Advances in the study of postpancreatectomy acute pancreatitis / 中华外科杂志

Postpancreatectomy acute pancreatitis (PPAP) is an acute inflammation of the remnant pancreas in the early postoperative period caused by a variety of factors. With the progress of related research,PPAP has been confirmed as an independent risk factor for many severe complications such as postoperative pancreatic fistula. In some cases, it progresses to necrotizing PPAP, increasing the risk of mortality. Currently, the International Study Group for Pancreatic Surgery has standardized and graded PPAP as an independent complication, taking into account factors including serum amylase, radiological features, and clinical impact. This review summarizes how the concept of PPAP was proposed, as well as the latest progress in the research related to its etiology, prognosis, prevention, and treatment. However, given the large heterogeneity of relevant studies and the fact that they were mostly retrospective, in the future, it is necessary to place more emphasis on PPAP and elucidate the problems through more standardized studies to optimize strategies for the prevention and management of complications after pancreatic surgery.

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.

Fístula pancreática posduodenopancreatectomía: Pancreatogastrostomía vs. Pancreatoyeyunostomía / Pancreatic fistula after pancreaticoduodenectomy: Pancreaticogastrostomy vs. Pancreaticojejunostomy

Antecedentes: la duodenopancreatectomía (DPC) continúa siendo el tratamiento de elección para los tumores periampulares. Con una mortalidad de alrededor del 5% y una morbilidad que puede llegar a alrededor del 50%, la fístula pancreática es todavía la complicación preponderante. Diversos autores sostienen que la anastomosis del páncreas con el estómago tiene menor índice de fístula que cuando se realiza con el yeyuno. Objetivo: comparar la incidencia de fístula pancreática en las pancreatogastrostomías (PG) versus pancreatoyeyunostomías (PY). Evaluar algunos factores de riesgo de fístula. Material y métodos: se evaluaron 91 DPC, 43 de ellas con reconstrucción con PG y 48 con PY. Se evaluaron datos demográficos, quirúrgicos, y se comparó la incidencia de fístula entre ambos. Resultados: la incidencia global de fístula fue de 13 pacientes (14,3%), 5 de las cuales fueron de relevancia clínica. En la comparación de ambos grupos hubo diferencias en cuanto a edad y número de pacientes con Wirsung < 3 mm, el resto de los parámetros fue similar. No hubo diferencias entre ambos grupos con respecto a la cantidad de fístulas (p: 0,478). Respecto de la evaluación de factores predisponentes para fístula, tan solo un diámetro del Wirsung < 3 mm fue significativo. Conclusión: en nuestra serie y al igual que en otras no hubo diferencias en cuanto a fístulas pancreáticas entre PG y PY, lo que nos permite inferir que la adopción y confección sistemática de una ellas obtendrá los mejores resultados.

Background: Pancreaticoduodenectomy is still the treatment of choice in patients with periampullary tumors. Pancreatic fistula is the most common complication with a mortality rate of 5% and 50% of morbidity. Some authors state that the anastomosis of the pancreas with the stomach would decrease the incidence of pancreatic fistula when compared with pancreaticojejunostomy. Objective: The aim of this study was to compare the incidence of pancreatic fistula after pacreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) and analyze the risk factors associated with the development of fistula. Material and methods: 91 patients undergoing pancreaticoduodenectomy were evaluated; 43 with PG reconstruction and 48 with PJ reconstruction. Demographic and surgical data were evaluated and the incidence of pancreatic fistula with both techniques was compared Results: The incidence of fistula for the total series was 14.3% (n = 13) and 5 were clinically relevant. There were differences in age and pancreatic duct diameter < 3 mm between the groups. The incidence of fistula was similar in both groups (p = 0.478). Pancreatic duct diameter < 3 mm was the only significant predisposing factor for the development of fistula. Conclusion: In our series, and in coincidence with others, there were no differences in the incidence of pancreatic fistulas between PG and PJ. Practicing and mastering a repetitive, standardized technique would yield the best results.

O valor da amilase, obtido precocemente nos drenos abdominais, é teste útil em prever a ocorrência de fístula pancreática após duodenopancreatectomia: lições aprendidas de um centro do Sul do Brasil / Early drain fluid amylase is useful to predict pancreatic fistula after pancreatoduodenectomy: lessons learned from a southern brazilian center

ABSTRACT BACKGROUND: Pancreatic fistula represents the most feared complication after pancreatoduodenectomies, being the major responsible for the high morbidity and mortality after this operation. Its incidence remains around 10% to 30%. In recent years, several authors have studied the value of amylase in abdominal drains fluid, measured at an early stage after the surgical procedure, as a useful tool to identify patients at risk of developing pancreatic fistula. OBJECTIVE: To analyze the value of early drain fluid amylase as a method to predict the occurrence and severity of postoperative pancreatic fistula in patients undergoing pancreatoduodenectomies. METHODS: We evaluated 102 prospective patients submitted to pancreatoduodenectomies from January 2013 to June 2017. The mensuration of amylase in abdominal drains was performed on days 1, 3, 5 and 7 in all patients. Patients were divided into three groups according to postoperative day 1 (POD1) results: values <270 U/L (group 1); between 271 and 5.000 U/L (group 2); and values >5.000 U/L (group 3). RESULTS: The incidence of pancreatic fistula was 25.5%, being 3.33%, 27.3% and 41.02% in the three groups, respectively. Compared with group 1, the risk of developing pancreatic fistula increased with increasing amylase values on POD1. Amylase values on POD1 and POD3 of patients with pancreatic fistula were higher than in the other ones without this complication (P<0.001). In addition, in group 3, 37.5% of patients with pancreatic fistula evolved to death (P<0.001). Finally, in this group, patients who died had drain fluid amylase values on POD1 significantly higher than the others in the same group (P<0.001). CONCLUSION: Early drain fluid amylase value is a useful test to stratify patients in relation to the risk of developing pancreatic fistula after pancreatoduodenectomies, in addition to correlate with the severity of this complication.

RESUMO CONTEXTO: A fístula pancreática representa a complicação mais temida após as duodenopancreatectomias, sendo a grande responsável pela elevada morbi-mortalidade após esta operação. Sua incidência permanece em torno de 10% a 30%. Nos últimos anos, diversos trabalhos têm estudado o valor da amilase nos drenos abdominais, medido de forma precoce após o procedimento cirúrgico, como ferramenta útil para a identificação dos pacientes sob risco de desenvolver fístula pancreática. OBJETIVO: Avaliar o valor da amilase no fluido dos drenos abdominais, obtido precocemente no pós-operatório, como método para prever a ocorrência e severidade da fístula pancreática nos pacientes submetidos a duodenopancreatectomias. MÉTODOS: Foram avaliados 102 pacientes prospectivos submetidos a duodenopancreatectomias no período de janeiro de 2013 a junho de 2017. A dosagem da amilase nos drenos abdominais foi realizada nos dias 1, 3, 5 e 7 em todos os pacientes. Os pacientes foram divididos em três grupos conforme os resultados do 1o PO: valores <270 U/L (grupo 1); entre 271 e 5.000 U/L (grupo 2); e valores >5.000 U/L (grupo 3). RESULTADOS: A incidência de fístula pancreática foi de 25,5%, sendo 3,33%, 27,3% e 41,02% nos três grupos, respectivamente. Comparados ao grupo 1, o risco de desenvolver fístula pancreática foi crescente com o aumento da amilase no 1o PO. Os valores das amilases no 1o PO e 3o PO dos pacientes com fístula pancreática foram maiores do que nos pacientes sem essa complicação (P<0,001). Além disso, no grupo 3, 37,5% dos pacientes com fístula pancreática evoluíram para óbito (P<0,001). Por fim, neste grupo, os pacientes que evoluíram para óbito tiveram valores de amilase no 1o PO significativamente maiores do que os demais pacientes (P<0,001). CONCLUSÃO: O valor da amilase, medido de forma precoce nos drenos abdominais no pós-operatório de duodenopancreatectomias, é teste útil para estratificar pacientes em relação ao risco de apresentar fístula pancreática, além de se correlacionar com a severidade dessa complicação.

Pancreatoyeyunoanastomosis con técnica de Blumgart modificada para reconstrucción post-pancreatoduodenectomía: estudio de serie de casos con seguimiento / Pancreatojejunostomy with modified Blumgart technique for post-pancreatoduodenectomy reconstruction

Resumen Introducción: La pancreatoduodenectomía es una cirugía compleja, con cifras de morbilidad cercanas a 30% y mortalidad entre 1 a 5%. El principal factor responsable de morbilidad y mortalidad es la fístula pancreática posoperatoria (FPPO). En la actualidad no existe una técnica universalmente estandarizada para la reconstrucción pancreática. Objetivo: Determinar la prevalencia de FPPO clínicamente relevante en una serie de pacientes en los que se realizó reconstrucción pancreática con pancreatoyeyunoanasto- mosis con técnica de Blumgart modificada para reconstrucción post-pancreatoduodenectomía en Hospital Hernán Henríquez Aravena entre los años 2014-2017. Material y Método: Serie de casos con seguimiento de julio de 2014 a abril de 2017. Se incluyeron pacientes a quienes se realizó reconstrucción pancreática con técnica de Blumgart modificada. La modificación consistió en el uso de pledgets® (poli-tetrafluoro- etileno) en los puntos iniciales en el páncreas con la idea de disminuir la posibilidad de desgarro del tejido. Se excluyeron pacientes a quienes se realizó otra técnica de reconstrucción. Se consideró FPPO clínicamente relevante (grado B/C) para evaluar morbilidad. Se utilizó estadística descriptiva con medidas de tendencia central y dispersión. Resultados: Serie de casos de 12 pacientes, 9 (75%) de género femenino y 3 (25%) de género masculino. La edad promedio fue de 59 ± 8,5 años. La morbilidad fue de 25% y la tasa de fístula grado B/C fue 0%. Todas las fístulas pancreáticas fueron grado A (33,3%), sin relevancia clínica. Conclusión: La técnica de Blumgart modificada parece ser una técnica segura y reproducible para pancreato-yeyuyoanastomosis.

Introduction: Pancreatoduodenectomy is a complex surgery, with morbidity close to 30% and mortality between 1% and 5%. The main contributing factor to morbidity and mortality is postoperative pancrea- tic fistula (POPF). At present, there is no globally standardized technique for pancreatic reconstruction. Aim: To determine the prevalence of clinically relevant POPF in a sample of patients who underwent pancreaticojejunal anastomosis reconstruction with Blumgart's modified technique for post-pancreato- duodenectomy reconstruction at Hospital Hernán Henríquez Aravena between 2014 and 2017. Material and Method: Case series with follow-up from july 2014 to april 2017. Patients who underwent pancreatic reconstruction with Blumgart's modified technique were included. The modification consisted of the use of Pledgets® (poly-tetrafluoro-ethylene) at the inicial points in páncreas with the idea of reducing the possibility of tissue tearing. We excluded patients who underwent another reconstruction technique. Clinically relevant POPF (grade B/C) was considered to asses morbidity. Descriptive statistics were used with measures of central tendency and dispersion. Results: Case series of 12 patients, 9 (75%) were female and 3 (25%) were male. The mean age was 59 ± 8.5 years. The morbidity was 25% and the rate of grade B/C fistula was 0%. All pancreatic fistulas were grade A, not clinically relevant. Conclusion: The Blumgart's modified technique seems to be a safe and reproducible technique for pancreticojejunal anastomosis.

Management of pancreaticopleural fistulas secondary to chronic pancreatitis / Tratamento das fístulas pancreaticopleurais secundárias à pancreatite crônica

ABSTRACT Introduction: Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Objective: To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. Methods: Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. Results: The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. Conclusion: Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

RESUMO Introdução: A fístula pancreaticopleural é complicação rara da pancreatite crônica. Objetivo: Descrever a fístula pancreaticopleural consequente à pancreatite crônica e fazer revisão extensa da literatura sobre o tópico. Métodos: Revisão narrativa abrangente através de pesquisa online nas bases de dados Medline e Lilacs para artigos publicados nos últimos 20 anos. Resultados: Houve 22 relatos de casos e quatro séries de casos selecionadas. A principal indicação para o tratamento cirúrgico é a falha de tratamentos clínicos e/ou endoscópicos. A cirurgia é baseada na drenagem pancreática interna, especialmente por meio de pancreaticojejunostomias e/ou ressecções pancreáticas. Conclusão: A fístula pancreaticopleural é complicação rara da pancreatite crônica e o procedimento de Frey pode ser opção terapêutica apropriada em casos selecionados quando os tratamentos clínico e endoscópico não obtiverem êxito.

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.

Complicaciones de la pancreatoduodenectomía, diagnóstico y manejo / Diagnosis and management of pancreatoduodenectomy complications

Pancreatoduodenectomy continues to have a high rate of complications. The most common and severe complications are intra or postoperative bleeding, pancreatic fistulae and derangements of gastric emptying. Each of these requires a great deal of clinical suspicion and an multidisciplinary management. This is a review of these complications, their clinical manifestations and their management.

A pesar de la disminución observada en las cifras de mortalidad de la pancreatoduodenectomía, continúa siendo una intervención asociada a una alta tasa de complicaciones. Las más comunes y asociadas a una mayor morbimortalidad son: el sangrado intra y post operatorio, la fístula pancreática y trastornos asociados al vaciamiento gástrico. Cada una de los eventos anteriores, requiere de un alto grado de sospecha clínica y de un manejo de tipo multidisciplinario. En este reporte se analizan las complicaciones anteriormente descritas, sus manifestaciones clínicas y los principios de su manejo.

Two Cases of Portal Annular Pancreas / 대한소화기학회지

Portal annular pancreas is one of the pancreatic fusion anomalies in which the uncinate process of the pancreas extends to fuse with the dorsal pancreas by encircling the portal vein or superior mesenteric vein. We report two consecutive patients with portal annular pancreas. The first case is a 71-year-old male patient who underwent a pancreaticoduodenectomy for intraductal papillary mucinous neoplasm in the head of pancreas. His preoperative computed tomography scan showed the suprasplenic type portal annular pancreas. The second case is a 74-year-old female patient who underwent a laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic body cancer. In operative finding, portal confluence (superior mesenteric vein-splenic vein-portal vein) was encased with the uncinate process of pancreas in both cases. Therefore, they required pancreatic division at the pancreatic neck portion twice. During the postoperative period, grade B and A, respectively, postoperative pancreatic fistulas occurred and were controlled by conservative management. Surgeons need to know about this rare pancreatic condition prior to surgical intervention to avoid complications, and to provide patients with well-designed, case-specific pancreatic surgery.

Fístula pancreática após duodenopancreatectomia: correlação dos aspectos intra-operatórios e histologicos do pâncreas / Correlation analysis between post-pancreatoduodenectomy pancreatic fistula and pancreatic histology

OBJETIVO: Avaliar a relação entre a ocorrência de fístula pancreática pós-anastomose pancreatojejunal, em doentes submetidos à duodenopancreatectomia por neoplasia maligna periampolar, com aspectos histológicos de fibrose e inflamação encontrados no tecido pancreático e com o calibre do ducto pancreático principal. MÉTODOS: Estudo retrospectivo interessando doentes que foram submetidos ao tratamento com ressecção cirúrgica. Verificou-se o índice de fístulas pancreáticas encontradas. Classificou-se de acordo com a histologia da fibrose e da inflamação pancreática. RESULTADOS: Identificaram-se 77 doentes, com média de idade de 57,6 anos, sendo 62,4% do sexo masculino. De acordo com o tipo de operação realizada, 66,3% constituíram-se em gastroduodenopancreatectomia e 33,7% em duodenopancreatectomia com preservação do piloro. Em relação ao número de fístulas diagnosticadas, identificou-se que 23,4% doentes apresentaram tal complicação pós-operatória, sendo que em 66,7% a causa era neoplasia de papila. Achados macroscópicos intraoperatórios, identificou-se classificação da textura pancreática, tida como normal, em 85,8% e, quanto ao calibre do ducto principal pancreático, foi encontrada média de 4,9mm. Houve relação importante entre a consistência endurecida do coto pancreático e a ausência da fístula. Nos doentes com tecido normal ou amolecido, o índice de fístula foi 25,4%. Quanto ao diâmetro ductal, identificou-se (p <0,05) maior número de deiscências da anastomose pancreática na ausência de dilatação ductal. Evidenciou-se que doentes com valores médios do diâmetro de ducto de 5,4mm (76,7%) não mostraram esta complicação. CONCLUSÃO: A presença de fibrose e de dilatação ductal habitualmente coexistem e estão relacionadas à menor porcentagem de fístulas enteropancreáticas.

OBJECTIVE: To evaluate the relationship between the occurrence of pancreatic fistula after pancreatojejunal anastomosis in patients undergoing pancreaticoduodenectomy for periampullary malignancy and the histological fibrosis and inflammation found in pancreatic tissue and the caliber of the main pancreatic duct. METHODS: We conducted a retrospective study with patients that were treated with surgical resection. The rate of pancreatic fistulae was recorded. Histology classification was performed according to fibrosis and pancreatic inflammation. RESULTS: We identified 77 patients, mean age was 57.6 years; 62.4% were male. As for the type of operation performed, 66.3% were gastroduodenopancreatectomies and 33.7% pancreatoduodenectomies with pylorus preservation. Regarding the number of fistulas diagnosed, it was found that 23.4% patients displayed this postoperative complication and in 66.7% the cause was cancer of the papilla. As for intraoperative macroscopic findings, we identified the classification of pancreatic texture, seen as normal in 85.8%, and the caliber of the main pancreatic duct, finding an average of 4.9 mm. There was a significant relationship between the hardened pancreatic stump and the absence of fistula. In patients with normal or soft tissue, the rate of fistula was 25.4%. Regarding ductal diameter, we identified a higher number of pancreatic anastomotic dehiscences in the absence of ductal dilation (p <0.05). We noticed that patients with an average ductal diameter of 5.4 mm (76.7%) did not show this complication. CONCLUSION: The presence of fibrosis and ductal dilation usually coexist and is related to a lower percentage of pancreatic fistulae.

Pancreaticoyeyunostomía ducto-seromuscular término-lateral en la operación whipple: experiencia en 27 casos / Seromuscular end pancreaticojejunostomy-duct-side in the whipple operation: experience with 27 cases

Presentar la experiencia con la anastomosis ductoserosa termino-lateral en la pancreaticoyeyunostomía del Whipple, en el Servicio de Cirugía General del Instituto Autónomo Hospital Universitario de Los Andes, Mérida-Venezuela. Estudio prospectivo, descriptivo en pacientes sometidos a duodenopancreatectomía por patología maligna a nivel pancreático y región periampular entre los años 2003 a 2007. En todos los casos se realizó preservación pilórica con anastomosis ducto-serosa termino-lateral del remanente pancreático, con colocación de stent intraductal, excepto en un caso donde se realizó la técnica invaginante término-terminal. Se evaluaron las complicaciones postoperatorias inherentes a la técnica quirúrgica, haciendo especial énfasis en la fístula pancreática. Un total de 27 pacientes durante el período 2003 a 2007 fueron sometidos a duodenopancreatectomía cefálica en forma electiva por etiología maligna tales como: ampuloma II casos, colangiocarcinoma distal 2 casos, cáncer de páncreas 12 casos, tumor neuroendocrino 1 caso, adenoma velloso malignizado de colédoco 1 caso. Las edades estuvieron comprendidas entre 42-81 años con promedio de 61 años, predominantemente del sexo femenino en una proporción 4:1. Entre las complicaciones posquirúrgicas relacionadas con la técnica encontramos 4 casos (14.8 por ciento) dado por: 2 fístulas pancreáticas (una de ellas por la ligadura accidental del stent intraductal), 1 dehiscencia de la duodenopancreatectomía, siendo la causa de muerte, y finalmente un caso de atonía gástrica manejado médicamente en forma satisfactoria. La anastomosis ducto-serosa en el manejo del remanente pancreático del Whipple constituye una técnica de fácil ejecución y con buenos resultados, ya que ofrece menos morbimortalidad.

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.

A new technique of postoperative pancreatico gastric enterocutaneous fistula repair using de-tubularised afferent loop.

Postoperative fistula involving upper gastrointestinal tract surgery is a rare but troublesome occurrence. Reoperation on these patients is challenging and needs to be individualised. Various methods are described including primary closure, bypass procedures, serosal patch repair and Roux-en-Y repair. We present a new technique of repair using afferent loop that provided a vascularized bowel segment, which used in an anatomical fashion for closure of fistula.

Pancreatico-pericardial fistula: a rare complication of chronic pancreatitis.

A 16-year-old boy presented with pericardial effusion, bilateral pleural effusion and mediastinal fluid collection. CT scan of abdomen revealed pancreatic calcification and a fistulous tract from a pseudocyst going along the inferior vena cava wall up to the pericardial cavity. After initial pericardiocentesis and pleurocentesis, lateral pancreatico-jejunostomy with Roux-en-Y loop was performed. The patient is well at 6 months follow up.

Fístula pleuropancreática com pseudocisto intratorácico: relato de caso / Pancreaticopleural fistula with intrathoracic pseudocyst: case report

A fístula pleuropancreática, complicaçäo rara da pancreatite crônica, geralmente, é resultado da ruptura de pseudocisto ou do ducto pancreático, fistulizando para o espaço pleural. Os autores relatam caso de paciente de 44 anos, feodérmico, do sexo masculino, com diagnóstico prévio de pancreatite crônica de etiologia alcoólica, apresentando quadro de dispnéia aos esforços, tosse seca, dor torácica ventilatório-dependente com evoluçäo de sete dias. Foi submetido a toracocenteses de alívio, sendo a dosagem de amilase no líquido pleural de 27.816 UI/I. Radiografias de tórax evidenciaram esboço de coleçäo intrapleural, confirmada por tomografia computadorizada de tórax. O paciente foi tratado, clinicamente, com jejum e nutriçäo parenteral total durante 22 dias. Evoluiu com remissäo dos sintomas e do derrame pleural. A colangiopancreatografia endoscópica retrógada realizada ao final do tratamento näo demonstrou comunicaçäo pleuropancreática.

Duodenopancreatectomía con conservación de píloro / Pancreatoduodenectomy with pyloric preservation

Se presenta la experiencia de 9 años con el empleo de la técnica de duodenopancreatectomía con preservación pilórica. Son 39 pacientes, 18 hombres y 21 mujeres con edad promedio de 50 años. Hay 32 patologías malignas (20 ampulomas, 8 Ca de páncreas, 3 Ca vía biliar y 1 Ca vesicular) y 7 benignas (3 pancreatitis crónicas, 1 tumor poliquístico, 2 leiomiomas duodenales, 1 coledocolitiasis encastillada). La principal complicación postoperatoria, fue el retardo del vaciamiento gástrico inicial en 10 pacientes (25,6 por ciento), se produjo 3 fístulas pancreáticas (7,69 por ciento), todas con técnica de pancreatoyeyunoanastomosis T-T telescopada y no intubada (8 enfermos iniciales). En los últimos 31 enfermos con técnica de anastomosis T-L e intubada no se registró ninguna fístula pancreática. Hubo sólo un fallecido portador de insuficiencia renal crónica en plan de hemodiálisis, en falla orgánica múltiple y sin complicación quirúrgica detectable (2,56 por ciento). Los 20 ampulomas tuvieron una sobrevida actuarial a 5 años de 61 por ciento. Las lesiones benignas y las neoplásicas vivas y sin recidiva se encuentran en Visick 1-2 con recuperación ponderal promedio de 15 kg

Insulinoma pancreático / Pancreatic insulinoma

El insulinoma es un tumor de escasa incidencia, de origen endocrino que puede formar parte de los síndromes de neoplasia endocrina múltiple de tipo I. Se presentan casos diagnosticados y operados en el período de 1995 a 1999. Los casos fueron sometidos a resección quirúrgica. Los síntomas y signos de hipoglicemia más frecuentes fueron sudoración, taquicardia y compromiso de conciencia. El valor promedio de la glicemia de ayuno fue de 39 mg/dl y de 76 UI para la insulinemia. La sencibilidad del TAC y de la angiografía fue de 40 por ciento y 50 por ciento, respectivamente. Según localización, en 2 casos el tumor estabaen la cabeza, dos en el cuerpo y uno en la cola. Se realizaron tres enucleaciones, una pancreatectomía distal y una pancreatoduodenectomía. La evolución fue sin complicaciones en 3 de los 5 casos, uno desarrolló una fístula biliar manejada en forma conservadora y otro una fístula pancreática y colecciones intraabdominales que requirió reoperación con evolución posterior satisfactoria. Todos los pacientes analizados han sido seguidos por 19 meses de promedio, comprobándose su estado asistomático y normoglicémico. La cirugía parece ser curativa para la mayoría de los casos pero está exenta de morbilidad