Multifactorial mitigation strategy to reduce clinically relevant pancreatic fistula in high-risk pancreatojejunostomy following pancreaticoduodenectomy.

INTRODUCTION: Postoperative pancreatic fistula (POPF) is the most dreadful complication of pancreaticoduodenectomy (PD) and previous literature focused on technical modifications of pancreatic remnant reconstruction. We developed a multifactorial mitigation strategy (MS) and the aim of the study is to assess its clinical impact in patients at high-risk of POPF. METHODS: All patients candidate to PD between 2012 and 2018 were considered. Only patients with a high Fistula Risk Score (FRS 7-10) were included. Patients undergoing MS were compared to patients receiving Standard Strategy (SS). Clinical outcomes were compared between the two groups. Multivariate hierarchical logistic regression analyses were performed to detect independent predictors of POPF. RESULTS: Out of 212 patients, 33 were finally included in MS Group and 29 in SS Group. POPF rate was significantly lower in MS Group (12.1% vs 44.8%, p = 0.005). Delayed gastric emptying, postoperative pancreatitis, complications and hospital stay were also significantly lower in MS Group. Hierarchical logistic regression analyses showed that Body Mass Index (OR = 1.196, p = 0.036) and MS (OR = 0.187, p = 0.032) were independently associated with POPF. CONCLUSION: A multifactorial MS can be helpful to reduce POPF rate in patients with high FRS following PD. Personalized approach for vulnerable patients should be investigated in the future.

Clinical impact of preoperative tumour contact with superior mesenteric-portal vein in patients with resectable pancreatic head cancer.

INTRODUCTION: The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival. METHODS: All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV. RESULTS: Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis. CONCLUSION: Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.

Prehabilitation in patients undergoing pancreaticoduodenectomy: a randomized controlled trial.

INTRODUCTION: prehabilitation has been proposed as an effective tool to prevent postoperative complications in patients undergoing major abdominal surgery. However, no studies have demonstrated its effectiveness in pancreatic surgical patients. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing a pancreaticoduodenectomy (PD). METHODS: this was a randomized controlled trial. Eligible candidates who accepted to participate were randomized to the control (standard care) or intervention (standard care + prehabilitation) group. All patients with pancreatic or periampullary tumors who were candidates for pancreaticoduodenectomy were included. Patients who received neoadjuvant treatment were excluded. Prehabilitation covered three actions: a) nutritional support; b) control of diabetes and exocrine pancreatic insufficiency; and c) physical and respiratory training. The main study outcome was the proportion of patients who suffered postoperative complications. Secondary outcomes included the occurrence of specific complications (pancreatic leak and delayed gastric emptying) and hospital stay. RESULTS: forty patients were included in the analysis. Twenty-two patients were randomized to the control arm and 18, to the intervention group. No statistically significant differences were observed in terms of overall and major complications between the prehabilitation and standard care groups. Pancreatic leak was not statistically different between the groups (11% vs 27%, p = 0.204). However, DGE was significantly lower in the prehabilitation group (5.6% vs 40.9% in the standard care group, p = 0.01). CONCLUSION: prehabilitation did not reduce postoperative complications following pancreaticoduodenectomy. However, a reduction in DGE was observed. Further studies are needed to validate the role and the timing of prehabilitation in high-risk patients.

Microwave ablation of colorectal liver metastases: Impact of a 10-mm safety margin on local recurrence in a tertiary care hospital.

Microwave ablation (MWA) for colorectal liver metastasis (CLM) has been traditionally considered inferior to surgery due to the higher rate of local recurrence. The study investigated whether a safety margin of 10 mm can improve local control in patients undergoing surgical MWA. Surgical MWA was used to treat 53 lesions in 22 patients with CLM at our Institution from June 2012 to June 2017. The patients' mean age was 64.5 years, and the median size of the lesion was 16.5 mm (9-34 mm). MWA was associated with liver resection in 16 patients (72.7%). The median follow-up was 32.4 months. Univariate and multivariate analyses were performed to identify factors associated with tumor recurrence. Median ablation area was 36.6 mm2 (30-50 mm2). The complication rate was 22.7%. No local recurrence was observed during follow-up. Disease-free survival was 20 months (4.8-55.2 months). Univariate analysis revealed that the number of liver metastases and node-positive primary tumors were associated with tumor recurrence. Multivariate analysis revealed that node-positive primary tumor was the only factor significantly associated with tumor recurrence (p = 0.049; odds ratio, 12; 95% confidence interval, 1-143). When performed with a 10-mm safety margin, surgical MWA can lead to acceptable oncological outcomes with low morbidity. Therefore, it represents a good option in selected patients with CLM.

Prehabilitation in patients undergoing pancreaticoduodenectomy: a randomized controlled trial

Introduction: prehabilitation has been proposed as an effective tool to prevent postoperative complications in patients undergoing major abdominal surgery. However, no studies have demonstrated its effectiveness in pancreatic surgical patients. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing a pancreaticoduodenectomy (PD). Methods: this was a randomized controlled trial. Eligible candidates who accepted to participate were randomized to the control (standard care) or intervention (standard care + prehabilitation) group. All patients with pancreatic or periampullary tumors who were candidates for pancreaticoduodenectomy were included. Patients who received neoadjuvant treatment were excluded. Prehabilitation covered three actions: a) nutritional support; b) control of diabetes and exocrine pancreatic insufficiency; and c) physical and respiratory training. The main study outcome was the proportion of patients who suffered postoperative complications. Secondary outcomes included the occurrence of specific complications (pancreatic leak and delayed gastric emptying) and hospital stay. Results: forty patients were included in the analysis. Twenty-two patients were randomized to the control arm and 18, to the intervention group. No statistically significant differences were observed in terms of overall and major complications between the prehabilitation and standard care groups. Pancreatic leak was not statistically different between the groups (11% vs 27%, p = 0.204). However, DGE was significantly lower in the prehabilitation group (5.6% vs 40.9% in the standard care group, p = 0.01). Conclusion: prehabilitation did not reduce postoperative complications following pancreaticoduodenectomy. However, a reduction in DGE was observed. Further studies are needed to validate the role and the timing of prehabilitation in high-risk patients

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[Jaundice and chronic pancreatitis: common bile duct compression by pancreatic pseudocyst]. / Ictericia y pancreatitis crónica: compresión de la vía biliar principal por un seudoquiste pancreático.

In chronic pancreatitis, obstructive jaundice solely due to common bile duct compression by a pancreatic pseudocyst is highly unusual. In most of these cases, the jaundice is due to fibrotic stricture of the intrapancreatic portion of the common bile duct. We report two cases of obstructive jaundice in chronic pancreatitis with pseudocyst. Operative findings and follow-up during the postoperative period demonstrated compression by the pseudocyst over the common bile duct as the only etiologic factor of the jaundice. We believe that intraoperative cholangiography should be performed after drainage of a pseudocyst to correctly assess the etiology of obstruction.

[Tracheoesophageal fistula in an intubated patient. Treatment through exclusion and esophageal patch]. / Fístula traqueoesofágica en paciente intubado: tratamiento mediante exclusión y patch esofágico.

Currently, acquired benign tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. Their occurrence in intubated patients is infrequent but devastating and their therapeutic resolution is highly complex. We present the case of a patient with an extensive tracheoesophageal fistula following tracheal intubation that was surgically treated through esophageal exclusion (cervical esophagostomy and suture-stapling of the distal esophagus) and closure of the tracheal defect using the posterior esophageal wall.

Ictericia y pancreatitis crónica: compresión de la vía biliar principal por un seudoquiste pancreático / Jaundice and chronic pancreatitis: common bile duct compression by pancreatic pseudocyst

En la pancreatitis crónica, la ictericia obstructiva debida únicamente a la compresión de la vía biliar principal por un seudoquiste de páncreas es un hecho muy poco frecuente. En la mayoría de estas ocasiones, la ictericia se debe a la obliteración por fibrosis de la vía biliar intrapancreática. Presentamos 2 casos de ictericia obstructiva en el seno de una pancreatitis crónica, en los cuales los hallazgos operatorios y la evolución postoperatoria demuestran la etiología del seudoquiste como único factor causante de la ictericia. Creemos imprescindible la realización de una colangiografía intraoperatoria tras la descompresión del quiste para poder evaluar correctamente el origen de la obstrucción (AU)

In chronic pancreatitis, obstructive jaundice solely due to common bile duct compression by a pancreatic pseudocyst is highly unusual. In most of these cases, the jaundice is due to fibrotic stricture of the intrapancreatic portion of the common bile duct. We report two cases of obstructive jaundice in chronic pancreatitis with pseudocyst. Operative findings and follow-up during the postoperative period demonstrated compression by the pseudocyst over the common bile duct as the only etiologic factor of the jaundice. We believe that intraoperative cholangiography should be performed after drainage of a pseudocyst to correctly assess the etiology of obstruction (AU)

Fístula traqueoesofágica en paciente intubado: tratamiento mediante exclusión y patch esofágico / Tracheoesophageal fistula in an intubated patient. Treatment through exclusion and esophageal patch

En la actualidad, las fístulas traqueoesofágicas adquiridas, de etiología benigna, son principalmente lesiones iatrogénicas, producidas por una intubación traqueal prolongada. Su formación en pacientes intubados es infrecuente, pero suele comportar consecuencias devastado-ras, y su solución terapéutica es de gran complejidad. Presentamos el caso de un paciente con una amplia fístula traqueoesofágica postintubación traqueal, que se trató quirúrgicamente mediante exclusión esofágica (esofagostomía cervical y sutura-grapado de esófago distal) y cierre del defecto traqueal, utilizando la pared posterior del esófago (AU)

Currently, acquired benign tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. Their occurrence in intubated patients is infrequent but devastating and their therapeutic resolution is highly complex. We present the case of a patient with an extensive tracheoesophageal fistula following tracheal intubation that was surgically treated through esophageal exclusion (cervical esophagostomy and suture-sta-pling of the distal esophagus) and closure of the tracheal defect using the posterior esophageal wall (AU)

Variabilidad clínica del tumor carcinoide evolucionado / Clinical variability of carcinoid tumor. Our casuistics of advanced-stage carcinoid tumor

La presentación clínica del tumor carcinoide depende de su grado de malignidad, localización, volumen tumoral, funcionalidad y el tiempo de evolución del proceso. Se discuten nuestros casos de tumor carcinoide evolucionado y las nuevas aportaciones diagnósticas y terapéuticas. Se trata de 5 pacientes (3 mujeres y 2 varones). Un caso correspondió a tumor carcinoide hepático único sin síndrome carcinoide y 4 a tumores ileales avanzados con metástasis hepáticas de diverso grado (3 con síndrome carcinoide). Un caso de crisis carcinoide se manifestó durante la inducción anestésica. Los estudios morfológicos y de localización consistieron en la gammagrafía marcada con octreótido, la tomografía computarizada espiral, la resonancia magnética y la ecografía intraoperatoria. El estudio bioquímico funcional incluyó 5-HIA en plasma y orina, 5-HT y serotonina plasmática. El estudio inmunohistoquímico incluyó la determinación de cromogranina A. Los tratamientos incluyeron: sandostatina LAR (long-acting release), resección radical de tumores ileales, hepatectomía, embolización intraarterial de metástasis hepáticas y biopsia diagnóstica. Dos pacientes fallecieron tras el diagnóstico. Los 3 pacientes tratados tienen un seguimiento de 12, 13 y 17 meses (AU)