a silicone implant, it is essential that personal and family history of autoimmune disorders are ascertained and evaluated. Also, the patient should undergo regular check ups after having received the implant. In spite of the fact that certain epidemiological studies have not demonstrated a relationship between silicone implants and autoimmune disease, the continual appearance of new cases means that the physician should have an open attitude and be aware of the possibility.

Massive necrosis of the gastrointestinal tract after ingestion of hydrochloric acid.

OBJECTIVE: To describe our experience of dealing with patients admitted as emergencies after massive ingestion of hydrochloric acid, and to find out the most important prognostic factors. DESIGN: Retrospective review. SETTING: Teaching hospital, Spain. SUBJECTS: 21 patients with massive necrosis of the upper gastrointestinal tract after ingestion of acid who presented during the past 14 years (November 1984-March 1998). INTERVENTIONS: All patients were operated on immediately, 17 without an endoscopic examination. In all cases, the laparotomy showed various degrees of damage to the intra-abdominal oesophagus (from oedema to blackening) and gastric necrosis. Twelve patients also had necrosis of the entire duodenum. In the other nine, the necrosis did not affect more than the pylorus or duodenum. All these 12 patients were treated by a total oesophago-gastrectomy without thoracotomy. Of the 12 patients with total necrosis of the duodenum, 4 did not have resections and in 8, various massive resections of the necrotic structures were done. MAIN OUTCOME MEASURES: Mortality. RESULTS: Fourteen of the 21 patients died during the operation or in the early or late postoperative period. All 12 patients with total duodenal necrosis died, whereas only 2 patients in the other group. CONCLUSIONS: The ingestion of relatively small amounts of water-based solutions of hydrochloric acid of 24% or 32% concentration produces immediate and massive necrosis of the upper digestive tract, which results in high mortality. The poor prognosis might be improved by rapid responses to stop duodenal necrosis.