PANCREATODUODENECTOMY DUE TO LIPOMATOUS PSEUDOHYPERTROPHY OF THE PANCREAS.

BACKGROUND: Lipomatous pseudohypertrophy of the pancreas, pancreatic lipomatosis, pancreatic steatosis, non-alcoholic fatty pancreatic disease, or fatty pancreas is an extremely rare disease, characterized by the organ enlargement and a localized or diffuse replacement of pancreatic acinar cells by mature adipose tissue, preserving the pancreatic ductal system and islets of Langerhans. AIMS: To report a rare case of lipomatous pseudohypertrophy of the pancreas in a symptomatic patient and the surgical treatment employed. METHODS: A 24-year-old male patient with weight loss (10 kilograms in 8 months), hyperglycemia, severe and recurrent acute abdominal pain, epigastric discomfort associated with nausea, vomiting, and jaundice for 40 days. Magnetic resonance imaging was performed, revealing an irregular lipomatous pseudohypertrophy of the pancreas, measuring 6.0 × 5.6 cm in the head, uncinate process, and part of the body of the pancreas. The pancreatic duct dilation was diffuse and irregular, associated with atrophy of the remnant parenchyma, particularly in the tail of the pancreas. The patient underwent pancreatoduodenectomy without total mesopancreas excision followed by pancreatojejunostomy. RESULTS: The postoperative course was uneventful, the length of stay in the ICU was two days, and the patient was discharged on the seventh postoperative day. CONCLUSIONS: The disease treatment depends on the signs and symptoms at presentation and a pancreatoduodenectomy is indicated in patients with severe and recurrent abdominal pain.

Pancreatoduodenectomy due to lipomatous pseudohypertrophy of the pancreas / Pancreatoduodenectomia por pseudohipertrofia lipomatosa do pâncreas

ABSTRACT BACKGROUND: Lipomatous pseudohypertrophy of the pancreas, pancreatic lipomatosis, pancreatic steatosis, non-alcoholic fatty pancreatic disease, or fatty pancreas is an extremely rare disease, characterized by the organ enlargement and a localized or diffuse replacement of pancreatic acinar cells by mature adipose tissue, preserving the pancreatic ductal system and islets of Langerhans. AIMS: To report a rare case of lipomatous pseudohypertrophy of the pancreas in a symptomatic patient and the surgical treatment employed. METHODS: A 24-year-old male patient with weight loss (10 kilograms in 8 months), hyperglycemia, severe and recurrent acute abdominal pain, epigastric discomfort associated with nausea, vomiting, and jaundice for 40 days. Magnetic resonance imaging was performed, revealing an irregular lipomatous pseudohypertrophy of the pancreas, measuring 6.0 × 5.6 cm in the head, uncinate process, and part of the body of the pancreas. The pancreatic duct dilation was diffuse and irregular, associated with atrophy of the remnant parenchyma, particularly in the tail of the pancreas. The patient underwent pancreatoduodenectomy without total mesopancreas excision followed by pancreatojejunostomy. RESULTS: The postoperative course was uneventful, the length of stay in the ICU was two days, and the patient was discharged on the seventh postoperative day. CONCLUSIONS: The disease treatment depends on the signs and symptoms at presentation and a pancreatoduodenectomy is indicated in patients with severe and recurrent abdominal pain.

RESUMO RACIONAL: Pseudo-hipertrofia lipomatosa do pâncreas, lipomatose pancreática, esteatose pancreática, doença pancreática gordurosa não alcoólica ou pâncreas gorduroso é uma doença extremamente rara, caracterizada por aumento do órgão e substituição localizada ou difusa de células acinares pancreáticas por tecido adiposo, preservando o sistema ductal pancreático e as ilhotas de Langerhans. OBJETIVOS: Relatar um caso raro de pseudo-hipertrofia lipomatosa do pâncreas, em paciente sintomático e o tratamento cirúrgico empregado. MÉTODOS: Paciente do sexo masculino, 24 anos, com queixas de emagrecimento (10 quilos nos últimos 8 meses), hiperglicemia, dor abdominal aguda intensa e recorrente, desconforto epigástrico associado a náuseas, vômitos e icterícia há 40 dias. A ressonância magnética (RM) revelou pseudo-hipertrofia lipomatosa irregular do pâncreas, medindo 6,0 × 5,6 cm na cabeça, processo uncinado e parte do corpo do pâncreas. A dilatação do ducto pancreático era difusa e irregular, associada à atrofia do parênquima remanescente, principalmente na cauda do pâncreas. O paciente foi submetido à duodenopancreatectomia sem excisão total do mesopâncreas seguida de pancreatojejunostomia. RESULTADOS: O pós-operatório transcorreu sem intercorrências, o tempo de internação na UTI foi de 2 dias, com alta hospitalar no sétimo dia. CONCLUSÕES: O tratamento da doença depende dos sinais e sintomas na apresentação e a duodenopancreatectomia é indicada em pacientes com dor abdominal intensa e recorrente.

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS.

BACKGROUND: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. AIM: To understand the Brazilian practice patterns for pancreatoduodenectomy. METHOD: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. RESULTS: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. CONCLUSION: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Pancreatoduodenectomy: brazilian practice patterns / Duodenopancreatectomia: prática padrão do brasil

ABSTRACT Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

RESUMO Racional: A duodenopancreatectomia é um procedimento cirúrgico tecnicamente desafiador, com uma incidência de complicações pós-operatórias variando de 30% a 61%. O procedimento requer experiência de alto nível, e para minimizar complicações relacionadas à cirurgia uma padronização de alta qualidade é imperativa. Objetivo: Compreender o padrão da prática brasileira para duodenopancreatectomia. Método: Um questionário foi elaborado com a finalidade de obter uma visão geral da prática cirúrgica em câncer do pâncreas, treinamento específico e experiência em duodenopancreatectomia. O questionário foi enviado para cirurgiões com declarado interesse em cirurgia pancreática. Resultados: Um total de 60 questionários foi enviado e 52 retornaram (86,7%). A região sudeste foi a que mais respondeu, com 25 cirurgiões (48,0%). Apenas dois cirurgiões (3,9%), realizaram mais do que 50% das duodenopancreatectomia por videolaparoscopia. O procedimento clássico de Whipple foi realizado por 24 cirurgiões (46,2%) e a linfadenectomia padrão do Grupo Internacional de Estudo em Cirurgia Pancreática foi realizada por 43 cirurgiões (82,7%). Para a reconstrução, a pancreatojejunostomia foi realizada por 49 cirurgiões (94,2%), em alça única por 41 (78,9%), com anastomose do tipo ducto-mucosa por 38 (73,1%). O cateter transanastomose foi realizado por 26 cirurgiões (50%), reconstrução gástrica antecólica por 39 (75%) e enteroanastomose tipo Braun apenas por seis cirurgiões (11,5%). A drenagem abdominal profilática foi realizada por todos os cirurgiões e o uso de análogos da somatostatina por seis cirurgiões (11,5%). Nutrição enteral precoce no pós-operatório foi utilizada de rotina por 22 cirurgiões (42,3%) e 34 cirurgiões (65,4%), usaram sonda nasogástrica de rotina. Conclusão: Heterogeneidade foi observada na prática padrão da duodenopancreatectomia pelos cirurgiões no Brasil e, algumas delas em contraste com evidências estabelecidas na literatura.

Isolated caudate lobectomy: Left-sided approach. Case reports.

INTRODUCTION: The caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge. Left-sided approach was described for resection of small tumors originated in the Spiegel lobe but now the procedure has been performed even for tumors more than five centimeters. The aim of this study is to present three cases of tumor of caudate lobe underwent isolated lobectomy by left-sided approach. PRESENTATION OF CASE: Three patients with metastasis of colorectal cancer, carcinoma hepatocellular and metastasis of neuroendocrine tumor underwent resection. After modified Makuuchi incision, early control of short hepatic e short portal veins before hepatectomy was performed. The operative time was 200, 270 and 230min respectively. No blood transfusion was used and no postoperative complications were observed. The length of stay was 7, 11 and 5days respectively. DISCUSSION: Some approaches have been described to access and resect tumors of the caudate lobe, including the left-sided approach, right-sided approach, combined left- and right-sided approach and the anterior transhepatic approach. For liver resection in patients with malignant disease, parenchymal preservation is important in order to avoid postoperative liver failure or due to the risk of second hepatectomy. In these patients isolated caudate lobectomy is a safe option. CONCLUSION: Isolated caudate lobectomy is a feasible procedure. Left-sided approach can be preformed even for tumors larger than 5cm.

The ALPPS procedure for hepatocellular carcinoma larger than 10 centimeters.

INTRODUCTION: The only means of achieving long-term survival in hepatocellular carcinoma is complete tumor resection or liver transplantation. Patients with large hepatocellular carcinomas are currently not considered for liver transplantation. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is indicated in selected patients. We present the case of a patient with a huge hepatocellular carcinoma who underwent an ALPPS procedure. PRESENTATION OF CASE: A 57-year-old man initially presented with a tumor measuring 19cm×10cm in the right lobe of the liver. The liver function was normal and there was no evidence of portal hypertension. The first part of the procedure was performed without mobilizing the liver. The middle hepatic vein was divided during parenchymal transection. The second procedure was performed after 15days. During that procedure the right hepatic artery, right bile duct, and the right hepatic vein were ligated and divided. Liver segments 4-8 with the tumor were removed. The patient developed moderate ascites but recovered after ten days. After 90days, the patient is doing well with no signs of recurrence. DISCUSSION: Hepatocellular carcinoma is a complicated disease and ALPPS is not considered an optimal treatment option. However, patients with large tumors are not considered for liver transplantation or chemotherapy. Patients with Child-Pugh A liver disease without portal hypertension can benefit from surgical treatment for hepatocellular carcinoma; in some situations, surgery may be considerably better than other forms of treatment. CONCLUSION: ALPPS should be considered in selected patients with large hepatocellular carcinomas.

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.

Predictive factors of morbidity in distal pancreatic resections.

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.