International survey on opinions and use of robot-assisted and laparoscopic minimally invasive pancreatic surgery: 5-year follow up.

BACKGROUND: Evidence on the value of minimally invasive pancreatic surgery (MIPS) has been increasing but it is unclear how this has influenced the view of pancreatic surgeons on MIPS. METHODS: An anonymous survey was sent to members of eight international Hepato-Pancreato-Biliary Associations. Outcomes were compared with the 2016 international survey. RESULTS: Overall, 315 surgeons from 47 countries participated. The median volume of pancreatic resections per center was 70 (IQR 40-120). Most surgeons considered minimally invasive distal pancreatectomy (MIDP) superior to open (ODP) (94.6%) and open pancreatoduodenectomy (OPD) superior to minimally invasive (MIPD) (67.9%). Since 2016, there has been an increase in the number of surgeons performing both MIDP (79%-85.7%, p = 0.024) and MIPD (29%-45.7%, p < 0.001), and an increase in the use of the robot-assisted approach for both MIDP (16%-45.6%, p < 0.001) and MIPD (23%-47.9%, p < 0.001). The use of laparoscopy remained stable for MIDP (91% vs. 88.1%, p = 0.245) and decreased for MIPD (51%-36.8%, p = 0.024). CONCLUSION: This survey showed considerable changes of MIPS since 2016 with most surgeons considering MIDP superior to ODP and an increased use of robot-assisted MIPS. Surgeons prefer OPD and therefore the value of MIPD remains to be determined in randomized trials.

Pancreatectomía izquierda laparoscópica: ¿la sistematización de la técnica es de utilidad? / Laparoscopic left pancreatectomy: is systematization of the technique useful?

RESUMEN Antecedentes: la pancreatectomía izquierda laparoscópica es un procedimiento de alta complejidad que debe ser sistematizado para reducir complicaciones y tiempos quirúrgicos. Objetivo: Describir los resultados con una técnica sitematizada de esplenopancreatectomía laparoscópica. Material y métodos: se seleccionaron pacientes candidatos a realizar esplenopancreatecomía distal en el período comprendido entre 2007 y 2022. Se excluyeron pacientes con enfermedad sistémica. La técnica quirúrgica laparoscópica consiste en ligar los vasos cortos como primer paso, luego disecar y cortar la arteria esplénica, dejando la sección de la vena como último gesto quirúrgico. Esto evita la congestión venosa del bazo. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias. Resultados: sobre un total de 155 pacientes, 90 fueron intervenidos por vía laparoscópica y 65 por vía convencional. El tiempo quirúrgico promedio fue 168 minutos. Cuando se analizó el tiempo quirúrgico en los abordajes laparoscópicos, se observó una disminución del tiempo a partir del caso número 30. La mortalidad fue del 1,12%. La incidencia de fístula pancreática total fue 41%. La necesitad de transfusión intraoperatoria ocurrió en el 10,7% de los pacientes y la tasa de conversión fue del 13,3%. Conclusión: la sistematización de la técnica de la pancreatectomía laparoscópica permite la reducción de los tiempos quirúrgicos, adquirir mayor seguridad en la disección y realizar procedimientos cada vez más complejos.

ABSTRACT Background: Laparoscopic left pancreatectomy is a high complexity procedure that should be systematized to reduce complications and operative time. Objective: To describe the results achieved with a systematized technique for laparoscopic pancreatectomy and splenectomy. Materials and methods: We selected patients who were candidates for distal pancreatectomy and splenectomy between 2007 and 2022. Patients with systemic diseases were excluded. The laparoscopic technique consists of ligating the short vessels as a first step, then dissecting and cutting the splenic artery, leaving the section of the vein as the last surgical gesture to avoid venous congestion of the spleen. Perioperative, intraoperative and postoperative variables were analyzed. Results: A total of 155 patients were analyzed, 90 underwent laparoscopy and 65 underwent conventional surgery. Mean operative time was 168 minutes The operative time in the laparoscopic approach decreased from case 30 onwards. Mortality rate was 1.12%. The incidence of pancreatic fistula was 41%. Need for intraoperative transfusion occurred in 10.7% of the patients and the conversion rate was 13.3%. Conclusion: The systematization of the technique of pancreatic laparoscopy is essential to reduce surgical times, ensure safe dissections and performe more complex procedures.

Hemorragia digestiva baja: factores de riesgo de gravedad, necesidad de cirugía de urgencia y mortalidad hospitalaria / Lower gastrointestinal bleeding: risk factors of severity, need for emergency surgery and in-hospital Mortality

RESUMEN Antecedentes: Últimamente creció el interés en poder determinar, en etapas tempranas de las hemorragias digestivas bajas (HDB), aquellos factores de riesgo relacionados con la posibilidad de presentar resultados evolutivos adversos. Objectivo: Determinar los factores de riesgo asociados a sangrados graves, cirugía de urgencia y mortalidad hospitalaria. Material y métodos: Realizamos un estudio observacional y retrospectivo sobre 1.850 pacientes, atendidos en forma consecutiva entre enero de 1999 y diciembre de 2018 por HDB. Para evaluar el riesgo de gravedad analizamos trece variables en las primeras cuatro horas desde la admisión. Para determinar los factores relacionados con la cirugía de urgencia, agregamos la enfermedad diverticular y, para evaluar mortalidad, la cirugía de urgencia y el puntaje (score) preoperatorio de la Sociedad Americana de Anestesiología (ASA). Resultados: De los 1.850 casos, 194 fueron graves y 1656 leves/moderados. Resultaron estadísticamente significativos como factores de mayor gravedad: > 70 años, FC > 120 lat/min., TA < 90 mm Hg, oliguria, hematoquecia masiva, hematocrito < 30%, hemoglobina < 7 g/% y necesidad transfusional. Resultaron predictores significativos de cirugía de urgencia: > 70 años, anti-coagulación, hipotensión arterial, taquicardia, hemoglobina < 7 g/%, oliguria, transfusiones y hematoquecia masiva. Se construyó una fórmula pronóstica de requerimiento de cirugía (sensibilidad 94%, especificidad 74%, valor predictivo positivo 91% y valor predictivo negativo 81%). AUC: 0,89%. Fueron significativos para mortalidad: > 70 años, anticoagulados, hematoquecia masiva, transfusiones y cirugía urgente. De los dieciséis pacientes operados y fallecidos de la serie, quince presentaban un ASA ≥ IV. Conclusiones: Las variables utilizadas resultaron simples, fiables y estadísticamente significativas para predecir gravedad, cirugía de urgencia y mortalidad.

ABSTRACT Background: Background: There has been a growing interest in determining those risk factors associated with adverse outcomes in early stages of lower gastrointestinal bleeding (LGIB). Objective: The aim of our study was to analyze the risk factors associated with severe bleeding, emergency surgery and in-hospital mortality. Material and methods: We conducted an observational and retrospective study on 1850 patients consecutive managed between January 1999 and December 2018 for LGIB. We analyzed thirteen variables within the first four hours of hospitalization to evaluate risk severity. Diverticular disease was considered to determine factors associated with emergency surgery, and the preoperative American Society of Anesthesiologists (ASA) score was used to assess mortality and emergency surgery. Results: Out of 1850 cases, 194 were severe and 1656 were mild/moderate, Patients > 70 years, with HR > 120 beats/min, BP < 90 mm Hg, oliguria, massive hematochezia, hematocrit < 30%, hemoglobin < 7 g% and need for transfusions presented statistically significant associations with severe bleeding. Age > 70 years, anticoagulation, hypotension, tachycardia, hemoglobin < 7 g%, oliguria, need for transfusion and massive hematochezia were significant predictors of emergency surgery. A prognostic formula was constructed to predict the need for surgery (sensitivity 94%, specificity 74%, positive predictive value 91% and negative predictive value 81%). AUC-ROC: 0,89%. Age > 70 years, anticoagulation, massive hematochezia transfusions and emergency surgery were identified as predictors of mortality. Fifteen of the sixteen patients who underwent surgery and died had ASA ≥ grade 4. Conclusions: The variables analyzed are simple, reliable and statistically significant to estimate the risk of severe bleeding, need for emergency surgery and mortality.

Control de daños en las emergencias abdominales no traumáticas: causas, indicaciones, factores de riesgo y resultados / Damage control in non-traumatic abdominal emergencies: causes, indications, risk factors and results

RESUMEN Antecedentes : la estrategia de control de daños (ECD) es muy utilizada para el tratamiento de las emergencias abdominales no traumáticas. Objetivo : describir las causas y condiciones fisiopatológicas del empleo de la ECD, determinar la mortalidad según la etiología, criterios de aplicación y factores de riesgo asociados, y comparar la mortalidad observada con la esperada en una serie consecutiva. Material y métodos : se realizó un estudio observacional y retrospectivo, sobre 118 pacientes tratados con ECD, portadores de peritonitis secundarias y hemorragias abdominales graves, con síndrome compartimental abdominal, sepsis abdominal o sistémica o ambas, hipotensión y parámetros de acidosis metabólica asociados. Se analizaron varios factores de riesgo y se comparó la mortalidad observada versus la esperada (APACHE II). Resultados : 112 pacientes presentaron peritonitis generalizada y 6, sangrados intraabdominales graves. La mortalidad fue mayor en la isquemia intestinal grave (p = 0,002). Estuvo relacionada con mayor número de criterios fisiopatológicos de aplicación y con algunos factores de riesgo: glóbulos blancos (GB) ≥ 10 000 ×mm3, hemoglobina (HB) ≤ 9 g/%, creatininemia ≥ 1,3 mg/%, pH ≤ 7,25, ácido láctico ≥ 2,5 mmol/L, diabetes, puntuación (score) ASA ≥ 4, ≥ 4 operaciones y ausencia de cierre parietal inicial. La mortalidad global observada fue 43,1% y la esperada ‒según APACHE II‒ fue del 53%. Conclusiones : la mortalidad fue significativamente mayor en la isquemia intestinal grave y con la presencia de algunos de los factores de riesgo evaluados. Estuvo asociada al número de criterios de aplicación. La mortalidad observada fue menor que la esperada, aunque no significativa.

ABSTRACT Background : Damage control strategy (DCS) is usually used for the treatment of non-traumatic abdominal emergencies. Objective : The aim of the present study was to describe the main causes and pathophysiologic conditions to perform this strategy, the criteria applied and the associated factors and to compare the observed mortality with the expected mortality in the series. Material and methods : We conducted an observational and retrospective study of 118 patients treated with DSC, with secondary peritonitis and severe abdominal bleeding, abdominal compartment syndrome, abdominal or systemic sepsis or both, hypotension and parameters of metabolic acidosis. Several risk factors were analyzed and it was compared observed versus expected mortality (APACHE II). Results : 112 patients presented generalized peritonitis and 6 had severe intra-abdominal bleeding. Mortality was greater in severe mesenteric ischemia (p = 0.002) and was associated with the number of pathophysiologic criteria used for implementation and with white blood cell (WBC) count ≥ 10 000 x mm3, hemoglobin (Hb) ≤ 9 g/dL, creatinine level ≥ 1.3 mg/dL, pH ≤ 7.25, lactic acid ≥ 2.5 mmol/L, diabetes, ASA score ≥ 4, ≥ 4 operations and open abdomen. The overall observed mortality and expected mortality according to the APACHE II score were 43.1% and 53%, respectively. Conclusions : Mortality was significantly greater in patients with severe mesenteric ischemia, presence of some of the risk factors evaluated and was associated with the number of criteria used for implementation. The observed mortality was non-significantly lower than expected.

COVID-19 y cirugía. Impacto en los volúmenes de atención, complicaciones posoperatorias y mortalidad. Resultados después de un año de pandemia / COVID-19 and surgery. Impact on volumes of care, postoperative complications and mortality. Results after one year of the pandemic

RESUMEN Antecedentes: la pandemia por COVID-19 generó importantes cambios en la atención y tratamiento de los pacientes quirúrgicos. Objetivo: los objetivos de este estudio fueron comparar los volúmenes de prestaciones realizadas durante un año de pandemia con un período igual sin pandemia, proyectar su impacto asistencial e institucional, y comparar pacientes COVID+ versus COVID- para determinar complicaciones posoperatorias, mortalidad y los factores de riesgo asociados a estos eventos. Material y métodos: estudio observacional y retrospectivo. Comparamos el volumen de prestaciones realizadas entre el 19/3/20 y el 18/3/21 con idéntico período de 2019/20. Efectuamos un estudio de cohorte emparejada (2:1) entre los pacientes con COVID-19 y sin él y se analizaron las complicaciones posoperatorias, la mortalidad, y doce variables objetivas como factores de riesgo asociados. Resultados: todas las variables prestacionales analizadas disminuyeron, pero solo las internaciones programadas y las cirugías y endoscopias no urgentes cayeron significativamente. De los 979 ingresos, 41 casos fueron COVID+ (4,1%). La mortalidad fue del 29,2% en COVID+ (12/41) vs. 7,3% en COVID- (6/82) P = 0,021. Los factores de riesgo significativos asociados a mortalidad fueron: edad ≥ 75 años, hombres, COVID+, urgencias, neumonía, requerimiento de UTI y ARM. Los pacientes operados presentaron una tasa significativamente mayor de neumonías. El análisis de regresión logística (COVID+ vs. -) mostró que por ser COVID+ y registrar la necesidad de ARM, como variables determinantes, en los COVID+ solo la ARM fue determinante en la mortalidad. Conclusión: la pandemia por COVID-19 disminuyó la actividad prestacional y aumentó la mortalidad de los afectados por la virosis.

ABSTRACT Background: The COVID-19 pandemic produced significant changes in the care and treatment of surgical patients. Objectives: The aims of this study were to compare the volume of services provided during a year of pandemic with an equal period without pandemic, estimate its impact on health care and institutional care, and compare COVID-positive versus COVID-negative patients to determine postoperative complications, mortality and risk factors associated with these events. Material and methods: We conducted an observational and retrospective study, comparing the volume of services performed between March 19, 2020, and March 18, 2021, with the same period in 2019/2020. We performed a matched cohort study (in a 2:1 ratio) between patients with and without COVID-19 and analyzed the postoperative complications, mortality, and twelve objective variables as associated risk factors. Results: There was a significant decrease in planned hospitalizations and non-urgent surgeries and endoscopies, while all the other variables showed a non-significant reduction. Of the 979 admissions, 41 corresponded to COVID-positive patients (4.1%). Mortality was 29.2% in COVID-positive patients (12/41) vs. 7.3%% in those COVID negative (p = 0.021). The significant risk factors associated with mortality were age ≥75 years, male sex, COVID+, emergencies, pneumonia, requirement of ICU and MV. Patients operated on had a significantly higher rate of pneumonia. Logistic regression analysis between COVID+ patients and COVID- patients showed that COVID+ and need for MV were predictors of mortality. In COVID+ patients, only MV was a determinant of mortality. Conclusion: The COVID-19 pandemic reduced healthcare services and increased mortality in patients infected with the virus.

Pancreatitis aguda posduodenopancreatectomía cefálica con complicaciones locales / Acute pancreatitis with local complications after cephalic pancreaticoduodenectomy

RESUMEN Antecedentes: la pancreatitis aguda posduodenopancreatectomía cefálica inmediata es una complica ción cuya frecuencia puede llegar al 55% y condiciona la aparición de fístula pancreática. Objetivo: describir el manejo de 3 pacientes que presentaron pancreatitis aguda posduodenopancrea tectomía con complicaciones locales y realizar una revisión de la literatura. Material y métodos: se revisó una base de datos prospectiva de resecciones pancreáticas. Se identifi caron los pacientes con diagnóstico de pancreatitis aguda con lesiones locales posterior a la realización de duodenopancreatectomía. Se definió fístula pancreática de acuerdo con la clasificación del ISGPF y pancreatitis como la elevación de la amilasa o lipasa tres veces por encima del máximo valor sérico normal en asociación con dolor abdominal o confirmación radiológica. Resultados: entre 2008 y 2019 los autores realizaron 260 duodenopancreatectomías. Tres pacientes presentaron pancreatitis posoperatoria con complicaciones locales. Conclusiones: la pancreatitis aguda posoperatoria es una complicación de una frecuencia elevada. La mayoría de ellas se resuelven en forma espontánea. Pocos pacientes presentan complicaciones locales que pueden requerir tratamiento percutáneo o quirúrgico, predisponiendo al desarrollo de fístulas a veces de difícil manejo. No hay forma de prevenir la aparición de la fístula pancreática. El tratamiento de las complicaciones locales se realizará de acuerdo con su aparición y repercusión, pudiendo requerir desde la colocación de un drenaje percutáneo hasta la pancreatectomía total.

ABSTRACT Background: The incidence of acute pancreatitis immediately after cephalic pancreaticoduodenec tomy is up to 55% and is associated with the development of pancreatic fistula. Objective: The aim of this study is to report three cases of acute pancreatitis after pancreaticoduode nectomy with local complications with a review of the literature. Material and methods: The information about pancreatic resections was retrieved from a prospective database. Patients with diagnosis acute pancreatitis with local lesions immediately after pancreatico duodenectomy were identified. Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula (ISGPF) Definition and pancreatitis was defined as serum amylase or lipase >3x upper limit of normal associated with abdominal pain or imaging criteria. Results: A total of 260 pancreaticoduodenectomies were performed between 2008 and 2019. Three patients developed postoperative acute pancreatitis with local complications. Conclusions: Postoperative acute pancreatitis is a common complication that solves spontaneously in most cases. Few patients present local complications that may require percutaneous or surgical treatment, which may predispose to the development of fistulas that are sometimes difficult to mana ge. There is no way to prevent pancreatic fistulas. Local complications will be treated according to their occurrence and impact, and may require a variety of procedures, ranging from percutaneous drainage to total pancreatectomy.

La contemporización biliar percutánea como estrategia en el tratamiento de la lesión quirúrgica de la vía biliar / Percutaneous biliary interventon as an inital treatment for injury of the bile duct

Antecedentes: El drenaje biliar percutáneo (DBP) se ha utlizado para tratar lesiones quirúrgicas de la vía biliar y como complemento de la cirugía de reparación. Objetivo: Presentar los resultados del drenaje biliar percutáneo en una serie consecutiva de pacientes con lesiones quirúrgicas o secuelas de reparaciones quirúrgicas de la vía biliar. Material y Métodos: Se analizaron los pacientes tratados inicialmente mediante DBP. Se utlizó la cla-sificación de Strasberg y se registró: tpo de operación, vía de abordaje, número de reintervenciones, intentos de reparación biliar y presentación clínica. En los pacientes con continuidad bilioentérica, la primera opción fue el tratamiento percutáneo. Se evaluó el DBP en el pre, intra y postoperatorio y pre dilatación percutánea Resultados: En el hospital Argerich, período 2000 a 2014, se incluyeron 76 enfermos, 68.4% mujeres y post colecistectomía 97%. El 77,6% fueron lesiones Tipo E2 a E5. El porcentaje de enfermos con control de síntomas pre cirugía o dilatación percutánea fue: ictericia 59%, colestasis 5%, colangits 91%, fistula biliar 87%, prurito 90%, retro del hepaticostoma o Kehr 91%. En 13 de 16 pacientes con fistula biliar externa se internalizó el catéter biliar a la cavidad abdominal. En el 70% de 52 pacientes operados, el catéter facilitó la identificación de la vía biliar proximal. En el postoperatorio, no hubo fistulas biliares de la anastomosis bilioentérica, y se detectaron 3 pacientes con estenosis biliar residual y 2 con segmentos biliares aislados que fueron tratados. Conclusión: El DBP resulta útl en el preoperatorio, intraoperatorio y postoperatorio de los pacientes con lesiones quirúrgicas biliares.

Background: Percutaneous biliary drainage (PtibD) has been used to treat surgical bile duct injuries and as an adjunct to repair surgery. Objective: To present the results of PtidB in a consecutive series of patents with surgical injuries or sequelae of surgical repairs of the bile duct. Material and methods: Patents initally treated with PtibD were analyzed. Strasberg classificaton was used and recorded: type of operaton, surgical approach, number of reoperatons, biliary repair atempts and clinical presentaton. In patents with bilioenteric continuity, percutaneous biliary treatment was the frst opton. PtibD was evaluated in the pre, intra and postoperative period and in the pre dilataton period. Results: At the Hospital Argerich, from 2000 to 2014, 76 patents were included, 68.4% women and 97% post cholecystectomy. The lesions were Type E2 to E5 in 77% of cases. The percentage of patents with controlled symptoms before surgery or percutaneous dilataton was: jaundice 59%, cholestasis 5%, cholangits 91%, biliary fistula 87%, pruritus 90%, withdrawal hepaticos-toma or T-Kehr 91%. In 13 of 16 patents with external biliary fistula, the catheter could be internalized to abdominal cavity. In 70% of 52 operated patents, the catheter facilitated the identificaton of the proximal biliary duct. In the postoperative period, there were no biliary fistulas of the bilioenteric anastomoses and 3 patents with residual biliary stenosis and 2 with isolated biliary segments were detected and treated. Conclusion: PtibD is helpful in the pre, intra and postoperative treatment of patents with surgical bile duct injuries.

[Pancreatic arteriovenous malformation as cause of acute pancreatitis treated by endovascular access]. / Malformación arteriovenosa pancreática como causa de pancreatitis aguda tratada por vía endovascular.

Arteriovenous malformation in the pancreas is a rare anatomic abnormality that may produce acute pancreatitis. The diagnosis was suspected by computed tomography with intravenous contrast and by magnetic resonance imaging and it was confirmed by arteriography of the celiac trunk and superior mesenteric artery. The treatment received was endovascular, although the other valid option for the treatment of this disease is the surgical resection. The objective of this communication is to present a case of acute pancreatitis due to arteriovenous malformation treated by endovascular approach.

Malformación arteriovenosa pancreática como causa de pancreatitis aguda tratada por vía endovascular / Pancreatic arteriovenous malformation as cause of acute pancreatitis treated by endovascular access

La malformación arterio-venosa (MAV) en el páncreas es una anomalía anatómica poco frecuente que puede ser causa de pancreatitis aguda. Presentamos el caso de un paciente de 46 años cuyo diagnóstico se sospechó por los hallazgos de la tomografía computarizada con contraste endovenoso y por resonancia magnética y se confirmó mediante una arteriografía del tronco celíaco y de la arteria mesentérica superior. El tratamiento recibido fue por vía endovascular, aunque la otra opción válida para el tratamiento de esta enfermedad es la resección quirúrgica. El objetivo de esta comunicación es presentar un caso de pancreatitis aguda por MAV tratada por vía endovascular.

Arteriovenous malformation in the pancreas is a rare anatomic abnormality that may produce acute pancreatitis. The diagnosis was suspected by computed tomography with intravenous contrast and by magnetic resonance imaging and it was confirmed by arteriography of the celiac trunk and superior mesenteric artery. The treatment received was endovascular, although the other valid option for the treatment of this disease is the surgical resection. The objective of this communication is to present a case of acute pancreatitis due to arteriovenous malformation treated by endovascular approach.

Técnica de reconstrucción laparoscópica en la duodenopancreatectomía cefálica / Laparoscopic reconstructon technique of cephalic duodenopancreatectomy

Antecedentes: la duodenopancreatectomía cefálica (DPC) es la cirugía indicada para el tratamiento de los tumores ampulares y periampulares. El abordaje totalmente laparoscópico es técnicamente dificil de realizar pues requiere mucha destreza y experiencia por parte del equipo quirúrgico. La dificultad técnica de la pancreato-yeyuno anastomosis es quizás el factor limitante para confeccionar la duode-nopancreatectomía cefálica enteramente por vía laparoscópica. Objetivo: mostrar la técnica de reconstrucción laparoscópica con la pancreato-yeyuno anastomosis ductomucosa con la técnica de Blumgart modificada. Lugares de aplicación: Sanatorio de la Trinidad Mitre, Hospital Luciano y Mariano de la Vega, Hospital Argerich. Material y Métodos: se analizaron los pacientes operados enteramente por vía laparoscópica. Dichos pacientes fueron reconstruidos con una sola asa, realizando una pancreato-yeyuno anastomosis con la técnica de Blumgart modificada. Resultados: en los pacientes con DPC totalmente laparoscópica, el páncreas fue de textura intermedia en 3 pacientes y en 2 con textura blanda. El tempo operatorio medio fue 384 minutos. La estadía hospitalaria media fue 12 días. Dos pacientes desarrollaron fistula pancreática tipo A. Un paciente presentó retardo del vaciamiento gástrico que resolvió espontáneamente. Conclusiones: la reconstrucción completa por vía laparoscópica es factble y totalmente reproducible con la misma técnica que se utliza por vía laparotómica.

Background: pancreatoduodenectomy is the procedure indicated for the treatment of ampullary and periampullary tumors. The total laparoscopic approach for pancreatoduodenectomy is technically dificult to perform requiring skill and great experience of the surgical team. The technical dificulty of the pancreatojejunostomy is perhaps the limiting factor to perform the pancreatoduodenectomy totally laparoscopic. Objective: to describe the technique of the laparoscopic reconstructon using the pancreatojejunos-tomy according to the Blumgart modifed technique. Material and methods: patentis operated entrely by totally laparoscopic approach were analyzed. These patentis were reconstructed performing a pancreatojejunostomy with the Blumgart modifed technique. Resultis: in patentis with totally laparoscopic approach, pancreas texture was intermediatein 3 pa-tentis and 2 had sof texture. The average operating tme was 384 minutes. The average hospital stay was 12 days. Two patentis developed pancreatic fistula type A. One patent had delayed gastric emp-tying which resolved spontaneously. Conclusion: total laparoscopic reconstructon is feasible and reproducible with the same technique used by laparotomy.

Diagnóstico y tratamiento de la pancreatitis aguda en la Argentina. Resultados de un estudio prospectivo en 23 centros.

In Argentina there are no multicenter studies evaluating the management of patients with acute pancreatitis (AP) nationwide. OBJECTIVES: The main objective of this study is to know how the patients with AP are treated in Argentina. The secondary objective is to assess whether the results comply with the recommendation of the American College of Gastroenterology Guide. MATERIAL AND METHODS: Twenty three center participated in the study. They include in a database hosted online consecutive patients with acute pancreatitis from june 2010 to june 2013. RESULTS: 854 patients entered the study. The average age was 46.6 years and 495 (58%) belonged to the female sex. The most common cause (88.2%) of AP was biliary. Some prognostic system was used in 99 % of patients and the most used was Ranson (74.5%). Were classified as mild 714 (83.6%) patients and severe 140 (16.4%). Systemic complications occurred in 43 patients and local complications in 21. 86 patients underwent dynamic CT scans and 73 patients had pancreatic and / or peripancreatic necrosis. Mortality was 1.5%. There was no difference in mortality in relation to the size, complexity or affiliation of the center. The comply of key recommendations of the American College of Gastroenterology Guide was over 80%. CONCLUSIONS: The diagnosis and treatment of patients with AP in 23 health centers located throughout the country was optimal. The management complied with most of the recommendations of the American College of Gastroenterology Guide.

Diagnóstico y tratamiento de la pancreatitis aguda en la Argentina. Resultados de un estudio prospectivo en 23 centros.

In Argentina there are no multicenter studies evaluating the management of patients with acute pancreatitis (AP) nationwide. OBJECTIVES: The main objective of this study is to know how the patients with AP are treated in Argentina. The secondary objective is to assess whether the results comply with the recommendation of the American College of Gastroenterology Guide. MATERIAL AND METHODS: Twenty three center participated in the study. They include in a database hosted online consecutive patients with acute pancreatitis from june 2010 to june 2013. RESULTS: 854 patients entered the study. The average age was 46.6 years and 495 (58%) belonged to the female sex. The most common cause (88.2%) of AP was biliary. Some prognostic system was used in 99 % of patients and the most used was Ranson (74.5%). Were classified as mild 714 (83.6%) patients and severe 140 (16.4%). Systemic complications occurred in 43 patients and local complications in 21. 86 patients underwent dynamic CT scans and 73 patients had pancreatic and / or peripancreatic necrosis. Mortality was 1.5%. There was no difference in mortality in relation to the size, complexity or affiliation of the center. The comply of key recommendations of the American College of Gastroenterology Guide was over 80%. CONCLUSIONS: The diagnosis and treatment of patients with AP in 23 health centers located throughout the country was optimal. The management complied with most of the recommendations of the American College of Gastroenterology Guide.

Laparoscopic hepaticojejunostomy and gastrojejunostomy for palliative treatment of pancreatic head cancer in 48 patients.

INTRODUCTION: Approximately 80% of patients with pancreatic cancer are not candidates for curative resection at the time of diagnosis. The objective of this study is to show that although endoscopic treatment is the standard palliation, surgical laparoscopic treatment is both feasible and effective for these patients. MATERIALS AND METHODS: Preoperative resectability was evaluated by dynamic contrast-enhanced computed tomography scans. Endoscopic palliation was the first choice for patients with metastatic disease and for patients with locally advanced pancreatic cancer with bad performance status. Laparoscopic surgical palliation was indicated for patients with jaundice and locally advanced pancreatic cancer (elective palliation) and for patients with jaundice with metastatic disease and failure in the endoscopic/percutaneous treatment (necessary palliation). Elective palliation consisted of Roux-en-Y hepaticojejunostomy and gastrojejunostomy and necessary palliation consisted of laparoscopic hepaticojejunostomy alone. RESULTS: A total of 48 patients received laparoscopic surgical palliation. Morbidity rate was 33.3% and mortality was 2.08%. There was no need for late surgeries in any of the patients. CONCLUSION: Surgical laparoscopic palliation is a feasible treatment option for locally advanced pancreatic cancer. Even though metallic stents are still the best palliation method for patients with systemic disease, if stents fail, the laparoscopic approach is a viable treatment.

Changes in gastrosplenic circulation and splenic function after distal pancreatectomy with spleen preservation and splenic vessel excision.

INTRODUCTION: Distal pancreatectomy with spleen preservation and splenic vessel excision is a commonly used technique. However, it produces significant gastrosplenic circulation and splenic function changes. PURPOSE: The aim of this work was to determine the immediate consequences on gastrosplenic circulation, late consequences on splenic function, and development of varicose veins. METHODS: Thirty-five patients with pancreatic tumors and anatomical feasibility were included. Preoperative splenic circulation was evaluated by dynamic contrast-enhanced computed tomography (CT) scans. Early splenic perfusion was assessed by CT 7 days after surgery and late changes in gastrosplenic circulation 6 months after surgery. Varicose veins were evaluated by CT and endoscopy 6 months after surgery. Pitted cells and Howell-Jolly bodies were used as markers of splenic function. Postoperatory findings included changes in splenic perfusion 7 days and 6 months after surgery, development of varicose veins on CT scans and endoscopy, and detection of markers of splenic hypofunction on blood smears. RESULTS AND CONCLUSION: Seven days after surgery, 63% of patients had some degree of splenic hypoperfusion, and 6 months after surgery, 83% of patients had normal perfusion. CT scans showed varices in 26 patients, and endoscopy revealed varicose veins in 11. Two patients experienced bleeding; markers of splenic hypofunction were found in 59% of cases.

Factores determinantes de evolución en pacientes operados por complicaciones locales de la pancreatitis aguda

Antecedentes: La necrosis pancreática infectada y el seudoquiste son complicaciones que en general requieren algún tipo de tratamiento quirúrgico (laparoscópico, percutáneo o convencional). Objetivo: Identificar los factores determinantes de mortalidad en pacientes sometidos a cirugía por complicaciones locales de la pancreatitis aguda. Método: Se realizó una búsqueda bibliográfica en la National Library of Medicine mediante Pubmed limitada a los trabajos publicados en inglés, a partir de 1990 utilizando los siguientes términos solos o en combinación: "pancreatic necrosis", "necrosectomy", "mortality", "morbidity","local complications", "surgery"y "severe acute pancreatitis". En la base de datos LILACS se realizó también una búsqueda de los trabajos publicados en Argentina, en el período 2000 a 2011. Resultados: Se seleccionaron 119 trabajos y se excluyeron 82 por inadecuado análisis estadístico o insuficiente número de pacientes. Del análisis de los 37 trabajos seleccionados se identificaron 6 factores determinantes de mortalidad luego de la necrosectomía pancreática. Estos factores fueron: el intervalo de tiempo entre el ingreso y la necrosectomía, la composición líquida o sólida predominante, la presencia de infección, la extensión y localización de la necrosis pancreática, la presencia de disfunciones orgánicas y la organización de la necrosis. En la búsqueda de la base de datos LILACS se identificaron 7 trabajos publicados sobre cirugía de las complicaciones locales de la pancreatitis aguda. Conclusión: La bibliografía puede identificar seis factores determinantes de evolución en los pacientes sometidos a cirugías por complicaciones locales de la pancreatitis, lo cual tiene utilidad para el tratamiento.

Background: Infected pancreatic necrosis and pseudocyst are complications that, generally, require any type of surgical treatment (laparoscopic, percutaneous or open surgery). Objective: To identify mortality factors in patients who underwent surgery for local complications of acute pancreatitis. Method: It was conducted a literature search in the National Library of Medicine through Pubmed, limited to publications in English since 1990, using the following keywords: pancreatic necrosis, necrosectomy, mortality, morbidity local complications, surgery and severe acute pancreatitis. In the data base LILACS a similar search was conducted, limited to the Argentine literature, during the period 2000 - 2011. Results: 119 publications were selected and 82 were excluded because of inadequate statistical analysis or insufficient number of patients. After the analysis, 37 publications were selected and 6 mortality factors after pancreatic necrosectomy were identified. These factors were: time between admission and necrosectomy; predominance of liquid orsolid components; presence of infection; extensión and localization of pancreatic necrosis; presence of organ failure and walled off necrosis. In the search conducted in the LILACS data base, 7 publications about surgery of the local complications of acute pancreatitis were identified. Conclusión: After the literature search, six factors were identified related to the patient evolution after surgery for pancreatic local complications.

Factores determinantes de evolución en pacientes operados por complicaciones locales de la pancreatitis aguda

Antecedentes: La necrosis pancreática infectada y el seudoquiste son complicaciones que en general requieren algún tipo de tratamiento quirúrgico (laparoscópico, percutáneo o convencional). Objetivo: Identificar los factores determinantes de mortalidad en pacientes sometidos a cirugía por complicaciones locales de la pancreatitis aguda. Método: Se realizó una búsqueda bibliográfica en la National Library of Medicine mediante Pubmed limitada a los trabajos publicados en inglés, a partir de 1990 utilizando los siguientes términos solos o en combinación: "pancreatic necrosis", "necrosectomy", "mortality", "morbidity","local complications", "surgery"y "severe acute pancreatitis". En la base de datos LILACS se realizó también una búsqueda de los trabajos publicados en Argentina, en el período 2000 a 2011. Resultados: Se seleccionaron 119 trabajos y se excluyeron 82 por inadecuado análisis estadístico o insuficiente número de pacientes. Del análisis de los 37 trabajos seleccionados se identificaron 6 factores determinantes de mortalidad luego de la necrosectomía pancreática. Estos factores fueron: el intervalo de tiempo entre el ingreso y la necrosectomía, la composición líquida o sólida predominante, la presencia de infección, la extensión y localización de la necrosis pancreática, la presencia de disfunciones orgánicas y la organización de la necrosis. En la búsqueda de la base de datos LILACS se identificaron 7 trabajos publicados sobre cirugía de las complicaciones locales de la pancreatitis aguda. Conclusión: La bibliografía puede identificar seis factores determinantes de evolución en los pacientes sometidos a cirugías por complicaciones locales de la pancreatitis, lo cual tiene utilidad para el tratamiento.(AU)

Background: Infected pancreatic necrosis and pseudocyst are complications that, generally, require any type of surgical treatment (laparoscopic, percutaneous or open surgery). Objective: To identify mortality factors in patients who underwent surgery for local complications of acute pancreatitis. Method: It was conducted a literature search in the National Library of Medicine through Pubmed, limited to publications in English since 1990, using the following keywords: pancreatic necrosis, necrosectomy, mortality, morbidity local complications, surgery and severe acute pancreatitis. In the data base LILACS a similar search was conducted, limited to the Argentine literature, during the period 2000 - 2011. Results: 119 publications were selected and 82 were excluded because of inadequate statistical analysis or insufficient number of patients. After the analysis, 37 publications were selected and 6 mortality factors after pancreatic necrosectomy were identified. These factors were: time between admission and necrosectomy; predominance of liquid orsolid components; presence of infection; extensión and localization of pancreatic necrosis; presence of organ failure and walled off necrosis. In the search conducted in the LILACS data base, 7 publications about surgery of the local complications of acute pancreatitis were identified. Conclusión: After the literature search, six factors were identified related to the patient evolution after surgery for pancreatic local complications.(AU)

Management of gallstones and gallbladder disease in patients undergoing gastric bypass.

The appropriate management of gallstones and gallbladder disease in patients undergoing gastric bypass remains unknown. Several therapeutic modalities are used and include performing cholecystectomy on all patients at the time of gastric bypass, performing concomitant cholecystectomy only when patients have gallstones and performing cholecystectomy only in the presence of both symptoms and gallstones. Some groups administer ursodeoxycholic acid for gallstone prevention in the postoperative period. All treatment modalities are analyzed and their results and rationality are discussed.