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

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

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

Neoplasia pseudopapilar sólida del páncreas (tumor de Frantz) en una joven de 13 años / Solid pseudopapillary tumor of the pancreas (Frantz tumor) in a 13-year-old girl

RESUMEN El tumor sólido pseudopapilar de páncreas (TSP) es un tumor infrecuente, de bajo grado de malignidad, que representa el 1-3% de todas las neoplasias pancreáticas, con predilección por el sexo femenino, y es el tumor sólido de páncreas más frecuente en la infancia. Mujer de 13 años que consultó por dolor abdominal de 5 días de evolución, en hipocondrio derecho e irradiado a espalda, con náuseas y vómitos. TSP es diagnosticado con ecografía, tomografía computarizada (TC) y resonancia magnética (RM). Se realizó duodenopancreatectomía cefálica. La paciente fue dada de alta. El examen anatomopatológico informó un TSP de páncreas. El abordaje quirúrgico de estos tumores, abierto o laparoscópico, permite una excelente supervivencia alejada.

ABSTRACT Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm with a low malignant potential and represents 1- 3% of all pancreatic tumors. They usually occur in women and are the most common solid pancreatic tumor in children. A 13-year-old girl visited the emergency department due to abdominal pain in the right hypochondrium radiating to the back, nausea and vomiting lasting 5 days. A SPT was diagnosed by ultrasound, computed tomography (CT) scan and magnetic resonance imaging (MRI). The patient underwent cephalic pancreaticoduodenectomy and was discharged. The pathological study reported a SPT of the pancreas. The surgical approach of these tumors through open surgery or laparoscopy offers excellent long-term survival.

Prevention and management of pancreatic fistula after pancreatoduodenectomy with precise and comprehensive opinion / 中华消化外科杂志

Pancreaticoduodenectomy (PD) is a major operation of abdominal surgery, with high risk, complex operation, more complications and high mortality. Pancreatic fistula is the main cause of death after PD. Due to its complexity and obstinacy, pancreatic fistula has become the top challenge of pancreatic surgery. The authors review the relevant literature and summarize the prevention and management of pancreatic fistula after PD, such as the optimization strategies for pancreatic anastomosis, the use of external stents, prophylactic drains in surgical field, the applica-tion of somatostatin and its analogues, and whole-course nutrition management, based on the precise and comprehensive opinion, in order to provide reference for improving the prevention and treatment of pancreatic fistula after PD.

Pancreatoduodenectomy due to lipomatous pseudohypertrophy of the pancreas / Pancreatoduodenectomia por pseudohipertrofia lipomatosa do pâncreas

ABSTRACT BACKGROUND: Lipomatous pseudohypertrophy of the pancreas, pancreatic lipomatosis, pancreatic steatosis, non-alcoholic fatty pancreatic disease, or fatty pancreas is an extremely rare disease, characterized by the organ enlargement and a localized or diffuse replacement of pancreatic acinar cells by mature adipose tissue, preserving the pancreatic ductal system and islets of Langerhans. AIMS: To report a rare case of lipomatous pseudohypertrophy of the pancreas in a symptomatic patient and the surgical treatment employed. METHODS: A 24-year-old male patient with weight loss (10 kilograms in 8 months), hyperglycemia, severe and recurrent acute abdominal pain, epigastric discomfort associated with nausea, vomiting, and jaundice for 40 days. Magnetic resonance imaging was performed, revealing an irregular lipomatous pseudohypertrophy of the pancreas, measuring 6.0 × 5.6 cm in the head, uncinate process, and part of the body of the pancreas. The pancreatic duct dilation was diffuse and irregular, associated with atrophy of the remnant parenchyma, particularly in the tail of the pancreas. The patient underwent pancreatoduodenectomy without total mesopancreas excision followed by pancreatojejunostomy. RESULTS: The postoperative course was uneventful, the length of stay in the ICU was two days, and the patient was discharged on the seventh postoperative day. CONCLUSIONS: The disease treatment depends on the signs and symptoms at presentation and a pancreatoduodenectomy is indicated in patients with severe and recurrent abdominal pain.

RESUMO RACIONAL: Pseudo-hipertrofia lipomatosa do pâncreas, lipomatose pancreática, esteatose pancreática, doença pancreática gordurosa não alcoólica ou pâncreas gorduroso é uma doença extremamente rara, caracterizada por aumento do órgão e substituição localizada ou difusa de células acinares pancreáticas por tecido adiposo, preservando o sistema ductal pancreático e as ilhotas de Langerhans. OBJETIVOS: Relatar um caso raro de pseudo-hipertrofia lipomatosa do pâncreas, em paciente sintomático e o tratamento cirúrgico empregado. MÉTODOS: Paciente do sexo masculino, 24 anos, com queixas de emagrecimento (10 quilos nos últimos 8 meses), hiperglicemia, dor abdominal aguda intensa e recorrente, desconforto epigástrico associado a náuseas, vômitos e icterícia há 40 dias. A ressonância magnética (RM) revelou pseudo-hipertrofia lipomatosa irregular do pâncreas, medindo 6,0 × 5,6 cm na cabeça, processo uncinado e parte do corpo do pâncreas. A dilatação do ducto pancreático era difusa e irregular, associada à atrofia do parênquima remanescente, principalmente na cauda do pâncreas. O paciente foi submetido à duodenopancreatectomia sem excisão total do mesopâncreas seguida de pancreatojejunostomia. RESULTADOS: O pós-operatório transcorreu sem intercorrências, o tempo de internação na UTI foi de 2 dias, com alta hospitalar no sétimo dia. CONCLUSÕES: O tratamento da doença depende dos sinais e sintomas na apresentação e a duodenopancreatectomia é indicada em pacientes com dor abdominal intensa e recorrente.

Complicaciones pospancreatoduodenectomía de tumores periampulares en una unidad de cirugía hepatopancreatobiliar / Post pancreaticoduodenectomy complications of periampullary tumors in a hepatopancreatobiliary surgery unit

Resumen Introducción: Los tumores periampulares se definen como lesiones ubicadas en un radio de 2 cm alrededor de la ampolla de Vater, constituidos por 4 tipos de neoplasias con una alta tasa de malignidad que pueden originarse en páncreas, ampolla, vía biliar distal o duodeno. El manejo quirúrgico a través de la pancreatoduodenectomía sigue siendo la mejor elección en términos de resección curativa. Objetivo: Caracterizar los tumores peri-ampulares tratados en nuestra institución y que fueron llevados a pancreatoduodenectomía, asociando la relación entre tipo de tumor y complicaciones posoperatorias. Material y Método: Estudio transversal, retrospectivo y observacional con seguimiento a 45 pacientes sometidos a pancreatoduodenectomía en el Hospital Internacional de Colombia - Fundación Cardiovascular entre enero de 2011 y marzo de 2020 con diagnostico histopatológico de tumor peri-ampular. Resultados: Se realizaron 75 pancreatoduodenectomía de las cuales 45 pacientes presentaron tumor peri-ampular, siendo de origen pancreático en un 44%, seguido de ampolla 40%, vía biliar distal 8,8% y duodenal 6,6%. Las complicaciones posoperatorias más frecuentes fueron fístula pancreática y vaciamiento gástrico retardado. Falleció 1 paciente. Conclusión: La pancreatoduodenectomía es un procedimiento con alta morbilidad. Gracias al avance tecnológico, el diagnóstico de patología peri ampular es cada vez más exacto. El tipo de tumor peri-ampular puede influir no solo en su pronóstico, sino también en su morbilidad posquirúrgica.

Introduction: Periampullary tumors are defined as lesions that are located in a radius of 2 centimeters around the ampulla of Vater, constituted by 4 types of neoplasms with a high rate of malignancy originated in the pancreas, ampulla, distal bile duct or duodenum. Surgical management through the pancreatoduodenectomy remains the best choice in terms of curative resection. Objetive: To characterize periampullary tumors treated in our institution with pancreatoduodenectomy, associating the relationship between tumor type and postoperative complications. Material and Method: Cross-sectional, retrospective, observational study with a follow-up of 45 patients underwent pancreatoduodenectomy in the Hospital Internacional de Colombia - Fundación Cardiovascular between January 2011 and March 2020 with histopathological diagnosis of periampullary tumor. Results: Were performed 75 pancreatoduodenectomies, 45 patients presented with Periampullary tumor, 44% being of pancreatic origin, followed by ampulla 40%, distal bile duct 8.8% and duodenal 6.6%. Most frequent postoperative complications were pancreatic fistula and delayed gastric emptying. Mortality was of 1 patient. Conclusión: Pancreatoduodenectomy is a procedure with a high morbidity rate. Thanks to technological advances, the diagnosis of periampullary pathology is increasingly accurate. The type of periampullary tumor may influence not only in its prognosis, but also in its post-surgical morbidity.

Perioperative efficacy of robotic versus open approach for pancreaticoduodenectomy: a Meta-analysis / 中华消化外科杂志

Pancreatoduodenectomy (PD) is a very challenging operation in pancreatic surgery. Robotic surgery system has obvious advantages in precise operation. In specific patients, minimally invasive (laparoscopic and robotic surgery system) PD is less invasive than conventional open PD, showing good safety and feasibility. There are some differences between robotic surgery system and laparoscopic system in surgical field of vision, surgical operation and anastomosis mode. The authors review the relevant studies and conduct a Meta-analysis to evaluate the perioperative efficacy of robotic versus open approach for PD.

Influence of lymph node-related parameters on postoperative long-term prognosis of patients with distal cholangiocarcinoma / 国际外科学杂志

Objective:To analyse the correlation between the lymph nodes, the number of positive lymph nodes, the positive rate of lymph nodes and the long-term prognosis of patients with distal cholangiocarcinoma.Methods:The clinical data and follow-up results of 104 patients with distal cholangiocarcinoma admitted to Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2015 to December 2021 were retrospectively analyzed using a retrospective cohort study. All patients underwent pancreaticoduodenectomy. According to the nature of the patients′ lymph nodes, the number of positive lymph nodes, and the positive rate of lymph nodes, the X-tile software was used to analyze data respectively, and the critical value of SUVmax were determined, and the patients were divided into low-risk group and high-risk group by critical values. Based on this critical value, the patients were divided into low-risk groups and high-risk groups. There were 37 patients in the lymph node positive group and 67 patients in the negative group. In the lymph node positive group, according to the number of positive lymph nodes (the cut-off value=2), they were divided into the low-risk group( n=14), the high-risk group( n=23); grouped according to the lymph node positive rate (the cut off=0.13), and divided into the low-risk group( n=15), and the high-risk group( n=22). After grouping according to different lymph node parameters, the preoperative general data such as age, gender, laboratory examination, etc., the correlation between perioperative complications and long-term prognosis were analyzed. The measurement data conforming to the normal distribution was expressed as mean ± standard deviation( ± s), and the t test was used for comparison between groups; the measurement data that was not normally distributed was expressed as M ( Q1, Q3), and the comparison between groups was performed by the rank sum test. The enumeration data were expressed by the number of cases, and the comparison between groups was performed using the chi-square test. If the total number of cases was less than 50, and Fisher′s exact test was used. The optimal cut-off values for different lymph node parameters were determined using the x-tile 3.6.1 software. Survival curves were calculated and drawn using the Kaplan-Meier method, and the survival rates were compared using the Log-rank test. Results:All patients successfully underwent the operation, 5 patients(4.8%) died during the perioperative period. The median postoperative survival time of lymph node-positive patients and lymph node-negative patients was 17 months and 36 months, respectively, and the overall survival rates at 1, 3, and 5 years were 64.9%, 23.9%, 23.9%, and 81.5%, 49.8%, 41.7%( P=0.003). Among the patients grouped according to the number of positive lymph nodes, the median postoperative survival time of patients in the low-risk group and the high-risk group was 21 months and 17 months, and the 1-, 3-, and 5-year overall survival rates of the two groups were were 77.1%, 42.9%, 42.9% and 58.2%, 13.8%, 13.8%( P=0.284), respectively. Among the patients grouped according to the positive rate of lymph nodes, the median postoperative survival time of the patients in the low-risk group and the high-risk group was 30 months and 15 months, and the 1-, 3-, and 5-year overall survival rates of the two groups were 85.6%, 42.7%, 42.7% and 51.3%, 10.3%, 0.3%( P=0.020), respectively. Conclusions:Radical pancreaticoduodenectomy is the standard procedure for patients with distal cholangiocarcinoma. The prognosis of patients with positive lymph nodes is worse. For patients with positive lymph nodes, the positive rate of lymph nodes is a better predictor of the long-term prognosis compared with the number of positive lymph nodes.

Is the anatomical sequence of gastric and biliary anastomosis in the pancreatoduodenectomy reconstruction the cause of an increase in the incidence of cholangitis? a technical variant presentation and initial results / A sequência anatômica da anastomose gástrica e biliar na reconstrução da pancreatoduodenectomia é a causa de aumento da incidência de colangite? apresentação de variante técnica e resultados iniciais

ABSTRACT - BACKGROUND: Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis. AIMS: The objective of this study was to present the anatomical sequence of gastric and biliary continuity after pancreatoduodenectomy in patients with pancreatic tumor and to evaluate the short- and long-term results in an initial series of cases. METHODS: Two techniques were used: one with Roux-en-Y reconstruction and pancreaticojejunostomy and the other with a single jejunal loop and pancreatogastroanastomosis. In both the cases, the gastric anastomosis was placed performed before the biliary one. An analysis of demographic data, Wirsung's duct and common bile duct dilatation, the use of percutaneous drainage, and postoperative complications was carried out. RESULTS: A total of seven patients (four men and three women), with a mean age of 62 years, underwent surgery. All cases had Wirsung's duct and common bile duct dilatation. A percutaneous external biliary drainage was performed in four patients. There were three postoperative complications: one related to delayed gastric emptying and two related to wound infections. During a median follow-up of 12 months, no episode of cholangitis was recorded. CONCLUSIONS: Elevated percentages of cholangitis are reported in different reconstructions after pancreatoduodenectomy, and it is difficult to conclude reflux as the main etiology. The proposed gastric and biliary reconstructions show conforming results, facilitating posterior endoscopic access. Late follow-up and large number of cases may help assess whether the etiology of postoperative cholangitis is reflux or other factors unrelated to the order of the anastomoses.

RESUMO - RACIONAL: Múltiplas são as propostas de reconstrução do trânsito digestivo após as pancreadoduodenectomias. A anastomoses biliar posicionada antes da anastomose gástrica oferece argumentos de evitar refluxo e colangite pós-operatória. OBJETIVOS: apresentar a técnica de continuidade gástrica e biliar com sequência anatômica após pancreatoduodenectomia em portadores de adenocarcinoma de pâncreas e avaliar os resultados em uma série inicial de casos. MÉTODOS: Foram utilizadas duas técnicas, uma com reconstrução em Y de Roux e pancreaticojejunostomia e outra com alça única de jejuno e pancreatogastroanastomose. Em ambos, a anastomose gástrica foi colocada antes da biliar. E análise de dados demográficos, dilatação do ducto de Wirsung e ducto biliar comum, uso de drenagem percutânea e complicações pós-operatórias. RESULTADOS: Foram operados 7 doentes: 4 homens e 3 mulheres, com média de idade de 62 anos. Todos os casos apresentavam dilatação do ducto de Wirsung e ducto biliar comum. Em 4 dos casos foi realizada drenagem biliar externa percutânea. Ocorreram 3 complicações pós-operatórias, 1 esvaziamento gástrico retardado e 2 infecções de ferida operatória. Durante o acompanhamento médio de 12 meses, não foram registrados episódios de colangite. CONCLUSÕES: Porcentagens elevadas de colangite são relatadas nas diferentes reconstruções após pancreatodudenectomias, sendo difícil atribuir de forma absoluta o refluxo como a principal etiologia. As reconstruções gástrica e biliar propostas são mais harmoniosas, além de facilitar o acesso endoscópico posterior. Seguimento tardio e número maior de casos, pode esclarecer se a etiologia da colangite pós-operatória pode ser o refluxo ou a outros fatores não relacionados à ordem das anastomoses.

Prospective study on the effect of prophylactic octreotide administration in preventing pancreatic fistula after pancreatoduodenectomy / 中华胰腺病杂志

Objective:To evaluate the effect of prophylactic octreotide administration on pancreaticoduodenectomy (PD)associated postoperative pancreatic fistula (POPF), total complications, peri-operative death and postoperative in-hospital days.Methods:From January 2020 to August 2021, 148 patients who underwent PD in the Department of Biliary-Pancreatic Surgery in Ren Ji Hospital affiliated with School of Medicine of Shanghai Jiao Tong University were recruited into this single-center randomized control double-blinded clinical trial. Patients were randomly assigned into octreotide group ( n=74) and control group ( n=74). Octreotide group was subcutaneously injected with 0.1 mg (1 ml) octreotide after preoperative anesthesia, and was subcutaneously injected with the same dose every 8 hours for 5 days, with a total of 16 doses. Control group was injected with 1 ml normal saline in the same way, and relevant clinical data and indicators of the two groups were recorded. The primary endpoint was clinically relevant pancreatic fistula, and the secondary endpoints were total complications, perioperative death and postoperative in-hospital days. Univariate and multivariate logistic regression analysis were used to screen the risk factors of clinically related POPF after PD. Results:120 patients were finally enrolled, including 61 in octreotide group and 59 in control group. There were no significant differences on age, gender ratio, body mass index, preoperative surgery rate of jaundice reduction, preoperative major biochemical indicators, operation time, intraoperative blood loss, pancreatic duct diameter, pancreatic texture and pathological type composition ratio. The total incidence of clinical relevant POPF was 8.3%, and there were no significant differences on biochemical leakage (4.9% vs 8.5%, P=0.435), grade B fistula (4.9% vs 8.5%, P=0.435) and grade C fistula (1.6% vs 1.7%, P=0.981). The total complication incidence (24.5% vs 28.8%, P=0.601), perioperative mortality (0 vs 3.3%, P=0.147) and postoperative in-hospital days (20.6±11.1 d vs 19.5±12.2 d, P=0.633) were not significantly different between two groups. Univariate analysis showed that preoperative serum albumin level <30 g/L( P<0.001) and pathological type of pancreatic ductal adenocarcinoma ( P=0.036) were independent risk factors for POPF after PD, while multivariate analysis found no statistically significant risk factors. Conclusions:Octreotide can neither reduce the incidences of POPF, total complications and postoperative mortality, nor shorten postoperative in-hospital days. However, for patients with preoperative hypoproteinemia and (or) the pathological type of pancreatic duct adenocarcinoma, the prophylactic use of octreotide during PD and after PD may reduce the occurrence of POPF.

Prognostic analysis of robotic and open pancreatoduodenectomy for pancreatic cancer / 中华消化外科杂志

Objective:To investigate the prognosis of robotic pancreatoduodenectomy after the learning curve and open pancreatoduodenectomy for pancreatic cancer.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 396 patients who underwent curative pancreatoduodenectomy for pancreatic duct adenocar-cinoma in Ruijin Hospital of Shanghai Jiaotong University School of Medicine from January 2017 to December 2018 were collected. There were 244 males and 152 females, aged 64(range, 36?92)years. Of 396 patients, 86 cases undergoing robotic pancreatoduodenectomy were divided into robotic group, 310 cases undergoing open pancreatoduodenectomy were divided into open group. Observa-tion indicators: (1) propensity score matching and comparison of general data between the two groups after matching; (2) follow-up and survival analysis. Follow-up was conducted by telephone interview or outpatient examinations including tumor markers and abdominal imaging examina-tions to detect survival of patients up to March 2022. Overall survival was defined as the time from the surgery date to death or the last follow-up. Disease-free survival was defined as the time from the surgery date to tumor recurrence or the last follow-up. The propensity score matching was conducted by 1∶1 matching using the nearest neighbor method. Normality of measurement data was examined using the Shapiro-Wilk test. Measurement data with skewed distribution were described as M(range), and comparison between groups was analyzed using the Mann-Whitney rank-sum test. Count data were represented as absolute numbers, and comparison between groups was analyzed using the chi-square test. Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-Rank test was used for survival analysis. An intent-to-treat analysis was performed in this study, patients who were converted to laparotomy from robotic surgery were still divided into the robotic group. Results:(1) Propensity score matching and comparison of general data between the two groups after matching: 164 of 396 patients had successful matching, including 82 cases in robotic group and open group, respectively. Before propensity score matching, the body mass index, cases in stage T1, T2, T3, T4, cases in N0, N1, N2 were 23.4(range, 21.4?25.3)kg/m 2,24, 41, 10, 11, 52, 27, 7 for the robotic group, versus 22.4(range,20.3?23.9)kg/m 2,57, 144, 22, 87, 131, 132, 47 for the open group, showing significant differences in the above indicators between the two groups ( Z=3.01, 2.63, 3.03, P<0.05). After propensity score matching, cases of males, age, body mass index, cases with American Society of Anesthesiologists (ASA) score as 1, 2, 3, CA19-9, cases with preoperative biliary drainage, cases with portal vein resection, cases with pancreatic resection margin <1 mm, cases in stage T1, T2, T3, T4, cases in stage N0, N1, N2, cases with nerve invasion, cases with tumor differentiation as high-medium differentiation, medium-low differentiation, low differentiation, cases with adjuvant chemotherapy were 51, 65(range, 59?69)years, 23.0(range, 21.0?25.2)kg/m 2, 32, 41, 9, 160.4(range, 46.7?377.2)U/mL, 21, 9, 8, 21, 40, 10, 11, 48, 27, 7, 76, 26, 47, 9, 53 for the robotic group, versus 58, 65(range, 58?69)years, 23.3(range, 21.4?25.3)kg/m 2, 35, 39, 8, 172.0(range, 69.7?402.9)U/mL, 26, 9, 10, 24, 40, 7, 11, 49, 28, 5, 76, 22, 49, 11, 57 for the open group, showing no significant difference in the above indicators between the two groups ( χ2=1.34, Z=0.18, 0.34, 0.49, 0.51, χ2=0.75, 0.00,0.25, Z=0.59, 0.27, χ2=0.00, Z=0.76, χ2=0.44, P>0.05). (2) Follow-up and survival analysis: after propensity score matching, 164 patients were followed up for 54(range, 1?67)months. The follow-up time of patients was 55(range, 51?59)months for the robotic group, versus 54(range, 50?58)months for the open group, respectively, showing no significant difference between the two groups ( Z=0.48, P>0.05). During the follow-up, the 1-year overall survival rate, 3-year overall survival rate, the median survival time, 1-year disease-free survival rate, 3-year disease-free survival rate, the median disease-free survival time, tumor recurrence rate, cases with recurrence pattern as local recurrence, liver recurrence, other distant recurrence, local and distant recurrence were 81.7%, 39.0%, 27 months(95% confidence interval as 19?33 months), 61.0%, 34.2%, 15 months(95% confidence interval as 12?18 months), 54.9%(45/82), 12, 16, 9, 8 for the robotic group. The above indicators were 79.3%, 36.0%, 24 months(95% confidence interval as 19?31 months), 59.8%, 27.5%, 15 months(95% confidence interval as 10?20 months), 58.5% (48/82), 10, 22, 6, 10 for the open group. There was no significant difference in overall survival or disease-free survival between the two groups ( χ2=0.39, 0.47, P>0.05). There was no significant difference in tumor recurrence rate or tumor recurrence site between the two groups either ( χ2=0.22, 1.86, P>0.05). Conclusion:After the learning curve, robotic pancreato-duodenectomy has non-inferior prognosis compared with open pancreatoduodenectomy.

GIST duodenal asociado a hemorragia digestiva alta: reporte de caso / Duodenal GIST associated with upper gastrointestinal bleeding: case report

Resumen Introducción Los tumores del estroma gastrointestinal (GIST) corresponden al 1% de todas las neoplasias gastrointestinales, sin embargo, sólo el 3-5% de estos se desarrollan en el duodeno. Objetivo Reportar el caso de un paciente masculino con localización atípica de un tumor de estroma gastrointestinal y su manejo. Caso clínico paciente masculino de 50 años con antecedente de traumatismo encefalo craneano (TEC) con daño orgánico cerebral secundario, tabaquismo, consumidor de alcohol ocasional y sometido a quistectomía branquial en la infancia, que consulta en el servicio de urgencias por cuadro de hemorragia digestiva alta con compromiso hemodinámico. Tras realizar endoscopia digestiva alta (EDA), resonancia nuclear magnética (RNM) y tomografía computada (TC) de abdomen, se pesquisa masa tumoral en segunda porción de duodenal. Discusión A pesar de que la presentación clínica de los GIST es variable, lo más frecuente es que sean pacientes asintomáticos. En algunas ocasiones, al igual que en este reporte, pueden presentarse con dolor abdominal y/o hemorragia digestiva alta. El diagnóstico preoperatorio fue difícil ya que el estudio con imágenes (TC, RNM, EDA) sólo permite establecer la sospecha; el diagnóstico definitivo se realizó con biopsia (no contamos con endosonografía en nuestro centro). Debido a los sitios de reparo anatómico, no existe una cirugía estandarizada; en este caso, debido a la localización, infiltración y características, se decidió realizar una pancreatoduodenectomía.

Introduction Gastrointestinal stromal tumors (GIST), corresponds to 1%, of all gastrointestinal neoplasms, however, only 3%-5% developed in duodenum. Aim To report a case of a male patient with atypical location of gastrointestinal stroma tumor and the treatment proposed. Case report 50-year-old male patient, with medical history of organic brain damage secondary a traumatic brain injury, smoker, occasional alcohol consumer and branquial cystomy during childhood. Consulted in the emergency department for a high digestive hemorrhage case with hemodynamic compromise. Upper digestive endoscopy, computed tomography and nuclear magnetic resonance were performed, which impresses tumor-like lesion in the second duodenal portion. Discussion Although the GIST clinical presentation is variable, most often they are asymptomatic patients. In some times, as in this report, they may present with abdominal pain and/or upper gastrointestinal bleeding. The preoperative diagnosis was difficult, because the imaging study (CT, RNM, EDA) only stablished the suspicion and the final diagnosis was made by biopsy (we don't have endosonography in our center). Due to the anatomic repair, there is not a standardized surgery, in this case, due tumor location, infiltration and characteristics, it was decided to perform a pancreatoduodenectomy.

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)

Clinical application of " variable diameter measurable pancreatic duct" in laparoscopic pancreaticoduodenectomy / 中华肝胆外科杂志

Objective:To evaluate the safety and effectiveness of clinical application of " variable diameter measurable pancreatic duct" in laparoscopic pancreaticoduodenectomy (LPD).Methods:A retrospective study was conducted at the Second Hospital, Hebei Medical University Liver Surgical Team from July 2019 to July 2020 using the " HongShi single stitch" method of pancreatic duct to jejunum anastomosis on 147 patients who underwent LPD. According to the type of pancreatic duct, the patients were divided into having normal pancreatic ducts (the normal group, n=61) and those having " variable diameter measuring pancreatic duct" (the variable diameter group, n=86). The perioperative data and postoperative complications were compared and analyzed. Results:There were 89 males and 58 females, aged (56.7±1.5) years. There were no significant differences in age, gender and body mass index between groups ( P>0.05). For the variable diameter group, the diameter of the divided pancreatic stump was (3.2±0.1) mm, and the depth of internal pancreatic duct stenting was (4.7±0.2) cm. However, it could not be measured accurately in the normal group. The incidence of postoperative pancreatic fistula rate was significantly lower in the variable diameter group than the normal group [2.32% (2/61) vs. 11.47% (7/86), P=0.023]. Conclusion:The variable diameter measurement of pancreatic duct was safe and effective in choosing patients to undergo LPD.

Application of superior mesenteric artery priority approach in infracolic compartment in surgical treatment of resectable pancreatic head cancer / 中华胰腺病杂志

Objective:To investigate the clinical efficacy of superior mesenteric artery priority approach in infracolic compartment in the surgical treatment of resectable pancreatic head cancer.Methods:The clinical data of 79 patients with resectable pancreatic head cancer who underwent radical pancreaticoduodenectomy (PD) in the Department of Hepatobiliary Surgery of Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2016 to December 2019 were analyzed retrospectively. According to the surgical approach, they were divided into arterial priority approach group (arterial priority group, 48 cases) and conventional approach group (conventional approach group, 31 cases). The arterial priority group was to first explore the superior mesenteric artery in the subcolone, then cut off the tumor blood supply after ascertaining that the tumor can be removed, and finally remove the tumor and anastomose it routinely. The conventional approach group underwent traditional radical PD. The operation time, intraoperative bleeding, intraoperative blood transfusion, lymph node metastasis, number of lymph node dissections, resection criteria, tumor length diameter, degree of tumor differentiation, occurrence of postoperative complications (pancreatic fistula, impaired gastric emptying, abdominal bleeding, biliary fistula and diarrhea), postoperative hospital stay and postoperative chemotherapy were observed. The patients were followed up by the way of outpatient and/or telephone. The follow-up time was up to March 2021. The survival rate was calculated by Kaplan Meier method.Results:Compared with the conventional approach group, the amount of intraoperative bleeding in the arterial priority group was significantly reduced (400 ml vs 600 ml, P=0.005), the intraoperative blood transfusion rate was significantly reduced (39.6% vs 64.5%, P=0.030), the number of lymph node dissections was significantly increased (19 vs 13, P=0.024), the R 0 resection rate was significantly increased (83.3% vs 58.1%, P=0.013), but the incidence of diarrhea was significantly increased (39.6% vs 16.1%, P=0.027). The differences were statistically significant. The median survival time of arterial priority group and conventional approach group was both 19 months. The overall survival rates of 1, 2 and 3 years were 72.0%, 39.5%, 28.5% and 64.1%, 33.7% and 15.4% respectively. The median tumor free survival time was 15 months and 12 months. There was no significant difference. However, the 1, 2 and 3-year tumor free survival rate of patients in arterial priority group was significantly improved (61.2%, 39.5% and 25.9% vs 46.0%, 21.3% and 7.1%, P=0.042) , and the difference was statistically significant. Conclusions:Superior mesenteric artery priority approach in infracolic compartment can improve R 0 resection rate, prolong postoperative survival time, reduce recurrence and improve prognosis.

Application value of pancreatoduodenectomy with preservation of the gastric tube / 中华消化外科杂志

Objective:To investigate the application value of pancreatoduodenectomy (PD) with preservation of the gastric tube.Methods:The retrospective and descriptive study was conducted. The clinicopathological date of 3 male patients who underwent PD with preservation of the gastric tube for the treatment of periampullary tumor in Nanjing Drum Tower Hospital affiliated to Nanjing University Medical School from May 2018 to November 2019 were collected. The 3 patients were aged from 66 to 77 years, with a median age of 76 years. All 3 patients with surgical history of radical resection of esophageal tumors and tubular gastric surgery underwent PD with preservation of the gastric tube. Observation indications: (1) preoperative three-dimensional (3D) reconstruction; (2) surgical and postoperative situations; (3) follow-up. Follow-up using outpatient exa-mination or telephone interview was conducted to detect survival of patients and tumor metastasis and recurrence up to April 2021. Measurement date with skewed distribution were expressed as M(range).Count date were expressed as absolute numbers. Results:(1) Preoperative 3D recons-truction: results of preoperative 3D reconstruction for the 3 patients showed none of patients with vascular variation. (2) Surgical and postoperative situations: 3 patients underwent PD with preserva-tion of the gastric tube successfully. The operation time and the volume of intraoperative blood loss were 402 minutes(range, 345?480 minutes) and 330 mL(range, 300?400 mL) for the 3 patients. Of 3 patients, 1 case had postoperative grade B pancreatic fistula and 1 case had chylous leakage, respectively, who were improved after conservative treatment. There was no perioperative death. The duration of postoperative hospital stay was 18 days(range, 15?20 days) for the 3 patients. Results of postoperative histopathological examination for the 3 patients showed that 1 case with pancreatic cancer as T2N0M0 stage, 1 case with ampulla carcinoma as T2N0M0 stage and 1 case with intraductal papillary mucinous neoplasms of the pancreas. (3) Follow-up: 3 patients were followed up for 12 to 18 months, with a median follow-up time of 16 months. Results of abdominal enhanced computed tomography examination at postoperative 14 month for the 3 patients showed that the right gastroepiploic artery and vein around the pancreas were unobstructed. Of 3 patients, 1 case with pancreatic cancer who did not receive chemotherapy died at postoperative 14 months due to tumor recurrence and metastasis. There was no recurrence and metastasis in the other two cases.Conclusion:PD with preservation of the gastric tube is safe and feasible, which can be used for patients with periampullary lesions who underwent radical resection of esophageal tumors and tubular gastric surgery in the past.

Margen positivo (R1) en la biopsia intraoperatoria durante una gastrectomía total por cáncer gástrico / Positive margin (R1) in the intraoperative biopsy during a total gastrectomy for gastric cancer

Resumen El cáncer gástrico es una patología de alta incidencia en Chile. Afortunadamente es baja la incidencia de márgenes R1 cuando se realiza una cirugía con intención curativa. Al tener un tumor subcardial o cardial es perentorio realizar una biopsia rápida (intraoperatoria), en caso que ésta resulte positiva, es difícil tomar una decisión sobre qué realizar a continuación, ya que el realizar una esofagoyeyunoanastomosis intratorácica aumenta el riesgo quirúrgico. Para esto, es de suma importancia tener la información de las características histopatológicas del tumor, el riesgo de filtración, la recurrencia, la sobrevida, las terapias adyuvantes y la realidad país. Se realizó una revisión de la literatura con el fin de poder guiar la toma de decisiones.

Gastric cancer is a pathology with a high incidence in Chile, fortunately, the incidence of R1 margins is low when performing surgery with curative intent. When having a sub cardial or cardial tumor, it is essential to perform a rapid (intraoperative) biopsy, if this is positive when cutting the esophagus just under the pillars, it is difficult to make the decision of what to do next, since performing an inthrathoracic esophagojejunostomy increases the surgical risk. For this, it is very important to have information about the histopathological characteristics of the tumor, the leakage risk, there currence, the survival, the adjuvant therapies and the reality of the country. A review of the literature was done in order to guide the decisions.

Spectrum of Cholangiocarcinoma with Special Emphasis on Treatment Modalities and Outcome at a Rural Tertiary Care Centre.

Cholangiocarcinoma (CCA) is a heterogeneous group of aggressive malignancies emerging from the canals of Hering to the CBD. CCA are rare tumours accounting for 3% of gastrointestinal tumours with an incidence of <2/100000, with an increased incidence in Asia. They present late and have a grave prognosis. The only curative option is surgical resection. The aim was to study the demographic and clinical spectrum of CCA with special emphasis on practicable diagnostic modalities, treatment strategies and their outcome at our rural tertiary setup.METHODSThis was a single centre observational study with a longitudinal design conducted over a period of 2 years. 30 patients presenting with features or diagnosis of CCA to the Department of General Surgery and the Department of Radiotherapy of North Bengal Medical College and Hospital, were studied with special reference to treatment and outcome. Data was collected, compiled on Excel sheet and analysed using GraphPad QuickCalcs 2018 (San Diego, CA).RESULTSMean age of the patients was 52.36 years with a female: male ratio 1.5:1. They presented mainly with jaundice (90%), clay coloured stool (83.3%), pruritus (66.6%), anaemia (56.6%), abdominal lump (43.3%) and pain abdomen (33.6%) reflecting a late presentation. Diagnosis and staging were done by blood parameters and available imaging studies in our setup (abdominal ultrasound, CECT and MRCP). The most common type was Distal CCA (60%) followed by Perihilar CCA (33.3%) and Intra-hepatic CCA (6.6%). Pancreaticoduodenectomy was done in 26.6% of patients and resection with hepaticojejunostomy in 10% of patients; surgical biliary bypass in 20% of patients, chemotherapy in 6.6% and PTBD followed by chemotherapy in 36.6%. After 1 year 72.7% of those who underwent curative surgery were having disease free life and 26.3% of those who underwent palliative treatment were having improved quality of life.

Risk factors for 30-day unplanned reoperation after pancreatoduodenectomy: A single-center experience

Objective: The purpose of this study was to investigate the rate and reasons and also the risk factors for unplanned reoperation after pancreatoduodenectomy (PD) in a single center. Patients and Methods: This retrospective analysis included patients who underwent PD in the First Affiliated Hospital of Nanchang University between January 2010 and January 2018. The patients were divided into nonreoperation and reoperation groups according to whether they underwent unplanned reoperation following the primary PD. The incidence and reasons were examined. In addition, multivariate logistic regression analysis was performed to identify the risk factors for unplanned reoperation. Results: Of the 330 patients who underwent PD operations, 22 (6.67%) underwent unplanned reoperation. The main reasons for reoperation were postpancreaticoduodenectomy hemorrhage (PPH) (12/22 [54.5%]) and pancreaticoenteric anastomotic (PEA) leak (5/22 [22.7%]). Multivariate logistic regression analyses identified that diabetes (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.06–12.90; P = 0.04), intraoperative blood loss ≥400 mL (OR, 4.06; 95% CI, 1.29–12.84; P = 0.02), occurrence of postoperative complications in the form of PPH (OR, 30.67; 95% CI, 8.85–106.31; P < 0.001), and PEA leak (OR, 11.53; 95% CI, 3.03–43.98, P < 0.001) were independent risk factors for unplanned reoperation. Conclusions: Our results suggest that diabetes, intraoperative blood loss ≥400 mL, PPH, and PEA leak were independent risk factors for unplanned reoperation after primary PD

Application of 3D laparoscopy in pancreaticoduodenectomy / 临床肝胆病杂志

Pancreaticoduodenectomy is one of the most difficult abdominal operations, and the difficulty in resection and complicated digestive tract reconstruction have brought great challenges for surgeons. At present, laparoscopic pancreaticoduodenectomy has been widely used in clinical practice, and compared with traditional 2D laparoscopy, 3D laparoscopy has the features of high magnification, high definition, and three-dimensional vision, which enables surgeons to see more clearly and operate more accurately, and thus it has great potential to be widely used in pancreaticoduodenectomy.

First experience with robotic pancreatoduodenectomy in Singapore

INTRODUCTION@#Recent studies reported that laparoscopic pancreatoduodenectomy (LPD) is associated with superior perioperative outcomes compared to the open approach. However, concerns have been raised about the safety of LPD, especially during the learning phase. Robotic pancreatoduodenectomy (RPD) has been reported to be associated with a shorter learning curve compared to LPD. We herein present our initial experience with RPD.@*METHODS@#A retrospective review of a single-institution prospective robotic hepatopancreaticobiliary (HPB) surgery database of 70 patients identified seven consecutive RPDs performed by a single surgeon in 2016-2017. These were matched at a 1:2 ratio with 14 open pancreatoduodenectomies (OPDs) selected from 77 consecutive pancreatoduodenectomies performed by the same surgeon between 2011 and 2017.@*RESULTS@#Seven patients underwent RPD, of which five were hybrid procedures with open reconstruction. There were no open conversions. Median operative time was 710.0 (range 560.0-930.0) minutes. Two major morbidities (> Grade 2) occurred: one gastrojejunostomy bleed requiring endoscopic haemostasis and one delayed gastric emptying requiring feeding tube placement. There were no pancreatic fistulas, reoperations or 90-day/in-hospital mortalities in the RPD group. Comparison between RPD and OPD demonstrated that RPD was associated with a significantly longer operative time. Compared to open surgery, there was no significant difference in estimated blood loss, blood transfusion, postoperative stay, pancreatic fistula rates, morbidity and mortality rates, R0 resection rates, and lymph node harvest rates.@*CONCLUSION@#Our initial experience demonstrates that RPD is feasible and safe in selected patients. It can be safely adopted without any compromise in patient outcomes compared to the open approach.