ROBOTIC ASSISTED VERSUS LAPAROSCOPIC DISTAL PANCREATECTOMY: A RETROSPECTIVE STUDY.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown. AIMS: To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias. METHODS: This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS). RESULTS: Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP - 72,4% versus LDP - 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP). CONCLUSIONS: The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher.

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

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

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

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

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

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

Clinical Course, Genetic, and Immunohistochemical Characterization of Solid Pseudopapillary Tumor of the Pancreas (Frantz Tumors) in a Brazilian Cohort.

Frantz tumors or solid pseudopapillary pancreatic neoplasm (SPN) are rare exocrine neoplasms that carry a favorable prognosis; they represent up to 3% of all tumors located in the region of the pancreas and have specific age and gender predispositions. In recent years, the rising curve of diagnosis is entitled to the evolution and access of diagnostic imaging. In this paper, we have retrospectively reviewed and described the clinical course of 40 patients with SPN from three institutions in Brazil, who had their diagnosis between 2005 and 2020, and analyzed the clinicopathological, genetic, and surgical aspects of these individuals. In accordance with the literature, most patients were women, 60% with unspecified symptoms at diagnosis, with tumors mainly located in the body and tail of the pancreas, of whom 70% underwent a distal pancreatectomy with sparing splenectomy as a standard procedure, and none of the cases have experienced recurrence to date. Surgery still remains the mainstay of treatment given the low metastatic potential, but more conservative approaches as observed in this cohort are evolving to become the standard of care. Herein, we present an in-depth analysis of cases focusing on the latest literature and report some of the smallest tumor cases in the literature. To our knowledge, this is the first report evaluating germline genetic testing and presenting a case of detected Li-Fraumeni syndrome.

HOW TO PERFORM LAPAROSCOPIC DISTAL PANCREATECTOMY USING THE CLOCKWISE TECHNIQUE.

BACKGROUND: Laparoscopic pancreatectomy is currently a widely used approach for benign and malignant lesions of the pancreas. AIMS: This study aimed to describe how to perform a laparoscopic distal pancreatectomy using The Clockwise Technique. METHODS: An 18-year-old female patient presented with a well-defined tumor in the pancreatic body with 4 cm in diameter that suggested a diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was recommended for laparoscopic distal pancreatectomy by using The Clockwise Technique. RESULTS: The clockwise, caudal-to-cephalic approach appears to have other significant technical advantages that facilitate the performance of the procedure. CONCLUSIONS: A laparoscopic distal pancreatectomy performed using The Clockwise Technique provides satisfactory outcomes.

Neoadjuvant chemotherapy or upfront surgery in localized pancreatic cancer: a contemporary analysis.

Neoadjuvant chemotherapy is considered a new treatment option for potentially resectable pancreatic cancer. However, data are not well established on overall survival and delaying surgery in resectable pancreatic cancer, as well as on those patients that ultimately cannot undergo surgery. We analyzed pancreatic cancer patients treated in a tertiary hospital from January 2016 to December 2020. Patients with resectable stage I and II pancreatic cancer were evaluated regarding surgery, neoadjuvant treatment, and other clinical demographics. The survival function was estimated using the Kaplan-Meier method, and the relationship between the variables of interest and the overall survival (OS) was assessed by adopting the proportional regression Cox models. A total of 216 patients were evaluated. 81 of them with resectable/borderline resectable disease and 135 with unresectable /metastatic disease at diagnosis. Median OS for stage I and II disease were 36 and 28 months, respectively. For resectable pancreatic cancer median OS was 28 months, for borderline resectable pancreatic cancer median OS was 11 months. Median OS for stage III (locally advanced) and stage IV (metastatic) were 10 and 7 months, respectively (p < 0.0001). Median OS of 9 months were obtained for patients with stage I and II that did not undergo surgery compared to 25 months in patients that underwent surgery in any time (p < 0.001). Comparing patients with localized disease, median OS for patients treated with upfront surgery was 28 months, compared to 15 months in patients treated with neoadjuvant approach (p = 0.04). Most patients that did not undergo surgery have decline of performance status or disease progression on neoadjuvant treatment. On multivariable analysis in pancreatic cancer stages I and II, including age, sex, borderline or resectable disease, CA 19-9, positive lymph nodes and neoadjuvant treatment, the surgery was the only factor associated with improved overall survival (p = 0.04). Upfront surgery should still be considered a standard of care approach for resectable pancreatic cancer. Biomarker driven studies and randomized trials with combination therapies are necessary to address neoadjuvant chemotherapy and delaying surgery in purely resectable pancreatic cancer.

Surgery or active surveillance for pNETs < 2 cm: Preliminary results from a single center Brazilian cohort.

BACKGROUND AND OBJECTIVES: Incidence of pancreatic neuroendocrine tumors (pNETS) seems to be rising over the years, with many cases incidentally diagnosed. Surgery and active surveillance are current treatment modalities for small pNETS. We review our institutional series and compare outcomes for small asymptomatic and nonfunctioning tumors. METHODS: This retrospective cohort study included patients with 2 cm or less and well differentiated pNETS at a single Brazilian Cancer Center. From 2002 to 2020, patients received active surveillance or surgery as a treatment strategy. Short and long-term results were compared. RESULTS: Sixty-four patients were included, 41 in surgical strategy and 23 in the active surveillance approach. Baseline group characteristics were comparable. More patients on active surveillance underwent abdominal magnetic resonance imaging (MRI) and had tumors located in the pancreatic head (41% vs. 17%, p = 0.038). Minimally invasive procedure was chosen in 80.1% of the surgical patients. No patient died after surgery. Median follow-up period was 38.6 and 46.4 months for active surveillance and surgery cohorts, respectively. No difference in disease progression rate was observed. CONCLUSION: Both approaches seem to be safe for small pNETs. Long-term outcome and quality of life should be considered when discussing such options with patients.

Distal pancreatectomy: experience in a National Hospital.

AIMS: To compare the short-term outcomes of patients undergoing open DP (ODP) and laparoscopic DP (LDP); and to analyze the association between the section site of the pancreas and pancreatic fistula. MATERIALS AND METHODS: Clinical, perioperative, and histopathologic data of patients who underwent ODP and LDP between 2009 and 2019 were retrospectively analyzed. RESULTS: 70 patients were included. 39 (56%) underwent ODP and 31 (44%) underwent LDP. The tumor size in ODP group was 70mm and in LDP group was 45mm (p = 0,032) Blood loss was lower in LDP group (229mL versus 498mL) (p = 0,001). Operative time, spleen preservation, B/C pancreatic fistula, major morbidity, reoperation, and length of hospital stay, were similar in both groups. There was no postoperative mortality. No differences were found in B/C pancreatic fistula rate regarding to pancreatic transection site. CONCLUSIONS: LDP is a safe procedure, with perioperative outcomes similar to ODP and with less blood loss. The pancreatic transection site did not influence post-operative pancreatic fistula rate.

OBJETIVOS: Comparar los resultados a corto plazo de pacientes intervenidos mediante pancreatectomía distal abierta (PDA) y laparoscópica (PDL); y analizar si el lugar de la sección del páncreas tiene relación con la formación de fístula pancreática. MATERIALES Y MÉTODOS: Serie retrospectiva y descriptiva de las PD realizadas, desde enero del 2009 a diciembre del 2019. Se compararon las características clínicas, perioperatorias e histopatológicas de pacientes con PDA y PDL. RESULTADOS: Se incluyeron 70 pacientes. Treinta y nueve casos (56%) con PDA y 31 casos (44%) con PDL. El tamaño tumoral promedio en la PDA fue de 70 mm y en la PDL 45 mm (p = 0.032). La pérdida sanguínea fue menor en la PDL (229 vs. 498 ml) (p = 0.001). No se encontró diferencia significativa en tiempo operatorio, porcentaje de preservación esplénica, fístula pancreática B/C, reoperación, morbilidad mayor y estancia hospitalaria. No hubo mortalidad postoperatoria. No hubo diferencias en la formación de fístula pancreática con respecto al lugar de sección del páncreas. CONCLUSIONES: La PDL es un procedimiento seguro, con resultados perioperatorios similares a la PDA y con menor pérdida sanguínea. El lugar de sección del páncreas no tuvo relación con la formación de fístula pancreática.

Laparoscopic Enucleation of Pancreatic Neoplasms: A Single-Center Experience and Outcomes.

Background: Laparoscopic technique has been increasingly applied in the treatment of selected pancreatic tumors. The aim of this study is to evaluate the experience with laparoscopic enucleation of pancreatic neoplasms (LEPNs), for selected pancreatic diseases, at a high-volume referral center. Methods: Between May 2012 and October 2020, LEPNs was attempted in 16 patients with selected pancreatic neoplasms. The localization of tumors, etiology, indications, and clinical outcomes were analyzed. Results: Sixteen patients were included. LEPN was successfully performed in 13 patients, 3 conversions to open procedure were required. The definitive histopathological result of the resected pieces showed prevalence of intraductal papillary mucinous neoplasms. Postoperative major complications occurred for 3 patients (18.7%), the 3 of them presented postoperative pancreatic fistula (POPF). The median hospital stay was 4.5 days (range 2-7) for patients without POPF and 14.6 days (3-30) for those who presented with POPF. No deaths were registered. During a median follow-up of 43.8 months (0.2-109), no new-onset exocrine or endocrine insufficiency was diagnosed, no patient experienced tumor recurrence and, the 4 patients who underwent LEPN for insulinoma, remained asymptomatic. Conclusion: LEPNs has become a valuable alternative for patients with benign or low risk of malignancy tumors. Appropriate preoperative imaging is key for localization. Whenever feasible, this technique not only reduces the risks of exocrine and endocrine insufficiency, but also adds the well-known advantages of minimally invasive techniques, making it a safe and feasible treatment.

Minimally Invasive Resection of the Uncinate Process of the Pancreas: Anatomical Considerations and Surgical Technique.

BACKGROUND: Low-grade lesions may benefit from pancreatic-sparing techniques. Resection of the uncinate process is rarely performed and reported due to its complexity that requires careful patient selection and accurate knowledge of the pancreatic anatomy. This study describes relevant anatomical elements to safely perform this complex operation in the minimally invasive setting. METHODS: In this study, consecutive patients undergoing resection of the uncinate process of the pancreas were studied. Patients undergoing open approach were used for comparison. Preoperative and intraoperative variables were recorded, and the diagnosis and tumor size were determined from the pathology reports. Immediate postoperative results and hospital stay were analyzed. Follow-up was used to assess long-term complications and endocrine and exocrine functions. RESULTS: Twenty-nine patients underwent resection of the uncinate process. The median age was 57 years. There were 21 males and eight females. Twenty patients underwent minimally invasive resection (14 laparoscopic and six by robotic approach) and nine were operated by open approach. A clinically relevant postoperative pancreatic fistula was observed in one patient (3.4%). Biochemical leakage was present in 44.8% of our patients. Mean follow-up was 62 months (3-147). Two patients needed reoperation during follow-up. No patient presented exocrine or endocrine insufficiency during late follow-up. CONCLUSION: Minimally invasive resection of the uncinate process of the pancreas is a complex but a feasible procedure that preserves the pancreatic endocrine and exocrine functions. This pancreas-sparing procedure is an interesting alternative to pancreaticoduodenectomy in selected patients.

Laparoscopic Pancreatectomy in Rats: The Development of an Experimental Model.

INTRODUCTION: several pancreatectomy techniques in rats have been described and utilized for research concerning the pancreas endocrine and exocrine functions. However, we did not find a description of any kind of laparoscopic pancreatectomy in rats in the consulted databases. The objective of this study is to describe a laparoscopic splenic lobe pancreatectomy in rats. METHODS: ten Wistars rats weighting more then 300 g were operated for standardizing the laparoscopic pancreatosplenectomy technique, aided by previous descriptions of laparoscopic splenectomy and open pancreatectomy in rats. Adjustments have been progressively adopted for technical refinement. RESULTS: In five animals a low-cost rat laparoscopic set was used. In other five animals we used a standard laparoscopic set. Three rats died early due to different causes: transection of the gastroesophageal junction, hemorrhagic shock and inadvertent colonic injury. The postoperative period of the other seven rats was uneventful until the seventh postoperative day. DISCUSSION: laparoscopic distal pancreatectomy and splenectomy in rats is feasible and safe, even with a low-cost set, in which the results were alike the standard laparoscopic set.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND: Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates. METHODS: Observational retrospective multicenter study. INCLUSION CRITERIA: patient undergoing TP, PD or DP plus CAR for a pancreatic cancer. RESULTS: Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups. CONCLUSION: It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

Hipoglucemia hiperinsulínica en un adulto con nesidioblastosis / Hyperinsulinic Hypoglycemia in an Adult with Nesidioblastosis

RESUMEN Introducción: La Nesidioblastosis es una rara afección pancreática que provoca hipoglucemia por hipersinsulinismo endógeno en la infancia. Es poco habitual en el adulto; solo se han publicado casos aislados desde su descripción. Objetivo: Caracterizar la presentación de una hipoglucemia hiperinsulínica en un paciente adulto con Nesidioblastosis. Caso clínico: Paciente adulto de 35 años, blanco, sexo masculino, sospecha de insulinoma, con episodios de hipoglucemia en ayunas o tras un ejercicio que revertía con la ingesta de alimentos o soluciones glucosadas. Se le realizó pancreatectomía de un 85 por ciento y en el estudio histológico se detectó una Nesidioblastosis. Conclusiones: Es infrecuente en el adulto, realizar su diagnóstico es difícil, se llega a la cirugía con el conocimiento de un estado hiperinsulínico endógeno, sin la certeza de su origen(AU)

ABSTRACT Introduction: Nesidioblastosis is a rare pancreatic condition that causes hypoglycemia due to endogenous hypersinsulinism in childhood. It is unusual in adults; only isolated cases have been published including its description. Objective: To characterize a case of hyperinsulinic hypoglycemia, in an adult patient with nesidioblastosis. Clinical case: A 35-year-old, white, male, adult patient with suspected insulinoma, with episodes of hypoglycemia in the fasting state or after exercise that was reversed with ingestion of food or glucose solutions. 85 percent pancreatectomy was performed and nesidioblastosis was detected in the histological study. Conclusions: It is rare in adults, making its diagnosis is difficult, and surgery is reached with the knowledge of an endogenous hyperinsulinic state, without the certainty of its origin(AU)

Neoplasia quística mucinosa gigante del páncreas tratada con pancreatectomía corporocaudal y preservación esplénica / Giant mucinous cystic neoplasm of the pancreas undergoing pancreatectomy with splenic preservation

RESUMEN: La neoplasia quística mucinosa del páncreas (NQMP) es un tumor infrecuente, que afecta predominantemente a mujeres (90-95 %), afectando especialmente entre la quinta y séptima década de la vida; cuyo descubrimiento suele ser incidental. Por lo general, son lesiones solitarias, sin compromiso del conducto pancreático principal; poco sintomáticas y asociadas a malignidad (10 % a 40 %). El objetivo de este manuscrito fue reportar un caso de neoplasia quística mucinosa gigante del páncreas intervenida quirúrgicamente y revisar la evidencia existente respecto de sus características morfológicas, terapéuticas y pronósticas. Mujer de 29 años, con masa abdominal poco sintomática. El diagnóstico se verificó por medio de ultrasonografía, tomografía axial computarizada y resonancia nuclear magnética. Se intervino quirúrgicamente, realizándose pancreatectomía corporocaudal con preservación esplénica, sin incidentes. La paciente fue dada de alta al quinto día, sin complicaciones, y evolucionó de forma adecuada, sin complicaciones postoperatorias. La NMQP es una lesión compleja, que puede asociarse a malignidad, pero el diagnóstico preoperatorio de malignidad no puede establecerse con seguridad. El pronóstico depende de un diagnóstico precoz y un tratamiento oportuno.

SUMMARY: Mucinous cystic neoplasm of the pancreas (MCNP) are variable types of tumors, which predominantly affect women (90-95 %), and usually appear incidentally in the 5th to 7th decade of life. They are generally solitary lesions, with no involvement of the main pancreatic duct, rarely symptomatic and are associated with malignancy (10 % to 40 %). The aim of this manuscript was to report a case of giant mucinous cystic neoplasm of the pancreas surgically treated and review the existing evidence regarding its morphological, therapeutic and prognosis characteristics. Patient: A 29-year-old woman with a slightly symptomatic abdominal mass. The diagnosis was verified with ultrasound, computed axial tomography and magnetic nuclear resonance. The patient underwent surgery; an uneventful corporocaudal pancreatectomy with splenic preservation was performed. She was discharged on the fifth day, and has evolved adequately, without postoperative complications. MCNP is a complex lesion, which can be associated with malignancy, but the preoperative diagnosis of malignancy cannot be established with certainty. Its prognosis depends on early diagnosis and timely treatment.

Defining postoperative weight change after pancreatectomy: Factors associated with distinct and dynamic weight trajectories.

BACKGROUND: Weight change offers the simplest indication of a patient's recovery after an operation. There have been no studies that have thoroughly investigated postoperative weight dynamics after pancreatectomy. The aim of this study was to define postoperative weight change after a pancreatectomy and determine factors associated with optimal and poor weight trajectories. METHODS: From 2004 to 2019, 1,090 proximal (65%) and distal (35%) pancreatectomies were performed in patients with adequate data in the medical records. Patient weights were acquired preoperatively and at postoperative months 1, 3, and 12. Optimal (top quartile, weight restoration) and poor (bottom quartile, persistent weight loss) postoperative weight cohorts were identified at 1 year postoperatively. RESULTS: The median percentage weight change 1 year postpancreatectomy was -6.6% (interquartile range: -1.4% to -12.5%), -7.8% for proximal pancreatectomy, and -4.2% for distal pancreatectomy. For most patients (interquartile range cohort), the median percentage weight change at 1, 3, and 12 months was -6.2%, -7.2%, and -6.6%. The independent factors associated with weight restoration were age <65, nonobesity (body mass index <30kg/m2), receiving total parenteral nutrition/total enteral nutrition preoperatively, experiencing preoperative weight loss >10%, distal pancreatectomy, not undergoing vascular resection, and no readmission within 30 days. Conversely, persistent weight loss was associated with American Society of Anesthesiologists classes III to IV, obesity, malignancy, proximal pancreatectomy, blood loss ≥350mL, and experiencing readmission within 30 days. Focusing on pancreatic ductal adenocarcinoma (n = 372) patients, the factors associated with persistent weight loss were obesity, proximal pancreatectomy, and experiencing recurrence within 1 year; however, weight cohorts were not associated with overall survival for pancreatic ductal adenocarcinoma patients. CONCLUSION: These data define weight kinetics after pancreatectomy. Ultimately, postoperative weight trajectories appear to be largely predetermined but may be mitigated by limiting readmissions and complications. Clinicians should use these data to identify patients who continue to lose weight between the first and third month postoperatively with a high suspicion for the requirement of nutritional monitoring or other interventions.

[Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery]. / Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas.

PURPOSE: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume. METHODS: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-Whitney U-test. RESULTS: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09). CONCLUSION: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery / Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas

Abstract Purpose: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume. Methods: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-WhitneyU-test. Results: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09). Conclusion: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Resumo Justificativa: O presente estudo teve como objetivo examinar os fatores associados à Lesão Renal Aguda (LRA) no pós-operatório, centrando-se na hipotensão e perda de sangue intraoperatórias. Método: Estudo de coorte retrospectivo de pacientes submetidos a cirurgia de pâncreas entre Janeiro de 2013 e Dezembro de 2018. O desfecho primário foi ocorrência de LRA em até 7 dias após a cirurgia e o secundário, o tempo de hospitalização. A análise multivariada foi usada para determinar os fatores explicativos associados à LRA; a interação entre o valor integrado da hipotensão e volume de perda de sangue foi avaliada. As diferenças no tempo de hospitalização foram comparadas pelo teste U de Mann-Whitney. Resultados: Dos 274 pacientes, 22 pacientes apresentaram LRA. A raiz cúbica da área sob a pressão arterial média intraoperatória < 65 mmHg (Odds Ratio = 1,21; Intervalo de Confiança de 95% 1,01-1,45; p = 0,038) e volume de perda sanguínea > 500 mL (Odds Ratio = 3,81; Intervalo de Confiança de 95% 1,51-9,58; p = 0,005) estavam independentemente associados à lesão renal aguda. A interação entre hipotensão arterial média e volume de perda sanguínea em relação à lesão renal aguda apontou o modelo como significante (p < 0,0001) com efeito de interação (p = 0,0003). A LRA não apresentou relação significante com o tempo de hospitalização (19 vs. 28 dias, p = 0,09). Conclusões: A área sob hipotensão arterial e o volume de perda sanguínea > 500 mL no intraoperatório apresentaram associação com LRA no pós-operatório. Entretanto, se a pressão arterial média se mantém, mesmo em pacientes com grande volume de perda sanguínea, o risco de desenvolver LRA no pós-operatório é comparável ao risco dos pacientes com pequeno volume de perda sanguínea.

Robotic pancreatic resection. Personal experience with 105 cases.

OBJECTIVE: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. METHODS: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. RESULTS: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. CONCLUSIONS: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

Hiperplasia de células neuroendocrinas que simula tumor sólido de páncreas / Neuroendocrine cell hyperplasia mimicking a solid pancreatic tumor

RESUMEN La hiperplasia de células neuroendocrinas pancreáticas es una patología donde se produce un aumen to en el número de células de los islotes de Langerhans y a veces puede simular un proceso tumoral. Caso clínico: presentamos el caso de un paciente con tumor sólido de cola de páncreas, sintomático, al que se le realizó esplenopancreatectomía corporocaudal laparoscópica. El resultado anatomopatoló gico posterior informó una hiperplasia neuroendocrina. Conclusión: la hiperplasia de células neuroen docrinas debería considerarse en el diagnóstico diferencial de tumores sólidos de páncreas. La alterna tiva quirúrgica laparoscópica es factible cuando no es posible establecer el diagnóstico prequirúrgico con estudios de imágenes o biopsia.

ABSTRACT Pancreatic endocrine cell hyperplasia is defined as an increase in the number of cells of Langerhans islets and can sometimes mimic a tumoral process. Case report: a male patient with a symptomatic solid tail of pancreas tumor underwent laparoscopic distal pancreatectomy and splenectomy. The pathological examination reported neuroendocrine cell hyperplasia. Conclusion: pancreatic endocrine cell hyperplasia should be considered in the differential diagnosis of solid pancreatic tumors. Laparoscopic surgery is feasible when the preoperative diagnosis with imaging tests of biopsy is not possible.