Fístula pancreática: una complicación temida. Experiencia en una unidad de cirugía hepatobiliopancreática de cuarto nivel / Pancreatic fistula: A feared complication. Experience in a fourth level hepatobiliopancreatic surgery unit

Introducción. La fístula pancreática postoperatoria es una de las complicaciones más importantes en la cirugía hepatobiliopancreática. Su diagnóstico se hace mediante la presencia de un nivel de amilasa en el líquido de drenaje al menos tres veces por encima del valor de la amilasa en suero a partir del tercer día postoperatorio. El objetivo de este estudio fue caracterizar los pacientes con fístula pancreática postoperatoria en nuestra institución, evaluando la importancia de la detección temprana y el establecimiento de un manejo oportuno. Métodos. Estudio descriptivo, retrospectivo, que incluyó los pacientes sometidos a pancreatoduodenectomía, con diagnóstico de fístula pancreática postoperatoria como complicación de cirugía hepatobiliopancreática, en el Hospital Internacional de Colombia, en Piedecuesta, entre enero del 2017 y diciembre de 2020. Se excluyeron los pacientes con otro tipo procedimiento quirúrgico y aquellos que decidieron no participar en el estudio. Resultados. Se evaluaron 69 pacientes, con un predominio del sexo femenino (n=38; 55,1 %) y mediana de la edad de 57 años. El 33,3 % (n=24) de los pacientes intervenidos desarrollaron fístula pancreática postoperatoria, siendo el 23,2 % fuga bioquímica, grado B 8,7 % y grado C 2,9 %, para quienes se indicaron manejo expectante, control ecográfico y reintervención, respectivamente. Fallecieron 5 pacientes (7,2 %). Conclusiones. La fístula pancreáticapostoperatoria es una complicación para tener en cuenta en todos los pacientes sometidos a pancreatoduodenectomía. Existen estrategias que pueden permitir disminuir la incidencia de esta complicación, con el fin de mejorar el desenlace, el pronóstico y la morbilidad posquirúrgica.

Introduction. Postoperative pancreatic fistula is one of the most important complications in hepatobiliopancreatic surgery. Its diagnosis is made by the presence of an amylase level in the drainage fluid at least three times above the serum amylase value from the third postoperative day. The objective of this study was to characterize patients with postoperative pancreatic fistula at our institution, evaluating the importance of early detection and to establish a timely management. Methods. Descriptive, retrospective study that included patients who underwent pancreatoduodenectomy with a diagnosis of postoperative pancreatic fistula as a complication of hepatobiliopancreatic surgery at the Hospital Internacional Colombia, between January 2017 and December 2020. Patients with another type of procedure performed by this specialty and those who did not decide to participate in the study were excluded. Results. A total of 69 patients were included, the median age was 57 years with a predominance of females (n=38; 55.1%). 33.3% (n=24) of the operated patients developed postoperative pancreatic fistula, with 23.2% having a biochemical leak, grade B in 8.7% and grade C in 2.9%, for whom expectant management, ultrasound control and reintervention were indicated, respectively. Five patients died (7.2%). Conclusions. Pancreatic fistula is a complication to take into account in all patients undergoing pancreatoduodenectomy. There are strategies that can reduce the incidence of this complication and thus improve not only the outcome but also the prognosis and postoperative morbidity.

Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

Síndrome de desconexión del conducto pancreático

El síndrome del ducto pancreático desconectado (SDPD) consiste en la disrupción del ducto pancreático principal con pérdida de continuidad entre el remanente pancreático distal viable y el tracto gastrointestinal, generalmente causado por necrosis ductal secundaria a pancreatitis aguda grave. Esto resulta en fuga de fluido pancreático, provocando un curso de enfermedad prolongado y complicaciones. La literatura sobre este tema es limitada, con algoritmos de tratamiento poco claros. Hemos realizado una revisión de la literatura sobre el tema. Revisión en Pubmed y Scielo (2011-2021) de artículos en inglés y español utilizando términos «síndrome del conducto pancreático desconectado», «DPDS» y «páncreas desconectado» encontrando 16 artículos relevantes. Dadas las pocas citas, se revisaron las referencias de estos artículos. Finalmente, revisamos un total de 21 artículos. Entre las referencias encontradas existe 1 metaanálisis, 4 estudios prospectivos y no existen ensayos aleatorizados.

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the viable upstream pancreatic parenchyma and the gastrointestinal tract, generally caused by ductal necrosis after severe acute necrotizing pancreatitis. This compromised ductal integrity leads to extraductal leakage of pancreatic secretions, causing a prolonged disease course and complications. The existing literature is limited, with unclear therapeutic algorithms. We have performed a review of the literature on DPDS. Review in Pubmed and Scielo (2011-2021) of articles in English and Spanish using the terms "disconnected pancreatic duct syndrome", "DPDS" and "disconnected pancreas" finding 16 relevant articles. Given the few citations, the references of these articles was reviewed. Finally, we found 21 articles. Among them, there is one meta-analysis, 4 prospective studies and no randomized trials.

Alternative fistula risk score and first postoperative day drain fluid amylase as predictors of pancreatic fistula after pancreaticoduodenectomy / Escore alternativo de risco de fístula e níveis de amilase do fluido de drenagem no primeiro dia de pós-operatório como preditores de fístula pancreática após pancreaticoduodenectomia

ABSTRACT BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

RESUMO RACIONAL: A alta morbimortalidade da pancreaticoduodenectomia está associada, principalmente, à anastomose pancreatojejunal, a mais frágil e suscetível a complicações como a fístula pancreática pós-operatória clinicamente relevante (clinically relevant postoperative pancreatic fistula - CR-POPF). OBJETIVOS: O escore alternativo de risco de fístula (alternative fistula risk score) e os níveis de amilase do fluido de drenagem no primeiro dia pós-operatório (first postoperative day drain fluid) são preditores da ocorrência de fístula pancreática pós-operatória clinicamente relevante. Nenhum consenso foi alcançado sobre qual das pontuações é um melhor preditor; além disso, seu poder preditivo combinado permanece obscuro. Até onde sabemos, essa associação ainda não havia sido estudada. MÉTODOS: Este estudo avaliou o efeito preditivo do escore alternativo de risco de fístula e/ou do fluido de drenagem no primeiro dia pós-operatório em uma coorte retrospectiva de 58 pacientes após pancreaticoduodenectomia. Os testes de Shapiro-Wilk e Mann-Whitney foram aplicados para avaliar a distribuição das amostras e para comparar as medianas, respectivamente. A curva de características operacionais do receptor e a matriz de confusão foram utilizadas para analisar os modelos preditivos. RESULTADOS: Os valores do escore alternativo de risco de fístula não foram estatisticamente diferentes entre os pacientes dos grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 59,5, p=0,12). Os valores de fluido de drenagem no primeiro dia pós-operatório foram estatisticamente diferentes entre os grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 27, p=0,004). O escore alternativo de risco de fístula e fluido de drenagem no primeiro dia pós-operatório foram independentemente menos preditivos para fístula pancreática pós-operatória clinicamente relevante, em comparação com escore alternativo de risco de fístula + fluido de drenagem no primeiro dia pós-operatório combinados. CONCLUSÕES: O modelo combinado envolvendo escore alternativo de risco de fístula>20% + fluido de drenagem no primeiro dia pós-operatório=5.000 U/L foi o preditor mais eficaz da ocorrência de fístula pancreática pós-operatória clinicamente relevante após pancreaticoduodenectomia.

Abordaje percutáneo transgástrico en la disrupción ductal del páncreas: serie de casos / Percutaneous transgastric approach in pancreatic ductal disruption: Case series

Resumen Se presentan 6 pacientes con disrupción ductal del páncreas (DDP) tratados mediante drenaje percutáneo guiado por imágenes con apoyo de la endoscopia. Inicialmente, los pacientes presentaron necrosis pancreática infectada tratada con drenaje percutáneo transgástrico y luego de resolver la infección desarrollaron DDP. En el estudio por imágenes se diagnosticaron 4 pacientes con disrupción ductal parcial y 2 con disrupción total, a quienes se les indicó la colocación de una prótesis transgástrica percutánea para lograr el drenaje del líquido pancreático hacia el estómago. La duración promedio de la prótesis fue de 183 días; no hubo casos de mortalidad. Se pudo evidenciar que esta opción terapéutica mínimamente invasiva tiene baja morbimortalidad, por lo que se plantea el abordaje percutáneo transgástrico apoyado por la endoscopia como posible tratamiento de la DDP.

Abstract A total of six patients with pancreatic ductal disruption (PDD), treated with image-guided endoscopy percutaneous drainage were enrolled. Initially, patients had infected pancreatic necrosis, treated with transgastric percutaneous drainage, and after the infection was controlled, they developed PDD. In the imaging study process, four patients were diagnosed with partial duct disruption and two patients with complete duct disruption. In both cases the placement of a percutaneous transgastric prosthesis to drain the pancreatic fluids to the stomach was indicated. The prosthesis remained 183 days on average and there were no mortality cases. This therapeutic minimally invasive alternative has low rates of morbimortality and thus, the endoscopy percutaneous transgastric approach is considered as a viable treatment in PPD.

Drenaje percutáneo trans-gástrico de necrosis pancreática amurallada complicado en paciente pediátrico / WON transgastric percutaneous drainage complicated in a pediatric patient

Resumen Las complicaciones de la pancreatitis aguda se dividen en sistémicas y locales, y entre estas últimas se encuentran las colecciones líquidas pancreáticas agudas, la colección necrótica aguda, el pseudoquiste y la necrosis amurallada pancreática. Se reporta el caso de niña de nueve años con pancreatitis aguda idiopática severa, quien desarrolló una necrosis pancreática amurallada de 75 x 45 mm. Por la persistencia del dolor abdominal y la intolerancia a la vía oral, a pesar del manejo médico, se indicó un abordaje percutáneo transgástrico para su tratamiento. Se obtuvo éxito técnico y terapéutico a través del drenaje de la colección, permitiendo iniciar la vía oral y disminuyendo los requerimientos de analgesia. La paciente evolucionó satisfactoriamente, con alta quirúrgica a los 13 días y retiro del catéter a los 30 días. A los cuatro meses de seguimiento se evidenció una colección recidivante asintomática, manejándose de manera conservadora. Lo anterior permite considerar que el abordaje percutáneo transgástrico es una técnica segura y eficaz; sin embargo, evaluar la efectividad y morbimortalidad en población pediátrica requiere de otros estudios que posibiliten llegar conclusiones que generen mayor evidencia científica.

Abstract The complications of acute pancreatitis are divided into systemic and local such as acute pancreatic fluid collections, acute necrotic collection, pseudocyst and pancreatic walled necrosis. The case of a nine-year-old girl with idiopathic severe acute pancreatitis who developed a pancreatic walled necrosis of 75 x 45mm is reported. Due to the persistence of abdominal pain and intolerance to the oral route, despite medical treatment, a trans gastric percutaneous approach was indicated for the treatment of pancreatic walled necrosis. Technical and therapeutic success was obtained through the drainage of the collection, allowing to start the oral route and decreasing the analgesia requirements. The patient evolved satisfactorily, with surgical discharge after 13 days and removal of the catheter after 30 days. After 4 months of follow-up, a recurrent asymptomatic collection was evidenced, being handled in a conservative manner. The above mentioned allows considering that the trans-gastric percutaneous approach is a safe and effective technique; however, evaluating the effectiveness and morbimortality in pediatric population requires other studies that make possible to reach conclusions that generate more scientific evidence.

Fístula pancreática posduodenopancreatectomía: Pancreatogastrostomía vs. Pancreatoyeyunostomía / Pancreatic fistula after pancreaticoduodenectomy: Pancreaticogastrostomy vs. Pancreaticojejunostomy

Antecedentes: la duodenopancreatectomía (DPC) continúa siendo el tratamiento de elección para los tumores periampulares. Con una mortalidad de alrededor del 5% y una morbilidad que puede llegar a alrededor del 50%, la fístula pancreática es todavía la complicación preponderante. Diversos autores sostienen que la anastomosis del páncreas con el estómago tiene menor índice de fístula que cuando se realiza con el yeyuno. Objetivo: comparar la incidencia de fístula pancreática en las pancreatogastrostomías (PG) versus pancreatoyeyunostomías (PY). Evaluar algunos factores de riesgo de fístula. Material y métodos: se evaluaron 91 DPC, 43 de ellas con reconstrucción con PG y 48 con PY. Se evaluaron datos demográficos, quirúrgicos, y se comparó la incidencia de fístula entre ambos. Resultados: la incidencia global de fístula fue de 13 pacientes (14,3%), 5 de las cuales fueron de relevancia clínica. En la comparación de ambos grupos hubo diferencias en cuanto a edad y número de pacientes con Wirsung < 3 mm, el resto de los parámetros fue similar. No hubo diferencias entre ambos grupos con respecto a la cantidad de fístulas (p: 0,478). Respecto de la evaluación de factores predisponentes para fístula, tan solo un diámetro del Wirsung < 3 mm fue significativo. Conclusión: en nuestra serie y al igual que en otras no hubo diferencias en cuanto a fístulas pancreáticas entre PG y PY, lo que nos permite inferir que la adopción y confección sistemática de una ellas obtendrá los mejores resultados.

Background: Pancreaticoduodenectomy is still the treatment of choice in patients with periampullary tumors. Pancreatic fistula is the most common complication with a mortality rate of 5% and 50% of morbidity. Some authors state that the anastomosis of the pancreas with the stomach would decrease the incidence of pancreatic fistula when compared with pancreaticojejunostomy. Objective: The aim of this study was to compare the incidence of pancreatic fistula after pacreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) and analyze the risk factors associated with the development of fistula. Material and methods: 91 patients undergoing pancreaticoduodenectomy were evaluated; 43 with PG reconstruction and 48 with PJ reconstruction. Demographic and surgical data were evaluated and the incidence of pancreatic fistula with both techniques was compared Results: The incidence of fistula for the total series was 14.3% (n = 13) and 5 were clinically relevant. There were differences in age and pancreatic duct diameter < 3 mm between the groups. The incidence of fistula was similar in both groups (p = 0.478). Pancreatic duct diameter < 3 mm was the only significant predisposing factor for the development of fistula. Conclusion: In our series, and in coincidence with others, there were no differences in the incidence of pancreatic fistulas between PG and PJ. Practicing and mastering a repetitive, standardized technique would yield the best results.

Actualidad en fístula pancreática postoperatoria / Current status in postoperative pancreatic fistula

RESUMEN Fundamento: el cáncer de páncreas presenta una alta mortalidad, producto que la mayoría de las veces se diagnóstica en etapa avanzada. El tratamiento de elección es la resección quirúrgica, la cual debida a su complejidad está acompañada de una morbimortalidad importante, cuando no se realiza en centros de alto volumen. Dentro de las complicaciones, la fístula pancreática postoperatoria, es de aparición frecuente. Objetivo: realizar una revisión sistemática actualizada acerca del concepto y clasificación de la fístula pancreática postoperatoria. Métodos: se realizó una revisión sistemática de la literatura con la base de datos SCOPUS bajo los criterios que establecen sus revisores, se utillizaron las siguientes palabras claves: pancreatic fistula, pancreatic surgery, complications, mortality, Whipple procedure. Se incluyeron todas las publicaciones en inglés y español. El método de análisis y síntesis se utilizó para la interpretación de la bibliografía. Resultados: se revisaron 175 artículos, de los cuales, se escogieron 55, que cumplían con los criterios de selección. Entre ellos, cuatro metanálisis, ocho artículos de revisión y 33 artículos originales. Conclusiones: el concepto y clasificación de la fístula pancreática postoperatoria constituye una herramienta válida para la comparación de resultados quirúrgicos entre instituciones. La centralización de la atención en centros de alto volumen constituye la principal medida para disminuir esta complicación.

ABSTRACT Background: pancreatic cancer presents a high mortality, a product that most of the time is diagnosed in advanced stage. The treatment of choice is surgical resection, which due to its complexity is accompanied by significant morbidity and mortality when it is not performed in high-volume centers. Among the complications, the postoperative pancreatic fistula is of frequent appearance. Objective: to carry out an updated systematic review about the concept and classification of postoperative pancreatic fistula. Methods: a systematic review of the literature was carried out using the SCOPUS database under the criteria established by its reviewers, using the following keywords: pancreatic fistula, pancreatic surgery, complications, mortality, Whipple procedure. All publications in English and Spanish were included. The method of analysis and synthesis was used for the interpretation of the bibliography. Results: 175 articles were reviewed, of which 55 were chosen that met the selection criteria. Among them, 4 meta-analyzes, 8 review articles and 33 original articles. Conclusions: the concept and classification of postoperative pancreatic fistula constitutes a valid tool for the comparison of surgical results between institutions. The centralization of care in high-volume centers is the main measure to reduce this complication.

O valor da amilase, obtido precocemente nos drenos abdominais, é teste útil em prever a ocorrência de fístula pancreática após duodenopancreatectomia: lições aprendidas de um centro do Sul do Brasil / Early drain fluid amylase is useful to predict pancreatic fistula after pancreatoduodenectomy: lessons learned from a southern brazilian center

ABSTRACT BACKGROUND: Pancreatic fistula represents the most feared complication after pancreatoduodenectomies, being the major responsible for the high morbidity and mortality after this operation. Its incidence remains around 10% to 30%. In recent years, several authors have studied the value of amylase in abdominal drains fluid, measured at an early stage after the surgical procedure, as a useful tool to identify patients at risk of developing pancreatic fistula. OBJECTIVE: To analyze the value of early drain fluid amylase as a method to predict the occurrence and severity of postoperative pancreatic fistula in patients undergoing pancreatoduodenectomies. METHODS: We evaluated 102 prospective patients submitted to pancreatoduodenectomies from January 2013 to June 2017. The mensuration of amylase in abdominal drains was performed on days 1, 3, 5 and 7 in all patients. Patients were divided into three groups according to postoperative day 1 (POD1) results: values <270 U/L (group 1); between 271 and 5.000 U/L (group 2); and values >5.000 U/L (group 3). RESULTS: The incidence of pancreatic fistula was 25.5%, being 3.33%, 27.3% and 41.02% in the three groups, respectively. Compared with group 1, the risk of developing pancreatic fistula increased with increasing amylase values on POD1. Amylase values on POD1 and POD3 of patients with pancreatic fistula were higher than in the other ones without this complication (P<0.001). In addition, in group 3, 37.5% of patients with pancreatic fistula evolved to death (P<0.001). Finally, in this group, patients who died had drain fluid amylase values on POD1 significantly higher than the others in the same group (P<0.001). CONCLUSION: Early drain fluid amylase value is a useful test to stratify patients in relation to the risk of developing pancreatic fistula after pancreatoduodenectomies, in addition to correlate with the severity of this complication.

RESUMO CONTEXTO: A fístula pancreática representa a complicação mais temida após as duodenopancreatectomias, sendo a grande responsável pela elevada morbi-mortalidade após esta operação. Sua incidência permanece em torno de 10% a 30%. Nos últimos anos, diversos trabalhos têm estudado o valor da amilase nos drenos abdominais, medido de forma precoce após o procedimento cirúrgico, como ferramenta útil para a identificação dos pacientes sob risco de desenvolver fístula pancreática. OBJETIVO: Avaliar o valor da amilase no fluido dos drenos abdominais, obtido precocemente no pós-operatório, como método para prever a ocorrência e severidade da fístula pancreática nos pacientes submetidos a duodenopancreatectomias. MÉTODOS: Foram avaliados 102 pacientes prospectivos submetidos a duodenopancreatectomias no período de janeiro de 2013 a junho de 2017. A dosagem da amilase nos drenos abdominais foi realizada nos dias 1, 3, 5 e 7 em todos os pacientes. Os pacientes foram divididos em três grupos conforme os resultados do 1o PO: valores <270 U/L (grupo 1); entre 271 e 5.000 U/L (grupo 2); e valores >5.000 U/L (grupo 3). RESULTADOS: A incidência de fístula pancreática foi de 25,5%, sendo 3,33%, 27,3% e 41,02% nos três grupos, respectivamente. Comparados ao grupo 1, o risco de desenvolver fístula pancreática foi crescente com o aumento da amilase no 1o PO. Os valores das amilases no 1o PO e 3o PO dos pacientes com fístula pancreática foram maiores do que nos pacientes sem essa complicação (P<0,001). Além disso, no grupo 3, 37,5% dos pacientes com fístula pancreática evoluíram para óbito (P<0,001). Por fim, neste grupo, os pacientes que evoluíram para óbito tiveram valores de amilase no 1o PO significativamente maiores do que os demais pacientes (P<0,001). CONCLUSÃO: O valor da amilase, medido de forma precoce nos drenos abdominais no pós-operatório de duodenopancreatectomias, é teste útil para estratificar pacientes em relação ao risco de apresentar fístula pancreática, além de se correlacionar com a severidade dessa complicação.

Neoplasia sólida pseudopapilar del páncreas / Solid pseudopapillary tumor of the pancreas

Antecedentes: la neoplasia sólida pseudopapilar (NSSP) del páncreas es un raro tumor pancreático que se da comúnmente en mujeres jóvenes. Por lo general, son poco sintomáticos y el pronóstico es bueno ante cirugía resectiva. Objetivo: describir 6 casos tratados en 3 centros diferentes y hacer una revisión actualizada del tema. Material y métodos: análisis de historias clínicas, biopsias y protocolos quirúrgicos. Período enero de 2014 hasta abril de 2017. Resultados: encontramos 6 casos (5 mujeres y 1 hombre); el promedio de edad fue 39,7 años (rango 28 a 54 años). En 3 casos se trató de hallazgos incidentales. En todos los casos se utlizaron Ecografia y tomografia computarizada (TC) para el diagnóstico y en 2 casos se realizó resonancia magnética (RM). Todos los tumores se encontraron en el cuerpo o la cola del páncreas o en ambos. En 2 cirugías se realizó un abordaje videolaparoscópico; el tempo quirúrgico promedio fue de 91,17 minutos y el promedio de días de hospitalización fue de 5,5, con 3 pacientes que reingresaron por complicaciones durante el posoperatorio (un absceso y 2 fistulas pancreáticas). Conclusiones: se trata de tumores poco frecuentes; sin embargo, creemos que el avance en métodos por imágenes permitrá aumentar el diagnóstico y tratamiento de esta patología por lo que su incidencia aumentará. Queremos destacar la importancia del abordaje videolaparoscópico para este tpo de patología, ya que en la mayoría de los casos resulta factible con buenos resultados. Estas cirugías deben realizarse en centros donde puedan manejarse sus complicaciones para evitar reintervenciones.

Background: Solid Pseudopapillary Neoplasia (NSSP) pancreas is a rare pancreatic tumor commonly found in young women. They are usually not very symptomatic and the prognosis is good in resective surgery. Objective: to describe 6 cases from 3 diferent centers and to make an updated review of the topic. Materials and methods: analysis of clinical histories, biopsies and surgical protocols. Period from January 2014 to April 2017. Results: we found 6 cases, with 5 women and 1 male; the mean age was 39.7 years (range 28 to 54 years). In 3 cases we dealt with incidental findings. In all cases, echography and CAT were used for the diagnosis and in 2 cases, MRI was performed. All tumors were found in the body and / or tail of the pancreas. In 2 surgeries a videolaparoscopic approach was performed, the mean surgical tme was 91.17 minutes and the mean number of days of hospitalizaton was 5.5, with 3 patents reentered for postoperative complicatons (one abscess and two pancreatic fistulas). Conclusions: these tumors are rare; however we believe that the advances in imaging methods will increase the diagnosis and treatment of this pathology so that its incidence will increase. We want to emphasize the importance of the videolaparoscopic approach for this type of pathology since in most cases it is feasible with good results. These surgeries should be performed in a center where their complicatons can be managed to avoid reinterventons.

Drain amylase on the first postoperative day of whipple surgery: what value is the best predictor for early drain removal? / Amilase do dreno no primeiro dia de pós-operatório de operaçao de whipple: qual valor é melhor preditor para a retirada precoce do dreno?

ABSTRACT Background: The value of drain amylase on the first postoperative day after pancreatic resections has been described as an efficient predictor of pancreatic fistula. In spite of this, the cut-off point below which the drains can be removed early remains controversial. Aim: Validate the use of the amylase on the 1st postoperative day in the correlation with pancreatic fistula and define the value at which early drain removal is safe. Method: Were included patients undergoing Whipple surgery in the period of 2007 to 2016. Group 1 enrolled the ones who did not develop fistula and those who developed biochemical fistula for less than seven days postoperatively and group 2 included patients who developed persistent biochemical fistula between seven and 21 days and those with grade B and C fistula. Results: Sixty-one patients were included, 41 comprised group 1 and 20 group 2. The incidence of abdominal collections, need for reoperation and time of hospitalization were for group 1 and 2, respectively: 17.1%, 17.1% and 9.5 days, and 65%, 40% and 21.1 days. The median of the amylase from the drain at 1st postoperative day was in group 1 and 2, respectively: 175 U/l and 3172.5 U/l (p=0.001). Using a cut-off of 180 to predict the group to which the patient would belong there was obtained sensitivity, specificity, positive predictive value and negative predictive value of 100%, 48.8%, 50% and 100% respectively. Conclusion: It was validated the cut-off value of 180 U/l as appropriate to early drain removal.

RESUMO Racional: O valor da amilase do dreno no primeiro dia pós-operatório após ressecções pancreáticas é descrito como eficiente preditor de fístula pancreática. Entretanto, o valor abaixo do qual os drenos podem ser removidos precocemente permanece controverso. Objetivo: Validar o uso da amilase do primeiro dia pós-operatório na correlação com a fístula pancreática e definir o valor em que seja segura a retirada precoce do dreno. Método: Foram incluídos pacientes submetidos à operação de Whipple no período de 2007 a 2016. No grupo 1 entraram os que não desenvolveram fístula e os que desenvolveram fístula bioquímica por menos de sete dias de pós-operatório e no grupo 2 os que desenvolveram fístula bioquímica persistente entre 7 e 21 dias e aqueles com fístula grau B e C. Resultados: Sessenta e um pacientes foram incluídos, sendo 41 do grupo 1 e 20 do grupo 2. A incidência de coleções abdominais, necessidade de reoperação e tempo de internação foram para o grupo 1 e 2, respectivamente 17,1%, 17,1% e 9,5 dias, e 65%, 40% e 21,1 dias. A mediana da amilase no grupo 1 e 2, respectivamente foi de 175 U/l e 3172,5 U/l (p=0,001). Utilizando o ponto de corte de 180 para predizer o grupo a que o paciente pertenceria, obteve-se sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de: 100%, 48,8%, 50% e 100% respectivamente. Conclusão: Esta amostra pôde validar o ponto de corte de 180 U/l como adequado para a retirada precoce do dreno.

Pancreatoyeyunoanastomosis con técnica de Blumgart modificada para reconstrucción post-pancreatoduodenectomía: estudio de serie de casos con seguimiento / Pancreatojejunostomy with modified Blumgart technique for post-pancreatoduodenectomy reconstruction

Resumen Introducción: La pancreatoduodenectomía es una cirugía compleja, con cifras de morbilidad cercanas a 30% y mortalidad entre 1 a 5%. El principal factor responsable de morbilidad y mortalidad es la fístula pancreática posoperatoria (FPPO). En la actualidad no existe una técnica universalmente estandarizada para la reconstrucción pancreática. Objetivo: Determinar la prevalencia de FPPO clínicamente relevante en una serie de pacientes en los que se realizó reconstrucción pancreática con pancreatoyeyunoanasto- mosis con técnica de Blumgart modificada para reconstrucción post-pancreatoduodenectomía en Hospital Hernán Henríquez Aravena entre los años 2014-2017. Material y Método: Serie de casos con seguimiento de julio de 2014 a abril de 2017. Se incluyeron pacientes a quienes se realizó reconstrucción pancreática con técnica de Blumgart modificada. La modificación consistió en el uso de pledgets® (poli-tetrafluoro- etileno) en los puntos iniciales en el páncreas con la idea de disminuir la posibilidad de desgarro del tejido. Se excluyeron pacientes a quienes se realizó otra técnica de reconstrucción. Se consideró FPPO clínicamente relevante (grado B/C) para evaluar morbilidad. Se utilizó estadística descriptiva con medidas de tendencia central y dispersión. Resultados: Serie de casos de 12 pacientes, 9 (75%) de género femenino y 3 (25%) de género masculino. La edad promedio fue de 59 ± 8,5 años. La morbilidad fue de 25% y la tasa de fístula grado B/C fue 0%. Todas las fístulas pancreáticas fueron grado A (33,3%), sin relevancia clínica. Conclusión: La técnica de Blumgart modificada parece ser una técnica segura y reproducible para pancreato-yeyuyoanastomosis.

Introduction: Pancreatoduodenectomy is a complex surgery, with morbidity close to 30% and mortality between 1% and 5%. The main contributing factor to morbidity and mortality is postoperative pancrea- tic fistula (POPF). At present, there is no globally standardized technique for pancreatic reconstruction. Aim: To determine the prevalence of clinically relevant POPF in a sample of patients who underwent pancreaticojejunal anastomosis reconstruction with Blumgart's modified technique for post-pancreato- duodenectomy reconstruction at Hospital Hernán Henríquez Aravena between 2014 and 2017. Material and Method: Case series with follow-up from july 2014 to april 2017. Patients who underwent pancreatic reconstruction with Blumgart's modified technique were included. The modification consisted of the use of Pledgets® (poly-tetrafluoro-ethylene) at the inicial points in páncreas with the idea of reducing the possibility of tissue tearing. We excluded patients who underwent another reconstruction technique. Clinically relevant POPF (grade B/C) was considered to asses morbidity. Descriptive statistics were used with measures of central tendency and dispersion. Results: Case series of 12 patients, 9 (75%) were female and 3 (25%) were male. The mean age was 59 ± 8.5 years. The morbidity was 25% and the rate of grade B/C fistula was 0%. All pancreatic fistulas were grade A, not clinically relevant. Conclusion: The Blumgart's modified technique seems to be a safe and reproducible technique for pancreticojejunal anastomosis.

Neoplasias mucinosas papilares intraductales de páncreas en el Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú / Intraductal papillary mucinous neoplasms of the pancreas in Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru

Objetivo: Analizar en forma retrospectiva las características clínicas, radiológicas e histopatológicas, así como los resultados quirúrgicos de los pacientes con diagnóstico de neoplasia mucinosa papilar intraductal de páncreas (NMPI). Materiales y métodos: Usando la base de datos del servicio de Cirugía de Páncreas, Bazo y retroperitoneo del Hospital Nacional Guillermo Almenara Irigoyen (HNGAI) se identificaron a los pacientes con diagnóstico de NMPI sometidos a resección pancreática desde enero del 2006 a setiembre del 2013. Resultados: Se identificaron 11 pacientes (9 mujeres, 2 varones) con una edad promedio de 67,36 años. 2 casos fueron tipo conducto principal, 3 tipo rama y 6 tipo mixta. Todos los pacientes fueron sintomáticos, siendo el dolor el síntoma más frecuente, 27% presentaron pancreatitis. Para el diagnóstico 100% contaron con tomografía, 90% con resonancia magnética. En 10 pacientes se realizó una duodenopancreatectomía y en uno una pancreatectomía distal. Dos pacientes tuvieron fístula pancreática tipo C. Se reoperaron dos pacientes y hubo un fallecido. En 5 pacientes se observó displasia de bajo grado, en 2 displasia de moderado grado, en 1 displasia de alto grado y en 3 carcinoma invasor. Conclusiones: Esta patología está presente en nuestro medio, siendo más frecuente en mujeres. Las NMPI de tipo mixta son las de mayor frecuencia. La fístula pancreática es la complicación de mayor incidencia y la mortalidad es baja. El potencial de malignidad encontrado fue alto.

Objective: To analyze retrospectively the clinical, radiologic and pathologic features as well as the surgical results of the patients with diagnosis of intraductal papillary mucinous neoplasms of the pancreas (IPMN). Materials and methods: Patients with diagnosis of IPMN who underwent pancreatectomy were identified from January 2006 to September 2013, using the prospective data base of the Pancreas, Spleen and retroperitoneum HNGAI service. Results: A total of 11 patients were found (9 females and 2 males). The mean age was 67.36 years. 2 were main duct type IPMN, 3 branch type and 6 mixed type. All patients had symptoms. The pain was the most frequent symptom, 27% had pancreatitis. For the diagnosis 100% had CT scan, 90% MRI. 10 patients underwent pancreaticoduodenectomy and 1 distal pancreatectomy. 2 patients had type C pancreatic fistula. 2 patients underwent reoperation and 1 died. 5 patients had low grade dysplasia, 2 moderate dysplasia, 1 high grade dysplasia and 3 invasive carcinoma. Conclusions: This entity is present in our country being more common in women. The mixed type IPMN is the most frequent type. Complication with the highest incidence is the pancreatic fistula and the mortality rate is low. The IPMN´s malignancy potential founded was high.

Disección del proceso uncinado y mesopáncreas como paso inicial durante la duodenopancreatectomía cefálica: adaptación de un procedimiento laparoscópico / Open pancreatoduodenectomy with initial dissection of the uncinate process and mesopancreas: adaptation from a laparoscopic procedure

Usualmente cuando un procedimiento laparoscópico es realizado, los pasos utilizados en la cirugía abierta son adaptados o modificados con la intención de hacerlo factible desde el punto de vista laparoscópico, la presentación de esta técnica quirúrgica demuestra la situación inversa. La disección de manera inicial del proceso uncinado pudiera permitir una mejor exposición de los vasos mesentéricos superiores y dirigir una correcta disección linfática y neurovascular del tejido conocido como mesopáncreas, con el propósito de obtener un mayor porcentaje de resecciones R0. Es así como se expone la técnica quirúrgica utilizada en un caso clínico(AU)

When a laparoscopic procedure is done, the surgical steps are adapted from open surgery in order to make it feasible, in this case presentation it shows the inverse situation. The dissection of the uncinate process and the neurovascular tissue known as mesopancreas, at the first steps in surgery could achieve better results for negative margins. The paper ilustrate the surgical technique performed in a clinical case presentation(AU)

Morbimortalidad de la duodenopancreatectomía cefálica en el Hospital Nacional (Itauguá) / Morbidity and mortality in pancreaticoduodenectomy at the National Hospital (Itauguá)

RESUMEN La duodenopancreatectomía cefálica constituye la técnica de elección para el tratamiento de tumores benignos y malignos de la región periampular. Se presenta revisión de 14 pacientes con diagnóstico de ictericia neoplásica. Hubo un elevado índice de comorbilidades posoperatorias: gastroparesia (78,5%), fístula pancreática (64,2%), dehiscencia de las anastomosis (42,8%), óbito (21,4%).

ABSTRACT Pancreaticoduodenectomy is the procedure of choice for the treatment of benign and malignant tumors of the periampullary region. A review of 14 patients present with jaundice diagnosed neoplastic. There was a high incidence of postoperative morbidities: gastroparesis (78.5%), pancreatic fistula (64.2%), anastomotic dehiscence (42.8%), death (21.4%).

Cirugía preservadora del páncreas, ¿es la fístula pancreática un elemento menor a considerar? / Pancreatic preserving surgery: it is the pancreatic fistula a minor issue to consider?

Objetivo: La insuficiencia pancreática en especial la de carácter endocrino, reviste vital relevancia como complicación tardía de la cirugía pancreática esto debido a la morbilidad asociada y el difícil manejo de la diabetes pancreaticogénica, ante esta situación, se han ideado técnicas quirúrgicas que permitan preservar el mayor tejido pancreático intentando evitar esta temible complicación. Métodos: Se presenta una serie de casos (n=3) con tumores pancreáticos de potencial maligno bajo, a quienes se les practicó una cirugía preservadora del páncreas de los siguientes tipos: pancreatectomía central, pancreatectomía distal de margen mínimo y enucleación de tumor en la cabeza de páncreas, todas las lesiones fueron superiores a los 3 cm de diámetro. Resultados: Dos de los 3 pacientes presentaron fístulas pancreáticas: uno grado A y el otro grado B, con prolongación en su estancia hospitalaria, las cuales fueron manejadas medicamente hasta lograr su resolución. Los pacientes poseen un seguimiento promedio de 31,66 meses, siendo la de mayor seguimiento de 57 meses, actualmente todos se encuentra con eufunción endocrina y exocrina del páncreas, sin recurrencia de la enfermedad neoplásica. Conclusión: La cirugía preservadora ha demostrado ser segura desde el punto de vista oncológico; sin embargo, en lesiones que superen los 3 cm de diámetro hay que sopesar el riesgo dela fístula pancreática asociada(AU)

Objective: The pancreatic insufficiency related to pancreatic resection is one of the most dreaded complications, the difficult management of pancreaticogenic diabetes and the morbidity associated has pushed to create less aggressive surgery in order to preserve more pancreatic tissue. Methods: Case series presentation (n=3) with low malignant pancreatic tumors, were performed three types of surgeries: central resection, distal resection with minimum margin, and enucleation of tumor in the pancreatic head. All of tumors measured above 3 cm.Results:Two of 3 patients developed pancreatic fistulas, one type A and the other type B, the post-operative course was complicated by the fistula, extending the hospital stay, the pancreatic fistulas were management only medically until get resolution. The patients follow up was 31,66 month, with the longest of 57 months. All patients have normal pancreatic function and oncologic disease free. Conclusion: The pancreatic preserving surgery has demonstrated to be saving in terms of oncology, but tumor over 3 cm ithas to be taken in consideration the complication associated to pancreatic fistula(AU)

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas / Predictive factors of morbidity in distal pancreatic resections

OBJETIVO: Avaliar a morbidade pós-operatória e investigar a existência de seus fatores preditivos. MÉTODOS: O estudo foi realizado de forma retrospectiva, a partir de uma base de dados mantida de forma prospectiva. De 1994 a 2008, 100 pacientes consecutivos foram submetidos à ressecções pancreaticas esquerdas. A principal variável de interesse foi a morbidade pós-operatória, tendo diversas outras características da população sido registradas simultaneamente. Posteriormente, para a análise de fatores preditivos de morbidade pós-operatória o subgrupo de pacientes que foi submetido aos procedimentos de pancreatectomia distal com preservação do baço (n=65) foi analisado separadamente quanto à relevância das diferentes técnicas de secção do parênquima pancreático, assim como, outros possíveis fatores preditivos à ocorrência de morbidade pós-operatória. RESULTADOS: Considerando-se juntamente todas as ressecções pancreáticas esquerdas realizadas, a ocorrência de complicações globais, de complicações relevantes e graves foi 55%, 42% e 20%, respectivamente. Os fatores que se mostraram preditivos à ocorrência de morbidade pós-operatória após pancreatectomia distal com preservação do baço foram a técnica de secção do parênquima pancreático, idade, índice de massa corporal e a realização de operação abdominal concomitante. CONCLUSÃO: A morbidade associada às ressecções pancreáticas, à esquerda dos vasos mesentéricos superiores, foi importante. De acordo com a estratificação adotada baseada na gravidade das complicações, alguns fatores preditivos foram identificados. Estudos futuros com coortes maiores de pacientes são necessários para confirmar tais resultados.

OBJECTIVE: To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS: The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS: Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION: The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Fístula pancreática após duodenopancreatectomia: correlação dos aspectos intra-operatórios e histologicos do pâncreas / Correlation analysis between post-pancreatoduodenectomy pancreatic fistula and pancreatic histology

OBJETIVO: Avaliar a relação entre a ocorrência de fístula pancreática pós-anastomose pancreatojejunal, em doentes submetidos à duodenopancreatectomia por neoplasia maligna periampolar, com aspectos histológicos de fibrose e inflamação encontrados no tecido pancreático e com o calibre do ducto pancreático principal. MÉTODOS: Estudo retrospectivo interessando doentes que foram submetidos ao tratamento com ressecção cirúrgica. Verificou-se o índice de fístulas pancreáticas encontradas. Classificou-se de acordo com a histologia da fibrose e da inflamação pancreática. RESULTADOS: Identificaram-se 77 doentes, com média de idade de 57,6 anos, sendo 62,4% do sexo masculino. De acordo com o tipo de operação realizada, 66,3% constituíram-se em gastroduodenopancreatectomia e 33,7% em duodenopancreatectomia com preservação do piloro. Em relação ao número de fístulas diagnosticadas, identificou-se que 23,4% doentes apresentaram tal complicação pós-operatória, sendo que em 66,7% a causa era neoplasia de papila. Achados macroscópicos intraoperatórios, identificou-se classificação da textura pancreática, tida como normal, em 85,8% e, quanto ao calibre do ducto principal pancreático, foi encontrada média de 4,9mm. Houve relação importante entre a consistência endurecida do coto pancreático e a ausência da fístula. Nos doentes com tecido normal ou amolecido, o índice de fístula foi 25,4%. Quanto ao diâmetro ductal, identificou-se (p <0,05) maior número de deiscências da anastomose pancreática na ausência de dilatação ductal. Evidenciou-se que doentes com valores médios do diâmetro de ducto de 5,4mm (76,7%) não mostraram esta complicação. CONCLUSÃO: A presença de fibrose e de dilatação ductal habitualmente coexistem e estão relacionadas à menor porcentagem de fístulas enteropancreáticas.

OBJECTIVE: To evaluate the relationship between the occurrence of pancreatic fistula after pancreatojejunal anastomosis in patients undergoing pancreaticoduodenectomy for periampullary malignancy and the histological fibrosis and inflammation found in pancreatic tissue and the caliber of the main pancreatic duct. METHODS: We conducted a retrospective study with patients that were treated with surgical resection. The rate of pancreatic fistulae was recorded. Histology classification was performed according to fibrosis and pancreatic inflammation. RESULTS: We identified 77 patients, mean age was 57.6 years; 62.4% were male. As for the type of operation performed, 66.3% were gastroduodenopancreatectomies and 33.7% pancreatoduodenectomies with pylorus preservation. Regarding the number of fistulas diagnosed, it was found that 23.4% patients displayed this postoperative complication and in 66.7% the cause was cancer of the papilla. As for intraoperative macroscopic findings, we identified the classification of pancreatic texture, seen as normal in 85.8%, and the caliber of the main pancreatic duct, finding an average of 4.9 mm. There was a significant relationship between the hardened pancreatic stump and the absence of fistula. In patients with normal or soft tissue, the rate of fistula was 25.4%. Regarding ductal diameter, we identified a higher number of pancreatic anastomotic dehiscences in the absence of ductal dilation (p <0.05). We noticed that patients with an average ductal diameter of 5.4 mm (76.7%) did not show this complication. CONCLUSION: The presence of fibrosis and ductal dilation usually coexist and is related to a lower percentage of pancreatic fistulae.

Resultados del tratamiento quirúrgico en un traumatismo pancreaticoduodenal / Results of the surgical treatment in a pancreaticoduodenal trauma

Introducción: la ruptura del páncreas y el duodeno es un evento poco común, cuyas cifras oscilan entre el 2 y el 4 por ciento de los traumatismos abdominales. La mayoría ocurre en heridas abdominales penetrantes y en traumatismos compresivos en accidentes de tránsito. Métodos: se presenta una serie de 19 pacientes operados por traumatismo pancreaticoduodenal, en 5 hospitales clinicoquirúrgicos de Ciudad de La Habana, desde 2008 a 2010. Se realizó un estudio retrospectivo, mediante el uso de encuestas diseñadas a tal efecto, aplicadas a los cirujanos actuantes en el período estudiado. Resultados: el 63 por ciento de los pacientes fueron por traumatismos cerrados, con predominio de accidentes de tránsito, la mayoría clasificados como grado I (15 pacientes), y 2 pacientes como grado II. Ambos grupos acumularon el 90 por ciento de las lesiones. El procedimiento quirúrgico más frecuentemente empleado fue la pancreatectomía distal con esplenectomía. Se complicaron 8 pacientes (42 por ciento), y la más frecuente fue la fístula pancreática externa en 4 pacientes, seguida por la peritonitis en 2; fallecieron 3 (15 por ciento), distribuidos de la manera siguiente: de 13 pacientes clasificados como grado I, falleció 1 (7 por ciento), y 2 pacientes clasificados como grado III (100 por ciento). Conclusiones: para obtener resultados favorables en este tipo de paciente es necesaria una clasificación acertada según la localización y severidad de las lesiones, así como una adecuada selección del procedimiento quirúrgico(AU)

Introduction: rupture of pancreas and duodenum is a uncommon event, whose figures fluctuate between the 2 and the 4 percent of the abdominal traumata. Most occur in penetrating abdominal wounds and in compressive traumata in road accidents. Methods: a total of 19 patients were operated on due to a pancreaticoduodenal trauma in five clinical surgical hospitals of Ciudad de La Habana from 2008 to 2010. A retrospective study was conducted using the surveys designed to that end, applied to acting surgeons during the study period. Results: the 63 percent of patients had closed traumata with predominance of road accidents, most qualified as grade I (15 patients) and two patients as grade III. Both groups accounted for the 90 percent of injuries. The more frequent surgical procedure used was the distal pancreatectomy with splenectomy. Eight patients had complications (42 percent) where the most frequent one was the external pancreatic fistula in 4 patients, followed by peritonitis in two patients; three dyed (15 percent), distributed as follow: from13 patients classified as degree I, one dyed (7 percent) and two patients classified as degree III (100 percent). Conclusions: to obtain favorable results in this type of patient, it is necessary an appropriate classification according to location and severity of the injuries, as well as a proper selection of the surgical procedure(AU)

Surgical treatment of cystic neoplasms of the pancreas / Tratamento cirúrgico das neoplasias císticas do pâncreas

CONTEXT: Diagnosis and treatment of cystic neoplasms of the pancreas increased significantly in the last decades. There are only a few Brazilian publications on these tumors. The majority of them are limited to reports of one or few cases. OBJECTIVE: To present our experience with 27 patients with cystic neoplasms of the pancreas. METHODS: Demographic data, clinical manifestations, diagnostic exams, surgical procedures, postoperative complications, and follow-up data of 27 patients with cystic neoplasms of the pancreas were analyzed, according to the histological type of the tumor. RESULTS: There were 10 (37 percent) serous cystic tumors, 10 (37 percent) mucinous cystic tumors, 4 (15 percent) intraductal papillary mucinous tumors, and 3 (11 percent) solid pseudopapillary tumors or Frantz tumor. All serous cystic tumors, 6 (60 percent) mucinous tumors, 2 (50 percent) intraductal papillary mucinous tumors, and 2 (67 percent) solid pseudopapillary tumors were benign. The age of the patients varied from 31 to 82 years and all tumors were more common in female. Two patients had been treated previously as a pseudocyst. Surgical procedures depended on the location and extension of the tumor. Two patients underwent only laparotomy with tumor biopsy, one cholecystectomy with Roux-en-Y hepaticojejunostomy for jaundice treatment, 6 pancreatoduodenectomy, and 18 partial pancreatectomy. The most common postoperative complication was pancreatic fistula (n = 5; 19 percent). One patient died of necrotic pancreatitis. Of the 10 patients with serous cystic tumor, only 1 had tumor recurrence at the section border. The three patients with mucinous cystoadenocarcinoma in which was not possible to resect the tumor, died 6 to 24 months after laparotomy. The six patients with benign mucinous tumors did not have tumor recurrence. CONCLUSIONS: The most common cystic neoplasms of the pancreas are serous and mucinous cysts. These tumors are more frequent in female...

RACIONAL: O diagnóstico e tratamento das neoplasias císticas do pâncreas aumentaram significativamente nas últimas décadas. Existem poucas publicações brasileiras sobre estes tumores, sendo que a maioria é limitada à descrição de um ou poucos casos. OBJETIVO: Apresentar a experiência com 27 pacientes com neoplasia cística do pâncreas. MÉTODOS: Os dados demográficos, quadro clínico, exames complementares, procedimento cirúrgico com as suas complicações e a evolução pós-operatória de 27 pacientes com neoplasia cística do pâncreas foram analisados, conforme o tipo histológico do tumor. RESULTADOS: O exame anatomopatológico evidenciou 10 (37 por cento) casos de tumor seroso, 10 (37 por cento) de tumor mucinoso, 4 (15 por cento) de neoplasia intraductal papilar mucinosa e 3 (11 por cento) de neoplasia sólida pseudopapilar ou tumor de Frantz. Todos os tumores serosos, seis (60 por cento) mucinosos, dois (50 por cento) tumores intraductais papilares mucinosos e dois (67 por cento) tumores sólidos pseudopapilares eram benignos. A idade dos pacientes variou amplamente de 31 a 82 anos e o sexo feminino predominou em todos os tipos de tumores. Dois pacientes tinham sido tratados previamente como pseudocisto de pâncreas. As operações realizadas dependiam da localização e extensão do tumor. Dois pacientes foram submetidos somente a laparotomia com biopsia do tumor, 1 a colecistectomia e hepaticojejunostomia em Y-de-Roux para aliviar a icterícia, sem ressecção da neoplasia, 6 a pancreatoduodenectomia e 18 a pancreatectomia parcial. A complicação pós-operatória mais comum foi fístula pancreática (n = 5; 19 por cento). Um paciente morreu no pós-operatório imediato por pancreatite necrótica. Dos 10 pacientes com cistoadenoma seroso, apenas 1 apresentou recidiva próxima à borda de secção do tumor. Os três pacientes com cistoadenocarcinomas mucinosos em que não foi realizada a ressecção do tumor foram a óbito de 6 a 24 meses após a operação. Os seis pacientes...