Risk factors for suboptimal laparoscopic surgery in rectal cancer patients.

PURPOSE: Laparoscopic surgery for rectal cancer is technically complex. This study aimed to identify risk factors for suboptimal laparoscopic surgery (involved margins, incomplete mesorectal excision, and/or conversion to open surgery) in patients with rectal cancer. METHODS: We included patients undergoing laparoscopic anterior resection for rectal cancer between June 2009 and June 2018. We defined the outcome variable suboptimal laparoscopic surgery as conversion to open surgery or inadequate histopathological specimens (margins < 1 mm or involved and/or poor-quality mesorectal excision). To identify independent predictors of suboptimal laparoscopic surgery, we analyzed 15 prospectively recorded demographic, clinical, and anthropometric variables obtained from our rectal cancer unit's database. Subanalyses examined the same variables with respect to conversion and to inadequate histopathological specimens. RESULTS: Of the 323 patients included, 91 (28.2%) had suboptimal laparoscopic surgery. In the multivariate analysis, the independent factors associated with all suboptimal laparoscopic surgery were tumor location ≤ 5 cm from the anal verge (OR = 2.95, 0.95% CI 1.32-6.60; p = 0.008) and the intertuberous distance (OR = 0.79, 0.95% CI 0.65-0.96; p = 0.019). In the subanalyses, the promontorium-retropubic axis was an independent predictor of conversion (OR 0.70, 0.95% CI 0.51-0.96; p = 0.026), and tumor location ≤ 5 cm from the anal verge (OR 3.71, 0.95% 1.51-9.15; p = 0.004) was an independent predictor of inadequate histopathological specimens. CONCLUSIONS: Predictive factors for suboptimal laparoscopic anterior resection for rectal cancer were tumor location and the intertuberous distance. These results could help surgeons decide whether to use other surgical approaches in complex cases. TRIAL REGISTRATION: The study was registered at Clinicaltrials.org (No. NCT03107650).

Duodenal tumors on cross-sectional imaging with emphasis on multidetector computed tomography: a pictorial review.

Duodenal tumours are uncommon, but they can cause significant morbidity and mortality. As stomach and colon are a more common site of gastrointestinal malignancies, radiologists sometimes neglect the duodenum. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can accurately locate and characterize mass-forming duodenal lesions, making them invaluable for the differential diagnosis and determining management strategies such as biopsy or surgery. Although conventional endoscopy continues to play an important role in the diagnosis of duodenal tumors, MDCT and MRI are very useful for evaluating the duodenal wall, extraduodenal space, and surrounding viscera, as well as the intraluminal content seen on endoscopy. This pictorial review aims to illustrate the most common benign and malignant mass-forming duodenal lesions and to focus on the imaging features that are most helpful in reaching the correct diagnosis.

Imaging of non-neoplastic duodenal diseases. A pictorial review with emphasis on MDCT.

A wide spectrum of abnormalities can affect the duodenum, ranging from congenital anomalies to traumatic and inflammatory entities. The location of the duodenum and its close relationship with other organs make it easy to miss or misinterpret duodenal abnormalities on cross-sectional imaging. Endoscopy has largely supplanted fluoroscopy for the assessment of the duodenal lumen. Cross-sectional imaging modalities, especially multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), enable comprehensive assessment of the duodenum and surrounding viscera. Although overlapping imaging findings can make it difficult to differentiate between some lesions, characteristic features may suggest a specific diagnosis in some cases. Familiarity with pathologic conditions that can affect the duodenum and with the optimal MDCT and MRI techniques for studying them can help ensure diagnostic accuracy in duodenal diseases. The goal of this pictorial review is to illustrate the most common non-malignant duodenal processes. Special emphasis is placed on MDCT features and their endoscopic correlation as well as on avoiding the most common pitfalls in the evaluation of the duodenum. TEACHING POINTS: • Cross-sectional imaging modalities enable comprehensive assessment of duodenum diseases. • Causes of duodenal obstruction include intraluminal masses, inflammation and hematomas. • Distinguishing between tumour and groove pancreatitis can be challenging by cross-sectional imaging. • Infectious diseases of the duodenum are difficult to diagnose, as the findings are not specific. • The most common cause of nonvariceal upper gastrointestinal bleeding is peptic ulcer disease.

La estenosis del tronco celiaco y duodenopancreatectomía cefálica: ¿un riesgo infravalorado? / Celiac artery stenosis and cephalic duodenopancreatectomy: An undervalued risk?

Introducción La estenosis significativa del tronco celiaco habitualmente cursa de forma asintomática. No obstante, cuando se interrumpe la arcada de las arterias pancreatoduodenales, puede producirse isquemia visceral. El objetivo de este estudio es determinar si la estenosis preoperatoria del tronco celiaco es un factor de riesgo de complicaciones en pacientes sometidos a duodenopancreatectomía (DPC). Material y métodos Hemos analizado retrospectivamente a 58 pacientes consecutivos sometidos a DPC. Hemos relacionado la estenosis significativa del tronco celiaco con la evolución posquirúrgica. En todos los casos se ha realizado un estudio mediante tomografía computarizada multidetector (TCDM) de 16 canales en tres fases hepáticas. Hemos revisado la TCDM prequirúrgica centrándonos en la morfología del tronco celiaco, especialmente la presencia o ausencia de estenosis significativa (> 50%).Resultados Encontramos estenosis del tronco celiaco > 50% en 13 pacientes (22%). La mortalidad total fue de 3 pacientes (5%). La morbilidad total fue del 62%. En 16 pacientes (28%) hubo complicaciones graves, de los que 8 (62%) pertenecen al grupo de estenosis significativa del tronco celiaco (p=0,004); 10 pacientes (17%) presentaron fístula pancreática, 5 (38%) vs. 5 (11%) (p=0,036); 14 pacientes (24%) necesitaron reoperación, 7 (54%) vs. 7 (16%) (p=0,009); 7 pacientes (12%) presentaron hemoperitoneo, 4 (31%) vs. 3 (7%) (p=0,038), en los grupos con y sin estenosis del tronco celiaco respectivamente. Conclusiones La estenosis radiológicamente significativa del tronco celiaco es un factor de riesgo de complicaciones graves tras DPC. El estudio del calibre de la AMS con TCDM debería ser sistemático antes de una DPC. Debería valorarse preoperatoriamente la corrección de la estenosis significativa del tronco celiaco (AU)

Introduction Significant celiac trunk or artery stenosis (CAS) is normally asymptomatic. However, when the arteries of the pancreatoduodenal arcade are occluded, it could trigger avisceral ischaemia. The objective of this study is to determine whether preoperative CAS is a risk factor for developing complications in patients subjected to duodenopancreatectomy(DPC). Material and methods: We have retrospectively analysed 58 consecutive patients subjected to DPC. We have associated significant CAS with post-surgical outcome. In all cases a 16-channel multidetector computed tomography (MDCT) in three hepatic phases was performed. We have reviewed the pre-surgical MDCT focusing on the morphology of the celiacartery (CA), particularly in the presence or absence of significant stenosis (>50%). Results: We found CAS >50% in 13 patients (22%). The overall mortality was 5% (3 patients). Serious complications developed in 16 (28%) patients, 8 (62%) of whom belonged to the group with significant CAS (P = .004). Ten patients (17%) had a pancreatic fistula, 5 (38%) vs. 5 (11%)(P = .036); Fourteen patients (24%) needed new surgery, 7 (54%) vs. 7 (16%) (P = .009); Seven patients (12%) had a haemoperitoneum, 4 (31%) vs. 3 (7%) (P = .038), in the group with and without CAS, respectively. Conclusions: Significant radiological CAS is a risk factor of serious complications after DPC. The study of the calibre of the superior mesenteric artery (SMA) with MDCT should beroutine before a DPC. The correction of a significant CAS should be evaluated preoperatively (AU)

[Celiac artery stenosis and cephalic duodenopancreatectomy: an undervalued risk?]. / La estenosis del tronco celiaco y duodenopancreatectomía cefálica: ¿un riesgo infravalorado?

INTRODUCTION: Significant celiac trunk or artery stenosis (CAS) is normally asymptomatic. However, when the arteries of the pancreatoduodenal arcade are occluded, it could trigger a visceral ischaemia. The objective of this study is to determine whether preoperative CAS is a risk factor for developing complications in patients subjected to duodenopancreatectomy (DPC). MATERIAL AND METHODS: We have retrospectively analysed 58 consecutive patients subjected to DPC. We have associated significant CAS with post-surgical outcome. In all cases a 16-channel multidetector computed tomography (MDCT) in three hepatic phases was performed. We have reviewed the pre-surgical MDCT focusing on the morphology of the celiac artery (CA), particularly in the presence or absence of significant stenosis (>50%). RESULTS: We found CAS >50% in 13 patients (22%). The overall mortality was 5% (3 patients). Serious complications developed in 16 (28%) patients, 8 (62%) of whom belonged to the group with significant CAS (P=.004). Ten patients (17%) had a pancreatic fistula, 5 (38%) vs. 5 (11%) (P=.036); Fourteen patients (24%) needed new surgery, 7 (54%) vs. 7 (16%) (P=.009); Seven patients (12%) had a haemoperitoneum, 4 (31%) vs. 3 (7%) (P=.038), in the group with and without CAS, respectively. CONCLUSIONS: Significant radiological CAS is a risk factor of serious complications after DPC. The study of the calibre of the superior mesenteric artery (SMA) with MDCT should be routine before a DPC. The correction of a significant CAS should be evaluated preoperatively.

Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras / Major hepatectomies are safe in patients with cholangiocarcinoma and jaundice

Introducción En el tumor de Klatskin la única posibilidad de cura es la extirpación quirúrgica radical. No obstante, la resección quirúrgica es difícil. Objetivo El objetivo de este trabajo es valorar la necesidad de drenaje biliar preoperatorio, el índice de resecabilidad, el porcentaje de hepatectomías, la morbimortalidad y la supervivencia a largo plazo. Material y métodos Desde el año 2005 hasta el año 2008, se estudió a 26 pacientes con tumor de Klatskin mediante tomografía computarizada helicoidal con multidetectores y colangiorresonancia magnética en casos especiales. Siete pacientes se consideraron irresecables (27%). A los restantes 19 pacientes se les realizaron 8 hepatectomías izquierdas, 5 derechas y 6 resecciones exclusivamente de la vía biliar con linfadenectomía y hepático yeyunostomía a todos ellos. La resecabilidad fue del 73%, la transfusión del 53% y el drenaje biliar preoperatorio se utilizó en 7 casos (37%). La morbilidad fue del 58% y la mortalidad del 10%. La supervivencia y la recidiva a los 48 meses fueron respectivamente del 63 y del 37%.Al comparar la evolución de los 9 pacientes con bilirrubina inferior a 15mg/dl y los 10 pacientes con bilirrubina superior a 15mg/dl, no hubo diferencias en los datos epidemiológicos. Seis pacientes (67%) con bilirrubina baja frente a un paciente (10%) del grupo de bilirrubina alta habían recibido un drenaje biliar preoperatorio (p=0,02). La bilirrubina del grupo no ictérico era de 4,7±4,3 frente a 22,1±3,9 del grupo con ictericia (p<0,001). No hubo diferencias en la evolución postoperatoria. En conclusión, la resecabilidad y la supervivencia postoperatoria de los pacientes con tumor de Klatskin han mejorado sensiblemente en los últimos años. En casos seleccionados, las hepatectomías mayores en pacientes con ictericia sin desnutrición ni colangitis preoperatoria son seguras (AU)

Background Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary. Objective The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre. Patients and methods From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree. Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%).There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin <15mg/dL and the 10 patients with bilirubin >15mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1±3.9 vs. 4.7±4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups. Conclusion Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe (AU)

[Major hepatectomies are safe in patients with cholangiocarcinoma and jaundice]. / Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras.

BACKGROUND: Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary. OBJECTIVE: The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre. PATIENTS AND METHODS: From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree. RESULTS: Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%). There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin<15 mg/dL and the 10 patients with bilirubin>15 mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1+/-3.9 vs. 4.7+/-4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups. CONCLUSION: Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe.

Peripheral zone prostate cancer in patients with elevated PSA levels and low free-to-total PSA ratio: detection with MR imaging and MR spectroscopy.

PURPOSE: To retrospectively assess the value of endorectal magnetic resonance (MR) imaging and MR spectroscopy combined with the free-to-total prostate-specific antigen (PSA) ratio for detecting prostate cancer in men with elevated PSA levels. MATERIALS AND METHODS: The institutional review board approved the study, and all patients provided informed written consent. Endorectal MR imaging and MR spectroscopy were performed in 54 patients with PSA levels greater than 3 ng/mL but less than 15 ng/mL and free-to-total PSA ratio of less than 20%, followed by sextant biopsy in the peripheral zone. For each patient, MR imaging and MR spectroscopic findings, PSA level, and free-to-total PSA ratio were analyzed and compared with biopsy results and/or histopathologic tumor maps with regard to a sextant-modified distribution. The likelihood of cancer in each sextant according to MR and MR spectroscopic findings was graded independently on a scale of 1 (benign) to 5 (malignant). Detection accuracy and a multivariate logistic regression analysis were used to determine the most accurate combination of imaging, and clinical tests were used to detect prostate cancer according to the area under the receiver operating characteristic curve (AUC). RESULTS: The model incorporating MR imaging, MR spectroscopy, and free-to-total PSA ratio (AUC = 97.5%) was significantly more accurate in predicting prostate cancer than models using MR imaging alone (AUC = 85.1%; P = .007), MR spectroscopy alone (AUC = 87.2%; P = .041), or MR imaging and free-to-total PSA ratio combined (AUC = 90.8%; P = .038). CONCLUSION: MR and MR spectroscopy combined with free-to-total PSA ratio improves the predictive value for prostate cancer detection.

[Results of hepatobiliary and pancreatic surgery according to DRG in a level 2 hospital surgery department during the years 2005-2006]. / Resultados de la cirugía hepatobiliopancreática en un servicio de cirugía de un hospital de segundo nivel según los GRD durante el bienio 2005-2006.

OBJECTIVE: To assess the results of the hepatobiliary and pancreatic surgery of a surgery department during 2005-2006 using the diagnostic related groups. MATERIALS AND METHOD: The data were obtained from the CMBD-HA of the Catalan Health Service. We assessed the frequency, hospital stay and mortality of the surgical procedures. The results were compared with the 63 public hospitals, and the 8 of them belonging to the Catalan Health Institute. RESULTS: In our area, a clear trend is observed in referrals for certain types of complex procedures on the liver, pancreas and biliary system excluding cholecystectomy with or without associated morbidities (7-11%) without exceeding the population percentage (12%). In our centre, the impact on hospital stay is more evident in complex procedures. The total savings in our centre during the years 2005-2006 compared with the XHUP hospitals group were 2212 days of hospital stay with an equivalent cost saving of more than one million euro. The frequency and the results of hospital stay and mortality of laparoscopic and open cholecystectomy were those expected for the population covered by a general hospital. The mortality in complex procedures was half of that of the whole public network or the ICS centres. CONCLUSIONS: In the complex hepatobiliary-pancreatic pathology, the mortality, and cost savings in our centre appear to be the result of, not only the high volume of procedures, but also to specialisation and factors related to the structure of the department, and surgeon training.

Resultados de la cirugía hepatobiliopancreática en un servicio de cirugía de un hospital de segundo nivel según los GRD durante el bienio 2005-2006 / Results of hepatobiliary and pancreatic surgery according to DRG in a level 2 hospital surgery department during the years 2005-2006

Objetivo. Evaluar los resultados de la cirugía hepatobiliopancreática de un servicio de cirugía durante el bienio 2005-2006, mediante los grupos relacionados por el diagnóstico. Materiales y método. Los datos se han obtenido del Registro del Conjunto Mínimo Básico de Datos de los Hospitales de Agudos del CatSalut. Se ha valorado la frecuencia, la estancia y la mortalidad. Los resultados han sido comparados con los 63 hospitales públicos de Cataluña (XHUP) y con los 8 de ellos que pertenecen al Instituto Catalán de la Salud (ICS). Resultados. Se observa, en nuestra área de influencia, una clara tendencia a la referencia para cierto tipo de procedimientos complejos (7-11%), sin superarla proporción poblacional (12%). En nuestro centro, el impacto en las estancias hospitalarias es más evidente en los procedimientos complejos. El ahorro total de recursos de nuestro servicio en el bienio2005-2006 en relación con el grupo de hospitales de la XHUP fue de 2.212 días de estancia hospitalaria, cuyo coste equivale a más de un millón de euros. La frecuencia y los resultados sobre las estancias hospitalarias y la mortalidad de la colecistectomía son los esperados para la población que se atiende como hospital general. La mortalidad en los procedimientos complejos fue la mitad que la observada para el conjunto de hospitales de la XHUP o del ICS. Conclusiones. En la patología hepatobiliopancreática compleja, creemos que la mortalidad y el ahorro de recursos en nuestro centro se deben no sólo al volumen, sino a la especialización y los factores relacionados con la estructura del servicio y el entrenamiento de los cirujanos (AU)

Objective. To assess the results of the hepatobiliary and pancreatic surgery of a surgery department during2005-2006 using the diagnostic related groups. Materials and method. The data were obtained from the CMBD-HA of the Catalan Health Service. We assessed the frequency, hospital stay and mortality of the surgical procedures. The results were compared with the 63 public hospitals, and the 8 of them belonging to the Catalan Health Institute. Results. In our area, a clear trend is observed in referrals for certain types of complex procedures on the liver, pancreas and biliary system excluding cholecystectomy with or without associated morbidities(7-11%) without exceeding the population percentage(12%). In our centre, the impact on hospital stay is more evident in complex procedures. The total savings in our centre during the years 2005-2006 compared with the XHUP hospitals group were 2212 days of hospital stay with an equivalent cost saving of more than one million euro. The frequency and the results of hospital stay and mortality of laparoscopic and open cholecystectomy were those expected for the population covered by a general hospital. The mortality in complex procedures was half of that of the whole public network or the ICS centres. Conclusions. In the complex hepatobiliary-pancreatic pathology, the mortality, and cost savings in our centre appear to be the result of, not only the high volume of procedures, but also to specialization and factors related to the structure of the department, and surgeon training (AU)

Duodenopancreatectomía cefálica en tumores periampulares. Disección de la arteria mesentérica superior como abordaje inicial. Descripción de la técnica y evaluación de nuestra experiencia inicial / Cephalic duodenopancreatectomy in periampullary tumours. Dissection of the superior mesenteric artery as aninitial approach. Description of the technique and an assessment of our initial experience

Introducción. La duodenopancreatectomía cefálica (DPC) con abordaje inicial de la arteria mesentérica superior (AMS) ha sido descrita como una técnica útil para reducir las pérdidas de sangre y evitar una intervención inútil si hay afectación arterial. Objetivos. Analizar los resultados de dos modificaciones recientes en la técnica quirúrgica de la DPC introducidas en nuestro grupo: disección primaria de la AMS y la gastroenterostomía antecólica. Pacientes y método. Se dividió a los pacientes en 2 grupos, según hayan recibido o no disección inicial de la AMS. También se analizaron los resultados según el tipo de reconstrucción gástrica. Se comparan los resultados perioperatorios y a largo plazo. Resultados. La mortalidad general fue del 5% sin diferencias entre la DPC con abordaje inicial de la AMS y la técnica convencional. La tasa de transfusión (p < 0,001), el volumen transfundido (p = 0,001) y la incidencia general de complicaciones fue menor (p = 0,01) en el grupo con disección de la AMS. La estancia postoperatoria también fue significativamente menor (p # 0,001). A pesar de que la afectación ganglionar fue más frecuente en los pacientes operados con abordaje inicial de la AMS (p = 0,001), la tasa de recidiva fue la misma que con la técnica convencional. Dentro del grupo con disección inicial de la AMS, aquellos con reconstrucción antecólica presentaron con menor frecuencia retraso en el vaciamiento gástrico (p = 0,008). Conclusiones. La DPC con abordaje inicial de la AMS es una técnica segura. La transfusión, las complicaciones y la estancia hospitalaria son mejores. Cuando se asocia a reconstrucción duodenoyeyunal antecólica, los retrasos de vaciamiento gástrico son menos frecuentes (AU)

Introduction. Pancreatoduodenectomy (PD) with initial dissection of the superior mesenteric artery (SMA) has been described as a useful technical variant to reduce blood loss and to avoid an unnecessary intervention in those cases with arterial involvement. Objectives. To analyse the results of two recent technical modifications of PD introduced by our group: initial dissection of SMA and antecolic gastroenterostomy. Patients and method. Patients were divided into two groups: with and without initial dissection of the SMA. The results were also analysed according to the type of gastric reconstruction. Perioperative and long-term results are compared. Results. The overall mortality was 5%, with no significant differences between the initial SMA dissection and conventional PD. The transfusion rate (p < 0.001), the volume of blood products transfused (p = 0.001), and the overall complication rate were lower (p = 0.01) in the initial SMA dissection group. Also the postoperative hospital stay was significantly lower (p # 0.001). Despite a higher frequency of lymph node involvement in patients treated with initial SMA dissection (p = 0.001), the recurrence rate was similar between both groups. Among patients with initial SMA dissection, those who received antecolic reconstruction had a lower rate of delayed gastric emptying (p = 0.008). Conclusions. Initial SMA dissection PD is a safe technique. The transfusion rate, morbidity and postoperative hospital stay are better when compared with conventional CPD. When an antecolic duodenal-jejunal reconstruction is associated, delayed gastric emptying cases are less frequent (AU)

[Role of intra-operative echography and computed tomography with multiple detectors in the surgery of hepatic metastases: a prospective study]. / Papel de la ecografía intraoperatoria y la tomografía computarizada con multidetectores en la cirugía de las metástasis hepáticas: estudio prospectivo.

OBJECTIVES: To study the performance of the intraoperative ecography in the diagnosis of new liver metastases in the era of computerized tomography (CT) with multidetectors and its impact on the surgical operation. PATIENTS AND METHOD: Between February 2005 and April 2006 patients with resectable liver metastases where studied prospectively in a multidisciplinary meeting (surgeons, radiologist, oncologist). The preoperative CT findings were compared with the intraoperative findings and ultrasound study and the results of the surgical operation. RESULTS: Forty-five candidates for curative surgery had a total of 171 hepatic lesions. CT correctly detected 115 lesions with a sensitivity of 67%, and a positive predictive value of 97%, with a false negative rate of 33% and false positive rate of 2%. In 5 patients intraoperative findings were the cause of changing the surgical procedure, three patients were unresectable (rate of resectability of 93%) and two patients needed a larger hepatic resection. CONCLUSIONS: CT with multidetectors and multidisciplinary meetings are the most important factors in the decision making of surgery of liver metastases with a high resectability rate. Intraoperative ecography is useful for the detection of 10% more liver metastases, but rarely involves a change in the surgical procedure.

[Cephalic duodenopancreatectomy in periampullary tumours. Dissection of the superior mesenteric artery as aninitial approach. Description of the technique and an assessment of our initial experience]. / Duodenopancreatectomía cefálica en tumores periampulares. Disección de la arteria mesentérica superior como abordaje inicial. Descripción de la técnica y evaluación de nuestra experiencia inicial.

INTRODUCTION: Pancreatoduodenectomy (PD) with initial dissection of the superior mesenteric artery (SMA) has been described as a useful technical variant to reduce blood loss and to avoid an unnecessary intervention in those cases with arterial involvement. OBJECTIVES: To analyse the results of two recent technical modifications of PD introduced by our group: initial dissection of SMA and antecolic gastroenterostomy. PATIENTS AND METHOD: Patients were divided into two groups: with and without initial dissection of the SMA. The results were also analysed according to the type of gastric reconstruction. Perioperative and long-term results are compared. RESULTS: The overall mortality was 5%, with no significant differences between the initial SMA dissection and conventional PD. The transfusion rate (p < 0.001), the volume of blood products transfused (p = 0.001), and the overall complication rate were lower (p = 0.01) in the initial SMA dissection group. Also the postoperative hospital stay was significantly lower (p

Papel de la ecografía intraoperatoria y la tomografía computarizada con multidetectores en la cirugía de las metástasis hepáticas: estudio prospectivo / Role of intra-operative echography and computed tomography with multiple detectors in the surgery of hepatic metastases: a prospective study

Objetivos. Estudiar el papel de la ecografía intraoperatoria en el diagnóstico de nuevas metástasis hepáticas en la era de la tomografía computarizada (TC) con multidetectores y su impacto en el acto quirúrgico. Pacientes y método. Entre febrero de 2005 y abril de 2006 se estudió de forma prospectiva, en sesiones multidisciplinarias (cirujanos, radiólogos y oncólogos), a los pacientes con metástasis hepáticas resecables de cáncer colorrectal. Los hallazgos preoperatorios de la TC se compararon con los de la ecografía intraoperatoria, su correlación histológica y el resultado final de la intervención quirúrgica. Resultados. Se estudió a 45 pacientes candidatos a cirugía curativa, con un total de 171 metástasis hepáticas. La TC detectó correctamente 115 lesiones con una sensibilidad del 67%, un valor predictivo positivo del 97%, una tasa de falsos negativos del 33% y una tasa de falsos positivos del 2%. En 5 ocasiones los hallazgos intraoperatorios condicionaron un cambio en el acto quirúrgico programado: en 3 pacientes eran irresecables (tasa de resecabilidad del 93%) y 2 pacientes precisaron de resecciones más amplias de las previamente programadas. Conclusiones. La TC con multidetectores como prueba de imagen preoperatoria y las sesiones multidisciplinarias son el factor más importante en la toma de decisiones en la cirugía de las metástasis hepáticas y nos permiten obtener una alta tasa de resecabilidad. La ecografía intraoperatoria hepática nos permite encontrar un mayor número de metástasis y realizar una correcta delimitación anatómica y, en ocasiones, condiciona un cambio en el acto quirúrgico programado (AU)

Objectives. To study the performance of the intraoperative ecography in the diagnosis of new liver metastases in the era of computerized tomography (CT) with multidetectors and its impact on the surgical operation. Patients and method. Between February 2005 and April 2006 patients with resectable liver metastases where studied prospectively in a multidisciplinary meeting (surgeons, radiologist, oncologist). The preoperative CT findings were compared with the intraoperative findings and ultrasound study and the results of the surgical operation. Results. Forty-five candidates for curative surgery had a total of 171 hepatic lesions. CT correctly detected 115 lesions with a sensitivity of 67%, and a positive predictive value of 97%, with a false negative rate of 33% and false positive rate of 2%. In 5 patients intraoperative findings were the cause of changing the surgical procedure, three patients were unresectable (rate of resectability of 93%) and two patients needed a larger hepatic resection. Conclusions. CT with multidetectors and multidisciplinary meetings are the most important factors in the decision making of surgery of liver metastases with a high resectability rate. Intraoperative ecography is useful for the detection of 10% more liver metastases, but rarely involves a change in the surgical procedure (AU)