Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

The guideline for prevention and treatment of common complications after pancreatic surgery (2022) / 中华外科杂志

In order to further standardize the prevention and treatment of postoperative complications of pancreatic surgery, the editorial board of the Chinese Journal of Surgery organized relevant experts to formulate this guideline under the promotion of the Study Group of Pancreatic Surgery in China Society of Surgery of Chinese Medical Association and Pancreatic Disease Committee of China Research Hospital Association. According to the grading of recommendations assessment, development, and evaluation system, this guide discusses the hot issues on postoperative complications such as pancreatic fistula, biliary fistula, chylous fistula, post-pancreatectomy hemorrhage, abdominal infection, delayed gastric emptying, etc., quantitatively evaluates the level of evidence in clinical studies, and forms recommendations after repeatedly consulting. It is hoped to provide reference for pancreatic surgeons in the prevention and treatment of postoperative complications.

Complicaciones pospancreatoduodenectomía de tumores periampulares en una unidad de cirugía hepatopancreatobiliar / Post pancreaticoduodenectomy complications of periampullary tumors in a hepatopancreatobiliary surgery unit

Resumen Introducción: Los tumores periampulares se definen como lesiones ubicadas en un radio de 2 cm alrededor de la ampolla de Vater, constituidos por 4 tipos de neoplasias con una alta tasa de malignidad que pueden originarse en páncreas, ampolla, vía biliar distal o duodeno. El manejo quirúrgico a través de la pancreatoduodenectomía sigue siendo la mejor elección en términos de resección curativa. Objetivo: Caracterizar los tumores peri-ampulares tratados en nuestra institución y que fueron llevados a pancreatoduodenectomía, asociando la relación entre tipo de tumor y complicaciones posoperatorias. Material y Método: Estudio transversal, retrospectivo y observacional con seguimiento a 45 pacientes sometidos a pancreatoduodenectomía en el Hospital Internacional de Colombia - Fundación Cardiovascular entre enero de 2011 y marzo de 2020 con diagnostico histopatológico de tumor peri-ampular. Resultados: Se realizaron 75 pancreatoduodenectomía de las cuales 45 pacientes presentaron tumor peri-ampular, siendo de origen pancreático en un 44%, seguido de ampolla 40%, vía biliar distal 8,8% y duodenal 6,6%. Las complicaciones posoperatorias más frecuentes fueron fístula pancreática y vaciamiento gástrico retardado. Falleció 1 paciente. Conclusión: La pancreatoduodenectomía es un procedimiento con alta morbilidad. Gracias al avance tecnológico, el diagnóstico de patología peri ampular es cada vez más exacto. El tipo de tumor peri-ampular puede influir no solo en su pronóstico, sino también en su morbilidad posquirúrgica.

Introduction: Periampullary tumors are defined as lesions that are located in a radius of 2 centimeters around the ampulla of Vater, constituted by 4 types of neoplasms with a high rate of malignancy originated in the pancreas, ampulla, distal bile duct or duodenum. Surgical management through the pancreatoduodenectomy remains the best choice in terms of curative resection. Objetive: To characterize periampullary tumors treated in our institution with pancreatoduodenectomy, associating the relationship between tumor type and postoperative complications. Material and Method: Cross-sectional, retrospective, observational study with a follow-up of 45 patients underwent pancreatoduodenectomy in the Hospital Internacional de Colombia - Fundación Cardiovascular between January 2011 and March 2020 with histopathological diagnosis of periampullary tumor. Results: Were performed 75 pancreatoduodenectomies, 45 patients presented with Periampullary tumor, 44% being of pancreatic origin, followed by ampulla 40%, distal bile duct 8.8% and duodenal 6.6%. Most frequent postoperative complications were pancreatic fistula and delayed gastric emptying. Mortality was of 1 patient. Conclusión: Pancreatoduodenectomy is a procedure with a high morbidity rate. Thanks to technological advances, the diagnosis of periampullary pathology is increasingly accurate. The type of periampullary tumor may influence not only in its prognosis, but also in its post-surgical morbidity.

Cirugía mínimamente invasiva del páncreas / Minimally Invasive Pancreatic Surgery

Introducción: La cirugía mínimamente invasiva del páncreas se enmarca dentro de la actual historia de la cirugía con gran impacto y desarrollo, especialmente en el campo de las pancreatectomías distales. Objetivo: Actualizar los aspectos generales y actuales de la cirugía mínimamente invasiva en las afecciones pancreáticas. Métodos: Se realizó una revisión sistemática a partir de la consulta de artículos científicos relacionados con el tema, indexados en las bases de datos Pubmed, Ebsco y SciELO. La información se analizó y se seleccionaron artículos publicados hasta 2020, relacionados con las indicaciones de cirugía laparoscópica y la robótica en las afecciones pancreáticas, la variabilidad de procederes quirúrgicos laparoscópicos y la morbimortalidad. Desarrollo: La cirugía mínimamente invasiva del páncreas ha alcanzado considerables niveles de complejidad y seguridad (desde la laparoscopia diagnóstica hasta las grandes resecciones pancreáticas). Se identifican las indicaciones de cirugía laparoscópica y la robótica en las afecciones pancreáticas, la variabilidad de procederes quirúrgicos laparoscópicos y se exponen los procederes realizados en el Centro Nacional de Cirugía de Mínimo Acceso durante estos últimos 3 años por el grupo dedicado a esta entidad. Conclusiones: La cirugía mínimamente invasiva y la robótica en afecciones pancreáticas son capaces de ofrecer resultados satisfactorios, siempre que sean realizadas por cirujanos con experiencia en cirugía hepato-biliopancreática y cirugía laparoscópica. Garantiza un riesgo de intervención mucho menor y una óptima recuperación en el menor tiempo posible con resultados similares en cuanto a morbimortalidad con la cirugía convencional(AU)

Introduction: Minimally invasive pancreatic surgery is framed within the current history of surgery with great impact and development, especially in the field of distal pancreatectomies. Objective: To update the general and current aspects of minimally invasive surgery in pancreatic disorders. Methods: A systematic review was carried out based on the consultation of scientific articles about the subject, indexed in the Pubmed, Ebsco and SciELO databases. The information was analyzed and articles published up to 2020 were selected, related to the indications for laparoscopic and robotic surgery in pancreatic conditions, the variability of laparoscopic surgical procedures, as well as morbidity and mortality. Development: Minimally invasive pancreatic surgery has reached considerable levels of complexity and safety (from diagnostic laparoscopy to large pancreatic resections). The indications for laparoscopic and robotic surgery in pancreatic disorders, together with the variability of laparoscopic surgical procedures, are identified, and the procedures performed at the National Center for Minimally Access Surgery during the last three years by the group dedicated to this entity are presented. Conclusions: Minimally invasive surgery and robotic surgery in pancreatic affections can offer satisfactory outcomes, as long as they are performed by surgeons with experience in hepatobiliopancreatic surgery and laparoscopic surgery. It guarantees a much lower risk of intervention and optimal recovery in the shortest possible time, with similar outcomes in terms of morbidity and mortality to conventional surgery(AU)

Abdominal drain amylase on the first day after pancreatectomy: a predictive factor for pancreatic fistula

SUMMARY OBJECTIVE: To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. METHODS: From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. RESULTS: Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. CONCLUSIONS: Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

Impacto das complicações pós-transplante simultâneo pâncreas-rim sobre o custo da internação hospitalar / Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost

RESUMO Objetivo: avaliar o impacto financeiro das complicações pós-operatórias no transplante simultâneo pâncreas-rim durante a internação hospitalar. Métodos: estudo retrospectivo dos dados da internação hospitalar dos pacientes submetidos consecutivamente ao transplante simultâneo pâncreas-rim no período de janeiro de 2008 a dezembro de 2014 no Hospital do Rim/Fundação Oswaldo Ramos. As principais variáveis estudadas foram a reoperação, pancreatectomia do enxerto, óbito, complicações pós-operatórias (cirúrgicas, infecciosas, clínicas e imunológicas) e os dados financeiros da internação para o transplante. Resultados: a amostra foi composta de 179 pacientes transplantados. As características dos doadores e receptores foram semelhantes nos pacientes com e sem complicações. Na análise dos dados, 58,7% dos pacientes apresentaram alguma complicação pós-operatória, 21,8% necessitaram de reoperação, 12,3%, de pancreatectomia do enxerto e 8,4% evoluíram para o óbito. A necessidade de reoperação ou pancreatectomia do enxerto aumentou o custo da internação em 53,3% e 78,57%, respectivamente. A presença de complicação pós-operatória aumentou significativamente o custo. Entretanto, a presença de óbito, hérnia interna, infarto agudo do miocárdio, acidente vascular cerebral e disfunção do enxerto pancreático não apresentaram significância estatística no custo, cuja média foi de US$ 18,516.02. Conclusão: complicações pós-operatórias, reoperação e pancreatectomia do enxerto aumentaram significativamente o custo médio da internação hospitalar do SPK, assim como as complicações cirúrgicas, infecciosas, clínicas e imunológicas. No entanto, o óbito durante a internação, a hérnia interna, o infarto agudo do miocárdio, o acidente vascular cerebral e a disfunção do enxerto pancreático não interferiram estatisticamente neste custo.

ABSTRACT Objective: considering simultaneous pancreas-kidney transplantation cases, to evaluate the financial impact of postoperative complications on hospitalization cost. Methods: a retrospective study of hospitalization data from patients consecutively submitted to simultaneous pancreas-kidney transplantation (SPKT), from January 2008 to December 2014, at Kidney Hospital/Oswaldo Ramos Foundation (Sao Paulo, Brazil). The main studied variables were reoperation, graft pancreatectomy, death, postoperative complications (surgical, infectious, clinical, and immunological ones), and hospitalization financial data for transplantation. Results: the sample was composed of 179 transplanted patients. The characteristics of donors and recipients were similar in patients with and without complications. In data analysis, 58.7% of the patients presented some postoperative complication, 21.8% required reoperation, 12.3% demanded graft pancreatectomy, and 8.4% died. The need for reoperation or graft pancreatectomy increased hospitalization cost by 53.3% and 78.57%, respectively. The presence of postoperative complications significantly increased hospitalization cost. However, the presence of death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not present statistical significance in hospitalization cost (in average US$ 18,516.02). Conclusion: considering patients who underwent SPKT, postoperative complications, reoperation, and graft pancreatectomy, as well as surgical, infectious, clinical, and immunological complications, significantly increased the mean cost of hospitalization. However, death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not statistically interfere in hospitalization cost.

Factores asociados a reingreso hospitalario precoz posterior a resecciones hepáticas y pancreáticas / Hospital readmission rates after hepatic and pancreatic resections

Resumen Objetivo: Determinar la frecuencia de reingreso hospitalario y sus factores asociados en pacientes sometidos a resecciones hepáticas o pancreáticas en nuestro centro. Metodología: Se revisaron registros de pacientes sometidos a resecciones hepáticas o pancreáticas entre 2012 y 2014. Se registraron variables biodemográficas, quirúrgicas y reingresos hasta 30 días posalta. Se excluyó la cirugía de urgencia, pacientes fallecidos durante la hospitalización, pacientes sometidos a resecciones hepáticas menores a dos segmentos, cirugías no anatómicas o cirugía no resectiva. El análisis estadístico univariable se realizó con prueba χ2 para variables categóricas y T Student/Mann Whitney para variables continuas. El análisis multivariable se realizó con regresión logística. Resultados: Se incluyeron 116 pacientes, 50,9% mujeres. La estadía promedio fue de 14 días. El adenocarcinoma pancreático fue el diagnóstico más frecuente (25,9%) y 40,5% de los procedimientos quirúrgicos fueron pancreatoduodenectomías. La tasa de reingreso global fue 18,1%, mayor en pancreatectomías respecto a hepatectomías (23,7 vs 12,2% respectivamente p < 0,05). Los factores asociados a reingreso fueron: resección de páncreas, leucocitos preoperatorios, complicaciones posoperatorias y tiempo de estadía hospitalaria. Tras el análisis multivariable, sólo el tiempo hospitalario se asocia de forma independiente al reingreso precoz [OR 1,2 IC 95% 1,1-1,5 (p = 0,001)]. Conclusión: La estadía hospitalaria prolongada es un factor de riesgo consistente en la literatura para la rehospitalización posterior a resecciones hepáticas o pancreáticas. La tasa de reingreso posterior a resecciones hepáticas o pancreáticas es elevada, incluso en centros de alto volumen. Recomendamos el uso de este parámetro como un nuevo instrumento de medición de calidad en los resultados quirúrgicos en nuestro país.

Aim: To determine readmission rates and its associated factors in patients undergoing pancreatic and hepatic resections at our center. Matherial and Methods: Perioperative variables of patients undergoing pancreatic and hepatic resections between 2012-2014 were reviewed. Demographic and perioepartive data, as well as up —to postoperative day 30— readmisson rates were analyzed. Emergency cases, postoperative mortality and/or patients undergoing less extensive surgery (less than 2 Couinaud's segments, non-anatomical resections and non resective cases such as bilioenteric anastomoses) were excluded. Readmission associated factors were identified using both univariate (χ2 for categorical and t-student's/Mann-Whitney for continuous variables) and multivariate (logistic regression) analysis. Results: 116 cases were included, 50.9 % female. Mean postoperative stay was 14 days. Pancreatic adenocarcinoma was the most frequent diagnosis (25.9%), and the 40.5% of surgical procedures were pancreaticoduodenectomy. Overall 30-day readmission rate was 18.1%, with a 23.7% for pancreatic resections and 12.2% for hepatic resections. According to univariate analysis; readmission associated factors were: pancreatic resection, preoperative White cell count, the development of postoperative complications and postoperative length of stay. On Multivariate analysis only postoperative stay was the only significant associate factor [OR 1,2 CI 95% 1.1- 1.5 (p = 0.001)]. Conclussion: Readmission rates after pancreatic and hepatic resections are elevated, even in high-volume centers. Postoperative length of stay is a consistent risk factor for readmission after these type of surgeries. We highly recommend including this parameter as a quality marker of our surgical results in our country.

Comparing the enzyme replacement therapy cost in post pancreatectomy patients due to pancreatic tumor and chronic pancreatitis

ABSTRACT Background - Among late postoperative complications of pancreatectomy are the exocrine and endocrine pancreatic insufficiencies. The presence of exocrine pancreatic insufficiency imposes, as standard treatment, pancreatic enzyme replacement. Patients with chronic pancreatitis, with intractable pain or any complications with surgical treatment, are likely to present exocrine pancreatic insufficiency or have this condition worsened requiring adequate dose of pancreatic enzymes. Objective - The aim of this study is to compare the required dose of pancreatic enzyme and the enzyme replacement cost in post pancreatectomy patients with and without chronic pancreatitis. Methods - Observational cross-sectional study. In the first half of 2015 patients treated at the clinic of the Department of Gastrointestinal Surgery at Hospital das Clínicas, Universidade de São Paulo, Brazil, who underwent pancreatectomy for at least 6 months and in use of enzyme replacement therapy were included in this series. The study was approved by the Research Ethics Committee. The patients were divided into two groups according to the presence or absence of chronic pancreatitis prior to pancreatic surgery. For this study, P<0.05 was considered statistically significant. Results - The annual cost of the treatment was R$ 2150.5 ± 729.39; R$ 2118.18 ± 731.02 in patients without pancreatitis and R$ 2217.74 ± 736.30 in patients with pancreatitis. Conclusion - There was no statistically significant difference in the cost of treatment of enzyme replacement post pancreatectomy in patients with or without chronic pancreatitis prior to surgical indication.

RESUMO Contexto - Dentre as complicações pós-operatórias tardias da pancreatectomia estão as insuficiências pancreáticas exócrina e endócrina. O reconhecimento da presença de insuficiência pancreática exócrina impõe, como tratamento padrão, a reposição de enzimas pancreáticas. Pacientes portadores de pancreatite crônica, com dor clinicamente intratável ou com alguma complicação com indicação de tratamento cirúrgico, podem vir a apresentar insuficiência pancreática exócrina ou ter essa condição agravada requerendo adequação de dose de enzimas pancreáticas. Objetivo - O objetivo deste estudo é comparar a dose necessária de enzima pancreática e o custo do tratamento de reposição enzimática em pacientes pancreatectomizados, com e sem pancreatite crônica. Métodos - Estudo transversal observacional. No primeiro semestre de 2015 pacientes acompanhados no ambulatório de Cirurgia do Aparelho Digestivo do HC-FMUSP, submetidos a pancreatectomia há pelo menos 6 meses e em terapia de reposição enzimática foram incluídos nessa casuística. O estudo foi aprovado pelo Comitê de Ética. Os pacientes foram divididos em dois grupos, de acordo com a presença ou ausência de pancreatite crônica prévia à cirurgia pancreática. Para este estudo, P<0,05 foi considerado como estatisticamente significante. Resultados - O custo anual do tratamento foi R$ 2150,51 ± 729,39; R$ 2118,18 ± 731,02 em pacientes sem pancreatite crônica e R$ 2217,74 ± 736,30 em pacientes com pancreatite crônica. Conclusão - Não houve diferença estatisticamente significante no custo do tratamento de reposição enzimática entre pacientes pancreatectomizados com ou sem pancreatite crônica prévia à indicação cirúrgica.

Distal pancreatectomy with splenectomy for the management of splenic hilum metastasis in cytoreductive surgery of epithelial ovarian cancer / 부인종양

OBJECTIVE: Distal pancreatectomy with splenectomy may be required for optimal cytoreductive surgery in patients with epithelial ovarian cancer (EOC) metastasized to splenic hilum. This study evaluates the morbidity and treatment outcomes of the uncommon procedure in the management of advanced or recurrent EOC. METHODS: This study recruited 18 patients who underwent distal pancreatectomy with splenectomy during cytoreductive surgery of EOC. Their clinicopathological characteristics and follow-up data were retrospectively analyzed. RESULTS: All tumors were confirmed as high-grade serous carcinomas. The median diameter of metastatic tumors located in splenic hilum was 3.5 cm (range, 1 to 10 cm). Optimal cytoreduction was achieved in all patients. Eight patients (44.4%) suffered from postoperative complications. The morbidity associated with distal pancreatectomy and splenectomy included pancreatic leakage (22.2%), encapsulated effusion in the left upper quadrant (11.1%), intra-abdominal infection (11.1%), pleural effusion with or without pulmonary atelectasis (11.1%), intestinal obstruction (5.6%), pneumonia (5.6%), postoperative hemorrhage (5.6%), and pancreatic pseudocyst (5.6%). There was no perioperative mortality. The majority of complications were treated successfully with conservative management. During the median follow-up duration of 25 months, nine patients experienced recurrence, and three patients died of the disease. The 2-year progression-free survival and overall survival were 40.2% and 84.8%, respectively. CONCLUSION: The inclusion of distal pancreatectomy with splenectomy as part of cytoreduction for the management of ovarian cancer was associated with high morbidity; however, the majority of complications could be managed with conservative therapy.

Complicações após pancreatectomias: estudo prospectivo após as novas classificações GIEDFP e GIECP / Complications after pancreatectomies: prospective study after ISGFP and ISGPS new classifications

RACIONAL: No Brasil existe escassa publicação científica destinada à divulgação dos resultados das ressecções pancreáticas. OBJETIVO: Apresentar os resultados cirúrgicos das ressecções pancreáticas. MÉTODOS: Analisou-se prospectivamente 54 casos consecutivos de pacientes submetidos à pancreatectomias. Foi avaliada a ocorrência de complicações pós-operatórias (fístula pancreática, retardo do esvaziamento gástrico e hemorragia pós-operatória) fundamentadas nos critérios dos Grupos Internacionais de Estudo sobre a Definição de Fístula Pancreática e de Cirurgia Pancreática. RESULTADOS: Das 54 pancreatectomias, 32 foram realizadas em mulheres (59,26%) e 22 em homens (40,74%). A média de idade dos pacientes foi de 54,5 anos. O procedimento mais praticado foi à cirurgia de Whipple em 38 pacientes. Em oito destes, houve ressecção do eixo mesentérico-portal. O tempo médio de internação foi de 20,7 dias. A maioria dos pacientes (51%) esteve internada por até 10 dias. A fístula pancreática foi observada em 50% da amostra em 44,7% dos pacientes submetidos à operação de Whipple. O sangramento pós-operatório e o retardo do esvaziamento gástrico nos pacientes submetidos à essa operação ocorreram, respectivamente, em 13,15% e 18,41%. Na amostra a taxa global de morbidade e mortalidade foi respectivamente de 62,9% e 5,5%. CONCLUSÃO: Há necessidade das publicações nacionais assimilarem os conceitos e critérios apresentados pelas classificações GIEDFP e GIECP para permitir a comparação dos resultados obtidos com o tratamento cirúrgico de doenças pancreáticas, no contexto brasileiro. Quem sabe, se o grande avançado visto nos últimos 40 anos em termos de redução das taxas de mortalidade associadas com ressecções pancreáticas também pode ocorrer com os níveis persistentemente elevados de complicações pós-operatórias.

BACKGROUND: Scientific publications focusing on the results of pancreatic resections in Brazil are scarce. AIM: To present the surgical results of pancreatic resections. METHODS: Were analyzed prospectively 54 consecutive cases of patients undergoing consecutive pancreatectomy evaluating the occurrence of postoperative complications (pancreatic fistula, delayed gastric emptying and postoperative hemorrhage) based on the criteria of the International Study Group on Pancreatic Fistula Definition and International Study Group of Pancreatic Surgery. RESULTS: Of the 54 pancreatectomy, 32 occurred in women (59,26%) and 22 in men (40,74%). The mean age of patients was 54,5 years. The most performed procedure was the Whipple operation, in 38 patients. In eight of those cases, mesenteric-portal confluence was ressected. The mean period of hospitalization was 20,7 days. The hospitalization in 51% of patients was up to 10 days. A pancreatic fistula was observed in 50% of the cases submitted to the Whipple surgery. The postoperative hemorrhage and delayed gastric emptying in patients undergoing the surgery occurred respectively in 13,15% and 18,41%. The overall morbidity and mortality was respectively 62.9% and 5.5%. CONCLUSION: There is a need for the national publications to assimilate the concepts and criteria presented by the ISGFP² and ISGPS23,25 to enable comparison of the results obtained with surgical treatment of pancreatic disorders, in the Brazilian context. Who knows, therefore, whether the great advanced seen in the last 40 years in terms of the reduction in mortality rates associated with pancreatic resections may also occur with the persistently high levels of postoperative complications.

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas / Predictive factors of morbidity in distal pancreatic resections

OBJETIVO: Avaliar a morbidade pós-operatória e investigar a existência de seus fatores preditivos. MÉTODOS: O estudo foi realizado de forma retrospectiva, a partir de uma base de dados mantida de forma prospectiva. De 1994 a 2008, 100 pacientes consecutivos foram submetidos à ressecções pancreaticas esquerdas. A principal variável de interesse foi a morbidade pós-operatória, tendo diversas outras características da população sido registradas simultaneamente. Posteriormente, para a análise de fatores preditivos de morbidade pós-operatória o subgrupo de pacientes que foi submetido aos procedimentos de pancreatectomia distal com preservação do baço (n=65) foi analisado separadamente quanto à relevância das diferentes técnicas de secção do parênquima pancreático, assim como, outros possíveis fatores preditivos à ocorrência de morbidade pós-operatória. RESULTADOS: Considerando-se juntamente todas as ressecções pancreáticas esquerdas realizadas, a ocorrência de complicações globais, de complicações relevantes e graves foi 55%, 42% e 20%, respectivamente. Os fatores que se mostraram preditivos à ocorrência de morbidade pós-operatória após pancreatectomia distal com preservação do baço foram a técnica de secção do parênquima pancreático, idade, índice de massa corporal e a realização de operação abdominal concomitante. CONCLUSÃO: A morbidade associada às ressecções pancreáticas, à esquerda dos vasos mesentéricos superiores, foi importante. De acordo com a estratificação adotada baseada na gravidade das complicações, alguns fatores preditivos foram identificados. Estudos futuros com coortes maiores de pacientes são necessários para confirmar tais resultados.

OBJECTIVE: To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS: The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS: Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION: The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Clinical Comparison of Distal Pancreatectomy with or without Splenectomy

The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this study was to compare the perioperative and postoperative courses of patients with conventional DP and spleen-preserving distal pancreatectomy (SPDP) for benign lesions or tumors with low-grade malignant potential occurred at the body or tail of the pancreas. A retrospective analysis was performed for the hospital records of all the patients undergoing DP and SPDP between January 1995 and April 2006. One-hundred forty-three patients underwent DP and 37 patients underwent SPDP. There were no significant differences in age, sex, indications of operation, estimated blood loss, operative time, and postoperative hospital stay between the two groups. Pancreatic fistula occurred in 21 (13.3%) patients following DP and in 3 (8.1%) following SPDP without a significant difference (p=0.081). Portal vein thrombosis occurred in 4 patients after DP. Splenic infarction occurred in one patient after SPDP. Overwhelming postosplenectomy infection was observed in one patient after DP. SPDP can be achieved with no increase in complication rate, operative time, or length of postoperative hospitalization as compared to conventional DP. Additionally, it has the advantage of reducing the risk of overwhelming postsplenectomy infection and postoperative venous thrombosis.

Pancreatectomía distal: indicaciones y resultados quirúrgicos inmediatos / Indications and early results of distal pancreatectomy

Introducción: Se denomina pancreatectomía distal a la resección pancreática a la izquierda del eje mesentérico portal. Los objetivos del trabajo son analizar las indicaciones y los resultados quirúrgicos de esta operación en enfermos con un tumor pancreático. Material y métodos: Estudio retrospectivo de 38 pacientes operados entre 1990 y 2005. Se analizaron las características clínicas, quirúrgicas y el estudio anatomopatológico. Resultados: Se operaron 29 mujeres y 9 hombres, de 52,9 + 5 años. El motivo de consulta más frecuente fue dolor abdominal en 26 enfermos. El diagnóstico se realizó con una ecografía en 7 pacientes y en 31 con una tomografía o una resonancia de abdomen. La indicación quirúrgica fue la presencia de un tumor pancreático en los 38 enfermos, quístico en 24 y sólido en 14. A 25 pacientes se les realizó una esplenectomía. Diez enfermos presentaron complicaciones postoperatorias; las más frecuentes fueron: fístula pancreática en 5, sepsis en 3 e infección del catéter central en 3. No hubo diferencias en la frecuencia de complicaciones ni en el desarrollo de una fístula pancreática entre los enfermos con y sin esplenectomía. Un enfermo falleció por sepsis abdominal. El estudio anatomopatológico mostró 28 tumores benignos y 10 tumores malignos, siendo los más frecuentes el cistoadenoma mucinoso y el adenocarcinoma, respectivamente. Conclusiones: Las pancreatectomías distales se realizaron principalmente por un tumor quístico benigno. La complicación más frecuente fue la fístula pancreática, la que llevó a la muerte a un paciente. Los enfermos esplenectomizados no presentaron más complicaciones postoperatorias que los sin esplenectomía.

Background: Resection of the pancreatic portion located to the left of the portal mesenteric axis is called distal pancreatectomy Aim: To analyze the indications and surgical results of distal pancreatectomy in patients with pancreatic tumors. Material and methods: Retrospective review of medical records of patients subjected to a distal pancreatectomy for pancreatic tumors, between 1990 and 2005. Patient features, and early complications were evaluated. Results: In the study period, 38 patients aged 53 + 5 years (29 females), were operated. The tumor was cystic in 24 patients and solid in 14. Ten patients had postoperative complications. The most common complications were pancreatic fistula in five patients, sepsis in three and catheter infection in three. No differences in the rate of complications or development of pancreatic fistula, were observed between patients subjected or not subjected to splenectomy. One patient died due to abdominal sepsis. Pathology showed 28 benign tumors (mucinous cystadenoma the most common) and 10 malignant tumors (adenocarcinoma the most common). Conclusions: The most frequent complication of distal pancreatectomy was pancreatic fistula. One patient died as a consequence of this complication. Patients subjected to splenectomy did not have a higher rate of complications.

Acrodermatitis Enteropathica-like Eruption Associated with Combined Nutritional Deficiency

We present here a case of acrodermatitis enteropathica-like eruption associated with essential free fatty acid and protein deficiencies as well as borderline zinc deficiency that occurred after Whipple's operation in a 31-yr-old woman. Her eruptions were improved not by zinc supplements alone, but her condition was improved by total parenteral nutrition including amino acids, albumin, lipid and zinc. Although we could not exactly decide which of the nutrients contributed the most to her manifestations, we inferred that all three elements in concert caused her dermatoses. This case shows that even though the patient's skin manifestations and laboratory results are suggestive of acrodermatitis enteropathica, the physicians should keep in mind the possibility that this disease can be associated with other nutritional deficiencies such as free fatty acid or protein deficiency.

Pancreatogastroanastomosis luego de la operación de Whipple / Pancreatogastroanastomoses after Whipple technique

Antecedentes: Después de la resección pancreaticoduodenal la fístula pancreática es una temida complicación, con una mortalidad estimada del 10 al 20 por ciento de los casos. Objetivo: Intentar reducir la frecuencia y la severidad de la fístula anastomótica postoperatoria luego de la pancreatoyeyunoanastomosis (PYA) en pacientes con dduodenopancreatectomía cefálica (DPC). Resumen: La pancreatogastroanastomosis (PGA) se realizó como una reconstrucción alternativa luego de DPC. Desde 1991 a 1997 hemos realizado 15 DPC. En 9 pacientes empleamos la PGA y en 6 la PYA. La mortalidad fue del 0 por ciento. Pero la morbilidad alcanzó el 56 por ciento. La fístula pancreática estuvo presente en el 13 por ciento del grupo de PYA y 0 por ciento en PGA. Conclusión: Estos resultados confirman que la PGA es un seguro método de reconstrucción luego de la DPC

Technical alternatives for pancreatojejunal anastomosis after partial pancreaticoduodenectomy

Após as gastroduodenectomias as anastomoses pancreático-jejunais podem ser realizadas segundo diferentes métodos. As complicaçöes mais sérias no pós-operatório säo pancreatites e/ou fístulas pancreáticas, devidas às deiscências nastomóticas. Nova proposta de realizaçäo técnica de anastomose pancreático-jejunal é apresentada, procurando obviar aquelas complicaçöes. A mucosa jejunal é dissecada, obtendo-se um manguito, suturado a partir das suas bordas, deixando-se um orifício central que é suturado ao ducto pancreático. A seguir, parte proximal do pâncreas remanescente é invaginada no jejuno e mantido com sutura envolvendo seromuscular do jejuno e da superficie do pâncreas. A drenagem pancreática é assegurada com dreno de polivinil, através de jejunostomia a Witzel

Informe sobre un caso de pancreatectomia total por trauma: soporte metabolico / Report of one case of total pancreatectomy after trauma: metabolic support

La pancreatectomia total por trauma tiene una muy alta incidencia de complicaciones y una elevada tasa de mortalidad; y el manejo posterior de un paciente pancreatectomizado constituye un reto clinico y terapeutico. En el presente caso no habia alternativa quirurgica, dada la magnitud del trauma. El exito del tratamiento se debio a la buena tecnica quirurgica, al refinado cuidado del estado critico postoperatorio y al manejo metabolico moderno acorde con el buen entendimiento de los procesos metabolicos como respuesta al trauma. Se presentan pautas de manejo que pueden servir de guia para el cuidado de pacientes con estres por trauma, y por cirugia de similar magnitud.

Síndrome de regressäo caudal (SRC) em filho de mäe diabética pós-pancreatectomia / Caudal regression syndrome in son of diabetic mother post-pancreatectomy

Os autores relatan um caso de síndrome de Regressäo Caudal associado ao diabetes materno pós-pancreatectomia. Säo apresentados dados clínicos, laboratoriais e radiológicos do caso, revisäo da literatura e discutidos os aspectos etiológicos da síndrome. Trata-se do 1§ caso da literatura de SRC associado com diabetes pós-pancreatectomia