[Survival of patients with pancreatic ductal adenocarcinoma]. / Sobrevida del adenocarcinoma ductal de páncreas.

OBJECTIVE: The objective of this study is to analyze the epidemiological presentation and survival of patients with pancreatic ductal adenocarcinoma according to their clinical stage and the type of intervention performed, in a cohort of patients treated at a clinic in Lima, Peru. MATERIALS AND METHODS: A retrospective cohort study evaluated patients diagnosed with pancreatic ductal adenocarcinoma from January 2015 to February 2021, considering various epidemiological factors, radiological findings, oncological staging, receipt of neoadjuvant or adjuvant chemotherapy, undergoing surgery, and post-intervention survival. RESULTS: Out of the 249 patients analyzed, 75 of them required resective surgery. Among the main findings, it was observed that those with a CA 19-9 level below 200 U/mL had a higher median survival compared to those with a CA 19-9 level above 200 U/mL (HR: 1.96; 95% CI: 0.18-0.53; p≤0.001). Furthermore, when comparing patients according to their stage, those with resectable tumors had a median survival of 37.72 months, while those with locally advanced tumors had a median survival of 13.47 months, and those with metastatic tumors had a median survival of 7.69 months (HR: 0.87; 95% CI: 0.31-0.25; p≤0.001). Additionally, receiving neoadjuvant treatment was associated with a better prognosis of survival for patients (HR: 0.32; 95% CI: 0.19-0.53; p≤0.001). Furthermore, 5 pancreatectomies with metastatic resection were performed in oligometastatic patients treated with salvage chemotherapy, and the median survival for these patients was 22.51 months. CONCLUSION: Resective surgery at an early clinical stage, CA 19-9 levels below 200 U/mL, and receiving neoadjuvant chemotherapy are statistically correlated with a higher overall survival.

[Performance and prognosis assessment of the solid pseudopapillary tumors of the pancreas]. / Evaluación del comportamiento y pronóstico de los tumores sólidos pseudopapilares del pancreas.

INTRODUCTION: Solid pseudopapillary tumors (SPT) of the pancreas are rare neoplasms of low malignant potential that typically affect young women. These are slow-growing lesions and very often reach large size. RESULTS: Between June 2003 and July 2013 24 patients were submitted to surgery. Twenty three (96%) were females with a median age of 32.4 ± 13.2 years old (range 11 to 69 years old). The mean tumor size was 91.3 ± 49 mm (range 30 to 200 mm). The type of procedure performed was duodenopancreatectomy in 9 cases, middle pancreatectomy in 4, distal pancreatectomy in 8, duodenum preserving pancreatectomy in 2 and diagnostic laparoscopy in 1. SPT had a benign anatomopathology and behaviour in 17 cases, while 3 had a carcinoma pattern and 4 developed distant metastases. Median follow up was 58 months (range 5 to 128 months). Recurrence occurred in 4 patients (16.6%) as liver metastases in 2 and carcinomatosis in 2. The overall survival rate at 5 and 10 years was 94% and 63%, respectively. CONCLUSION. SPT are uncommon neoplasms which are mostly benign. However, up to 20% may display a malignant behavior. More studies are needed to investigate predicting factors of malignant potential. The overall survival is high, even after resection of metastases.

[Clinicopathologic characteristics of the pancreatic cystic tumors]. / Características clínico patológicas de los tumores quísticos del páncreas.

UNLABELLED: Formerly an infrequent pathology, pancreatic cystic tumors stand nowadays for 25% of all pancreatic surgical diseases. OBJECTIVE: Evaluate the frequency of the presentation of each type and the behavior of the pancreatic cystic tumors that went to surgery in our unit. MATERIALS AND METHODS: In our Pancreas Unit, 708 patients with pancreatic tumors underwent surgery in the period between October 2002 and December 2013. 146 cases of pancreatic cystic tumors taken from that group are the topic of the present study. RESULTS: Even when diagnosing pancreatic tumors as cystic tumors was possible in 91% of cases during pre-op evaluation, categorizing the type of cystic tumor was only possible in 73% of cases. In 128 cases (88%), cystic tumors were removable. Due to advanced disease, in 3 cases only diversion surgery was possible and, in 15 cases, exploration and biopsy was the only choice. When the frequency of malignancy was assessed for all four types of pancreatic cystic tumors, the one most frequently becoming malignant was mucinous papillary intraductal (53%), followed by mucinous cystic (50%). Solid pseudopapillary pancreatic cystic tumors became malignant in 29% of cases and for serous cystoadenoma the frequency of malignancy was nihil. CONCLUSIONS: Cystic tumors are the most frequent type of pancreatic lesion. It's of paramount importance to categotize them since risk of malignancy can be as high as 52% in case of mucinous intraductal papillary type.

[Impact of duodenopancreatectomy in elder patients]. / Impacto de la duodenopancreatectomía en los pacientes adultos mayores.

UNLABELLED: The incidence of periampullary neoplasms substantially increases with age. If we take into account that this incidence is higher in the elder patient and that life expectancy is nowadays longer, questioning surgical approach in this group of patients turns out to be controversial. OBJECTIVE: [corrected] Asses if in the elder patients the duodenopancreatectomy has a higher mortality and complications. MATERIALS AND METHODS: A retrospective study including patients who underwent duodenopancreatectomy between October 2002 and June 2012 was undertaken to assess whether the elder ones had a higher morbidity and mortality after surgery. Patients were distributed in two groups according to age. The first group included 240 patients younger than 75 years, and the second one included 74 patients older than 75 years. There wasn't NO significant difference in morbidity between the two groups. RESULTS: General mortality for the whole series was 4%. The first group had a 2.9% mortality whereas in the second one mortality reached 4.9%, a significant difference. However, when we changed the reference age from 75 years to 65 or 70 years the difference was not significant any more. CONCLUSION: From this study we can ascertain that an age more than 75 years significantly increases the mortality risk in duodenopancreatectomy patients. This age, however, doesn't proscribe surgical approach, since surgery is the only choice for curative treatment in patients with this type of cancer.

[Is Peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours?]. / ¿Es la anastomosis pancreato yeyunal de Peng más efectiva que la anastomosis muco-mucosa en la duodenopancreatectomía por neoplasias de páncreas y periampulares?

INTRODUCTION: The pancreatic fistula is the most feared complication after a duodenopancreatectomy, and is the most common independent factor of post-surgical mortality. Peng et al. recently published a pancreaticojejunal anastomosis technique (binding anastomosis) which showed 0% pancreatic fistulas. The objective of this study is to evaluate and validate this new anastomosis technique compared with the conventional pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis. MATERIAL AND METHOD: A prospective, non-randomised study was conducted to evaluate and validate this new anastomosis technique compared with the conventional pancreaticojejunal terminolateral duct to mucosa anastomosis. The study included 63 patients who were subjected to a duodenopancreatectomy due to having a pancreatic or periampullary neoplasm. A binding pancreaticojejunostomy according to the technique described by Peng et al. was performed on 30 patients (Group A), and a pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis (conventional technique) was performed on 33 patients (Group B). RESULTS: When the results of the 2 techniques were compared, 2/30 (6%) of patients had a pancreatic fistula with the Peng technique, and 4/33 (12%) with the conventional technique, but this was not statistically significant (P=.674). Nor were there any significant differences between the 2 groups on comparing, morbidity, hospital stay and mortality. CONCLUSION: The results of this study show that the anastomosis method described by Peng is safe, but is not associated with a lower frequency of pancreatic fistula, general morbidity, or mortality. This leads to the uncertainty of whether it really has any advantages over other techniques.

[Evaluation and validation of surgical indications in acute pancreatitis with necrosis, at the National Hospital Edgardo Rebagliati Martins]. / Evaluación y validación de las indicaciones quirúrgicas en la pancreatitis aguda con necrosis, en el Hospital Nacional Edgardo Rebagliati Martins.

OBJECTIVE: The purpose of this study is to evaluate efficacy of the surgical indications in acute pancreatitis. MATERIAL AND METHODS: During the period from May 2000 to June 2009, 107 operated patients with pancreatic necrosis were treated in the Severe Acute Pancreatitis Unit of the HNERM a comparison was made by separating the patients in two groups according to the surgical indication. An analysis was carried out in order to evaluate which type of surgical indication has the best results according to age, severity of the case, return to oral intake, hospital stay, complications and mortality. RESULTS: On evaluating the indication by positive puncture for detecting necrosis infection we found that 89% of the patients operated due to this indication showed infected necrosis while those operated due to the indication of "sepsis without response to the ICU treatment" only reached 51%. Surgical complications and re operations, was higher among the patients whose indication was "sepsis without response to the ICU treatment" (Indication B) in comparison with positive FNA. (Indication A) CONCLUSION: Positive fine needle aspiration is the surgical indication par excellence in acute pancreatitis with necrosis. We consider that the indication of "sepsis that do not respond for more than 72 hours to treatment in the ICU regardless that negative FNA" should not be taken into account, due to the very high percentage of sterile necrosis found at the time of surgery.

[Is the prophylactic antibiotic therapy with Imipenem effective for patients with pancreatic necrosis?]. / Es la antibióticoterapia profiláctica con Imipenem efectiva en los pacientes con necrosis pancreática?

OBJECTIVE: to evaluate the capacity of Imipenem as a prophylactic treatment for decreasing the number of infected necrosis and surgeries, as well as for diminishing septic complications and the mortality rate among patients with severe acute necrotizing pancreatitis. MATERIAL AND METHODS: from May 2005 to December 2007 a prospective randomized study was conducted in order to evaluate the efficacy of a prophylactic antibiotic therapy in patients with pancreatic necrosis. During this time period 58 patients entered the study protocol. Patients were divided in two groups; the first one underwent antibiotic therapy with Imipenem while the second group received no prophylactic treatment at all. All patients received early enteral nutrition. RESULTS: both studied groups had comparable age, gender ratio, and C.R.P and necrosis percentages. When comparing general morbidity in both groups no difference was found between the group receiving a prophylactic antibiotic and the group that did not receive it (58% vs. 56%). Moreover, when the septic complications were evaluated, it was confirmed that these were more frequent among the group of patients receiving Imipenem (29%), in comparison to the group that did not received antibiotics (15%). 12.5% of the patients that received Imipenem developed pancreatic necrosis infection, while said infection only appeared in 6% of the patients in the group that did not receive antibiotic prophylaxis; nevertheless, none of the comparisons reached statistical significance. The number of patients who required surgery was similar in both groups. When comparing the hospital stay, it was observed that this was longer among the patients receiving prophylactic therapy. No patient died during the study. CONCLUSION: The present study finds no benefits in the use of antibiotic therapy with Imipenem regarding the risk of developing pancreatic necrosis infection and septic complications, and neither when trying to reduce the number of surgeries among patients with severe acute pancreatitis with necrosis.

Sobrevida del adenocarcinoma ductal de páncreas

El objetivo de este trabajo es analizar la presentación epidemiológica y la sobrevida de los pacientes con adenocarcinoma ductal de páncreas de acuerdo con su estadío clínico y al tipo de intervención realizada, en una cohorte de pacientes atendidos en una clínica en Lima, Perú. Estudio de cohortes retrospectivas que evaluó desde enero del 2015 a febrero del 2021 a pacientes con diagnóstico de adenocarcinoma ductal de páncreas considerando diversos factores epidemiológicos, radiológicos, estadiaje oncológico, haber recibido quimioterapia neoadyuvante o adyuvante, haber sido sometidos a cirugía y la sobrevida posterior a alguna de las intervenciones realizadas. De los 249 pacientes analizados, se encontró que 75 de ellos requerían cirugía resectiva. Entre los principales resultados obtenidos, se observó que aquellos con un nivel de CA 19-9 menor a 200 U/mL presentaban una media de sobrevida más alta en comparación con aquellos cuyo nivel de CA 19-9 era superior a 200 U/mL (HR: 1,96; IC95%: 0,18-0,53; p≤0,001). Asimismo, al comparar a los pacientes según su etapa, se encontró que aquellos con tumores resecables tenían una media de sobrevida de 37,72 meses, mientras que aquellos con tumores localmente avanzados tenían una media de sobrevida de 13,47 meses y aquellos con tumores metastásicos tenían una media de sobrevida de 7,69 meses (HR: 0,87; IC95%: 0,31-0,25; p≤0,001). Igualmente, se observó que recibir tratamiento neoadyuvante se asociaba con un mejor pronóstico de sobrevida para los pacientes (HR: 0,32; IC95%: 0,19-0,53; p≤0,001). Asimismo, se llevaron a cabo 5 pancreatectomías con resección metastásica en pacientes oligometastásicos tratados con quimioterapia de rescate, y se encontró que la media de sobrevida para estos pacientes fue de 22,51 meses. Conclusión: La cirugía resectiva en un estadío clínico temprano , presentar valores de CA 19-9 por debajo de 200 U/mL y haber recibido quimioterapia neoadyuvante se correlaciona estadísticamente con una mayor esperanza de sobrevida.

The objective of this study is to analyze the epidemiological presentation and survival of patients with pancreatic ductal adenocarcinoma according to their clinical stage and the type of intervention performed, in a cohort of patients treated at a clinic in Lima, Peru. A retrospective cohort study evaluated patients diagnosed with pancreatic ductal adenocarcinoma from January 2015 to February 2021, considering various epidemiological factors, radiological findings, oncological staging, receipt of neoadjuvant or adjuvant chemotherapy, undergoing surgery, and post-intervention survival. Out of the 249 patients analyzed, 75 of them required resective surgery. Among the main findings, it was observed that those with a CA 19-9 level below 200 U/mL had a higher median survival compared to those with a CA 19-9 level above 200 U/mL (HR: 1.96; 95% CI: 0.18-0.53; p≤0.001). Furthermore, when comparing patients according to their stage, those with resectable tumors had a median survival of 37.72 months, while those with locally advanced tumors had a median survival of 13.47 months, and those with metastatic tumors had a median survival of 7.69 months (HR: 0.87; 95% CI: 0.31-0.25; p≤0.001). Additionally, receiving neoadjuvant treatment was associated with a better prognosis of survival for patients (HR: 0.32; 95% CI: 0.19-0.53; p≤0.001). Furthermore, 5 pancreatectomies with metastatic resection were performed in oligometastatic patients treated with salvage chemotherapy, and the median survival for these patients was 22.51 months. Conclusion: Resective surgery at an early clinical stage, CA 19-9 levels below 200 U/mL, and receiving neoadjuvant chemotherapy are statistically correlated with a higher overall survival.

Medical versus surgical management for emphysematous pancreatic necrosis: is gas within pancreatic necrosis an absolute indication for surgery?

OBJECTIVES: The aim of this study was to evaluate whether pancreatic necrosis with presence of gas is an absolute indication for surgery or if there is a possibility for the medical management of this pathology. METHODS: This study is a retrospective study including 56 patients with diagnosis of pancreatic necrosis and gas on computed tomography from April 2003 to March 2011. We recorded all the factors related to each group of treatment, including APACHE II score, C-reactive protein level, Tomographic Severity Index, organ and multiorgan failure, and infected necrosis after fine-needle puncture, to evaluate the differences between surgical and medical treatment. RESULTS: Thirty-six (64%) of these patients were submitted to surgery, whereas 20 (36%) were managed conservatively. Twenty-eight patients (78%) who underwent surgery had infected necrosis. Thirty-five percent of the patients (7 patients) in the medical group had organ failure versus 83% of the patients in the surgical group. CONCLUSIONS: Pancreatic necrosis with gas on computed tomography is a relative indication for surgery. Medical management is a feasible and safe possibility for this pathology in selected cases. The presence of organ failure and infected necrosis often precludes a surgical treatment.

Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients.

HYPOTHESIS: Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas. DESIGN: Retrospective case series of patients with pancreatic cystic lesions. SETTING: University-affiliated tertiary care referral center. PATIENTS: Two hundred twelve patients with pancreatic cystic lesions seen in our surgical practice during 5 years (April 1997-March 2002). MAIN OUTCOME MEASURES: Presence or absence of symptoms, cyst size and location, cytologic or pathologic diagnosis, surgical treatment, and outcome. RESULTS: Seventy-eight (36.7%) of 212 patients were asymptomatic. Incidental cysts were smaller (3.3 +/- 1.9 vs 4.6 +/- 2.7 cm; P<.001) and were found in older patients (65 +/- 13 vs 56 +/- 15 years; P<.001). Seventy-eight percent of the asymptomatic patients and 87% of those with symptoms underwent surgery, with a single operative death in the entire group (0.5%). Seventeen percent of asymptomatic cysts were serous cystadenomas; 28%, mucinous cystic neoplasms; 27%, intraductal papillary mucinous neoplasms; and 2.5%, ductal adenocarcinomas. The respective numbers for symptomatic cysts were 7%, 16%, 40%, and 9%. Ten percent of asymptomatic patients had a variety of other cystic lesions, and in 12%, no definitive cytologic or pathologic diagnosis was obtained. Overall, 17% of asymptomatic patients had in situ or invasive cancer, and 42% had a premalignant lesion. When evaluated as a function of size, only 1 (3.5%) of 28 asymptomatic cysts smaller than 2 cm had cancer compared with 13 (26%) of 50 cysts larger than 2 cm (P =.04). The proportion of premalignant lesions, however, remained high in both groups (46% and 38%, respectively). Pseudocysts comprised only 3.8% of asymptomatic cysts compared with 19.4% of symptomatic cysts (P =.003). CONCLUSIONS: Incidental pancreatic cysts are common, occur in older patients, are smaller than symptomatic cysts, and are unlikely to be pseudocysts. More than half of them are either malignant or premalignant lesions and therefore cannot be dismissed.

[Necrotic acute pancreatitis in the intensive care unit: a comparison between conservative and surgical medical treatment]. / Pancreatitis Aguda Necrótica en la Unidad de Cuidados Intensivos: Una Comparación entre el Tratamiento Médico Conservador y Quirúrgico.

OBJECTIVE: To determine the prognosis of patients with necrotic acute pancreatitis receiving medical and surgical treatments. SUMMARY: The severe acute pancreatitis treatment is multidisciplinary and requires a daily evaluation of the patient that will allow to observe changes and apply therapy in due time. The treatment includes: Admission in the ICU, fluids, nutrition and antibiotics, as well as other life supports for high-risk patients. Thus, patients undergo conservative treatment or, if it is necessary, surgery. METHODS: A retrospective study of patients with necrotic acute pancreatitis admitted to the ICU between January 2004 and August 2006. The patients with necrotic acute pancreatitis without signs of sepsis underwent a conservative medical treatment, while fine needle punction-aspiration was performed in all patients who were suffering from necrotic acute pancreatitis and persistent sepsis four weeks after their admission and after discarding and eradicating every non-pancreatic focus of infection. All Gram stain or culture positive patients underwent surgery immediately. RESULTS: Seventy patients with necrotic acute pancreatitis were included in the study. Thirty-six patients (51%) suffered acute pancreatitis with sterile necrosis and underwent a conservative treatment, while 34 patients (49%) developed acute pancreatic with infected necrosis and underwent surgery. The average age was 55.19 vs. 57.65 (p=0.57). The average amylase was 1421.74 vs. 1402.45. (p=0.96). The tomography severity index was 8.47 vs. 8.79 (p=0.36). The Apache II was 8.22 vs. 9 (p=0.46). The average number of failed organs was 0.39 vs. 0.68. (p=0.19). The ICU stay was 10.75 vs. 26.5 days (p<0.05) while the total hospital stay was 46.47 vs. 57.26 days (p<0.05). The mortality rate was (3/36) 8.3% vs. (9/34) 26.5% (p<0.05) for conservative medical treatment vs. surgical treatment, respectively. Between the first and the twelfth month the evaluated patients who attended consultation, after discharge, showed: pancreatic pseudocyst 9/36 (25%) vs. 8/34(23.5%); recurring abdominal pain 3/36 (8.3%) vs. 4/34 (11.8%); and relapsing acute pancreatitis 3/36 (8.3%) vs. 2/34 (5.8%); while 4/36 (11.1%) vs. 3/34 (8.8%) did not show any problem. There were not significant differences between the conservative and the surgical medical treatment, respectively. CONCLUSIONS: Patients suffering acute pancreatitis with sterile necrosis can undergo conservative medical treatment which will result in a lower mortality rate, while the hospital stay, in comparison with acute pancreatitis with infected necrosis, will not be affected.

Características clínico patológicas de los tumores quísticos del páncreas / Clinicopathologic characteristics of the pancreatic cystic tumors

Los tumores quísticos del páncreas han pasado de ser una entidad poco frecuente a representar hasta el 25% de la patología quirúrgica de este órgano. Objetivo: Evaluar la frecuencia de presentación de cada variedad y el comportamiento de los tumores quísticos de páncreas operados en nuestra unidad. Materiales y métodos: Durante el período comprendido entre octubre de 2002 y diciembre de 2013 en la Unidad de Páncreas han sido operados 708 pacientes con tumores de páncreas, de los cuales se analizan 146 casos de tumores quísticos. Resultados: El diagnóstico preoperatorio de tumor quístico se realizó en el 91% de los casos, sin embargo solo fue posible identificar de qué tipo de tumor quístico se trataba en el 73%. En 128 (88%) casos se pudo resecar el tumor quístico, mientras en 3 pacientes se realizó una cirugía derivativa y en 15 se efectuaron una exploración y biopsia por tratarse de casos avanzados con extensión de la enfermedad. Al evaluar el comportamiento en lo que respecta a la malignidad de cada uno de los cuatro tipos de tumores quísticos, observamos que el que presentaba mayor incidencia de cáncer en la serie fue el intraductal papilar mucinoso con 53%, seguido de las neoplasias mucinosas quísticas con 50% en tanto que el sólido pseudopapilar presentó 29% de degeneración maligna, no existiendo ningún caso de cistoadenocarcinoma seroso con cáncer. Conclusiones: Los tumores quísticos son lesiones frecuentemente encontradas en el páncreas. Es muy importante diferenciar cada uno de ellos debido a que presentan un alto potencial de malignidad, el cual puede llegar hasta 53% como es el caso del intraductal papilar mucinoso...

Formerly an infrequent pathology, pancreatic cystic tumors stand nowadays for 25% of all pancreatic surgical diseases. Objective: Evaluate the frequency of the presentation of each type and the behavior of the pancreatic cystic tumors that went to surgery in our unit. Materials and methods: In our Pancreas Unit, 708 patients with pancreatic tumors underwent surgery in the period between October 2002 and December 2013. 146 cases of pancreatic cystic tumors taken from that group are the topic of the present study. Results: Even when diagnosing pancreatic tumors as cystic tumors was possible in 91% of cases during pre-op evaluation, categorizing the type of cystic tumor was only possible in 73% of cases. In 128 cases (88%), cystic tumors were removable. Due to advanced disease, in 3 cases only diversion surgery was possible and, in 15 cases, exploration and biopsy was the only choice. When the frequency of malignancy was assessed for all four types of pancreatic cystic tumors, the one most frequently becoming malignant was mucinous papillary intraductal (53%), followed by mucinous cystic (50%). Solid pseudopapillary pancreatic cystic tumors became malignant in 29% of cases and for serous cystoadenoma the frequency of malignancy was nihil. Conclusions: Cystic tumors are the most frequent type of pancreatic lesion. ItÆs of paramount importance to categotize them since risk of malignancy can be as high as 52% in case of mucinous intraductal papillary type...

[Evaluation of conditioning factors of morbimortality in duodenopacreatectomy in periampullary neoplasms]. / Evaluación de los factores condicionantes de morbi-mortalidad en la duodenopancreatectomía por neoplasias periampulares.

OBJECTIVE: The purpose of this study is to define the factors that condition complications and mortality in a group of 119 patients with periampullary neoplasms operated on at a general hospital. MATERIALS AND METHOD: Between October 2002 and December 2006, 119 patients who were diagnosed with periampullary neoplasms and underwent a pancreatoduodenectomy at Rebagliati Hospital were evaluated. RESULTS: Age and sex were not conditioning factors of complications. A significant difference in the type of pancreatic anastomosis used was noticed, whereby telescoping was a conditioning factor of complication (p<0.009) compared with mucous-mucous anastomosis.After analyzing the bleeding associated with each complication, a significant connection was established between the greatest bleeding volume obtained in the operating room with the development of pancreatic fistulas (p<0.03), re-operation (p<0.01), abscesses (p<0.006) and intestinal fistulas (p<0.001).The complications related to mortality in patients who underwent a pancreatoduodenectomy (PD) were evaluated. It was observed that pancreatic fistulas (p<0.003), intestinal fistulas (p<0.003) and gallbladder fistulas (p<0.03), intra-abdominal hemorrhaging and bleeding during a standard operating procedure (SOP), transfusions and re-operations were factors that increased mortality significantly. When the surgeon was evaluated as a factor of morbimortality, it was proven that there was a connection between the surgical volume and the incidence of complications and mortality.There was a shorter hospital stay, a lower incidence of intra-operative bleeding and lower morbimortality in the high surgical volume group. CONCLUSIONS: The most-feared complications, since they are directly related to mortality, are intestinal fistulas, intra-abdominal hemorrhaging, intra-abdominal abscesses, gallbladder fistulas and the need to undergo repeated operations. Both complications and mortality are directly related to the surgeon factor, which, according to our analysis is the most important factor in decreasing costs, morbidity and mortality in this type of surgery.

Impacto de la duodenopancreatectomía en los pacientes adultos mayores / Impact of duodenopancreatectomy in elder patients

La incidencia de las neoplasias peri ampulares se incrementa sustancialmente con la edad, teniendo en cuenta que la incidencia de estas neoplasias se presenta mucho más en pacientes mayores y que la expectativa de vida cada vez es más alta es muy difícil cuestionar la cirugía en este grupo de pacientes. Objetivo: Evaluar la conveniencia de realizar una duodenopancreatectomía en los pacientes adultos mayores y si ésta presenta mayores complicaciones y mortalidad en este grupo de pacientes. Materiales y métodos: Durante el periodo comprendido entre octubre del 2002 hasta junio del 2012 se realizó un estudio retrospectivo en 314 pacientes sometidos a una duodenopancreatectomía para evaluar si los pacientes ancianos presentaban una mayor morbilidad y mortalidad luego de esta cirugía. Se distribuyó a los pacientes en dos grupos de acuerdo a la edad. En el primero se incluyeron a 240 pacientes que eran menores de 75 años y en el segundo se incluyeron a 74 pacientes mayores de 75 años. No existió diferencia significativa en la morbilidad de los dos grupos. Resultados: La mortalidad general en toda la serie fue de 4%. En el primer grupo la mortalidad fue de 2,9% mientras que en el segundo grupo subió a 9,4% ,siendo esta diferencia significativa. Sin embargo, cuando redujimos la edad de comparación a 65 años y a 70 años pudimos comprobar que la diferencia ya no fue significativa. Conclusion: Luego de este estudio podemos afirmar que la edad mayor de 75 años aumenta el riesgo de mortalidad de manera significativa en los pacientes sometidos a una duodenopancreatectomía, pero no contraindica la cirugía ya que es la única opción para tratar de curar a una paciente con este tipo de cáncer.

The incidence of periampullary neoplasms substantially increases with age. If we take into account that this incidence is higher in the elder patient and that life expectancy is nowadays longer, questioning surgical approach in this group of patients turns out to be controversial. Objetive: Asses if in the elder patients the duodenopancreatectomy has a higher mortality and complications. Materials and methods: A retrospective study including patients who underwent duodenopancreatectomy between October 2002 and June 2012 was undertaken to assess whether the elder ones had a higher morbidity and mortality after surgery. Patients were distributed in two groups according to age. The first group included 240 patients younger than 75 years, and the second one included 74 patients older than 75 years. There wasn't NO significant difference in morbidity between the two groups. Results: General mortality for the whole series was 4%. The first group had a 2.9% mortality whereas in the second one mortality reached 4.9%, a significant difference. However, when we changed the reference age from 75 years to 65 or 70 years the difference was not significant any more. Conclusion: From this study we can ascertain that an age more than 75 years significantly increases the mortality risk in duodenopancreatectomy patients. This age, however, doesn't proscribe surgical approach, since surgery is the only choice for curative treatment in patients with this type of cancer.

Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients.

OBJECTIVE: To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis. SUMMARY BACKGROUND DATA: Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described. METHODS: Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality. RESULTS: The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02). CONCLUSIONS: Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement.

Evaluación y validación de las indicaciones quirúrgicas en la pancreatitis aguda con necrosis, en el Hospital Nacional Edgardo Rebagliati Martins / Evaluation and validation of surgical indications in acute pancreatitis with necrosis, at the National Hospital Edgardo Rebagliati Martins

OBJETIVO: El objetivo de este estudio es evaluar la eficacia de las indicaciones quirúrgicas en la pancreatitis aguda. MATERIALES Y MÉTODOS: Durante el periodo comprendido entre Mayo del 2000 a Junio del 2009 se realizo un estudio de manera prospectiva donde se incluyo a 107 pacientes con Pancreatitis aguda grave con necrosis que fueron operados en la Unidad de Pancreatitis del Hospital Rebagliati. Se dividió a los pacientes de acuerdo a la indicación quirúrgica recibida. Indicación A: Aquellos pacientes que fueron operados por presentar punción por aguja fina positiva (PAF) Indicación B: Pacientes operados por presentar sepsis en ausencia de foco infeccioso extra pancreático. RESULTADOS: Cuando evaluamos la efectividad de cada indicación quirúrgica para detectar infección de la necrosis pancreática pudimos observar que cuando se opero al paciente utilizando la indicación quirúrgica A el 89% presentaban necrosis pancreática infectada, mientras que cuando se utilizo la indicación B solo se encontró infección de la necrosis pancreática en el 51% de los casos (p=0.001). Por lo tanto cuando se utilizo la primera indicación solo el 11% de los operados presento una necrosis estéril mientras que cuando usamos la indicación B operamos por ôerrorõ de esta a un 48% de pacientes que no tenían una indicación quirúrgica por no presentar una necrosis infectada. CONCLUSIONES: La punción por aguja fina es la indicación quirúrgica por excelencia en la pancreatitis aguda grave con necrosis descartando a la indicación de ôSepsisõ en ausencia de foco infeccioso extra pancreático que no responde al tratamiento en UCI por más de 72 horas (indicación B), ya que no es una adecuada indicación porque nos induce a operar pacientes que no tienen una real indicación quirúrgica (necrosis estéril) debido a que estos pacientes pueden ser manejados médicamente.

OBJECTIVE: The purpose of this study is to evaluate efficacy of the surgical indications in acute pancreatitis MATERIAL AND METHODS: During the period from May 2000 to June 2009, 107 operated patients with pancreatic necrosis were treated in the Severe Acute Pancreatitis Unit of the HNERM a comparison was made by separating the patients in two groups according to the surgical indication. An analysis was carried out in order to evaluate which type of surgical indication has the best results according to age, severity of the case, return to oral intake, hospital stay, complications and mortality. RESULTS: On evaluating the indication by positive puncture for detecting necrosis infection we found that 89% of the patients operated due to this indication showed infected necrosis while those operated due to the indication of sepsis without response to the ICU treatment only reached 51%. Surgical complications and re operations, was higher among the patients whose indication was sepsis without response to the ICU treatment (Indication B) in comparison with positive FNA. (Indication A) CONCLUSION: Positive fine needle aspiration is the surgical indication par excellence in acute pancreatitis with necrosis. We consider that the indication of sepsis that do not respond for more than 72 hours to treatment in the ICU regardless that negative FNA should not be taken into account, due to the very high percentage of sterile necrosis found at the time of surgery.

[Morbidity and mortality rates in relation to the "surgeon factor" after duodenopancreatectomy]. / Morbilidad y mortalidad postoperatorias de acuerdo al "factor cirujano" tras duodenopancreatectomía.

OBJECTIVES: The present study was designed to determine whether the surgeon factor has an independent effect on morbidity and mortality rates after duodenopancreatectomy. MATERIAL AND METHOD: Between October 2002 and December 2006, we performed a study of 119 patients who underwent duodenopancreatectomy. The surgeons were divided into 3 groups according to the number of interventions they performed each year: a low volume group (three Whipple procedures per year), a medium volume group (four to 10 Whipple procedures per year) and a high volume group (> 10 Whipple procedures per year). RESULTS: The morbidity rate was higher in the low volume group (82%) than in the high volume group (35%). Length of hospital stay was clearly longer in the low and medium volume groups (27 days, and 21 days) than in the high volume group (17 days). Comparison of the results of the 3 groups revealed that the group performing three or less interventions per year (low volume) had the highest mortality rate (47%), while the group performing more than 10 interventions per year (high volume) had a very low mortality rate (4%). CONCLUSIONS: We found that the volume-to-surgeon ratio was inversely proportional to morbidity, length of hospital stay, return to oral intake, and mortality rates. Therefore, increasing surgical volume could improve morbidity and mortality rates.

[Solid pseudopapilar pancreatic tumors: report of 7 cases and review of the literature]. / Tumores sólidos pseudopapilares de páncreas: reporte de 7 casos y revisión de la literatura.

INTRODUCTION: The cystic tumors of the pancreas represent an uncommon entity and the less frequent type among them is the solid pseudopapillary tumor of the pancreas. Its main difference lies in the fact that this type of tumor is more frequent in young patients. Solid pseudopapillary tumors are generally tumors of large size and the majority of them have a benign behavior. MATERIAL AND METHOD: During a period of three years, seven patients with this neoplasia underwent surgery. Six patients (86%) were females and just one was a male, all of them between the ages of 11 and 37. None of these cases showed metastasis and there were no signs of malignancy reported in the pathological anatomy. The average tumor size was 8 cm and the head of the pancreas was the most frequent location (57%). Of the resections performed in these patients, three were middle pancreatectomies, two were distal pancreatectomies one was a duodenopancreatectomy and one was duodenum preserving head resection of the pancreas. DISCUSSION: The solid pseudopapillary tumors are uncommon tumors which are generally benign or premalignant neoplasias. Nevertheless, 9% of them can behave like carcinomas; therefore, these tumors should not be ignored.

[Surgical treatment of giant serous cystadenoma of pancreas: report of two cases]. / Tratamiento quirúrgico de los cistoadenoma serosos gigantes del páncreas reporte de dos casos.

INTRODUCTION: The cystic tumor of the pancreas is a relatively uncommon entity. There are different types of pancreatic cystic tumors and they all exhibit different degrees of malignancy. These tumors represent 1% of all primary pancreatic tumors and only 15% of the cystic lesions. The serous cystadenomas (SCA) are mostly benign lesions with an average size of 4 cm; nevertheless, in some rare cases these are giant lesions, generally larger than 15 cm. Sometimes these tumors produce a symptomatology caused by the compression of neighboring structures, therefore they are generally operable. MATERIAL AND METHOD: During the period from June 2004 to June 2005, the 3A II unit of the Edgardo Rebagliati Martins Hospital operated on two cases of giant serous cystadenomas of the pancreas, one located in the tail of the pancreas and the other in the head of the pancreas, with an average size of 16 cm. DISCUSSION: The giant SCAs of the pancreas are rarely seen lesions that, according to different authors, are usually larger than 10 to 15 cm. in diameter. These lesions do not represent a diagnosis problem and are generally operable since they produce a symptomatology by compression. The surgical resection can be complicated due to their large size and to the considerable neovascularization.

[Sodium valproate as a cause of acute pancreatitis: a case report]. / Valproato de sodio como causa de pancreatitis aguda: Reporte de un caso.

Valproic acid (VPA) is a commonly used medication approved by the U.S. FDA for the treatment of epilepsy, migraines and bipolar disorders. Adverse effects associated with VPA are typically benign, but there are more serious effects that are less frequent. These effects include hepatotoxicity, teratogenicity, possible polycystic ovaries with a potential sterile effect and acute pancreatitis. Even though acute pancreatitis is an adverse effect of very low frequency, it is very important due to the high mortality rate of patients with acute pancreatitis as a consequence of the use of valproic acid. In medical literature, by 2005, 80 cases of acute pancreatitis caused by valproic acid were reported, 33 of these cases were patients under the age of 18. This is a description of the clinical case of a 16 year old patient with necrotic pancreatitis caused by VPA, who was treated at the Acute Pancreatitis Unit of Edgardo Rebagliati Martins National Hospital.