Accessory right hepatic artery and its significance for a surgeon: A case report

Right hepatic artery (RHA) is a branch of the common hepatic artery; however, there are cases documented in the literature showing anatomical variations. Accessory RHA is an incidental finding during hepatobiliary and pancreatic surgery. This artery should be identified, carefully separated, and preserved during these surgeries. We encounter the variation while doing Whipple’s procedure in a 61-year-old patient diagnosed with carcinoma of the head of the pancreas. Intra-operatively, accessory RHA was present which was arising from the superior mesenteric artery. It was identified, carefully separated, and preserved. Variations in the origin of the artery may make it vulnerable to injuries during surgical procedures if due care is not taken

Whipple's Disease: A Systematic Review of the Literature

Introduction: Whipple's disease is a chronic systemic disease with a predilection for the digestive system, especially the small intestine. It was first described in 1907 by George H. Whipple, who named it intestinal lipodystrophy. It is caused by a gram-positive bacterium belonging to the Actinomycetaceae family called Tropheryma whipplei. Objective: To characterize patients with Whipple's disease. Materials and methods: A systematic literature review was carried out using the DeCS terms enfermedad de Whipple (Whipple's disease) or (Tropheryma whipplei) in the Pubmed/Medline, Scopus, Scielo, Science Direct, Embase, Cochrane Library, BIREME, Proquest, and Redalyc databases; 123 articles were analyzed. Results: 123 published articles corresponding to case reports and series were examined, noting a higher prevalence in males (70.6%). The most frequent manifestations were joint symptoms (61%), followed by weight loss (47.1%) and diarrhea (43.4%). The most used diagnostic method was polymerase chain reaction (PCR) (63.2%), followed by biopsy (50.7%) and pathological examination with PAS (periodic acid Schiff) granules (47.8%). The management most used was antibiotic therapy with a predominance of trimethoprim/sulfamethoxazole and ceftriaxone. Conclusions: Whipple's disease has a low prevalence, occurs more frequently in white people, mainly affects the elderly, has a predilection for the male sex, and is characterized as a chronic systemic disease with a predilection for the digestive system, especially the small intestine.

Introducción: la enfermedad de Whipple es una enfermedad crónica sistémica con predilección por el aparato digestivo, especialmente el intestino delgado. Fue descrita por vez primera en 1907 por George H. Whipple, quien la denominó lipodistrofia intestinal. Es causada por una bacteria grampositiva perteneciente a la familia de los Actinomycetaceae denominada Tropheryma whipplei. Objetivo: caracterizar a los pacientes con enfermedad de Whipple. Materiales y métodos: se realizó una revisión sistemática de la literatura, de los términos DeCS enfermedad de Whipple (whipple Disease) o (Tropheryma whipplei) en las bases de datos Pubmed/Medline, Scopus, Scielo y Science Direct, Embase, Cochrane Library, BIREME, Proquest y Redalyc; se analizaron 123 artículos. Resultados: se analizaron 123 artículos publicados que correspondían a reportes y series de casos en los cuales se evidenció una mayor prevalencia en varones (70,6%). Las manifestaciones más frecuentes fueron los síntomas articulares (61%), seguidos de pérdida de peso (47,1%) y diarrea (43,4%). El método diagnóstico más usado fue la reacción en cadena de la polimerasa (PCR) (63,2%), seguido por la biopsia (50,7%) y, por último, examen anatomopatológico con gránulos PAS (ácido peryódico de Schiff) (47,8%). El manejo más empleado fue la antibioticoterapia con predominio de trimetoprima/sulfametoxazol y ceftriaxona. Conclusiones: la enfermedad de Whipple tiene una baja prevalencia, se presenta con mayor frecuencia en personas de raza blanca, afecta principalmente a los adultos mayores, tiene predilección por el sexo masculino y se caracteriza por ser una enfermedad crónica sistémica con predilección por el aparato digestivo, especialmente el intestino delgado.

Duodenopancreatectomía laparoscópica: evolución de los primeros casos en Venezuela / Laparoscopic duodenopancreatectomy: evolution of the first cases in Venezuela

La duodenopancreatectomía cefálica es la única opción con criterio curativo de los tumores periampulares y cabeza de páncreas. El abordaje mínimamente invasivo ha mostrado sus beneficios en la duodenopancreatectomía cefálica lo cual ha llevado a un mayor interés a nivel mundial por esta técnica. El objetivo es describir la técnica utilizada y analizar la evolución que presentaron los primeros casos realizados en Venezuela de duodenopancreatectomía laparoscópica y así dar a conocer nuestra experiencia, es un estudio retrospectivo, descriptivo, de corte transversal; se revisaron 106 historias clínicas, obteniendo 8 casos para este estudio: 5 femeninos y 3 masculinos, los promedios de edad y tiempo de evolución de la enfermedad fueron de 54,15 años y de 7 meses respectivamente, la indicación fue 4 tumores de cabeza de páncreas y 4 periampulares, el índice de masa corporal promedio fue de 23,44 kg/mt2, el tiempo quirúrgico osciló entre 315 ­ 475 min, la estancia hospitalaria de 4 ­ 24 días, las perdidas hemáticas fueron de 200cc ± 20cc, tres pacientes presentaron complicaciones post operatorias mediatas. En conclusión, los resultados que hemos observado en nuestro reporte inicial de casos de duodenopancreatectomía laparoscópica reúnen las características de otras publicaciones similares y se ratifica los beneficios de este abordaje, la clave para la duodenopancreatectomía laparoscópica de rutina es que sea realizada en centros especializados, con protocolos estandarizados, ejecutado por cirujanos hepatobiliar y pancreática con experiencia en laparoscopia avanzada(AU)

Duodenopancreatectomy is the only option with curative criteria of the periampullary tumors and pancreatic head. The minimally invasive approach has shown its benefits in cephalic duodenopancreatectomy which has led to greater interest worldwide in this technique. The objective is to describe the technique used and analyze the evolution presented by the first cases of laparoscopic duodenopancreatectomy and thus publicize our experience, it is a retrospective, descriptive, cross-sectional study; 106 medical records were reviewed, obtaining 8 cases for this study: 5 women and 3 men, the average age and the time of evolution of the disease were 54.15 years and 7 months, the indication was 4 pancreas head and 4 periampullary tumors, the average body mass index was 23, 44 kg/mt2, assisted surgery was performed in 4 patients and 4 totally laparoscopic, the surgical time ranged between 315 - 475 min, and the hospital stay was 4 - 24 days, the blood loss was 200cc ± 20cc, three patients presented mediated postoperative complications. In conclusion, the results we have observed in our initial case report of laparoscopic duodenopancreatectomy meet the characteristics of other similar publications and the benefits of this approach are ratified, the key to routine laparoscopic duodenopancreatectomy is that it is performed in specialized centers, with standardized protocols, executed by surgeons with experience in advanced laparoscopy in addition to hepatobiliary and pancreatic surgery(AU)

The Outcome of Patients with Different Pancreatic Tumors Treated by Whipple’s Operation at Bangabandhu Sheikh Mujib Medical University

Background: Whipple’s Operation was first introduced by Allan Whipple in the 1930s. During 1960s and 1970’s the mortality rate for the Whipple operation was very high. Pancreatic tumors are one of the important indications for Whipple’s operation. About 85% of patients had adenocarcinoma tumor of the pancreas. 15% of patients had other tumors in the head region. In the Whipple’s operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. The aim of the study was to find the outcome of patients with different benign and malignant pancreatic tumor who undergone Whipple’s surgery and compare the preoperative finding and postoperative complication.Material & Methods:This study was a cross-sectional observational study which was carried out at the Department of Hepatobiliary and Pancreatic Surgery in Bangabandhu Sheikh Mujib Medical University (B.S.M.M.U), Dhaka, Bangladesh. The study was conducted during the period of August 2010 to July 2012. There were a total of 20 cases.Results:100% having solid pseudo papillary tumor age below 35yrs. After Whipple’s operation for solid pseudo papillary tumor of the pancreas, or benign tumor group, 25% of patients had developed wound infection. But in the case of Whipple’s operation for adenocarcinoma pancreas, 62.25% of patients developed wound infection. At a follow-up after 1 year of Whipple’s surgery, none of the benign tumor cases needed readmission, as all 100% had normal liver function tests, normal levels of CA 19-9, and normal USG findings in the abdomen. On the other hand, 25% of the malignant tumor cases had some form of complication and needed readmission.Conclusion:Most pancreatic tumors were located in the head of the pancreas which can be treated by Whipple’s operation. Adenocarcinoma of the head is the most common indication of surgery and is surgically resect able.

Multiple Biliary Stones: a Rare Long-term Complication after Whipple Procedure / Múltiplos cálculos biliares: uma complicação rara a longo prazo após o procedimento de Whipple

A hypertensive, diabetic woman underwent a successful Whipple procedure at the age of 84 due to carcinoma of the ampulla of Vater. She presented an extremely rare complication 24 months after the surgery, consisting of acute cholangitis due to multiple biliary lithiases associated with a bilioenteric anastomotic stricture. The diagnosis was confirmed with computed tomography, magnetic resonance cholangiopancreatography, and cholangiography. The patient was successfully treated with multiple percutaneous transhepatic cholangioplasties (AU)

Uma mulher hipertensa e diabética foi submetida a um procedimento bem-sucedido de Whipple aos 84 anos devido a um carcinoma da ampola de Vater e apresentou uma complicação extremamente rara 24 meses após da cirurgia, consistindo em colangite aguda devido à presença de litíase biliar múltipla associada com estenose da anastomose bilio-entérica. O diagnóstico foi confirmado com tomografia computadorizada, colangiopancreatografia por ressonância mag-nética e colangiografia.O paciente foi tratado com sucesso com múltiplas colangioplastias transhepáticas percutâneas (AU)

Pancreatic Reconstruction With Modified Technique Using A “Double U Stitch Pancreatogastrostomy” Following A Laparoscopic Whipple’s Pancreaticoduodenectomy

Background: Pancreaticoduodenectomy is a standard procedure for periampullary tumours. Pancreatic anastomosis is the Achilles heel of the procedure with a significant leak rate and the associated high morbidity. We adopted a modified pancreatic stump drainage with pancreato-gastrostomy - pancreatic stump mobilization with invagination into the lumen of the stomach via posterior gastrotomy and fixation with two U shaped sutures to the posterior wall of the stomach traversing across the pancreatic parenchyma. Materials and Methods: We did a retrospective analysis of a prospectively maintained database of patients who underwent Laparoscopic Whipple’s pancreaticoduodenectomy (WPD) from November 2017 to March 2019 in our department, a tertiary referral centre of Northern India. A total of 34 patients underwent totally laparoscopic Whipple’s pancreatoduodenectomy with the modified Pancreatogastrostomy. Results: A total of 34 patients underwent totally laparoscopic WPD during this study period. The median age was 50 years (27 to 70 years) with 17 male and 17 female patients. Of these patients, 23 patients had their tumours arising from the ampulla, 6 from the duodenum, 3 from the pancreas, 1 SCN head of pancreas and 1 from the distal common bile duct. All patients had R0 resection with a median lymph node yield of 13 (6-19). 9 patients had stage 1 disease, 10 patients had stage 2 disease and 14 patients had stage 3 disease. 31 patients had moderately differentiated adenocarcinoma while 2 patients had well-differentiated tumour morphology. 14 patients had pancreato-biliary differentiation with the remaining 19 patients having intestinal differentiation. The overall number of significant complications according to Clavien-Dindo classification was 17.6% (Grade 3 and higher) . Conclusion: Laparoscopic WPD is a feasible procedure in the hands of a well-trained laparoscopic surgeon. Modified P-G as described, simplifies the pancreatic drainage with a low incidence of post-operative pancreatic fistula and its attendant complications.

Morbidity And Mortality Of Whipple Procedure

Background:To ascertain the rate and factors affecting morbidity and mortality in patients undergoing Whipple Procedure. KEY WORDS:Morbidity,Whipple procedure, post operative complications INTRODUCTION: Pancreaticoduodenectomy, also called the Whipple operation, is a common operation in major centers worldwide. It is done mostly for periampullary cancers and very rarely for benign diseases. Over the years the operation and its morbidity and mortality have been subject to much research. Starting from the initial days postoperative mortality rate has come down but morbidity rate still remains high. Material & Methods:A study of 12 cases of whipple procedure carried out in dept of general surgery, VS AND SVP hospital from January 2019 to June 2020 OBSERVATION AND Results:There were 12 patients and half of them developed morbidity. Surgical site infection was the most common complication (33.33%) followed by pulmonary complications (16.67%) and bile leak (8.33%). Half of the Mortality rate was due to pulmonary complication. Conclusion:Pancreatoduodenectomy was studied with regards to morbidity and mortality in our hospital. The morbidity rate is comparable to that of other centres. Pulmonary complications were the most common cause of mortality. Preoperative Hypoalbuminemia is a significant predictor of postoperative morbidity. Surgical site infection was the most common morbidity. Whipple procedure is a complex procedure with comparatively less mortality, but more morbidity in our hospital.

Enfermedad de whipple e hipertensión pulmonar reversible / Whipple's disease and reversible pulmonary hypertension

Resumen La enfermedad de Whipple es una enfermedad multisistémica crónica, causada por la bacteria Tropherima whipplei. Se han descripto aproximadamente 1200 casos en la literatura. La incidencia mundial se estima en 9.8 casos por millón de personas. Los datos provenientes de Sudamérica y Europa muestran que afecta a varones de mediana edad. Se cree que los factores inmunológicos del huésped son los que influyen en el curso de la infección y no el genotipo del agente. Dado que las características clínicas no suelen ser específicas y el espectro de manifestaciones en órganos individuales puede ser subestimado, el diagnóstico sigue siendo muy difícil. Presentamos un caso confirmado por histopatología con compromiso multisistémico. Consideramos importante su difusión dados los escasos casos documentados en Sudamérica y la relevancia de tener presente la sospecha diagnóstica para el abordaje terapéutico precoz que mejora el pronóstico de esta rara enfermedad.

Abstract Whipple's disease is a chronic mutisystem disease caused by the bacteria Tropherima whipplei. Approximately 1200 cases have been described in the literature. The worldwide incidence is estimated at 9.8 cases per million people. Data from South America and Europe show that it affects middle-aged males. It is believed that host immunological factors rather than agent genotypic traits influence the course of the infection. Since the clinical characteristics are usually nonspecific and the wide spectrum of manifestations in individual organs may be underestimated, the diagnosis remains challenging. We present a case with multisystem compromise confirmed by histopathology. We consider its publication important given the few cases documented in South America and the relevance of bearing in mind the importance of an early diagnosis for a prompt treatment that improves the prognosis of this rare disease.

Investigation of preoperative anemia and perioperative blood transfusion in patients with duodenal papillarycarcinoma in a tertiary hospital / 中国输血杂志

【Objective】 To investigate the preoperative anemia and perioperative blood transfusion in patients with duodenal papillary carcinoma who underwent Whipple surgery. 【Methods】 The clinical data of 1 959 cases with duodenal papillary carcinoma, subjected to Whipple surgery, were retrospectively analyzed. 【Results】 The rate of anemia in preoperative patients with duodenal papillary carcinoma was 54.87%(1 075/1 959). The incidence rate of anemia in the three age groups from low to high was 44.92% (≤50 years old, 190/423), 52.82% (51~64 years old, 506/958), and 65.57% (≥65 years old, 379/578) (P<0.05), and the highest rate of anemia occurred in patients aged above 65. There was a significant statistical difference among patients with different body mass index (BMI)(P<0.05). Patients with moderate or severe anemia received more red blood cells than patients with mild anemia during the perioperative period (P<0.05). The average hospitalization time of the blood transfusion patients was 27.25 days, and that of non-transfusion patients was 22.22 days (P<0.05). The amount of blood loss and hospitalization time of patients underwent laparoscopic and robotic surgery were significantly lower than those underwent open surgery patients (P <0.05). There were only 24.09%(186/772) treated with drugs for anemia intervention and the majority of patients (75.91%, 586/772) were treated with blood transfusions to interfere with anemia during hospitalization. 【Conclusion】 There are significant differences in the incidence rate of preoperative anemia among patients with duodenal papillary carcinoma who undergone Whipple surgery. Low BMI, abnormal WBC, and perioperative blood transfusion are high-risk factors for prolonged hospital stay, whereas anemia is not associated with prolonged hospital stay.

Tropheryma whipplei as the cause of acute pneumonia / 中华检验医学杂志

Tropheryma whipplei (TW) is an opportunistic pathogen that can cause Whipple′s disease (WD). Recently, the biomedical field is concerned about whether the bacteria cause pneumonia. When BALF was detected by PCR, the TW positive rate was about 6.1%. Etiology status is generally described as “associated” or “probable”. Immunocompromised status is the susceptible factor; Different species of the same genus have been reported. The current method may have missed detection. All relevant information needs further study. This article reviews the acute pneumonia caused by TW and the detection technology.

Procedimiento de Whipple: experiencia de un centro en fase de crecimiento en cirugía hepato-bilio-pancreática / Whipple procedure: hepatic-bilio-pancreatic single center experience

La operación de Whipple es el procedimiento quirúrgico de mayor complejidad en cirugía abdominal, este se realiza en pacientes con tumores de la encrucijada pancreatoduodenal, es la única alternativa para tratamiento curativo en fases tempranas de la enfermedad. Objetivo: Determinar los resultados del procedimiento Whipple, en pacientes intervenidos con tumores de la encrucijada pancreatoduodenal en el Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social, en el periodo de enero 2,015 a enero 2,020. Método: Descriptivo, observacional, retrospectivo. Resultados: Se incluyeron 42 procedimientos de Whipple, 29 (69%) casos del género masculino y 13 (31%) para el género femenino. La edad media fue de 61.5 años, el 54% presentaban comorbilidad asociada. El 24% utilizo transfusión transoperatoria de hemoderivados, el tiempo quirúrgico de 5.5 horas. La reintervención fue del 4.7%. Complicaciones postoperatorias tempranas 18%. La histología más común fue el carcinoma de cabeza de páncreas en el 43%. La mortalidad postoperatoria temprana fue del 4.7%. El OR de complicaciones asociadas a comorbilidades fue de 1.7 con un IC 0.3046-7.20 y un valor de P: 0.9251 que no es estadísticamente significativo. Conclusiones: Los tumores pancreatoduodenales en nuestra población se presentan en edades más tempranas a lo reportado. La morbimortalidad es similar a lo reportado en otros estudios a nivel latinoamericano, sin embargo las complicaciones están más elevadas que las mejores series internacionales. No existe asociación entre el riesgo de complicaciones con comorbilidades del paciente. (AU)

Whipple operation is the most complex surgical procedure in abdominal surgery, it's performed in patients with tumors of the pancreaticoduodenal crossroads, it is the only alternative for curative treatment in early stages of the disease. Objective: To determine the results of the Whipple procedure in patients operated on with tumors of the ancreaticoduodenal crossroads at the Hospital General de Enfermedades del IGSS in the period from January 2015 to January 2020. Method: Descriptive, observational, retrospective. Results: fourtytwo Whipple procedures were included, 29 (69%) cases of the male gender and 13 (31%) for the female gender. The mean age was 61.5 years, 54% had associated comorbidity. Twentyfour percent used intraoperative transfusion of blood products and surgical time of 5.5 hours. Reoperation was 4.7% with early postoperative complications of 18%. The most common histology was carcinoma of the head of the pancreas in 43%. Early postoperative mortality was 4.7%. The OR of complications associated with comorbidities was 1.7 with a CI 0.3046-7.20 and a P value: 0.9251, which is not statistically significant. Conclusions: Pancreaticoduodenal tumors in our population present at an earlier age than reported. Morbidity and mortality is similar to that reported in other studies. There is no association between the risk of complications with patient comorbidities. (AU)

Qualidade da declaração de idade nos dados de óbito do Censo demográfico brasileiro de 2010 / Quality of age statement in 2010 brazilian demographic Census death data

Resumo Introdução O debate em torno do quesito de óbito no Censo Demográfico brasileiro foi retomado pela proximidade do Censo Demográfico de 2020. Há certa vantagem em obter informações de óbito por meio do Censo, mas é importante garantir a qualidade dessa informação. Objetivo Analisar a qualidade da declaração de idade para os dados de óbito do Censo Demográfico de 2010. Método Foram utilizadas as informações acerca dos óbitos nos domicílios, coletadas no questionário do universo do Censo Demográfico de 2010 do IBGE. A análise foi realizada a partir dos índices de Whipple e Myers. Resultados Para o Brasil como um todo, os resultados observados atestam uma boa qualidade dos dados de declaração de idade dos óbitos. No entanto, quando é estratificada a análise ao âmbito de unidades federativas, algumas distorções foram verificadas, sobretudo nas unidades pertencentes às regiões Norte e Centro-Oeste. Conclusão O uso dos dados de mortalidade para as análises em âmbito macro, do país como um todo, não requer ajustes para adequar as qualidades das informações, assim como para as análises em termos das grandes regiões.

Abstract Background The debate on deaths in the Brazilian population census has been resumed by the proximity of the next 2020 census. There are some advantages in obtaining death information through the census, but it is important to ensure the quality of this information. Objective To analyze the quality of the age declaration for the 2010 demographic census death data. Method Information on household deaths collected from the 2010 IBGE demographic census questionnaire was used. The analysis was performed from the Whipple and Myers indices. Results For Brazil as a whole, the observed results attest to a good quality of the death declaration data. However, when the analysis at the state level is stratified, some distortions were found, especially in the North and Midwest areas. Conclusion The use of mortality data for macro-level analyzes of the country as a whole does not require adjustments to suit the quality of the information, as well as for analysis in terms of large regions.

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)

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.

Seguridad del procedimiento de Whipple: experiencia de 10 años en un centro de tercer nivel / Whipple procedure safety: 10 year experience in a third level center / Whipple procedure safety: 10 year experience in a third level center

Resumen Antecedentes: el procedimiento de Whipple, apesar de los avances en cirugía, continúa siendo el procedimiento más complejo en cirugía general. Su principal indicación es la patología neoplásica de páncreas, duodeno y vías biliares que persiste como un desafío terapéutico debido a su alta morbilidad y mortalidad que en nuestro país alcanza 40% a 60% y de 15% a 30%, respectivamente. Objetivo: determinar la seguridad del procedimiento de Whipple en una institución privada de tercer nivel. Materiales y métodos: se realizó un estudio observacional retrospectivo, desde 2007 hasta 2017 en el Hospital Metropolitano. Datos recolectados: indicación quirúrgica, complicaciones, estancia hospitalaria, entre otros, que se analizaron con JASP 0.9.2.0. Resultados: universo 30 pacientes, edad promedio: 60,1 años IC (95%: 39 a 79 años); mujeres: 56%, hombres: 44%. Estancia hospitalaria promedio: 15 días con un DS:15 días. Principales indicaciones: adenocarcinoma de páncreas 33,3%, adenocarcinoma de ámpula de Vatter 16,7% colangiocarcinoma 16,7%. Según la escala Clavien Dindo, el 76,7% presentó complicaciones; sin embargo, de éstas el 59,9% fueron leves. Mortalidad intrahospitalaria: 6,7%. Conclusiones: atribuimos los resultados, entre otros motivos, a la disponibilidad de facilidades técnicas y a la experiencia del equipo quirúrgico que enfatiza en la prevención de las complicaciones o, si se presentare, al diagnóstico oportuno y tratamiento adecuado con todo el arsenal terapéutico requerido.

Abstract: Background: The Whipple procedure, despite advances in surgery, remains the most complex procedure in general surgery, its main indication is the neoplastic pathology of pancreas, duodenum and bile ducts. This persists as a therapeutic challenge due to its high morbidity and mortality that in our country reaches from 40% to 60% and from 15% to 30%, respectively. Objective: Determine the safety of performing the Whipple procedure in a third level private institution. Materials and methods: A retrospective observational study was conducted from 2007 to 2017 at the Hospital Metropolitano, the data collected included: surgical indication, complications, hospital stay, among others; these were analyzed with JASP 0.9.2.0. Results: We included 30 patients, their mean age was 60.1 years, 95% CI: 39 -79 years; 56% were women and 44% men. The average hospital stay was 15 days with a SD:15 days. The main indications were: adenocarcinoma of the pancreas 33.3%, adenocarcinoma of the Vatter ampulla 16.7% and cholangiocarcinoma 16.7%. According to the Clavien Dindo scale, 76.7% presented complications, however, 59.9% of these were mild. In-hospital mortality reached 6.7%. Conclusions: We attribute the results shown, among others, to the availability of technical facilities, as well as to the experience of the surgical team, emphasizing the prevention of complications or in the case of occurrence, provide a timely diagnosis and adequate treatment with allthe required therapeutic methods.

Qualidade da informação da idade nos registros de óbito no Brasil, 1996-2015 / Quality of the information about age on the death registers in Brazil, 1996-2015 / Calidad de la información de la edad en los registros de óbito en Brasil, 1996-2015

Este artigo apresenta os resultados de uma pesquisa que teve como objetivo analisar a qualidade da declaração da idade nos registros de óbito no Brasil, de 1996 a 2015. Foi realizada uma análise por 'idade simples' dos microdados de óbitos no Brasil no período mencionado. A preferência por dígitos terminais 0 e 5 foi avaliada usando o índice de Whipple (IW). Já a preferência pelos dígitos terminais de 0 a 9 foi expressa usando o método de Myers (IM). A qualidade dos dados de idade foi alta no período [IWtot = 0,55 ­ 0,83 (masculino) e 0,71 ­ 0,93 (feminino); IM = 0,388 ­ 1,004 (masculino) e 0,430 ­ 1,589 (feminino)]. A qualidade da informação foi mais satisfatória entre homens e não houve tendência significativa a uma melhora, sugerindo sua estabilidade durante os 20 anos analisados. Foi encontrada preferência pelo dígito terminal 0 (zero) principalmente entre mulheres. Concluiu-se que os dados de óbito no Brasil, com relação à idade, são satisfatórios, podendo ser utilizados em análises demográficas e epidemiológicas.

This article presents the results of a research aimed at analyzing the quality of the information about the age on the death registers in Brazil, from 1996 to 2015. An analysis was performed by simple age of the deaths microdata in Brazil for that period. The preference for the last digits 0 and 5 was evaluated using the Whipple index (IW), while the preference for the last digits from 0 to 9 was expressed using the Myers (IM) method. The quality of the age data was high in the period [IWTtot = 0.55 - 0.83 (male) and 0.71 - 0.93 (female); IM = 0.388 - 1.004 (male) and 0.430 ­ 1.589 (female)]. The quality of the information was more satisfactory among men, and there was not a significant trend in the improvement suggesting stable quality during the 20 years analyzed. The preference was given to the last digit 0, mainly among women. It was concluded that data from death registers in Brazil regarding the age are satisfactory and can be used in demographic and epidemiological analyses.

Este artículo presenta los resultados de una investigación que tuvo como objetivo analizar la calidad de la declaración de la edad en los registros de óbito en Brasil, desde 1996 hasta 2015. Se realizó el análisis por edad simple de los microdatos de óbitos en Brasil en el periodo mencionado. La preferencia por dígitos finales 0 y 5 fue evaluada usando el índice de Whipple (IW). La preferencia por los dígitos finales desde 0 hasta 9 fue expresada usando el método de Myers (IM). La calidad de los datos de edad fue alta en el período [(IWtot = 0,55 - 0,83 (masculino) y 0,71 - 0,93 (femenino), IM = 0,388 - 1,004 (masculino) y 0,430 - 1,589 (femenino)]. La calidad de la información fue más satisfactoria entre hombres y no hubo tendencia significativa en la mejora, sugiriendo estabilidad en la calidad en los 20 años analizados. Se encontró una preferencia por el dígito terminal 0 principalmente entre mujeres. Se concluye que los datos de óbito en Brasil con relación a la edad son satisfactorios y pueden ser utilizados en análisis demográficos y epidemiológicos.

Doença de Whipple - uma condição não rara que pode mimetizar espondiloartrite e piora com o uso de imunobiológico anti-TNF / Whipple's Disease - an uncommon condition that can mimic spondyloarthritis and worsens with the use of anti-TNF immunobiological

A doença de Whipple é uma condição rara causada pela Tropheryma whipplei. Sua apresentação articular mais comum é a artralgia migratória de grandes articulações. Mais raramente cursa com oligoartrite ou poliartrite, que podem preceder as manifestações gastrointestinais em vários anos. Cursa com diarréia e má absorção, podendo também causar derrame pleural e linfonodomegalias. Alguns pacientes podem apresentar sacroiliite, uveíte e confundir com espondiloartrite, e neste contexto o uso de anti-TNF pode ser iniciado. Os autores relatam o caso de um paciente masculino, 50 anos, com quadro compatível com espondiloartrite em que o início do infliximabe determinou piora clínica e após reavaliação confirmou tratar-se de doença de Whipple.

Whipple's disease is a rare condition caused by Tropheryma whipplei. Its most common articular presentation is migratory arthralgia of large joints. More rarely it courses with oligoarthritis or polyarthritis, which can precede the gastrointestinal manifestations in several years. It causes diarrhea and malabsorption, and may also cause pleural effusion and lymphadenopathy. Some patients may present with sacroiliitis, uveitis and confuse with spondyloarthritis, and in this context the use of anti-TNF may be initiated. The authors report the case of a 50-year-old male patient with a spondyloarthritis-compatible condition in which the onset of infliximab caused clinical worsening and after reassessment confirmed that it was Whipple's disease.

Manifestaciones Neuropsiquiatricas De La Enfermedad De Whipple En Una Adolescente: A Propósito De Un Caso / Neuropsiquiatric Manifestations Of Whipple Disease In An Adolescent: Case Report

RESUMEN La enfermedad de Whipple (EW) es una rara infección sistémica crónica producida por el actinomiceto Tropheryma Whipplei. Las manifestaciones clínicas son principalmente intestinales, si bien en ocasiones se asocian presentaciones extraintestinales (articulares, cardiacas, pulmonares neurológicas…), e incluso pueden presentarse sólo éstas últimas. Se presenta una paciente de 15 años derivada al servicio de Psiquiatría , con el diagnóstico de depresión, con un evolución de 6 meses con empeoramiento, ingreso por intento autolítico y paralelamente refiere sintomatología neurológica atípica. Se le remite a Neurología para descartar patología orgánica, incluyendo patologías autoinmunes (encefalitis antiNMDA), encontrándose en el estudio, PCR positivo a Tropheryma Whipplei en LCR, diagnosticándose de enfermedad de Whipple con afectación neurológica. Se realizó tratamiento antibiótico según las pautas establecidas, repitiéndose al finalizar el tratamiento la punción lumbar, resultando ésta negativa y con mejoría clínica tanto neurológica como psiquiátrica.

SUMMARY Whipple disease (WD) is a rare chronic systemic infection caused by the actinomycete Tropheryma Whipplei. The clinical manifestations are mainly intestinal, although occasionally may present extraintestinal locations (joints, heart, pulmonary, central nervous system ...) , and even the last can be the only symptom. We present a 15-year-old female patient referred to the psychiatry service, with a diagnosis of depression, with a 6-month evolution with worsening, admission due to autolytic attempt and, at the same time, atypical neurological symptomatology. She is referred to Neurology to rule out organic pathology, including autoimmune pathologies (antiNMDA encephalitis, ...), finding in the study, PCR positive Tropheryma Whipplei, and being diagnosed of Whipple disease with neurological involvement. Antibiotic treatment was performed according to the established guidelines, repeated at the end of the treatment the lumbar puncture, resulting this negative and with clinical neurological improvement as well as psychiatric.

Tratamiento del ampuloma con cirugía de Whipple. Reporte del primer caso en el hospital regional de Tumbes / Ampulloma treatment with Whipple surgery. First case report in the regional hospital of Tumbes

Se presenta el primer caso de cirugía de Whipple realizada en el Hospital Regional de Tumbes para tratamiento de ampuloma con resultado exitoso. Reporte de caso de una paciente con diagnóstico de ampuloma en la que se realizó la primera cirugía de Whipple efectuada en el Hospital Regional de Tumbes en octubre del año 2014. La paciente con diagnóstico de síndrome ictérico obstructivo por ampuloma fue sometida a cirugía de Whipple, cursó el post operatorio con mejoría paulatina, no presentó patología respiratoria, ni cursó con fiebre, la paciente toleró la vía oral, la ictericia disminuyó y fue dada de alta hospitalaria a los 13 días. Cursó con fístula pancreática de gasto bajo (30 cc/día) la cual remitió a las 3 semanas. La paciente presentó mejoría clínica evidente y con resultados quirúrgicos satisfactorios hasta la fecha. La cirugía de Whipple es la técnica quirúrgica de elección en el tratamiento del ampuloma y es factible de realizarse, en casos que lo ameriten, en hospitales de frontera si se cuenta con el personal capacitado y la logística necesaria.

To report the first case of Whipple surgery performed at the Regional Hospital of Tumbes for the treatment of ampullary adenocarcinoma with successful results. A case report of a patient with diagnosis of ampullary adenocarcinoma, in whom was performed the first Whipple surgery at the Regional Hospital of Tumbes, in October, 2014. The patient diagnosed with an obstructive jaundice syndrome due to ampullary adenocarcinoma underwent Whipple surgery. She performed the postoperative period with gradual improvement, she did not present with respiratory pathology, she not have fever, the patient tolerated the oral route, the jaundice decreased and she was discharged after 13 days. She presented low-output pancreatic fistula (30 cc/day), which remitted at 3 weeks. The patient presented evident clinical improvement and satisfactory surgical results to date. Whipple surgery is the surgical technique of choice in the treatment of the ampullary adenocarcinoma and it is feasible to perform, in cases that is indicated, in bounderies hospitals if you have the trained personnel and necessary logistics.