Comportamiento clínico-epidemiológico de los tumores periampulares malignos diagnosticados en Gastroenterología

Introducción: Los tumores malignos ubicados en la región periampular pueden ser: ampular, biliar, pancreático o duodenal, y constituyen un problema de salud por su alta mortalidad. En su etiopatogenia se involucran múltiples factores de riesgo, cuyo comportamiento clínico y epidemiológico se desconoce en la población matancera. Objetivo: Determinar el comportamiento clínico y epidemiológico de los tumores periampulares malignos. Materiales y métodos: Se realizó un estudio descriptivo, prospectivo en 34 pacientes con diagnóstico de tumores periampulares malignos, atendidos en el Servicio de Gastroenterología del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas, de enero a diciembre de 2021. Se estudiaron variables como: grupos de edad, sexo, factores de riesgo y antecedentes patológicos personales, tiempo de evolución de los síntomas y localización del tumor. Los resultados fueron recogidos en una planilla de recolección de datos. Resultados: Predominó el sexo masculino y el grupo de 50 a 69 años. Los factores de riesgo más frecuentes fueron el consumo de café, tabaquismo y diabetes mellitus. El íctero fue el síntoma más frecuente. La mayoría de los pacientes iniciaron los síntomas de 1 a 3 meses antes del diagnóstico. El cáncer de páncreas fue el más frecuente. Conclusiones: Los tumores periampulares predominaron en la población mayor de 50 años. Los hábitos tóxicos fueron los factores de riesgo más frecuentes. El cáncer de páncreas tuvo mayor incidencia. El comportamiento clínico estuvo relacionado con la localización de la lesión, el tiempo de evolución de los síntomas, y los factores de riesgo que predominaron.

Introduction: Malignant tumors located in the periampullary region can be ampullary, biliary, pancreatic or duodenal and are a health problem due to their high mortality. Their etio-pathogenesis involves many risk factors, whose clinic and epidemiological behavior is unknown by the population of Matanzas. Objective: To determine the clinical-epidemiological behavior of malignant periampullary tumors. Materials and methods: A descriptive, prospective study was conducted in 34 patients with diagnosis of malignant periampullary tumors, treated in the Gastroenterology Service of the Clinical-Surgery University Hospital Comandante Faustino Perez Hernandez, of Matanzas, from January to December 2021. Variables such as age group, sex, risk factors and personal pathological history, time of evolution of symptoms and tumor location were studied. The results were collected in a data collection form. Results: Male sex and the 50-69 years age group predominated. The most frequent risk factors were coffee consumption, smoking and diabetes mellitus. Jaundice was the most frequent symptom. Most of the patients started symptoms one to three months before the diagnosis. Pancreatic cancer was the most frequent. Conclusions: Periampullary tumors predominated in the population older than 50 years. Toxic habits were the most common risk factors. Pancreatic cancer had a higher incidence. Clinical behavior was related to the location of the lesion, the time of evolution of the symptoms, and the risk factors that predominated.

Periampullary Mass as an Unusual Manifestation of Coccidioidomycosis. Case Report and Literature Review

In Colombia, coccidioidomycosis is a rare entity, and the intestinal manifestation is infrequent, with around a dozen cases reported in the world literature. This article reports the case of a 29-year-old male Venezuelan immigrant with a 4-month history of abdominal pain, jaundice, nausea, and vomiting. The tomography and the endoscopic study revealed a circumferential exophytic mass in the second portion of the duodenum. The biopsy revealed multiple spherules filled with round fungal endospores with a final diagnosis of disseminated coccidioidomycosis. The patient was discharged before the final pathology report with fluconazole doses of 200 mg every other day and an order for outpatient magnetic resonance cholangiography for outpatient follow-up, which he has not attended.

La coccidioidomicosis en Colombia es una entidad infrecuente y la presentación intestinal es extremadamente rara, con alrededor de una docena de casos reportados en la literatura mundial. En el presente artículo se reporta el caso de un paciente inmigrante venezolano masculino de 29 años con historia de dolor abdominal, ictericia, náuseas y vómito de 4 meses de evolución. La tomografía y el estudio endoscópico evidenciaron una masa exofítica circunferencial en la segunda porción del duodeno. La biopsia reveló múltiples esférulas llenas de endosporas fúngicas redondas con diagnóstico final de coccidioidomicosis diseminada. El paciente fue dado de alta antes del reporte final anatomopatológico con dosis de fluconazol de 200 mg interdiario y orden de colangiorresonancia ambulatoria para control ambulatorio, mismo al cual no ha asistido.

Manejo de los tumores periampulares malignos en pacientes evaluados en consulta multidisciplinaria

Introducción: Los tumores malignos ubicados en la región periampular pueden ser: ampular (carcinoma ampular), biliar (colangiocarcinoma), pancreático (tumores de la cabeza del páncreas) o duodenal (cáncer de la segunda porción duodenal), y constituyen un problema de salud por su alta mortalidad, y un motivo frecuente de consulta multidisciplinaria por oncología digestiva. Objetivo: Describir los procederes diagnósticos y resultados histopatológicos asociados al manejo de tumores periampulares en pacientes atendidos en consulta multidisciplinaria. Materiales y métodos: Se realizó un estudio descriptivo y prospectivo en 34 pacientes con diagnóstico de estas neoplasias, en el Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández. La fecha comprende de enero a diciembre del año 2021. Se estudiaron variables como: grupos de edad, sexo, resultados imagenológicos, endoscópicos e histológicos, vía para la realización de la biopsia y tratamiento definitivo. Los resultados fueron recogidos en una planilla de recolección de datos. Resultados: Predominaron el sexo masculino y el grupo de 50 a 69 años. La tomografía axial computarizada abdominal mostró mayor sensibilidad en el diagnóstico respecto al ultrasonido. La colangiopancreatografía endoscópica retrograda fue el método diagnóstico y terapéutico más utilizado, seguido del tratamiento quirúrgico paliativo. Conclusiones: El manejo de los tumores, al igual que su tratamiento definitivo, estuvo relacionado con su localización. Como todos no pudieron ser estadificados, fue necesario el estudio histológico.

Introduction: Malignant tumors located in the periampullary region may be: ampullary (ampullary carcinoma), biliary (chollangiocarcinoma), pancreatic (tumors of the pancreas head) or duodenal (cancer of the second duodenal portion). They constitute a health problem due to their high mortality and a reason of frequent multidisciplinary consultation by digestive oncology. Objective: To describe the diagnostic procedures and the histopathological results associated to the management of periampullary tumors in patients treated in multidisciplinary consultations. Materials and methods: A descriptive and prospective study was conducted in 34 patients diagnosed with these neoplasms at the Clinical-Surgical University Hospital Comandante Faustino Perez. The date ranges from January to December 2021. Variables such as age groups, sex, imaging, endoscopic and histological results, pathway for biopsy and definitive treatment were studied. The results were collected in a data collection form. Results: Male sex and the age group from 50 to 69 years predominated. Abdominal computed axial tomography showed higher sensitivity in the diagnosis than ultrasound. Retrograde endoscopic cholangiopancreatography was the most widely used diagnostic and therapeutic method, followed by palliative surgical treatment Conclusions: The management of the tumors, as well as their definitive treatment, was related to their location. Since all of them could not be staged, histological study was necessary.

Octreotide and postoperative pancreatic fistula after pancreaticoduodenectomy: What we know so far? A narrative review

Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon抯 discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords 搒omatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula� was made. Further filters were applied in the search 揅linical Trial, Meta?Analysis, Randomized Controlled Trial, Systematic Review, from 1990 � 2021,� and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate

Value of extrahepatic bile duct and main pancreatic duct segment patterns on MRCP to differentiate the periampullary carcinoma / 中华肝胆外科杂志

Objective:To investigate the value of the extrahepatic bile duct and main pancreatic duct segment patterns on magnetic resonance cholangiopancreatography (MRCP) for differentiating the periampullary carcinoma (PAC).Methods:The clinicopathologic data of 125 patients with PAC who were admitted to Wuxi No.2 People’s Hospital from June 2013 to December 2021 were retrospectively analyzed, including 72 males and 53 females, aged (64.9±8.6) years. According to its anatomy, the extrahepatic bile duct (B) was divided into suprapancreatic and intrapancreatic (including ampullary) segments, and the main pancreatic duct (P) was divided into tail-body and head segments. MRCP patterns: i. the extrahepatic bile duct or main pancreatic duct visible without dilatation, ii. cutoff of the distal extrahepatic bile duct or main pancreatic duct with upstream dilatation, iii. cutoff of the intrapancreatic or head segment with upstream dilatation and remnant intrapancreatic or head segments invisible, iv. cutoff of the intrapancreatic or head segment with upstream dilatation and nondilated remnant intrapancreatic or head segments, were represented as 0, 1, 2, and 3, respectively. Segment patterns of B1/P0+ B1/P1, B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3, B3/P0, and B0/P0+ B2/P0 on MRCP were compared in PAC patients.Results:Of the 125 patients, there were 57 (45.6%) with pancreatic head carcinoma, 36 (28.8%) with ampullary carcinoma, 20 (16.0%) with distal cholangiocarcinoma, and 12 (9.6%) with periampullary duodenal carcinoma. Segment patterns of B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3 were found in 52 patients with pancreatic head carcinoma (91.2%, 52/57), with a significant difference between PAC (χ 2=110.66, P<0.001). Segment patterns of B1/P0+ B1/P1were found in 36 patients with ampullary carcinoma (100.0%, 36/36), fallowed by 11 (91.7%, 11/12) with periampullary duodenal carcinoma, with a significant difference between PAC (χ 2=129.95, P<0.001). Segment pattern of B3/P0 presented in 16 patients with distal cholangiocarcinoma (80.0%, 16/20), with a significant difference between PAC (χ 2=62.45, P<0.001). The segment patterns of B0/P0+ B2/P0 were only seen in 3 of 57(5.3%) patients with pancreatic head carcinoma. Conclusion:On MRCP, cutoff of the head segment with upstream dilatation and remnant head segment invisible or nondilated indicates the pancreatic head carcinoma. Cutoff of the intrapancreatic segment with upstream dilatation, remnant intrapancreatic segment visible, and main pancreatic duct nondilated, indicates the distal cholangiocarcinoma. And cutoff of the distal extrahepatic segment with upstream dilatation and main pancreatic duct dilatation or not, indicates the ampullary or periampullary duodenal carcinoma.

Influencing of preoperative biliary drainage on surgery-related complications after pancreatico-duodenectomy / 中华消化外科杂志

Objective:To investigate the influencing of preoperative biliary drainage on surgery-related complications after pancreaticoduodenectomy.Methods:The retrospective case-control study was conducted. The clinical data of 267 patients with periampullary space-occupying lesion who were admitted to Beijing Friendship Hospital of Capital Medical University from January 2016 to July 2020 were collected. There were 166 males and 101 females, aged 61 (range, 54?84)years. Observation indicators: (1) comparison of preoperative situations in patients with and without preoperative biliary drainage; (2) comparison of intraoperative and postoperative situations in patients with and without preoperative biliary drainage; (3) methods and efficacy of preoperative biliary drainage; (4) factors influencing surgery-related complications after pancreaticoduodenec-tomy. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(rang) or M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Univariate analysis was conducted using the corresponding statistical methods based on data type. Multivariate analysis was conducted using the Logistic stepwise regression model. Results:(1) Comparison of preoperative situations in patients with and without preoperative biliary drainage. Of the 267 patients, there were 104 cases with preoperative biliary drainage and 163 cases without preoperative biliary drainage. Cases with malignant tumor, cases with borderline tumor, cases with chronic pancreatitis were 89, 13, 2 in patients with preoperative biliary drainage, versus 111, 41, 11 in patients without preoperative biliary drainage, showing significant differences in pathology type between them ( χ2=10.652, P<0.05). (2) Comparison of intraoperative and postoperative situations in patients with and without preoperative biliary drainage. There was no significant difference in operation time, volume of intra-operative blood loss, postoperative complications, grade B pancreatic fistula, grade C pancreatic fistula, biliary leakage, abdominal or gastrointestinal bleeding, incidence of abdominal infection, white blood cell count at postoperative day 1, white blood cell count at postoperative day 3, neutrophil-to-lymphocyte ratio at postoperative day 1, neutrophil-to-lymphocyte ratio at postoperative day 3, C-reactive protein-albumin ratio at postoperative day 1, C-reactive protein-albumin ratio at post-operative day 3, duration of hospital stay between the 104 patients with preoperative biliary drainage and the 163 patients without preoperative biliary drainage ( P>0.05). (3) Methods and efficacy of preoperative biliary drainage. Of the 104 patients with preoperative biliary drainage, there were 40 cases receiving endoscopic nasobiliary drainage with drainage time as (12±2)days, there were 38 cases receiving percutaneous transhepatic cholangial drainage with drainage time as (7±1)days, and there were 26 cases receiving endoscopic retrograde biliary drainage with drainage time as (19±2)days. The total bilirubin, direct bilirubin, aspartate transaminase, alanine aminotrans-ferase in 104 patients were (223±18)μmol/L, (134±11)μmol/L, (112±10)U/L, (160±16)U/L before biliary drainage and (144±13)μmol/L, (84±8)μmol/L, (79±8)U/L, (109±12)U/L after biliary drainage, showing significant differences in the above indicators ( t=3.544, 3.608, 2.523, 2.509, P<0.05). (4) Factors influencing surgery-related complications after pancreatocoduodenectomy. Results of multi-variate analysis showed that operation time was an independent factor influencing surgery-related complications after pancreaticoduodenectomy ( odds ratio=1.005, 95% confidence interval as 1.002?1.008, P<0.05). Conclusions:Preoperative biliary drainage does not increase the incidence of complications related to pancreaticoduodenectomy in patients with periampullary space-occupying lesion. Operation time is an independent factor influencing postoperative surgery-related complications.

Clinical characteristics of choledocholithiasis combined with periampullary diverticulum and influencing factor analysis for difficult cannulation of endoscopic retrograde cholangiopan-creatography: a report of 1 920 cases / 中华消化外科杂志

Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.

Differential expression of CK7, CK20, CDX2 in intestinal and pancreatobiliary types of preriampullary carcinoma

Context: Incidence of periampullary carcinoma is low, approximately 0.5–2% of all gastrointestinal malignancies. Histologic subtyping has a prognostic bearing. The purpose of this study is to differentiate periampullary carcinomas based on immunohistochemistry (IHC) by using cytokeratin 7 (CK7), cytokeratin 20 (CK20), caudal type homeobox 2 (CDX2). Aims: To analyze the usefulness of IHC as single/panel of markers that included CK7, CK20, and CDX2. Settings and Design: This was a prospective study done from January 2017 to September 2018. Subjects and Methods: A total 50 pancreaticoduodenectomy specimens were evaluated and classified as intestinal (INT) and pancreaticobiliary (PB) types based on their morphological and immunohistochemical features, respectively. The morphologic subtypes, expression of IHC markers were correlated with different histologic parameters. Statistical Analysis: Chi-square test was used to study the association between different IHC markers with histologic parameters. Probability (P) values <0.05 were regarded as statistically significant. Results: The expression of CK7, CK20, CDX2 were studied in 50 cases to classify them as INT and pancreatobiliary subtypes. CK7 has high sensitivity (88.2%), CDX2 has high specificity (96.4%), CK20+/CDX2+ has both high sensitivity (94.2 percent) and specificity (89.2 percent) in differentiating INT from pancreatobiliary subtypes. The morphologic subtypes showed correlation with two variables (tumor grade, pathologic T stage). CK20 and CK20/CDX2 expression showed a positive correlation with tumor grade, pathologic T staging, and lymphovascular invasion. Conclusions: In conclusion, morphological classification can significantly discriminate histologic types, IHC plays a moderate role. However, the combined expression of CK20 and CDX2 is helpful in subtyping.

Current epidemiology of periampullary malignancies in a tertiary referral center in the Philippines: A five-year review

Background@#Periampullary malignancies traditionally occur during the later decades of life, but casual observations at the Philippine General Hospital (PGH) have shown more patients presenting at younger ages. Updates on the epidemiology and clinical features of these uncommon cancers may improve detection and result in better outcomes. @*Objective@#The study aimed to describe the current epidemiology of adult patients diagnosed with periampullary malignancies seen in the past five years at the PGH Department of Surgery. @*Methods@#Demographic and clinical data were obtained on patients with either pancreatic head, ampullary, distal bile duct, or duodenal cancer diagnosed from 2015 to 2019. Age and sex distributions, rates of symptom presentation, utilization of diagnostic modalities, and prevalence of comorbid conditions were analyzed per individual primary site and for the entire study population. @*Results@#Two hundred seventy-seven patients were included in the study, comprised mostly of pancreatic head cancers (56.32%) followed by ampullary (19.86%), duodenal (9.75%), and distal CBD cancers (7.58%). The mean age of presentation was 59.30 years. 33.94% of cases occurred in the 6th decade of life, while 24.91% of patients were aged 50 years and below. There was a nearly equal distribution by sex (50.90% female, 49.10% male). Majority of patients presented with jaundice (89.65%) and abdominal pain (71.64%). CT scan was used to diagnose 71.48% of patients. We observed a higher prevalence of diabetes mellitus (21.32%), biliary stone disease (19.12%), and smoking history (36.88%) in the study group compared to the general Philippine population. @*Conclusion@#The epidemiology of periampullary malignancies at UP-PGH showed a younger age at presentation and an equal sex ratio compared to published data. Distributions of the primary sites, symptom frequency, and rate of associated comorbidities were consistent with previous findings from the literature.

Tratamiento quirúrgico paliativo de los tumores periampulares, una opción de paliación a largo plazo / Palliative surgical treatment of periampullary tumors, an option of long-term palliation

RESUMEN Introducción: los tumores de la encrucijada duodeno-bilio-pancreática o periampulares corresponden a un grupo heterogéneo de tumores. Se originan dentro de los 2 cm de la papila duodenal mayor. En los tumores irresecables, el tratamiento debe estar dirigido a la paliación más efectiva. El tratamiento quirúrgico paliativo va dirigido a resolver la obstrucción biliar, duodenal y el dolor, con el fin de optimizar la calidad de vida de los pacientes. Objetivo: describir el comportamiento del tratamiento quirúrgico paliativo de los tumores periampulares. Materiales y métodos: se realizó una investigación observacional, descriptiva y prospectiva con los pacientes con tumor periampular irresecable tributarios a tratamiento quirúrgico paliativo, en el Servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en la ciudad de Matanzas, desde enero del 2010 hasta diciembre del 2019. Resultados: el tumor de páncreas fue el más representado. Todos los pacientes fueron tributarios de derivación biliar quirúrgica paliativa, sin embargo, la derivación gástrica se realizó solo con confirmación endoscópica de infiltración tumoral u obstrucción duodenal y la esplacnicectomía química, siempre que fue factible técnicamente o las condiciones del paciente lo permitieron. La hepaticoyeyunostomía en Y de ROUX fue la derivación biliar de elección. La principal complicación quirúrgica fue la sepsis provocando las muertes. Conclusiones: la paliación quirúrgica es la alternativa de elección con mejores resultados a largo plazo, en los tumores periampulares irresecables con buen estado general, lo que contribuye a una mejor calidad de vida (AU).

ABSTRACT Introduction: the tumors of the duodenal-biliary-pancreatic junction or periampullary tumors correspond to a heterogeneous group of tumor. They originate inside the 2 cm of the major duodenal papilla. In unresectable tumors, the treatment should be intended for the most effective palliation. The surgical palliative treatment is intended for solving biliary, duodenal obstruction, and pain, with the aim of optimizing patients' life quality. Objective: to describe the behavior of the periampullary tumors palliative surgical treatment. Materials and methods: a prospective, descriptive, observational research was carried out in patients with unresectable periampullary tumor tributary to palliative surgical treatment, in the Service of General Surgery of the University Hospital "Comandante Faustino Perez Hernandez", of Matanzas, from January 2010 to December 2019. Results: pancreas tumor was the most represented one. All patients were tributary to biliary palliative surgical derivation, however, gastric derivation was performed only with endoscopic confirmation of tumor infiltration or duodenal obstruction, and chemical splanchnicectomy whenever it was technically feasible and the patient's conditions allowed it. Roux's Y-shaped hepaticojejunostomy was the elective biliary derivation. The main surgical complication was sepsis provoking deaths. Conclusions: surgical palliation is the election alternative with long- term better outcomes, in unresectable periampullary tumors with a good general status, contributing to better life quality (AU).

Dual malignancy: a rare presentation of synchronous periampullary carcinoma with renal cell carcinoma

The occurrence of synchronous pancreatic cancer and other primary cancer is not frequent and reaches about 5.6% as reported in autoptic studies. Double resections of the pancreas with another organ due to synchronous malignancies have been published only in quite sporadic sets of cases or individual case reports. We present a case report of a 40 years lady who presented with intermittent pain, fever and jaundice for 15 days. Examination revealed a palpable gall bladder, firm in consistency and tender to touch. She was admitted with a provisional diagnosis of cholangitis and started on intravenous antibiotics. Patient’s clinical condition improved and she was planned for a CECT and MRCP which revealed an heterogenously enhancing mass lesion in upper pole of left kidney, s/o of renal cell carcinoma (RCC) and an enhancing lesion in periampullary region s/o periampullary carcinoma with no evidence of free fluid or metastasis. ERCP guided biopsy revealed moderately differentiated adenocarcinoma and USG guided renal biopsy revealed clear cell carcinoma. Whipple’s procedure with left nephrectomy was performed. Intra operative findings revealed post-operative course and hospital stay was uneventful. Biopsy revealed poorly differentiated pancreaticobiliary adenocarcinoma with no lympho vascular or lymph nodal invasion (pT3aN0) and left sided clear cell renal carcinoma with no lympho vascular invasion (pT1N0). Synchronous malignancy of pancreas and kidney is a very rare presentation. Literature describes presence of RCC with periampullary metastasis and patients presenting with RCC post whipple’s procedure but only a handful of case reports describe presence of dual malignancy as reported above.

Adenocarcinoma de papila duodenal maior - Um relato de caso / Adenocarcinoma of the major duodenal papilla - A case report

Tumores periampulares (TP) são originados a partir de estruturas próximas a Ampola de Vater e correspondem a um grupo heterogêneo de neoplasias. O adenocarcinoma da papila duodenal maior faz parte desse grupo de neoplasias. As principais manifestações são a icterícia do tipo obstrutiva, prurido, colúria, acolia fecal, além de perda ponderal e dor abdominal, associado a elevação dos níveis séricos de bilirrubina e enzimas hepáticas. O prognóstico é obscuro, sendo os carcinomas do tipo pancreaticobiliar aqueles com pior prognóstico. A ecografia endoscópica é o método mais sensível para diagnóstico e estadiamento e o tratamento de escolha é pancreaticoduodenectomia, conhecida como cirurgia de Whipple, frequentemente associada à quimioterapia adjuvante ou terapia de quimiorradiação. O presente trabalho propõe descrever um caso de adenocarcinoma da ampola de Vater em paciente de 38 anos atendida no Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF), abrangendo desde a sintomatologia inicial, processo diagnóstico até a conduta terapêutica. Sua relevância está em alertar os profissionais da saúde sobre a importância de elencar os tumores periampulares entre os possíveis diagnósticos diferenciais para pacientes com síndrome colestática, dado que o diagnóstico e a ressecção cirúrgica precoce são os fatores decisivos para um melhor prognóstico. (AU)

Periampular tumors (PT) originate from structures close to Vater's Ampulla and correspond to a heterogeneous group of cancers. The adenocarcinoma of the major duodenal papilla is part of this group of cancers. The main manifestations are obstructive jaundice, pruritus, choluria, fecal acholia, weight loss and abdominal pain, associated with elevated serum levels of bilirubin and liver enzymes. The prognosis is poor, with pancreaticobiliar type carcinomas having the worst prognosis. Endoscopic ultrasound is the most sensitive method for diagnosis and staging, and the best treatment is pancreaticoduodenectomy, known as Whipple surgery, often associated with adjuvant chemotherapy or chemoradiation therapy. The article proposes to describe a case of adenocarcinoma of the Vater's ampulla in a 38-year-old patient treated at the University Hospital of the Federal University of Juiz de Fora (HU-UFJF), covering from the initial symptoms, the diagnostic process and the therapeutic conduct. Its relevance is to alert health professionals about the importance of listing periampular tumors among the possible differential diagnoses for patients with cholestatic syndrome, considering that the diagnosis and early surgical resection are decisive factors for a better prognosis. (AU)

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Postoperative morbidity following Whipple’s procedure for periampullary carcinoma: a retrospective study spanning 5 years

Background: The morbidity rates for Whipple’s procedure has remained high even as mortality rates were coming down. This study was intended to assess postoperative morbidity rates in  a tertiary care centre and to compare it with other centres.Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated.Results: There were 48 patients and half of them developed morbidity. Surgical site infection was the most common complication (18.8%) followed by pulmonary complications (12.5%) and bile leak (6.25%). Half of the patients having pulmonary complications died while nobody with surgical site infection or bile leak died.Conclusions: In this study the morbidity rates were comparable to other centres. Hypoalbuminemia is a significant predictor of morbidity. Surgical site infection was the most common morbidity. Pulmonary complications were the most common cause for death. Morbidity rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where the study was conducted.

Postoperative Mortality Rate Following Whipple’s Procedure for Periampullary Carcinoma: A 5 Year Cohort Study

The mortality rates for Whipple’s procedure has come down during the last few years. This study was intended to assess perioperative mortality rates in a tertiary care centre and to compare it with other centres. Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated. Results: There were 48 patients and 8 of them died. A median serum bilirubin level of 16.9 mg% was found statistically significant with respect to mortality. Similarly placed was median serum albumin levels of 2.71 gm% and poor differentiation of tumour. Conclusion: In this study the mortality rates were comparable to other centres. Hypoalbuminaemia is a significant predictor of mortality. Tumour size of more than 3 cm is associated with high mortality. High serum bilirubin levels is an independent predictor of mortality. Several studies also show similar predictors of death in Whipple’s procedure. Pulmonary complications were the most common cause for death. Mortality rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where it was studied.

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study

BACKGROUND/AIMS: Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls. METHODS: We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease. RESULTS: The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls. CONCLUSIONS: PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

One hundred sixty pancreaticoduodenectomies for periampullary cancers in a growing-volume setting: a single-institution and a single-surgeon's experience

PURPOSE: Many studies have concluded that cancer patients may have better outcomes when their surgery is performed in high-volume centers, especially when the procedure is pancreaticoduodenectomy (PD). However, some studies concluded that experienced surgeons or incorporation of expertise from high-volume centers may achieve satisfactory outcomes after PD in low-volume centers. METHODS: I retrospectively collected and analyzed the outcomes of PD for periampullary cancers treated with curative intent in my center. RESULTS: From August 2, 2005 to December 10, 2018, 160 pancreatic resections were done with curative intent in my center. The number of operations per year was 1 in 2005 and gradually increased to 21 in 2018. Thirty-day mortality was 0, and 90-day mortality was 1 (0.6%). Morbidity was found in 65 cases (40.6%). The median follow-up period was 23.2 months and 5-year survival rates were 28.5% for pancreas head cancer, 48.2% for distal CBD cancer, and 72.6% for AOV cancer. I divided patients into 2 groups by the number of annual operations, which is more than 21 per 2 years. The 2 groups showed no differences in terms of morbidity and mortality. CONCLUSION: A well-trained low-volume surgeon may perform PD safely at a well-equipped low-volume center.

Application of CT and MRI in diagnosis and preoperative evaluation of periampullary carcinoma / 中华全科医师杂志

Periampullary carcinoma includes carcinoma of head of pancreas, carcinoma of lower common bile duct, ampullary carcinoma and adenocarcinoma of duodenum. Most of the periampullary cancers shows the same clinical symptoms their imaging manifestations are overlapping or non-specific. Accurate qualitative positioning and staging of periampullary cancers are of great value in guiding of treatment plan and evaluate postoperative outcomes. CT and MRI examination have made progress in the diagnosis of periampullary carcinoma. CT scan has a good spatial and temporal resolution, while MRI has a good tissue resolution. CT and MRI examination can be used for preoperative assessment of tumor resectability and invasion range, which is of certain value.

Application of CT and MRI in diagnosis and preoperative evaluation of periampullary carcinoma / 中华全科医师杂志

Periampullary carcinoma includes carcinoma of head of pancreas, carcinoma of lower common bile duct, ampullary carcinoma and adenocarcinoma of duodenum. Most of the periampullary cancers shows the same clinical symptoms their imaging manifestations are overlapping or non-specific . Accurate qualitative positioning and staging of periampullary cancers are of great value in guiding of treatment plan and evaluate postoperative outcomes. CT and MRI examination have made progress in the diagnosis of periampullary carcinoma. CT scan has a good spatial and temporal resolution, while MRI has a good tissue resolution. CT and MRI examination can be used for preoperative assessment of tumor resectability and invasion range, which is of certain value.

A study on periampullary diverticula 6 years ERCP experience from a referral centre

Introduction: Periampullary diverticula (PAD) are mucosal outpouchings commonly situated on the medial aspect of second part of duodenum; usually within 2-3 cm of the ampulla of vater. PAD are usually asymptomatic incidental findings during side viewing scopy. We aimed to analyze the influence of PAD in the management of patients who underwent ERCP during past 6 years in our centre. Materials and methods: Patients between the ages of 13 and 74 with the diagnosis of pancreaticobiliary diseases who underwent ERCP at Institute of medical gastroenterology, Madras Medical College from January 2012 to December 2017 were taken into account for retrospective analysis. We assessed and compared ERCP results in patients with and without PAD. Results: A total of 3412 patients underwent ERCP that of these 197(5.77%) patients had PAD. Among the 3412 cases , the incidences of PAD in patients age group less than 50 years was 2.6% and age group more than 50 years was 8.1%(P<0.001). Successful biliary cannulation was achieved in 79.18% (n=156) of patients with PAD and 93.1% of patients of patients without PAD (P<0.001). Of that in patients with PAD, for 28.93 %( n=57) cases underwent precut needle papillotomy. The papilla Rabindranath Eswaran, Premkumar Karunakaran, Allwin James, Venkateswaran Arcot Rajeswaran, Rajkumar Solomon. A study on periampullary diverticula – 6 years ERCP experience from a referral centre. IAIM, 2018; 5(6): 20-26. Page 21 was undetectable in 6 cases with PAD. Incidence of PAD was higher in choledocholithiasis group (9.2% vs 4.1%, p=0.003), but in incidence of CBD stricture had no difference. Complete clearance of CBD stones was achieved lesser in patients with PAD (72.4% vs 86.8% P=0.02). Conclusion: The frequency of PAD increases with age and occurs more in choledocholithiasis cases. Our experience showed decreased rate of cannulation success with PAD, increased difficulty in cannulation and decreased rate of successful stone retrieval.