Considerations on pancreatic exocrine function after pancreaticoduodenectomy.

The pancreaticoduodenectomy (PD) procedure may lead to pancreatic exocrine and endocrine insufficiency. There are several types of reconstruction for this kind of operation. Pancreaticogastrostomy (PG) was introduced to reduce the rate of postoperative pancreatic fistula. Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy (PJ), recently some reports reveal benefits from the PG over the PJ. Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice, and the detrimental results over the exocrine pancreatic function. The pancreatic exocrine function can be measured with direct and indirect tests. Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement. Among the tubeless indirect tests, the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption. The patient compliance and time consuming makes it not so suitable for its clinical use. Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency, is not cumbersome, and has been used to study pancreatic function after resection. We analyze the FE1 levels in our patients after the PD with two types of reconstruction, PG and PJ, and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.

Indicaciones quirúrgicas en los pólipos de vesícula biliar / Surgical indications in gallbladder polyps

Introducción La cirugía por pólipo de vesícula biliar está poco definida debido a la carencia de guías clínicas basadas en la evidencia. Objetivo Analizar el manejo de los pólipos en nuestro medio, y revisión de la literatura y estándares de tratamiento. Material y métodos De la base de datos de Patología se extrajeron los informes de colecistectomía con pólipos vesiculares (PV). De la base de datos de Cirugía se identificó a pacientes intervenidos con diagnóstico de PV. Se confeccionó un listado único y se llevó a cabo la revisión de las historias clínicas incluyendo edad, sexo, clínica, informe ecográfico e informe anatomopatológico. Resultados Se incluyó a 30 pacientes, mediana de edad 51 años (rango 22-83), 21 mujeres. En 19 pacientes el diagnóstico ecográfico fue PV, 7 de PV y litiasis, y 4 de litiasis sin pólipo. Otros diagnósticos concurrentes con PV fueron hemangiomas múltiples (3), gran quiste simple único (1), quistes simples múltiples (1). Once pacientes tuvieron dolor típico (origen biliar), 5 de los cuales sin litiasis ecográfica. Ocho presentaron dolor inespecífico, persistiendo en 3 tras la colecistectomía. Se encontraron pseudopólipos en 20 vesículas, y pólipos verdaderos en 4 casos. En 3 casos no se hallaron pólipos en el examen patológico. Conclusiones El informe ecográfico debe especificar el tamaño, forma y número de pólipos. Los pacientes con dolor biliar típico se beneficiarán de una colecistectomía. Ante un PV menor de 10mm y edad menor de 50 años la probabilidad de malignidad es mínima y no requiere colecistectomía. Los PV mayores de 10mm deben ser indicación de colecistectomía (AU)

Introduction The surgery of gallbladder polyps is not well defined due to the lack of evidence-based clinical guidelines. Objective To analyse the management of polyps in Spain, and a review of the literature and treatment standards. Material and methods The reports on cholecystectomy with gallbladder polyps (GBP) were extracted from the Pathology data base. Patients subjected to surgery with a diagnosis of GBP were identified in the Surgery data base. A single list was prepared and a review was made of the clinical histories, including, age, gender, clinical data, ultrasound report, and histopathology report. Results A total of 30 patients, with a median age of 51 years (range 22-83), 21 of whom were female, were included. The ultrasound diagnosis was GBP in 19 patients, GBP and calculi in 7 cases, and calculi with no polyps in 4 cases. Other diagnoses concurrent with GBP were multiple haemangiomas (3), large single simple cyst (1), and multiple simple cysts (1). Eleven patients had typical pain (biliary origin), 5 of which showed no calculi on ultrasound. Eight had non-specific pain, which persisted in 3 cases after the cholecystectomy. Pseudopolyps were found in 20 gallbladders, and true polyps in 4 cases. In 3 cases, polyps were not found in the pathology study. Conclusions The ultrasound report must specify the size, shape, and number of polyps. Patients with biliary type pain would benefit from a cholecystectomy. The probability of malignancy is minimum if the GBP is less than 10mm and aged under 50 years, and a cholecystectomy is not required. A GBP greater than 10mm should be an indication of cholecystectomy (AU)

[Surgical indications in gallbladder polyps]. / Indicaciones quirúrgicas en los pólipos de vesícula biliar.

INTRODUCTION: The surgery of gallbladder polyps is not well defined due to the lack of evidence-based clinical guidelines. OBJECTIVE: To analyse the management of polyps in Spain, and a review of the literature and treatment standards. MATERIAL AND METHODS: The reports on cholecystectomy with gallbladder polyps (GBP) were extracted from the Pathology data base. Patients subjected to surgery with a diagnosis of GBP were identified in the Surgery data base. A single list was prepared and a review was made of the clinical histories, including, age, gender, clinical data, ultrasound report, and histopathology report. RESULTS: A total of 30 patients, with a median age of 51 years (range 22-83), 21 of whom were female, were included. The ultrasound diagnosis was GBP in 19 patients, GBP and calculi in 7 cases, and calculi with no polyps in 4 cases. Other diagnoses concurrent with GBP were multiple haemangiomas (3), large single simple cyst (1), and multiple simple cysts (1). Eleven patients had typical pain (biliary origin), 5 of which showed no calculi on ultrasound. Eight had non-specific pain, which persisted in 3 cases after the cholecystectomy. Pseudopolyps were found in 20 gallbladders, and true polyps in 4 cases. In 3 cases, polyps were not found in the pathology study. CONCLUSIONS: The ultrasound report must specify the size, shape, and number of polyps. Patients with biliary type pain would benefit from a cholecystectomy. The probability of malignancy is minimum if the GBP is less than 10mm and aged under 50 years, and a cholecystectomy is not required. A GBP greater than 10mm should be an indication of cholecystectomy.

Some reflexions on the modified Appleby procedure.

CONTEXT: Resection of pancreatic cancer with vascular invasion is a controversial issue, especially when the arterial trunks, such as the celiac axis, are involved. The modified Appleby procedure deals with the problem of encasement of the celiac trunk. CASE REPORT: Two patients with locally advanced pancreatic cancer are reviewed: a 65-year-old female and a 78-year-old male with pancreatic cancer and involvement of the celiac trunk and hepatic artery. The male patient received neoadjuvant chemoradiation. The former underwent an extended pancreatectomy with en-bloc resection of the hepatic artery, celiac trunk, gastric serosa and adrenal gland. Liberation of arterial trunk involvement in the second patient was performed. The margins were microscopically clear of tumor (R0) in both patients. The second patient died from cholecystitis owing to arterial insufficiency. CONCLUSIONS: CT vascular encasement is not always synonymous with real tumoral vascular invasion. Improvement in the quality of anesthesiological and surgical techniques has allowed vascular resections with lower morbidity. A cholecystectomy should always be performed using the modified Appleby procedure.

[Gallbladder cancer in a regional hospital]. / Cáncer de vesícula biliar en un hospital comarcal.

OBJECTIVES: To assess the management of gallbladder cancer (GBC) in our region. MATERIAL AND METHODS: Data on 372 patients who underwent cholecystectomy were identified from our database (January 2003 to February 2008) and 6 patients were found to have GBC. RESULTS: Four patients had incidental carcinoma, one case was preoperatively suspected, and one patient presented with jaundice and locally advanced neoplasia. The incidence was 2 per 100,000 inhabitants per year; incidental carcinoma in 1.1% of cholecystecomies. The ultrasonography showed multilithiasis in 2 patients, sludge and neoplasia in 1, gallstones more than 3cm in 2, and tumor mass only in 1 case. T stage: 1 case of T0 (in situ), 1 of T1, 2 of T2 and one T4. Incidental carcinomas were reoperated on when a T2 was established: 2 underwent lymphadenectomy and cystic stump resection, 1 segmentectomy IVb-V and lymphadenectomy. In the preoperative suspected neoplasia a cholecystectomy, lymphadenectomy, and partial hepatic gallbladder bed resection was initially performed. CONCLUSIONS: GBC has a low incidence but it will be found in 1% of cholecystectomies. There is no adjuvant treatment and T-based surgical treatment is the is the only opportunity to reach cure in those patients. A national GBC database would be helpful in the publication of national guidelines for this disease.

Utilidad de la ecoendoscopia en el diagnóstico etiológico de los pacientes con pancreatitis aguda idiopática / No disponible

No disponible

Colinesterasa plasmática como indicador de gravedad en procesos agudos / Cholinesterase as a marker in acute septic conditions

No disponible