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.

Cáncer de páncreas, un reto al sistema sanitario / Pancreatic cancer, a challenge to the health system

RESUMEN Fundamento: el cáncer de páncreas representa un serio problema de salud, por su elevada mortalidad. Un porciento considerable del diagnóstico de la enfermedad se hace en un estadio avanzado. Objetivo: actualizar los conocimientos sobre cáncer de páncreas, síntomas, signos de alarma, para lograr un umbral de sospecha más alto, dirigir al enfermo por los circuitos de atención resolutivos, y un diagnóstico más temprano. Métodos: la búsqueda de la información se realizó en el periodo de un mes, enero de 2018, se emplearon los siguientes descriptores: cáncer de páncreas, epidemiología, factores de riesgo, síntomas, signos. A partir de la información obtenida se realizó una revisión bibliográfica de 213 artículos publicados en las bases de datos MEDLINE, LILACS, BVS, Pubmed, SciELO Cuba, SciELO regional. Se utilizaron 47 citas, 12 artículos de revisión, cuatro tesis doctorales, cuatro conferencias de consenso médicas internacionales sobre cáncer de páncreas, seis artículos metodológicos, 14 artículos teóricos, dos comunicaciones, cinco editoriales y artículos de prensa on line. El 62 % de los últimos cinco años, de ellas 54,8 % de los años 2017 y 2018. Desarrollo: se describen aspectos como la prevalencia y mortalidad del cáncer de páncreas según regiones del mundo, factores de riesgos, principales signos y síntomas de sospecha. Se hace referencia al uso de los marcadores tumorales. Sobrepasa el interés de este artículo aspectos del tratamiento y estadio clínico, muy específicos una vez realizado el diagnóstico. Conclusiones: la ausencia de síntomas específicos tempranos y el diagnóstico tardío del cáncer de páncreas hacen que los pacientes no tengan la oportunidad de recibir el tratamiento adecuado. Promover la sensibilización, tanto dirigida a profesionales sanitarios como población general, sobre las ventajas de la detección precoz, es una prioridad. Solo la alta sospecha clínica, la sensibilización de los profesionales de la atención y la conducción del paciente por el sistema pueden lograr un diagnóstico en fases tempranas de esta enfermedad.

ABSTRACT Background: pancreatic cancer represents a serious health problem due to its high mortality. A considerable percentage of the diagnoses is late, and advanced the disease. Objective: to update knowledge about pancreatic cancer, symptoms, warning signs, and an earlier diagnosis of pancreatic cancer. Methods: the search for the information was made in the period of one month, January 2018, the following descriptors were used: pancreatic cancer, epidemiology, risk factors, symptoms, signs. Based on the information obtained, a bibliographic review of 213 articles published in MEDLINE, LILACS, VHL, Pubmed, SciELO Cuba, SciELO regional databases was carried out. It was used 47 citations, 12 review articles, four doctoral theses, four international medical consensus conferences on pancreatic cancer, six methodological articles, 14 theoretical articles, two communications, five editorials and online press articles. 62% of the last five years, of them 54.8 % of the years 2017 and 2018. Development: it is described aspects such as the prevalence and mortality of pancreatic cancer according to regions of the world, risk factors, main signs and symptoms of suspicion. Reference is made to the use of tumor markers. The interest of this article surpasses aspects of treatment and staging, very specific once the diagnosis has been made. Conclusions: the absence of specific early symptoms and the late diagnosis of pancreatic cancer mean that patients do not have the opportunity to receive adequate treatment. Promoting awareness, both directed to health professionals and the general population, about the advantages of early detection is a priority. Only the high clinical suspicion, the sensitization of the care professionals and the conduction of the patient through the system can achieve a diagnosis in early stages of this disease.

Proposal for a structured computed tomography report in the evaluation of pancreatic neoplasms based on expert opinions / Proposta para um laudo estruturado de tomografia computadorizada na avaliação da neoplasia de pâncreas baseada na opinião de especialistas

Abstract Objective: To create a structured computed tomography (CT) report for the systematic evaluation of pancreatic ductal adenocarcinoma (PDAC), based on the opinions of clinicians and surgeons. Materials and Methods: This was a prospective study in which we applied a 21-item questionnaire to experts in pancreatic diseases in order to create a model of a structured abdominal CT report. The questionnaire addressed the location and size of PDACs, as well as their effects on adjacent structures and on the vasculature, together with metastases. We used a Likert scale to determine which of those parameters should be included in the model. Results: A total of 18 experts (12 surgeons and 6 clinicians) from 9 institutions completed the questionnaire. All of the experts agreed that the following (if present) should be described in the CT report on a PDAC: the degree of enhancement; the diameter and location of the lesion; pancreatic duct obstruction; biliary dilatation; pancreatic atrophy; liver metastases; peritoneal nodules; ascites; lymph node enlargement; and invasion of adjacent structures. More than 80% of the experts agreed that the report should also describe the relationship between the PDAC and the surrounding vasculature. Conclusion: We have developed a template for a CT report on patients with PDAC, based on the opinions of experts involved in the treatment of such patients.

Resumo Objetivo: Criar um modelo de laudo estruturado de tomografia computadorizada (TC) para a avaliação sistemática do adenocarcinoma ductal de pâncreas (ADP) com base na opinião de clínicos e cirurgiões. Materiais e Métodos: Realizamos estudo prospectivo aplicando um questionário abrangendo 21 tópicos para um modelo de laudo estruturado de TC do abdome na avaliação do ADP, contemplando dados sobre localização e tamanho tumoral, efeito sobre estruturas adjacentes, comprometimento vascular e presença de metástases. Utilizamos a escala de Likert para definir a pertinência de se inserir uma determinada informação. Resultados: Obtivemos respostas de 18 especialistas de 9 instituições (12 cirurgiões e 6 clínicos). Todos concordaram que deveriam ser descritos o grau de realce, o diâmetro da lesão, a localização e a presença ou a ausência de: obstrução do ducto pancreático, dilatação biliar, atrofia pancreática, metástases hepáticas, nódulos peritoniais, ascite, linfonodomegalias e invasão de estruturas adjacentes. Mais de 80% concordaram que deveria ser mencionada a relação do tumor com os vasos circunjacentes. Conclusão: Elaboramos um modelo de laudo estruturado de TC para a avaliação do ADP de pâncreas, atendendo às expectativas dos especialistas envolvidos no atendimento destes pacientes.

Pancreatectomia distal com preservação do baço em tumor sólido pseudopapilar do pancreas (tumor de Frantz): relato de caso / Distal pancreatectomy with spleen preservation in solid pseudopapillary tumor of the pancreas (Frantz’s tumor): a case report

Tumor sólido pseudopapilar do pancreas, também conhecido como tumor de Frantz, a neoplasia rara, de etiologia desconhecida, baixo potencial maligno e bom prognóstico, que acomete geralmente pacientes jovens do sexo feminino. Relata-se um caso de tumor de Frantz em paciente feminino, de 29 anos de idade, cuja apresentação clínica foi de dor e massa abdominal palpável. A ressonância nuclear magnética do abdómen evidenciou grande lesão sólido-cística proveniente da porção distal do pancreas. O tratamento cirúrgico do tumor de Frantz pela ressecção distal do pancreas com preservação do baço foi realizado e mostrou ser eficaz e sem morbidade pós-operatória. A opção pela cirurgia conservadora deve ser considerada, pois o conhecimento de que pacientes esplenectomizados apresentam aumento da morbidade e mortalidade justifica a tendência de preservá-lo.

Solid pseudopapillary tumor of the pancreas, also known as Frantz? tumor, is a rare neoplasia of unknown etiology which usually attacks young female patients, but presents low malign potential and good prognosis. This paper reports on a case of Frantz?s tumor in a 29-year-old female patient suffering from pain and palpable abdominal mass. Abdominal nuclear magnetic resonance revealed severe solid-cystic tumor on the distal part of the pancreas. The surgical treatment of the tumor by means of distal resection with spleen preservation proved to be effective and cause no post-surgical morbidity. The option for the conservative surgery must be considered, as splenectomized patients are reported to suffer from increased morbidity and mortality.

Pancreatectomia corpo-caudal com preservação esplênica para o tratamento de tumor sólido pseudopapilar de pâncreas (Tumor de Frantz) / Corpo-caudal pancreatectomy with splenic preservation in the treatment of a solid pseudopapillary tumor (Frantz tumor)

Objetivos: descrever um caso de tumor sólido pseudopapilar de pâncreas (tumor de Frantz), neoplasia infrequente, que entretanto tem sido cada vez mais diagnosticada e relatada na literatura. Descrição do Caso: uma adolescente de18 anos consultou com queixa de dor abdominal persistente em hipocôndrio esquerdo. Ecografia abdominal e tomografia computadorizada de abdome revelaram lesão sólido-cística na transição entre o corpo e a cauda do pâncreas. A paciente foi submetida a pancreatectomia corpo-caudal com preservação esplênica. O exame anatomopatológico revelou tratar-se de um tumor sólido pseudopapilar de pâncreas. Houve excelente evolução pós-operatória, com resolução completa das queixas, estando a paciente assintomática seis meses após o procedimento. Conclusões: o tumor sólido pseudopapilar de pâncreas é uma neoplasia rara, ocorre predominantemente em mulheres jovens e é considerada uma lesão de baixo grau de malignidade. Sintoma de dor abdominal inespecífica é a apresentação clínica característica, e o diagnóstico é realizado por exames de imagem. Ressecção cirúrgica completa do tumor é o tratamento de escolha.

Aims: To present a case of solid pseudopapillary tumor (Frantz tumor), an infrequent pancreatic neoplasm, which has been increasingly diagnosed and reported in the literature. Case Description: A 18-year old woman presented with pain and tenderness in the left upper abdominal quadrant. Abdominal ultrasound and computed tomography scan revealed a solid and cystic lesion in the body of the pancreas. The patient underwent a corpo-caudal pancreatectomy with splenic preservation. Pathologic analysis of the specimen revealed a solid pseudopapillary tumor. Postoperative course was uneventful with complete resolution of the symptoms, and the patient is completely asymptomatic six months after the operation. Conclusions: Pancreatic solid pseudopapillary tumor is a rare neoplasm that predominantly occurs in young women, and is generally considered a low-grade malignant tumor. Its clinical presentation is nonspecific abdominal symptoms, and the diagnosis is performed by image tests. Complete surgical resection of primary tumor is the treatment of choice.