Quality Standards for Surgery of Colorectal Peritoneal Metastasis After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: The standardization of surgical outcomes throughout surgical procedures is mandatory. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) should provide proficient oncological and surgical outcomes. STUDY DESIGN: The aim of this study was to identify clinically relevant quality indicators and their quality standard, and to determine their acceptable quality limit. A systematic review on cytoreductive results from 2000 to 2018 was performed focusing on clinical guidelines, consensus conferences, and publications. After the selection of quality indicators, a systematic review of indexed references was performed in order to calculate the quality standard for each indicator. STUDY SELECTION: Unicentric/multicentric series, comparative studies, and clinical trials. Studies were to include outcomes after cytoreduction of colorectal origin and series with more than 50 patients. Quality indicators with at least 10 series were mandatory and objective measurements were also mandatory for inclusion. MAIN OUTCOME MEASUREMENTS: Quality indicators selected were 1- to 5-year survival, overall disease-free survival, 1- to 5-year disease-free survival, complete surgical resection, duration of surgery, length of stay, overall morbimortality, major morbidity, re-intervention, postoperative hemorrhage, intestinal fistula, anastomotic leakage, wound infection, postoperative medical complications, overall recurrence, and failure to rescue. RESULTS: The most relevant quality indicators and critical quality limits were overall disease-free survival and 5-year overall disease-free survival (14 months and <10 months, and 14% and <4%, respectively), completeness of surgical resection (89% and <80%, respectively), overall mortality (3% and >8%, respectively), overall morbidity (47% and >63%, respectively), failure to rescue (12% and <30%, respectively), reintervention (13 and <22%, respectively), anastomotic leakage (6% and <13%, respectively), and overall recurrence (60% and <74%, respectively). CONCLUSION: This is the first study to assess quality standards in CRS + HIPEC for colorectal peritoneal metastases. The current data are of particular relevance for future studies to control the variability of this surgery.

Anatomía quirúrgica aplicada a abordajes transperitoneales de la aorta abdominal y los troncos viscerales. Artículo dinámico / Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article

Los cirujanos cardiovasculares y del aparato digestivo deberían estar al corriente de las múltiples alternativas de abordaje de la aorta abdominal y sus troncos viscerales. Artículo narrativo, ilustrado y dinámico de las diferentes maniobras quirúrgicas descritas con este objetivo. Disección de 5 cadáveres realizadas durante tres cursos nacionales de Anatomía Quirúrgica aplicada a aorta integral, Cirugía hepatobiliopancreática y Cirugía abdominal digestiva. Maniobras quirúrgicas descritas: abordaje aórtico inframesocólico longitudinal, abordaje aórtico supracelíaco, abordaje del tronco celíaco, tres tipos de abordaje de la arteria mesentérica superior: retroperitoneal tras maniobra de Kocher, supramesocólico e inframesocólico, maniobra de Cattell-Braasch y dos tipos de maniobra de Mattox: retrorrenal y prerrenal. El conocimiento profundo de la anatomía intraabdominal es fundamental para la actuación quirúrgica sobre la aorta abdominal y el entrenamiento en cadáver a partir de la anatomía quirúrgica vascular y del tubo digestivo podría ayudar a desarrollar las habilidades quirúrgicas de los cirujanos en formación. (AU)

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient. (AU)

Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article.

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

Distal pancreatectomy with multivisceral resection: A retrospective multicenter study - Case series.

BACKGROUND: Multivisceral resection (MVR) is sometimes necessary to achieve disease-free margins in cancer surgery. In certain patients with pancreatic tumors that invade neighboring organs these must be removed to perform an appropriate oncological surgery. In addition, there is an increasing need to perform resections of other organs like liver not directly invaded by the tumor but which require synchronous removal. The results of MVR in pancreatic surgery are controversial. MATERIAL AND METHODS: A distal pancreatectomy retrospective multicenter observational study using prospectively compiled data carried out at seven HPB Units. The period study was January 2008 to December 2018. We excluded DP with celiac trunk resection. RESULTS: 435 DP were performed. In 62 (14.25%) an extra organ was resected (82 organs). Comparison of the preoperative data of MVR and non-MVR patients showed that patients with MVR had lower BMI, higher ASA and larger tumor size. In the MVR group, the approach was mostly laparotomic and spleen preservation was performed only in 8% of the cases, Blood loss and the percentage of intraoperative transfusion were higher in MVR group. Major morbidity rates (Clavien > IIIa) and mortality (0.8vs.4.8%) were higher in the MVR group. Pancreatic fistula rates were practically the same in both groups. Mean hospital stay was twice as long in the MVR group and the readmission rate was higher in the MVR group. Histology study confirmed a much higher rate of malignant tumors in MVR group. CONCLUSIONS: In order to obtain free margins or treat pathologies in several organs we think that DP + MVR is a feasible technique in selected patients; the results obtained are not as good as those of DP without MVR but are acceptable nonetheless. CLINICALTRIALS. GOV IDENTIFIER: NCT04317352.

Outcome quality standards for surgery of colorectal liver metastasis.

PURPOSE: Liver metastases are the most common malignant solid liver lesions, approximately 40% of which stem from colorectal tumors. Liver resection is currently the only curative treatment for colorectal cancer liver metastases (CRLM). However, there is a lack of consensus criteria to assess the results of this treatment. In order to evaluate the quality of surgical outcomes, it is necessary to identify quality indicators (QIs) and their corresponding quality standards (QS). We propose a simple method to determine QI and QS in CRLM surgery (CRLMS) and establish acceptable quality limits (AQL) for each QI. MATERIAL AND METHODS: A systematic review of CRLMS results published from 2006 to 2016. Clinical guidelines, consensus conferences, and publications related to the CRLMS were reviewed to identify and select QIs. Once selected, a new review of the papers including the results of at least one of the QIs was performed. Statistical process control (SPC) method was applied to calculate the QS and AQL of each QI. The limits of variability were established from mean and confidence intervals at 95% and 99.8%. RESULTS: The most relevant QIs and its AQLs were postoperative mortality (2%, < 4.5%), overall postoperative morbidity (33%, < 41%), liver failure (5%, < 8%), postoperative hemorrhage (1%, < 3%), biliary fistula (6%, < 10%), reoperation (3%, < 6%), R1 resection margins (18%, < 25%), and overall survival at 12 and 60 months (84%, > 77%; and 34%, > 25%, respectively). CONCLUSIONS: Despite its limitations, the present study constitutes the most extensive scientific evidence to date on QI and AQL in CRLMS and may constitute a reference in future studies.

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain.

INTRODUCTION: Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country.

INTRODUCCIÓN: Introducción: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. Métodos: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. Resultados: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95%: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95%: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95%: 7,6-13,3; rango, 2-33). Solo el 41,2% de los grupos utilizaban soporte nutricional antes de la cirugía (< 50% habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4% habían intentado administrar una dieta oral precoz, pero el 88,2% de los grupos usaron algún tipo de soporte nutricional y el 26,5% usaron NP en el 100% de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6% utilizaron NP siempre y NE en el 19,3% de los casos. Conclusiones: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4% de las unidades usan nutrición oral precoz y el 32,3% emplean la NE tras este tipo de cirugía. El 22,6% de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación.

Pautas simplificadas en el paciente portador de un hígado metastásico / Simplified guidelines in the patient with a metastatic liver

RESUMEN La presencia de metástasis hepática es frecuente en el momento del diagnóstico del tumor primario, o bien puede aparecer tiempo después de haber resecado el cáncer. La enfermedad metastásica anteriormente era considerada como inoperable, sin embargo, los adelantos en la cirugía, terapias adyuvantes y medicamentos quimioterapéuticos, han ofrecido nuevas esperanzas a estos pacientes. El diseño de protocolos, guías de atención y esquemas de seguimiento en estos enfermos ha sido un tema importante en los centros especializados, por lo que se propone plantear las principales pautas de actuación diagnóstica y terapéutica frente a enfermos portadores de un hígado metastásico, que de forma simplificada y orientativa pueda interpretarse y adecuarse a los pacientes afectos por esta dolencia, además, de ser factibles de interpretar y aplicar por profesionales de la salud pertenecientes a varias especialidades(AU)

ABSTRACT The presence of liver metastases is frequent at the time of diagnosis of the primary tumor, or it may appear sometime after the cancer has been resected. Metastatic disease was previously considered inoperable, however, advances in surgery, adjuvant therapies, and chemotherapeutic drugs have offered new hope for these patients. The design of protocols, care guides and monitoring schemes in these patients has been an important topic in specialized centers, so it is proposed to propose the main guidelines for diagnostic and therapeutic action against patients with metastatic liver, which in In a simplified and guiding way, it can be interpreted and adapted to the patients affected by this ailment, as well as being feasible to interpret and apply by health professionals belonging to various specialtiesAU)

Life-threating diarrhea and acute renal failure secondary to pancreatic VIPoma treated by surgery

Pancreatic neuroendocrine tumors represent less than 5% of all pancreatic tumors. They are a heterogeneous group of neoplasms with a diverse behavior and prognosis. Pancreatic vasoactive intestinal polypeptide tumor (VIPoma) is an exceptional tumor within this group due to its low incidence. The presence of pancreatic VIPoma should be clinically suspected in all patients with watery diarrhea, particularly when accompanied by a loss of potassium and bicarbonate and a pancreatic mass on imaging. There are other pathologies with similar symptoms; therefore, a correct differential diagnosis with an adequate treatment is essential for its management. We present the case of a 46-year-old patient who developed a prerenal kidney failure secondary to severe watery diarrhea after a diagnosis of pancreatic VIPoma. Thus, a resection was performed as the patient was rapidly deteriorating and required an intervention

No disponible

Life-threating diarrhea and acute renal failure secondary to pancreatic VIPoma treated by surgery.

Pancreatic neuroendocrine tumors represent less than 5% of all pancreatic tumors. They are a heterogeneous group of neoplasms with a diverse behavior and prognosis. Pancreatic vasoactive intestinal polypeptide tumor (VIPoma) is an exceptional tumor within this group due to its low incidence. The presence of pancreatic VIPoma should be clinically suspected in all patients with watery diarrhea, particularly when accompanied by a loss of potassium and bicarbonate and a pancreatic mass on imaging. There are other pathologies with similar symptoms; therefore, a correct differential diagnosis with an adequate treatment is essential for its management. We present the case of a 46-year-old patient who developed a prerenal kidney failure secondary to severe watery diarrhea after a diagnosis of pancreatic VIPoma. Thus, a resection was performed as the patient was rapidly deteriorating and required an intervention.

The fusion fascia of Fredet: an important embryological landmark for complete mesocolic excision and D3-lymphadenectomy in right colon cancer.

BACKGROUND: The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer. METHODS: First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital. RESULTS: The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120-380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9-39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4-20) days. Median follow-up time was 28 (16-41) months. Local and distal recurrence rate was 0. CONCLUSION: The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons.

Inicios de la cirugía pancreática oncológica en España. Un tributo a los pioneros / The origins of oncological pancreatic surgery in Spain. A tribute to pioneers

La duodenopancreatectomía cefálica (DPC) es una intervención quirúrgica muy compleja cuyo desarrollo tuvo lugar de forma muy lenta y en los centros de mayor prestigio del mundo. El objetivo de esta investigación es conocer quiénes fueron los cirujanos que realizaron las primeras DPC en España y las circunstancias en que se realizaron. En un contexto histórico caracterizado por la gran escasez de medios técnicos y económicos, como era España en los años 50 del siglo XX, las primeras DPC se llevan a cabo en Barcelona, en el Hospital de la Santa Creu i Sant Pau, donde se desarrolló una escuela de cirugía gastrointestinal liderada por cirujanos que se convirtieron en la punta de lanza de la cirugía española y referencias nacionales como fueron Pi-Figueras, Vicente Artigas, Soler-Roig y Antonio Llauradó. Casi de forma simultánea, en Oviedo, Luis Estrada introdujo también la DPC y la duodenopancreatectomía total tras un periodo de formación con los pioneros de la cirugía pancreática en Estados Unidos

Pancreaticoduodenectomy (PD) is a very complex operation. Its development took place very slowly at the most prestigious centers in the world. The aim of this investigation is to know who were the first surgeons to perform a PD in Spain as well as its historical circumstances. Despite all kinds of difficulties and very few resources, the first PD in Spain were carried out in Barcelona at the Hospital de la Santa Creu i Sant Pau where from the mid-50s a school of gastrointestinal surgery emerged with surgeons soon to become the spearhead of the Spanish surgery and a reference for the whole country: Pi-Figueras, Vicente Artigas, Antonio Soler-Roig and Antonio Llauradó. Almost simultaneously, in Oviedo, Luis Estrada also introduced the PD and total pancreaticoduodenectomy after a period of training with the pioneers of pancreatic surgery in the United States

The origins of oncological pancreatic surgery in Spain. A tribute to pioneers. / Inicios de la cirugía pancreática oncológica en España. Un tributo a los pioneros.

Pancreaticoduodenectomy (PD) is a very complex operation. Its development took place very slowly at the most prestigious centers in the world. The aim of this investigation is to know who were the first surgeons to perform a PD in Spain as well as its historical circumstances. Despite all kinds of difficulties and very few resources, the first PD in Spain were carried out in Barcelona at the Hospital de la Santa Creu i Sant Pau where from the mid-50s a school of gastrointestinal surgery emerged with surgeons soon to become the spearhead of the Spanish surgery and a reference for the whole country: Pi-Figueras, Vicente Artigas, Antonio Soler-Roig and Antonio Llauradó. Almost simultaneously, in Oviedo, Luis Estrada also introduced the PD and total pancreaticoduodenectomy after a period of training with the pioneers of pancreatic surgery in the United States.

Efficacy of hydrodynamic interleukin 10 gene transfer in human liver segments with interest in transplantation.

Different diseases lead, during their advanced stages, to chronic or acute liver failure, whose unique treatment consists in organ transplantation. The success of intervention is limited by host immune response and graft rejection. The use of immunosuppressant drugs generally improve organ transplantation, but they cannot completely solve the problem. Also, their management is delicate, especially during the early stages of treatment. Thus, new tools to set an efficient modulation of immune response are required. The local expression of interleukin (IL) 10 protein in transplanted livers mediated by hydrodynamic gene transfer could improve the organ acceptance by the host because it presents the natural ability to modulate the immune response at different levels. In the organ transplantation scenario, IL10 has already demonstrated positive effects on graft tolerance. Hydrodynamic gene transfer has been proven to be safe and therapeutically efficient in animal models and could be easily moved to the clinic. In the present work, we evaluated efficacy of human IL10 gene transfer in human liver segments and the tissue natural barriers for gene entry into the cell, employing gold nanoparticles. In conclusion, the present work shows for the first time that hydrodynamic IL10 gene transfer to human liver segments ex vivo efficiently delivers a human gene into the cells. Indexes of tissue protein expression achieved could mediate local pharmacological effects with interest in controlling the immune response triggered after liver transplantation. On the other hand, the ultrastructural study suggests that the solubilized plasmid could access the hepatocyte in a passive manner mediated by the hydric flow and that an active mechanism of transportation could facilitate its entry into the nucleus. Liver Transplantation 23:50-62 2017 AASLD.

Pancreatectomía córporo-caudal con resección del tronco celíaco por adenocarcinoma de cuerpo pancreático: intervención de Appleby modificada / Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: the modified Appleby procedure

La resección oncológica completa es el único procedimiento que permite la sobrevida a largo plazo en cáncer de páncreas. La afectación de la arteria hepática, tronco celíaco o arteria mesentérica superior constituyen una contraindicación quirúrgica porque se asocia a mal pronóstico y por las dificultades técnicas que implica conseguir la resección oncológica completa. Solo un grupo seleccionado de pacientes con buena respuesta a la quimioterapia y pasibles de resección R0 se benefician de la cirugía de resección del tronco celíaco. A partir de un caso clínico de un adenocarcinoma de páncreas con infiltración de la arteria hepática común y tronco celíaco que tras una buena respuesta a la neoadyuvancia y embolización de la arteria hepática común fue sometido a una esplenopancreatectomía córporo-caudal con resección del tronco celíaco, se realiza una revisión de la literatura sobre el tema y sus aspectos técnicos relevantes. El análisis realizado permite sugerir que en casos debidamente seleccionados la pancreatectomía córporo-caudal con resección del tronco celíaco en bloque es un procedimiento factible, seguro, y con buenos resultados quirúrgicos y oncológicos. En condiciones de respuesta a la quimioterapia neoadyuvante y experiencia del equipo quirúrgico pareciera que esta cirugía podría mejorar el pronóstico y calidad de vida de estos enfermos.

Abstract Complete oncologic resection is the only procedure that enables survival in pancreatic cancer. Compromise of the liver artery, the celiac artery or the superior mesenteric artery constitute a surgical contraidication since it is associated to a bad prognosis and it is technically hard to achieve a complete surgical resection. Only a selected group of patients who respond well to chemotherapy and may be subject to resection benefit from celiac artery resection surgery. A clinical case of adenocarcinoma of the pancreas with infiltration of the common liver artery and the celiac artery underwent a corporeo-caudal pancreatosplenectomy with celiac artery resection after a good response to neoadjuvant therapy and hepatic arterial embolization. Based on this, a review of literature on this issue and its relevant technical aspects was conducted. The analysis performed may suggest that in duly selected cases, corporeo-caudal pancreatosplenectomy with bloc celiac artery resection is a feasible and safe procedure with good surgical and oncologic results. Upon good response to neoadjuvant chemotherapy and an experienced surgical team, this surgery seems to improve prognosis and the quality of life of these patients.

Resumo A ressecção oncológica completa é o único procedimento que permite uma sobrevida em longo prazo a pacientes com câncer de pâncreas. O comprometimento da artéria hepática, tronco celíaco ou artéria mesentérica superior é uma contraindicação cirúrgica porque está associado a um prognóstico ruim e, devido às dificuldades técnicas que implica conseguir a ressecção oncológica completa. Somente um grupo selecionado de pacientes com boa resposta à quimioterapia e que possa ser submetido à ressecção R.0 pode se beneficiar da cirurgia de ressecção do tronco celíaco. A partir de um caso clínico de um adenocarcinoma de pâncreas com infiltração da artéria hepática comum e do tronco celíaco, que depois de apresentar boa resposta à quimioterapia e a embolização da artéria hepática comum, foi submetido a uma esplenopancreatectomia corpo-caudal com ressecção do tronco celíaco, realizou-se uma revisão da literatura sobre o tema e seus aspectos técnicos relevantes. A análise realizada permite sugerir que nos casos devidamente selecionados, a pancreatectomia corpo-caudal com ressecção em bloco do tronco celíaco é um procedimento factível, seguro, com bons resultados cirúrgicos e oncológicos. Quando se reúnem as condições de resposta adequada à quimioterapia neoadjuvante e a experiência da equipe de cirurgia, pareceria que esta intervenção poderia melhorar o prognóstico e a qualidade de vida destes pacientes.

Síndrome del ducto pancreático desconectado: transección completa del páncreas secundaria a pancreatitis aguda / Disconnected pancreatic duct syndrome: complete pancreas transection secondary to acute pancreatitis

No disponible

Disconnected pancreatic duct syndrome: complete pancreas transection secondary to acute pancreatitis.

Disconnected pancreatic duct syndrome is a serious complication of acute pancreatitis which is defined by a complete discontinuity of the pancreatic duct, such that a viable side of the pancreas remains isolated from the gastrointestinal tract. This pancreatic disruption is infrequently observed in the clinical practice and its diagnostic and therapeutic management are controversial. We present an extreme case of disconnected pancreatic duct syndrome with complete duct disruption and pancreatic transection following acute pancreatitis, as well as the diagnostic and therapeutic processes carried out.

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.

Pathology handling of pancreatoduodenectomy specimens: Approaches and controversies.

Pancreatic cancer, with a 5% 5-year survival rate, is the fourth leading cause of cancer death in Western countries. Unfortunately, only 20% of all patients benefit from surgical treatment. The need to prolong survival has prompted pathologists to develop improved protocols to evaluate pancreatic specimens and their surgical margins. Hopefully, the new protocols will provide clinicians with more powerful prognostic indicators and accurate information to guide their therapeutic decisions. Despite the availability of several guidelines for the handling and pathology reporting of duodenopancreatectomy specimens and their continual updating by expert pathologists, there is no consensus on basic issues such as surgical margins or the definition of incomplete excision (R1) of pancreatic ductal adenocarcinoma. This article reviews the problems and controversies that dealing with duodenopancreatectomy specimens pose to pathologists, the various terms used to define resection margins or infiltration, and reports. After reviewing the literature, including previous guidelines and based on our own experience, we present our protocol for the pathology handling of duodenopancreatectomy specimens.

Hepatocolangiocarcinoma combinado. Claves para su diagnóstico anatomopatológico / Keys to the histopathological diagnosis of combined hepatocellular-cholangiocarcinoma

El hepatocolangiocarcinoma combinado (HCC) es un tumor primario hepático poco frecuente. Se caracteriza por mostrar elementos inequívocos tanto de hepatocarcinoma (HC) como de colangiocarcinoma (CC), íntimamente relacionados entre sí. Presentamos 2 casos clínicos recientes, en los que el diagnóstico preoperatorio fue de CC en el caso 1 y de HC en el caso 2. Tras la resección quirúrgica el estudio histológico en ambos casos mostró un doble componente de hepatocarcinoma y colangiocarcinoma. Además, en el caso 2 existían áreas donde las células se hacían más indiferenciadas y expresaban marcadores de célula madre. La clasificación histológica de este tipo de tumores ha estado sometida a revisión recientemente y sería conveniente disponer de unas claves diagnósticas anatomopatológicas. En el presente trabajo se realiza una revisión de la literatura y se analizan lo que se consideran claves diagnósticas(AU)

Combined hepatocellular-cholangiocarcinoma is a rare primary hepatic tumour, characterized by unmistakable, intimately mixed elements of both hepatocellular carcinoma and cholangiocarcinoma. We report 2 cases in which the preoperative diagnosis was cholangiocarcinoma (case 1) and hepatocellular carcinoma (case 2). However, the microscopy of the surgical specimen revealed components of typical hepatocellular carcinoma as well as cholangiocarcinoma in both cases. Moreover, case 2 showed areas of undifferentiated cells expressing stem cell markers. As the classification of these tumours has recently changed, histopathological keys for their correct diagnosis would prove helpful. To this end, we have reviewed the pertinent literature in search of such diagnostic aids(AU)

Foregut cystic malformations in the pancreas. Are definitions clearly established?

CONTEXT: Foregut cystic malformations are common lesions in the mediastinum but are rarely found in subdiaphragmatic locations. Only a few cases have been described within the pancreas where they can easily be misdiagnosed as cystic neoplasms. CASE REPORT: We herein present the case of a 37-year-old female with acute cholangitis in whom a diagnostic work-up revealed a 1 cm solid-cystic heterogeneous lesion located at the head of the pancreas. The patient underwent a pancreaticoduodenectomy. Pathological evaluation demonstrated a cystic cavity lined by pseudostratified tall columnar ciliated epithelium with goblet cells, but lacking cartilage or smooth muscle bundles. Thus, the final diagnosis of the lesion was a ciliated foregut cyst of the pancreas. CONCLUSIONS: A review of the cases published regarding these lesions shows great variability in the taxonomy and a lack of accuracy in the definitions of each different subtype. An easy to use algorithm for the diagnosis of foregut cystic malformations subtypes, based on epithelial lining and wall features, is presented.