Intussusception of Gastrojejunostomy After Pancreatoduodenectomy With Billroth II Reconstruction.

Gastrojejunal anastomosis or gastrojejunostomy (GJ) is a surgical procedure used for allowing gastric emptying, especially in cases where complex reconstructions are needed. One of the less common complications but one of the most relevant in morbidity is the intussusception of the GJ. It requires a high index of suspicion, preoperative optimization of the patient, diagnostic corroboration, and identification of associated complications with the use of contrasted imaging. It was described for the first time by Bozzi in 1914; currently, multiple cases have been described in the literature, being more frequent in bariatric surgeries and reconstructions after distal gastrectomy. In hepatopancreaticobiliary surgery, it is an even uncommon complication. We present the case of a 60-year-old man with intussusception of the efferent loop of the GJ after a pylorus-preserving pancreatoduodenectomy with a Billroth II reconstruction in the setting of malignancy of the extrahepatic bile duct along with our emergency surgical treatment.

Pancreatic Cancer Cells Induce MicroRNA Deregulation in Platelets.

Pancreatic cancer is a pathology with a high mortality rate since it is detected at advanced stages, so the search for early-stage diagnostic biomarkers is essential. Liquid biopsies are currently being explored for this purpose and educated platelets are a good candidate, since they are known to present a bidirectional interaction with tumor cells. In this work, we analyzed the effects of platelets on cancer cells' viability, as determined by MTT, migration using transwell assays, clonogenicity in soft agar and stemness by dilution assays and stem markers' expression. We found that the co-culture of platelets and pancreatic cancer cells increased the proliferation and migration capacity of BXCP3 cells, augmented clonogenicity and induced higher levels of Nanog, Sox2 and Oct4 expression. As platelets can provide horizontal transfer of microRNAs, we also determined the differential expression of miRNAs in platelets obtained from a small cohort of pancreatic cancer patients and healthy subjects. We found clear differences in the expression of several miRNAs between platelets of patients with cancer healthy subjects. Moreover, when we analyzed microRNAs from the platelets of the pancreatic juice and blood derived from each of the cancer patients, interestingly we find differences between the blood- and pancreatic juice-derived platelets suggesting the presence of different subpopulations of platelets in cancer patients, which warrant further analysis.

A Nondilated Main Pancreatic Duct Predicts Type 2 Autoimmune Pancreatitis: Comparative Study of Resected Pancreatic Head Masses.

BACKGROUND: Chronic pancreatitis (CP), pancreatic cancer (PCa), and autoimmune pancreatitis (AIP) often present as a pancreatic mass. Accurate diagnosis is not always possible; up to 8% of surgical procedures are performed in benign pancreatic masses presumed to be malignant. OBJECTIVES: We aimed to compare clinical and imaging characteristics of resected focal type 2 AIP, CP, and PCa and identify factors that could improve preoperative differential diagnosis. METHODS: Charts from patients that underwent pancreatic resection under suspicion of PCa between 2000 and 2014 were reviewed. Clinical and imaging data were recorded. Subjects were grouped as type 2 AIP, CP, and PCa. RESULTS: We included 79 cases; 41 men, mean age of 57.3 years/old ± 15.6 SD. Pathology report was type 2 AIP (20%), CP (10%), and PCa (70%). According to international consensus criteria for AIP 11 cases were deemed probable type 2 and 5 as unspecific pancreatic mass. A nondilated main pancreatic duct (MPD) was associated with AIP (OR 9.3; 95% CI 3.05-28.7), p < 0.001; obstructive jaundice (OR 28.5; 95% CI 8.18-79.5); and a dilated MPD (OR 5.21; 95% CI 1.9-14.6) suggested malignancy. CONCLUSIONS: In the setting of undetermined pancreatic focal mass, a nondilated MPD suggests the diagnosis of type 2 AIP.

Nonmucinous cystadenomas of the pancreas with pancreatobiliary phenotype and ovarian-like stroma.

Among 31 benign cystic neoplasms of the pancreas diagnosed as mucinous cystadenomas, we identified 9 (29%) cases of nonmucinous cystadenomas with a pancreatobiliary phenotype and an ovarian-like stroma. Although both cystic tumors belong to the same family, they should be separated because their epithelial lining and cyst fluid are different. The lining cells of the nonmucinous cystadenomas consisted of a single layer of cuboidal cells, similar to the epithelial cells of the normal pancreatic ducts, and were not dysplastic (90%-100% of the lining cells). The cyst fluid was described as serous or clear. The remaining 22 classical mucinous cystadenomas, lined predominantly by mucinous and foveolar epithelium, revealed focal pancreatobiliary epithelium in 86% of the cases, and 6 pancreatic invasive mucinous cystadenocarcinomas failed to show pancreatobiliary differentiation. We believe that these nonmucinous cystadenomas of the pancreas represent a distinctive subset of cystic neoplasms of the pancreas that probably have no malignant potential.

Vascular invasion in pancreatic cancer: predictive values for endoscopic ultrasound and computed tomography imaging.

OBJECTIVES: To evaluate the accuracy of endoscopic ultrasound (EUS) to determine vascular invasion in patients with pancreatic cancer. METHODS: Data were obtained prospectively from patients with a pancreatic lesion who underwent EUS, computed tomographic (CT) imaging, and surgery from March 2005 to March 2010. RESULTS: Fifty patients were included with a mean ± SD age 61 ± 11.5 years; 27 (54%) were women. The sensitivity, specificity, positive predictive value, and negative predictive value for EUS were the following: 61.1 (95% CI, 38.6-79.7), 90.3 (95% CI, 75.1-96.7), 78.6 (95% CI, 52.4-92.4), and 80 (95% CI, 64.1-90), respectively. The area under the curve for EUS and that for CT were 0.80 (95% CI, 0.68-0.92) and 0.74 (95% CI, 0.61-0.86), respectively. The positive predictive value for arterial invasion was 100% (95% CI, 61-100) for EUS and 60% (95% CI, 31.3-83.2) for CT. There were no complications associated with the EUS or the CT. CONCLUSION: Endoscopic US is a very good option to detect vascular invasion in patients with pancreatic cancer and is especially sensitive for arterial invasion. When it is available, we recommend that it be performed in addition to CT staging.

[Clinical characteristics associated to resectability in patients with tumors of the ampulla of Vater in a third-level hospital in Mexico: an 18-year experience]. / Caracteristicas clínicas asociadas a resecabilidad en pacientes con tumores del ámpula de Vater en un hospital de tercer nivel en Mexico: experiencia de 18 años.

BACKGROUND: Ampulla of Vater's tumors (AVT) are rare and account for 0.2% of neoplasia in necropsies. The stage, comorbidities and surgical experience are crucial for prognosis. The aim of this work is to report the clinical characteristics, treatment and complication of a group of patients with AVT. MATERIAL AND METHODS: Patients with AVT were included in a retrospective manner. Descriptive statistics was used and data were shown as means and SD. RESULTS: One hundred and six patients were included with a mean age of 58.5 +/- 14 years and 58% were women. Jaundice was the most common clinical data and it was present in 90% of cases. Two-thirds of patients underwent a Whipple surgical procedure. Complications of surgery were present in 35% of cases and abdominal sepsis and pancreatic fistulae were the most common (32% and 29%, respectively). Adenocarcinoma was the most common histological type and 39% of cases were in stage IV at diagnosis. Age higher or equal to 65 years was associated with less surgical possibilities. Melena at presentation was associated with a higher probability of surgical resection. CONCLUSION: The probability of surgical resection is lower in patients older than 65 years and higher in those with melena at the diagnosis.

When should we be concerned about pancreatic necrosis? Analysis from a single institution in Mexico City.

BACKGROUND/AIM: Although pancreatic necrosis classifies acute pancreatitis (AP) as severe, many patients with tomographic evidence of necrosis never develop systemic complications. Our aim was to analyze the incidence of pancreatic necrosis, organ failure (OF), and the relationship between them. METHODS: Medical records from 165 patients with a first AP episode and in whom a contrast-enhanced computed tomography (CECT) was performed were analyzed. Pancreatic necrosis was diagnosed as non-enhancing areas of the pancreas on the CECT and was graded as <30%, 30%-50%, and >50%. Pancreatic infection was assessed by guided percutaneous aspiration. Organ failure was defined according to the Atlanta criteria. RESULTS: Of 165 patients (mean age 42 years, 85 men), 54 (33%) had pancreatic necrosis. Necrosis was graded as <30% in 25 subjects (46%), 30%-50% in 16 (30%), and >50% in 13 (24%). Pancreatic infection was diagnosed in 14 cases (26%). Organ failure occurred in 49 patients: in 20 patients (37%) with necrosis, and in 29 patients (26%) without necrosis (P = 0.20). Extensive pancreatic necrosis (>50%) (P < 0.05) and infected necrosis (P < 0.05) were significantly associated with OF. Eight patients, all of them with OF, died. In 6 of these cases infected pancreatic necrosis was present. CONCLUSIONS: Patients with pancreatic necrosis are not necessarily at risk of developing OF. However, it should be considered an important risk factor when the necrotizing process compromises more than 50% of the gland and is infected.

[Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy]. / Efecto del drenaje biliar preoperatorio en la evolución posquirúrgica de la pancreatoduodenectomía.

BACKGROUND/AIM: There are theoretic arguments in favor and against biliary drainage before the pancreatoduodenectomy. Most of the studies failed to show any beneficial effect of this approach whereas others even reported an increased postoperative morbidity related with biliary drainage. Therefore, the role of preoperative biliary drainage remains controversial. So, we decided to analyze our own results in a series of patients undergoing pancreatoduodenectomy in order to determine the association between preoperative biliary drainage and postoperative outcome. PATIENTS AND METHODS: We analyzed 109 patients undergoing pancreatoduodenectomy between January 1990 and May 2003. Patients were classified in 3 groups: Group 1 (n = 64) patients without preoperative biliary drainage, Group 2 (n = 27) patients who underwent preoperative biliary drainage with sphincterotomy and stent placement, and Group 3 (n = 18) only sphincterotomy. Demographic characteristics, surgical risk, comorbility, type of surgery, pathology and biochemical parameters were analyzed. We also, stratified patients with and without cholestasis (total bilirubin > 3 mg/dL), and divided patients in two groups: with biliary drainage and without biliary drainage. Surgical and medical complications, the frequency of patients with at least one complication (global morbidity) and mortality were compared between groups. Kruskal-Wallis, Mann-Whitney U, chi2 and Fisher tests were used for the analysis of categorical and dimensional variables. RESULTS: The most frequent postoperative diagnoses were biliopancreatic tumors. Global postoperative morbidity and mortality were 40% (n = 44) and 10% (n = 11), respectively. The frequency of surgery and medical complications were no significantly different among the 3 groups. However, when only patients with cholestasis were analyzed (n = 65), there was a lower frequency of surgical complications and global postoperative morbidity in patients with preoperative biliary drainage (p = 0.02, OR 0.14, CI 95% 0.04-0.50 and p < 0.001, OR 0.18, CI 95% 0.05-0.65, respectively). There were not significant differences in the frequency of medical complications (p = 0.09) and mortality. CONCLUSIONS: Preoperative biliary drainage should not be considered as a routine procedure in candidates undergoing pancreatoduodenectomy; however, this maneuver decreased approximately seven times the risk of postoperative global morbidity in patients with cholestasis, mainly by reducing surgical complications reduction.

Efecto del drenaje biliar preoperatorio en la evolución posquirúrgica de la pancreatoduodenectomía / Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy

Background/Aim. There are theoretic arguments in favor and against biliary drainage before the pancreatoduodenectomy. Most of the studies failed to show any beneficial effect of this aproach whereas others even reported an increased postoperative morbidity related with biliary drainage. Therefore, the role of preoperative biliary drainage remains controversial. So, we decided to analyze our own results in a series of patients undergoing pancreatoduodenectomy in order to determine the association between preoperative biliary drainage and postoperative outcome. Patients and Methods. We analyzed 109 patients undergoing pancreatoduodenectomy between January 1990 and May 2003. Patients were classified in 3 groups: Group 1 (n = 64) patients without preoperative biliary drainage, Group 2 (n = 27) patients who underwent preoperative biliary drainage with sphincterotomy and stent placement, and Group 3 (n = 18) only sphincterotomy. Demographic characteristics, surgical risk, comorbility, type of surgery, pathology and biochemical parameters were analyzed. We also, stratified patients with and without cholestasis (total bilirubin > 3mg/dL), and divided patients in two groups: with biliary drainage and without biliary drainage. Surgical and medical complications, the frequency of patients with at least one complication (global morbidity) and mortality were compared between groups. KruskaTWallis, Mann-Whitney U, x2 and Fisher tests were used for the analysis of categorical and dimensional variables. Results. The most frequent postoperative diagnoses were biliopancreatic tumors. Global postoperative morbidity and mortality were 40% (n = 44) and 10% (n = 11), respectively. The frequency of surgery and medical complications were no significantly different among the 3 groups. However, when only patients with cholestasis were analyzed (n = 65), there was a lower frequency of surgical complications and global postoperative morbidity in patients with preoperative biliary drainage (p = 0.02, OR 0.14, CI 95% 0.04-0.50 and p < 0.001, OR 0.18, CI 95% 0.05-0.65, respectively). There were not significant differences in the frequency of medical complications (p = 0.09) and mortality. Conclusions. Preoperative biliary drainage should not be considered as a routine procedure in candidates undergoing pancreatoduodenectomy; however, this maneuver decreased approximately seven times the risk of postoperative global morbidity in patients with cholestasis, mainly by reducing surgical complications reduction.

Antecedentes/Objetivo. Existen argumentos teóricos a favor y en contra para realizar un drenaje biliar previo a pancreatoduodenectomía. En la mayoría de los estudios no se ha podido establecer un efecto benéfico de esta conducta e incluso se ha informado un incremento en la morbilidad postoperatoria relacionada con el drenaje. Por lo tanto, la evidencia acerca de la utilidad de este procedimiento sigue siendo controversial, probablemente por la heterogeneidad en los estudios publicados. Con objeto de establecer una conducta basada en nuestra experiencia institucional analizamos una serie de pacientes sometidos a pancreatoduodenectomía para determinar la asociación entre el drenaje biliar preoperatorio y la evolución posquirúrgica. Pacientes y métodos. Se analizaron 109 pacientes consecutivos a quienes se les realizó pancreatoduodenectomía de enero de 1990 a mayo del 2003. Se dividieron en tres grupos: Grupo 1 (n = 64) sin drenaje biliar preoperatorio, Grupo 2 (n = 27) con esfinterotomía y colocación de endoprótesis y Grupo 3 (n = 18) sólo esfinterotomía. En todos los casos se analizaron las características demográficas, riesgo quirúrgico, comorbilidad, tipo de cirugía, estudio histopatológico y parámetros bioquímicos. Se estratificaron los pacientes de acuerdo a la presencia de colestasis, definida por bilirrubinas totales > 3 mg/dL y se agruparon en dos categorías: sin drenaje y con drenaje biliar. Se compararon las complicaciones postoperatorias quirúrgicas y médicas, así como el número de pacientes con al menos una complicación (morbilidad global) y la mortalidad. El análisis estadístico para la comparación entre los tres grupos se realizó con x2 y prueba exacta de Fisher para las variables categóricas y Kruskal-Wallis o U de Mann-Whitney para las variables dimensionales. Resultados. Los diagnósticos postoperatorios más frecuentes fueron tumores de la encrucijada biliopancreática. La morbilidad postoperatoria global fue de 40% (n = 44) y la mortalidad de 10% (n = 11). No hubo diferencias significativas en la frecuencia de complicaciones quirúrgicas y médicas entre los tres grupos. Sin embargo, cuando se analizaron sólo pacientes con colestasis (n = 65), la frecuencia de complicaciones quirúrgicas y morbilidad global postoperatoria fue significativamente menor en los grupos con drenaje biliar preoperatorio (p = 0.02, RM 0.14, IC 95% 0.04-0.50 y p < 0.001, RM 0.18, IC 95% 0.05-0.65, respectivamente). No se presentaron diferencias significativas en relación con la frecuencia de complicaciones médicas (p = 0.09) y mortalidad. Conclusiones. El drenaje biliar preoperatorio no debe ser considerado un procedimiento de rutina en candidatos a pancreatoduodenectomia; sin embargo, en los pacientes con colestasis, esta maniobra disminuye casi siete veces el riesgo de morbilidad global postoperatoria, predominantemente al reducir las complicaciones quirúrgicas.

Endoscopía y laparoscopía en el tratamiento de la colecistitis litiásica asociada a obstrucción beningna de vía biliar / Treatment of gallstones associated to bile duct obstruction using ERCP and laparoscopic cholecystectomy

Objetivo. Analizar la eficacia del tratamiento combinado (endoscopía-laparoscopía) en el manejo de la colecistitis crónica litiástica asociada a obstrucción benigna de la vía biliar. Diseño. Estudio prospectivo. Lugar. Centro de tercer nivel de atención médica. Pacientes. Entre octubre de 1991 y enero de 1994, 270 pacientes con colecistitis crónica litiásica, candidatos a resolución quirúrgica mediante colecistectomía laparoscípica, fueron atendidos en el Instituto Nacional de la Nutrición SalvadorZubirán. En 25 pacientes se prqctico colangiografía retrógrada preoperatoria por sospecha de obstrucción de la vía biliar. Este grupo constituye nuestro grupo de estudio. Resultados. En nueve pacientes (36 por ciento) se corroboró la existencia de colédocolitiasis, extrayéndose exitosamente los litos por esta vía en ocho de ellos. En cinco pacientes más se estableció el diagnóstico de odditis, practicándose papilotomía. En los 11 restantes la vía biliar fue normal. Posteriomente se practicó colecistectomía laparoscópica al grupo de pacientes con vía biliar permeable. Hubo una complicación relacionada con la papilotomía que consistió en perforación duodenal que culminó en defunción. Conclusión. El abordaje combinado (endoscópia/laparoscópica) de la colelitiasis asociada a colédocolitiasis parece ser una alternativa eficiente de manejo