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1.
HPB (Oxford) ; 24(10): 1592-1599, 2022 10.
Artículo en Inglés | MEDLINE | ID: mdl-35641405

RESUMEN

BACKGROUND: Randomized trials have compared laparoscopic pancreatoduodenectomy (LPD) to open pancreatoduodenectomy (OPD) with conflicting results. An IPDMA may give more insight into the differences between LPD and OPD, and could identify high-risk subgroups. METHODS: A systematic literature search was performed in the Pubmed, Embase, and the Cochrane library databases (October 2019). Out of 1410 studies, three randomized trials were identified. Primary outcome was major complications (Clavien-Dindo grade ≥ III). Subgroup analyses were performed for high-risk subgroups including patients with BMI of ≥25 kg/m2, pancreatic duct <3 mm, age ≥70 years, and malignancy. RESULTS: Data from 224 patients were collected. After LPD, major complications occurred in 33/114 (29%) patients compared to 34/110 (31%) patients after OPD (adjusted odds ratio (OR) 0.62; 95% confidence interval (CI) 0.3-1.4, P = 0.257). No differences were seen for major complications and 90-day mortality LPD 8 (7%) vs OPD 4 (4%) (adjusted OR 0.2; 95% CI 0.02-1.3, P = 0.080). With LPD, operative time was longer (420 vs 318 min, p < 0.001) and hospital stay was shorter (mean difference -6.97 days). Outcomes remained stable in the high-risk subgroups. CONCLUSION: LPD did not reduce the rate of major postoperative complications as compared to OPD. LPD increased operative time and shortened hospital stay with 7 days.


Asunto(s)
Laparoscopía , Neoplasias Pancreáticas , Pancreaticoduodenectomía , Anciano , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación , Tempo Operativo , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/métodos , Complicaciones Posoperatorias/epidemiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos
2.
Gut ; 70(2): 319-329, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-32409590

RESUMEN

OBJECTIVES: To characterise the association between type 2 diabetes mellitus (T2DM) subtypes (new-onset T2DM (NODM) or long-standing T2DM (LSDM)) and pancreatic cancer (PC) risk, to explore the direction of causation through Mendelian randomisation (MR) analysis and to assess the mediation role of body mass index (BMI). DESIGN: Information about T2DM and related factors was collected from 2018 PC cases and 1540 controls from the PanGenEU (European Study into Digestive Illnesses and Genetics) study. A subset of PC cases and controls had glycated haemoglobin, C-peptide and genotype data. Multivariate logistic regression models were applied to derive ORs and 95% CIs. T2DM and PC-related single nucleotide polymorphism (SNP) were used as instrumental variables (IVs) in bidirectional MR analysis to test for two-way causal associations between PC, NODM and LSDM. Indirect and direct effects of the BMI-T2DM-PC association were further explored using mediation analysis. RESULTS: T2DM was associated with an increased PC risk when compared with non-T2DM (OR=2.50; 95% CI: 2.05 to 3.05), the risk being greater for NODM (OR=6.39; 95% CI: 4.18 to 9.78) and insulin users (OR=3.69; 95% CI: 2.80 to 4.86). The causal association between T2DM (57-SNP IV) and PC was not statistically significant (ORLSDM=1.08, 95% CI: 0.86 to 1.29, ORNODM=1.06, 95% CI: 0.95 to 1.17). In contrast, there was a causal association between PC (40-SNP IV) and NODM (OR=2.85; 95% CI: 2.04 to 3.98), although genetic pleiotropy was present (MR-Egger: p value=0.03). Potential mediating effects of BMI (125-SNPs as IV), particularly in terms of weight loss, were evidenced on the NODM-PC association (indirect effect for BMI in previous years=0.55). CONCLUSION: Findings of this study do not support a causal effect of LSDM on PC, but suggest that PC causes NODM. The interplay between obesity, PC and T2DM is complex.


Asunto(s)
Diabetes Mellitus Tipo 2/complicaciones , Obesidad/complicaciones , Neoplasias Pancreáticas/etiología , Anciano , Índice de Masa Corporal , Péptido C/sangre , Estudios de Casos y Controles , Causalidad , Diabetes Mellitus Tipo 2/etiología , Diabetes Mellitus Tipo 2/genética , Escolaridad , Femenino , Hemoglobina Glucada/análisis , Humanos , Masculino , Análisis de Mediación , Persona de Mediana Edad , Obesidad/genética , Neoplasias Pancreáticas/complicaciones , Neoplasias Pancreáticas/genética , Polimorfismo de Nucleótido Simple/genética , Factores de Riesgo , Factores Sexuales , Fumar/efectos adversos
3.
Ann Surg ; 273(2): 334-340, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-30829699

RESUMEN

OBJECTIVE: The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort. BACKGROUND: MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD. METHODS: A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance. RESULTS: Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy. CONCLUSIONS: The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.


Asunto(s)
Laparoscopía/efectos adversos , Enfermedades Pancreáticas/cirugía , Fístula Pancreática/epidemiología , Pancreaticoduodenectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Robotizados/efectos adversos , Anciano , Estudios de Cohortes , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Pancreáticas/complicaciones , Enfermedades Pancreáticas/patología , Factores de Riesgo , Sensibilidad y Especificidad
4.
Ann Surg ; 274(5): 721-728, 2021 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-34353988

RESUMEN

OBJECTIVE: The aim of this study was to evaluate whether neoadjuvant therapy (NAT) critically influenced microscopically complete resection (R0) rates and long-term outcomes for patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy (PD) with portomesenteric vein resection (PVR) from a diverse, world-wide group of high-volume centers. SUMMARY OF BACKGROUND DATA: Limited size studies suggest that NAT improves R0 rates and overall survival compared to upfront surgery in R/BR-PDAC patients. METHODS: This multicenter study analyzed consecutive patients with R/BR-PDAC who underwent PD with PVR in 23 high-volume centers from 2009 to 2018. RESULTS: Data from 1192 patients with PD and PVR were collected and analyzed. The median age was 68 [interquartile range (IQR) 60-73] years and 52% were males. Some 186 (15.6%) and 131 (10.9%) patients received neoadjuvant chemotherapy (NAC) alone and neoadjuvant chemoradiotherapy, respectively. The R0/R1/R2 rates were 57%, 39.3%, and 3.2% in patients who received NAT compared to 46.6%, 49.9%, and 3.5% in patients who did not, respectively (P =0.004). The 1-, 3-, and 5-year OS in patients receiving NAT was 79%, 41%, and 29%, while for those that did not it was 73%, 29%, and 18%, respectively (P <0.001). Multivariable analysis showed no administration of NAT, high tumor grade, lymphovascular invasion, R1/R2 resection, no adjuvant chemotherapy, occurrence of Clavien-Dindo grade 3 or higher postoperative complications within 90 days, preoperative diabetes mellitus, male sex and portal vein involvement were negative independent predictive factors for OS. CONCLUSION: Patients with PDAC of the pancreatic head expected to undergo venous reconstruction should routinely be considered for NAT.


Asunto(s)
Venas Mesentéricas/cirugía , Páncreas/irrigación sanguínea , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Vena Porta/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Europa (Continente)/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Estadificación de Neoplasias , Páncreas/cirugía , Neoplasias Pancreáticas/irrigación sanguínea , Neoplasias Pancreáticas/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo
5.
Ann Surg ; 271(2): 356-363, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-29864089

RESUMEN

OBJECTIVE: To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers. BACKGROUND: Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking. METHODS: Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3). RESULTS: Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001). CONCLUSIONS: In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.


Asunto(s)
Procedimientos Quirúrgicos Mínimamente Invasivos , Enfermedades Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Anciano , Europa (Continente) , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedades Pancreáticas/mortalidad , Pancreaticoduodenectomía/mortalidad , Puntaje de Propensión , Estudios Retrospectivos
6.
Ann Surg ; 272(5): 731-737, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32889866

RESUMEN

OBJECTIVE: The aim of this study was to establish clinically relevant outcome benchmark values using criteria for pancreatoduodenectomy (PD) with portomesenteric venous resection (PVR) from a low-risk cohort managed in high-volume centers. SUMMARY BACKGROUND DATA: PD with PVR is regarded as the standard of care in patients with cancer involvement of the portomesenteric venous axis. There are, however, no benchmark outcome indicators for this population which hampers comparisons of patients undergoing PD with and without PVR resection. METHODS: This multicenter study analyzed patients undergoing PD with any type of PVR in 23 high-volume centers from 2009 to 2018. Nineteen outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers (NCT04053998). RESULTS: Out of 1462 patients with PD and PVR, 840 (58%) formed the benchmark cohort, with a mean age was 64 (SD11) years, 413 (49%) were females. Benchmark cutoffs, among others, were calculated as follows: Clinically relevant pancreatic fistula rate (International Study Group of Pancreatic Surgery): ≤14%; in-hospital mortality rate: ≤4%; major complication rate Grade≥3 and the CCI up to 6 months postoperatively: ≤36% and ≤26, respectively; portal vein thrombosis rate: ≤14% and 5-year survival for patients with pancreatic ductal adenocarcinoma: ≥9%. CONCLUSION: These novel benchmark cutoffs targeting surgical performance, morbidity, mortality, and oncological parameters show relatively inferior results in patients undergoing vascular resection because of involvement of the portomesenteric venous axis. These benchmark values however can be used to conclusively assess the results of different centers or surgeons operating on this high-risk group.


Asunto(s)
Benchmarking , Venas Mesentéricas/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Pancreaticoduodenectomía , Vena Porta/cirugía , Adulto , Anciano , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias
7.
HPB (Oxford) ; 22(9): 1339-1348, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-31899044

RESUMEN

BACKGROUND: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. METHOD: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. RESULTS: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. CONCLUSION: HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.


Asunto(s)
Neoplasias de los Conductos Biliares , Neoplasias de la Vesícula Biliar , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares , Conductos Biliares Intrahepáticos , Neoplasias de la Vesícula Biliar/cirugía , Hepatectomía , Humanos , Pancreaticoduodenectomía/efectos adversos
8.
Int J Cancer ; 144(7): 1540-1549, 2019 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-30229903

RESUMEN

Deciphering the underlying genetic basis behind pancreatic cancer (PC) and its associated multimorbidities will enhance our knowledge toward PC control. The study investigated the common genetic background of PC and different morbidities through a computational approach and further evaluated the less explored association between PC and autoimmune diseases (AIDs) through an epidemiological analysis. Gene-disease associations (GDAs) of 26 morbidities of interest and PC were obtained using the DisGeNET public discovery platform. The association between AIDs and PC pointed by the computational analysis was confirmed through multivariable logistic regression models in the PanGen European case-control study population of 1,705 PC cases and 1,084 controls. Fifteen morbidities shared at least one gene with PC in the DisGeNET database. Based on common genes, several AIDs were genetically associated with PC pointing to a potential link between them. An epidemiologic analysis confirmed that having any of the nine AIDs studied was significantly associated with a reduced risk of PC (Odds Ratio (OR) = 0.74, 95% confidence interval (CI) 0.58-0.93) which decreased in subjects having ≥2 AIDs (OR = 0.39, 95%CI 0.21-0.73). In independent analyses, polymyalgia rheumatica, and rheumatoid arthritis were significantly associated with low PC risk (OR = 0.40, 95%CI 0.19-0.89, and OR = 0.73, 95%CI 0.53-1.00, respectively). Several inflammatory-related morbidities shared a common genetic component with PC based on public databases. These molecular links could shed light into the molecular mechanisms underlying PC development and simultaneously generate novel hypotheses. In our study, we report sound findings pointing to an association between AIDs and a reduced risk of PC.


Asunto(s)
Enfermedades Autoinmunes/epidemiología , Enfermedades Autoinmunes/genética , Neoplasias Pancreáticas/epidemiología , Neoplasias Pancreáticas/genética , Estudios de Casos y Controles , Biología Computacional/métodos , Europa (Continente)/epidemiología , Femenino , Ontología de Genes , Predisposición Genética a la Enfermedad , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Factores de Riesgo
9.
BMC Surg ; 19(1): 40, 2019 Apr 24.
Artículo en Inglés | MEDLINE | ID: mdl-31014318

RESUMEN

BACKGROUND: Postoperative adhesions represent 75% of all acute small bowel obstructions. Although open surgery is considered the standard approach for adhesiolysis, laparoscopic approach is gaining popularity. METHODS: A retrospective study with data from a prospectively maintained data base of all patients undergoing surgical treatment for adhesive small bowel obstruction (ASBO) from January 2007 to May 2016 was conducted. Postoperative outcomes comparing open vs laparoscopic approaches were analysed. An intention to treat analysis was performed. The aim of the study was to evaluate the potential benefits of the laparoscopic approach in the treatment of ASBO. RESULTS: 262 patients undergoing surgery for ASBO were included. 184 (70%) and 78 (30%) patients were operated by open and laparoscopic approach respectively. The conversion rate was 38.5%. Patients in the laparoscopic group were younger (p < 0.001), had fewer previous abdominal operations (p = 0.001), lower ASA grade (p < 0.001), and less complex adhesions were found (p = 0.001). Operative time was longer in the open group (p = 0.004). Laparoscopic adhesiolysis was associated with a lower overall complication rate (43% vs 67.9%, p < 0.001), lower mortality (p = 0.026), earlier oral intake (p < 0.001) and shorter hospital stay (p < 0.001). Specific analysis of patients with single band and/or internal hernia who did not need bowel resection, also demonstrated fewer complications, earlier oral intake and shorter length of stay. In the multivariate analysis, the open approach was an independent risk factor for overall complications compared to the laparoscopic approach (Odds Ratio = 2.89; 95% CI 1.1-7.6; p = 0.033). CONCLUSIONS: Laparoscopic management of ASBO is feasible, effective and safe. The laparoscopic approach improves postoperative outcomes and functional recovery, and should be considered in patients in whom simple band adhesions are suspected. Patient selection is the strongest key factor for having success.


Asunto(s)
Obstrucción Intestinal/cirugía , Intestino Delgado/cirugía , Laparoscopía , Complicaciones Posoperatorias/cirugía , Adherencias Tisulares/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Conversión a Cirugía Abierta , Bases de Datos Factuales , Femenino , Humanos , Análisis de Intención de Tratar , Obstrucción Intestinal/etiología , Laparoscopía/efectos adversos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Tempo Operativo , Selección de Paciente , Estudios Retrospectivos , Factores de Riesgo , Adherencias Tisulares/complicaciones
10.
Ann Surg ; 268(5): 731-739, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30138162

RESUMEN

OBJECTIVE: To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery. SUMMARY BACKGROUND DATA: Laparoscopic PD is being progressively performed in selected patients. METHODS: An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis. RESULTS: Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found. CONCLUSIONS: Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection. TRIAL REGISTRY: ISRCTN93168938.


Asunto(s)
Laparoscopía/métodos , Pancreaticoduodenectomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Transfusión de Componentes Sanguíneos/estadística & datos numéricos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/clasificación , Estudios Prospectivos , Calidad de Vida , España , Resultado del Tratamiento
11.
Gut ; 66(2): 314-322, 2017 02.
Artículo en Inglés | MEDLINE | ID: mdl-26628509

RESUMEN

OBJECTIVE: Studies indicate an inverse association between ductal adenocarcinoma of the pancreas (PDAC) and nasal allergies. However, controversial findings are reported for the association with asthma. Understanding PDAC risk factors will help us to implement appropriate strategies to prevent, treat and diagnose this cancer. This study assessed and characterised the association between PDAC and asthma and corroborated existing reports regarding the association between allergies and PDAC risk. DESIGN: Information about asthma and allergies was collated from 1297 PDAC cases and 1024 controls included in the PanGenEU case-control study. Associations between PDAC and atopic diseases were studied using multilevel logistic regression analysis. Meta-analyses of association studies on these diseases and PDAC risk were performed applying random-effects model. RESULTS: Asthma was associated with lower risk of PDAC (OR 0.64, 95% CI 0.47 to 0.88), particularly long-standing asthma (>=17 years, OR 0.39, 95% CI 0.24 to 0.65). Meta-analysis of 10 case-control studies sustained our results (metaOR 0.73, 95% CI 0.59 to 0.89). Nasal allergies and related symptoms were associated with lower risk of PDAC (OR 0.66, 95% CI 0.52 to 0.83 and OR 0.59, 95% CI 0.46 to 0.77, respectively). These results were supported by a meta-analysis of nasal allergy studies (metaOR 0.6, 95% CI 0.5 to 0.72). Skin allergies were not associated with PDAC risk. CONCLUSIONS: This study shows a consistent inverse association between PDAC and asthma and nasal allergies, supporting the notion that atopic diseases are associated with reduced cancer risk. These results point to the involvement of immune and/or inflammatory factors that may either foster or restrain pancreas carcinogenesis warranting further research to understand the molecular mechanisms driving this association.


Asunto(s)
Asma/epidemiología , Carcinoma Ductal Pancreático/epidemiología , Neoplasias Pancreáticas/epidemiología , Rinitis Alérgica/epidemiología , Anciano , Estudios de Casos y Controles , Dermatitis Alérgica por Contacto/epidemiología , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Protectores
12.
Surg Endosc ; 31(7): 2837-2845, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-27804043

RESUMEN

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure that is becoming increasingly popular among surgeons. Postoperative pancreatic fistula (POPF) remains the most feared specific complication in reconstruction after PD. The Blumgart anastomosis (BA) has been established as one of the safest anastomosis for pancreas remnant reconstruction, with low rates of POPF and postoperative complications. The procedure for performing this anastomosis by laparoscopic approach has not been reported to date. METHODS: We describe our technique of LPD with laparoscopic-adapted BA (LapBA) and present the results obtained. A case-matched analysis with open cases of BA is also reported. RESULTS: Since February 2013 to February 2016, thirteen patients were operated of LapBA. An equivalent cohort of open PD patients was obtained by matching sex, ASA, pancreas consistency and main pancreatic duct diameter. Severe complications (grades III-IV) and length of stay were significantly lesser in LapBA group. No differences in POPF, readmission, reoperation rate and mortality were detected. CONCLUSIONS: The LapBA technique we propose can facilitate the pancreatic reconstruction after LPD. In this case-matched study, LPD shows superior results than open PD in terms of less severe postoperative complications and shorter length of stay. Randomized control trials are required to confirm these results.


Asunto(s)
Laparoscopía/métodos , Pancreaticoduodenectomía/métodos , Pancreatoyeyunostomía/métodos , Adulto , Anciano , Anastomosis Quirúrgica/métodos , Femenino , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Complicaciones Posoperatorias/prevención & control , Resultado del Tratamiento
13.
Int J Hyperthermia ; 33(2): 135-141, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-27633068

RESUMEN

PURPOSE: To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection. MATERIALS AND METHODS: A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode. RESULTS: No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm2 vs. 2.8 ± 4.0 ml/cm2, p = .006). No significant differences were observed in the rate of complications between the groups. CONCLUSIONS: The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.

14.
Pancreatology ; 16(1): 38-43, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-26639388

RESUMEN

BACKGROUND: Pancreatic duct ligation (PDL) has been used as a model of chronic pancreatitis and as a model to increase ß-cell mass. However, studies in mice have demonstrated acinar regeneration after PDL, questioning the long-term validity of the model. We aim to elucidate whether RF-assisted transection (RFAT) of the main pancreatic duct is a reliable PDL model, both in short (ST, 1-month) and long-term (LT, 6-months) follow-ups. METHODS: Eleven pigs were subjected to RFAT. Biochemical (serum/peripancreatic amylase and glucose) and histological changes (including a semiautomatic morphometric study of over 1000 images/pancreas and IHC analysis) were evaluated after ST or LT follow-up and also in fresh pancreas specimens that were used as controls for 1 (n = 4) and 6 months (n = 6). RESULTS: The distal pancreas in the ST was characterized by areas of acinar-to-ductal metaplasia (56%) which were significantly reduced at LT (21%) by fibrotic replacement and adipose tissue. The endocrine mass showed a normal increase. CONCLUSION: RFAT in the pig seems to be an appropriate PDL model without restoration of pancreatic drainage or reduction of endocrine mass.


Asunto(s)
Conductos Pancreáticos/cirugía , Amilasas/metabolismo , Animales , Proliferación Celular/fisiología , Reprogramación Celular/fisiología , Ligadura/métodos , Porcinos
15.
Int J Hyperthermia ; 32(3): 272-80, 2016 05.
Artículo en Inglés | MEDLINE | ID: mdl-26821683

RESUMEN

PURPOSE: The aim of this study was to assess the capacity of two methods of surgical pancreatic stump closure in terms of reducing the risk of pancreatic fistula formation (POPF): radiofrequency-induced heating versus mechanical stapler. MATERIALS AND METHODS: Sixteen pigs underwent a laparoscopic transection of the neck of the pancreas. Pancreatic anastomosis was always avoided in order to work with an experimental model prone to POPF. Pancreatic stump closure was conducted either by stapler (ST group, n = 8) or radiofrequency energy (RF group, n = 8). Both groups were compared for incidence of POPF and histopathological alterations of the pancreatic remnant. RESULTS: Six animals (75%) in the ST group and one (14%) in the RF group were diagnosed with POPF (p = 0.019). One animal in the RF group and three animals in the ST group had a pseudocyst in close contact with both pancreas stumps. On day 30 post-operation (PO), almost complete atrophy of the exocrine distal pancreas was observed when the main pancreatic duct was efficiently sealed. CONCLUSIONS: Our findings suggest that RF-induced heating is more effective at closing the pancreatic stump than mechanical stapler and leads to the complete atrophy of the distal remnant pancreas.


Asunto(s)
Ablación por Catéter , Páncreas/cirugía , Fístula Pancreática/prevención & control , Complicaciones Posoperatorias/prevención & control , Engrapadoras Quirúrgicas , Animales , Atrofia , Calor , Laparoscopía , Páncreas/patología , Porcinos
16.
Dig Surg ; 33(4): 290-8, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27216800

RESUMEN

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) for large pancreatic tumors may require prolonged dissection, and this could be associated with increased operative time and intraoperative complications. METHODS: From a total cohort of 190 consecutive patients undergoing LDP, 18 patients were found to have pancreatic tumors >5 cm and were included in the retrospective study of prospectively collected data. Three techniques were used to approach the splenic vessels: the superior pancreatic, the inferior supracolic and post-pancreatic transection. RESULTS: Of these 18 patients, 13 were women and 5 were men, the median age was 68 years and their median tumor size 7 cm. Exocrine pancreatic malignancy was diagnosed in 8 patients, 6 patients had neuroendocrine pancreatic tumors and 4 patients cystic neoplasm. The median number of resected nodes was 14. R1 resections for exocrine pancreatic malignancies were found in 50% of patients. Morbidity (grade >II) was found in 16.6% of patients and 30 days mortality in 1 patient. Overall median survival was 50 months and 29 months for patients with exocrine pancreatic malignancies. CONCLUSIONS: LDP for large tumors, while technically demanding, is possible without additional morbidity and did not compromise short- and long-term oncological outcomes.


Asunto(s)
Adenocarcinoma/patología , Adenocarcinoma/cirugía , Laparoscopía/métodos , Escisión del Ganglio Linfático/métodos , Neoplasias Quísticas, Mucinosas y Serosas/cirugía , Tumores Neuroendocrinos/cirugía , Pancreatectomía/métodos , Neoplasias Pancreáticas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Pérdida de Sangre Quirúrgica , Femenino , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Neoplasias Quísticas, Mucinosas y Serosas/patología , Tumores Neuroendocrinos/patología , Tempo Operativo , Pancreatectomía/efectos adversos , Neoplasias Pancreáticas/patología , Estudios Retrospectivos , Tasa de Supervivencia , Carga Tumoral
19.
Cir Esp ; 92(5): 336-40, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-24035528

RESUMEN

INTRODUCTION: Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO). PATIENTS AND METHODS: From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required. RESULTS: The mean age of the 33 patients who underwent surgery was 61.1 ± 17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83 ± 44 min. and 7.8 ± 11.2 days, respectively. Operative time (72 ± 30 vs 123 ± 63 min.), tolerance to oral intake (1.8 ± 0.9 vs 5.7 ± 3.3 days) and length of postoperative stay (4.7 ± 2.5 vs 19.4 ± 21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group. CONCLUSIONS: In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short hospital length of stay and low morbidity); its use would be fully justified in these cases.


Asunto(s)
Hernia/complicaciones , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Intestino Delgado , Laparoscopía , Adherencias Tisulares/complicaciones , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Mesenterio , Persona de Mediana Edad , Estudios Prospectivos
20.
Surg Endosc ; 27(10): 3710-9, 2013 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-23584822

RESUMEN

BACKGROUND: Postoperative pancreatic fistula (PPF) is the most frequent and serious complication after laparoscopic distal pancreatectomy (LDP). Our goal was to compare the performance, in terms of PPF prevention, and safety of a radiofrequency (RF)-assisted transection device versus a stapler device in a porcine LDP model. METHODS: Thirty-two animals were randomly divided into two groups to perform LDP using a RF-assisted device (RF group; n = 16) and stapler device (ST group; n = 16) and necropsied 4 weeks after surgery. The primary endpoint was the incidence of PPF. Secondary endpoints were surgery/transection time, intra/postoperative complications/deaths, postoperative plasmatic amylase and glucose concentration, peritoneal liquid amylase and interleukin 6 (IL-6) concentrations, weight variations, and histopathological changes. RESULTS: Two clinical and one biochemical PPF were observed in the ST and RF groups respectively. Peritoneal amylase concentration was significantly higher in the RF group 4 days after surgery, but this difference was no longer present at necropsy. Both groups presented a significant decrease in peritoneal IL-6 concentration during the postoperative follow-up, with no differences between the groups. RF group animals showed a higher postoperative weight gain. In the histopathological exam, all RF group animals showed a common pattern of central coagulative necrosis of the parenchymal surface, surrounded by a thick fibrosis, which sealed main and secondary pancreatic ducts and was not found in ST group. CONCLUSIONS: The fibrosis caused by an RF-assisted device can be at least as safe and effective as stapler compression to achieve pancreatic parenchyma sealing in a porcine LDP model.


Asunto(s)
Ablación por Catéter , Laparoscopía/métodos , Pancreatectomía/métodos , Fístula Pancreática/etiología , Complicaciones Posoperatorias/etiología , Grapado Quirúrgico , Amilasas/análisis , Animales , Líquido Ascítico/química , Líquido Ascítico/enzimología , Glucemia/análisis , Interleucina-6/análisis , Complicaciones Intraoperatorias/etiología , Tempo Operativo , Páncreas/patología , Fístula Pancreática/prevención & control , Atención Perioperativa , Complicaciones Posoperatorias/prevención & control , Sus scrofa , Porcinos
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