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.

Morbilidad y mortalidad de la duodenopancreatectomía cefálica convencional en pacientes con enfermedad del confluente biliopancreático

Introducción: La duodenopancreatectomía cefálica es una operación cada vez más frecuente en pacientes seleccionados. Objetivo: Identificar la morbilidad y la mortalidad concerniente a la duodenopancreatectomía cefálica convencional. Métodos: Se realizó un estudio observacional, descriptivo de una serie de 15 casos operados de duodenopancreatectomía cefálica. Se investigaron las variables: estadificación según clasificación tumor, linfonódulo, metástasis (TNM), diagnóstico anatomopatológico, complicaciones, tiempo quirúrgico y estado al egreso. Se utilizaron el número absoluto y el porcentaje como medidas de resumen para las variables estadificación y diagnóstico; la media, la mediana y el rango para el tiempo quirúrgico y el intervalo de confianza para el estado al egreso. Resultados: El diagnóstico anatomopatológico principal fue adenocarcinoma de páncreas con 9 pacientes (60,1 %) y de duodeno con 2 (13,3 %). El estadio posoperatorio IIA fue el que prevaleció con 5 (45,5 %). El retraso del vaciamiento gástrico fue la complicación quirúrgica que prevaleció, con 7 (46,7 %) enfermos, seguida de la fístula biliar con 3 (20,0 %). La fístula pancreática, la lesión de la vena mesentérica superior y la hemorragia posoperatoria se presentaron una sola vez (6,7 %), respectivamente. Estas 2 últimas, provocaron la muerte del enfermo en las primeras 48 horas del posoperatorio. Fallecieron 4 (26,7 %) pacientes de la serie. Conclusiones: Las complicaciones posquirúrgicas se observan principalmente a expensas del retardo del vaciamiento gástrico, la fístula biliar y pancreática. La mortalidad puede estar relacionada con la prolongación del tiempo quirúrgico igual o mayor de 5 horas, con el consiguiente aumento de las pérdidas hemáticas.

Introduction: Cephalic duodenopancreatectomy is an increasingly frequent operation in selected patients. Objective: To identify the morbidity and mortality related to conventional cephalic duodenopancreatectomy. Methods: An observational, descriptive study of a series of 15 cases operated on cephalic duodenopancreatectomy. The variables were investigated: staging according to the Tumor, Linphonod, Metastasis (TNM) classification, pathological diagnosis, complications, surgical time and discharge status. Absolute number and percentage were used as summary measures for the variables staging and diagnosis; mean, median and range for surgical time and confidence interval for discharge status. Results: The main pathological diagnosis was adenocarcinoma of the pancreas with 9 patients (60.1%) and of the duodenum with 2 (13.3%). Postoperative stage IIA was the one that prevailed with 5 (45.5%) patients. Delayed gastric emptying was the prevailing surgical complication, with 7 (46.7%) patients, followed by biliary fistula with 3 (20.0%). Pancreatic fistula, superior mesenteric vein injury, and postoperative hemorrhage occurred only once (6.7%), respectively. These last 2, caused the death of the patient in the first 48 hours of the postoperative period. Four (26.7%) patients in the series died. Conclusions: Postoperative complications are mainly observed at the expense of delayed gastric emptying and biliary and pancreatic fistula. Mortality may be related to the prolongation of surgical time equal to or greater than 5 hours with the consequent increase of blood loss.

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.

Caracterización clinicoepidemiológica de pacientes operados de duodenopancreatectomía cefálica con enfermedad del confluente biliopancreático / Clinical epidemiological characterization of patients operated on cephalic pancreaticoduodenectomy with disease of the biliopancreatic confluent

Introducción: La duodenopancreatectomía cefálica continúa siendo una intervención quirúrgica compleja. Objetivo: Caracterizar a los pacientes operados de duodenopancreatectomía cefálica según variables epidemiológicas, clínicas e histológicas seleccionadas. Métodos: Se realizó un estudio observacional, descriptivo y retrospectivo de una serie de 15 casos operados de duodenopancreatectomía cefálica en el Servicio de Cirugía General del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba, durante el quinquenio 2016-2020. Las variables analizadas fueron edad, sexo, comorbilidades, hábitos tóxicos, síntomas y signos, así como tipo histológico de las lesiones. Resultados: Predominaron los pacientes del sexo masculino (80,0 %) y el grupo de 50 a 55 años de edad (40,0 %). Las comorbilidades más frecuentes fueron la hipertensión arterial en 80,0 % de la casuística, seguida de la diabetes mellitus en 53,3 %. Prevalecieron el tabaquismo (66,7 %) y el alcoholismo (60,0 %), así como los signos de obstrucción biliar (73,3 %). El diagnóstico histológico principal fue adenocarcinoma de páncreas en 60,1 % de los afectados. Conclusiones: La duodenopancreatectomía cefálica se realiza predominantemente en pacientes con adenocarcinomas de páncreas y, en menor medida, con adenocarcinomas de duodeno y otras afecciones benignas; en afectados del sexo masculino, con edades intermedias y avanzadas de la vida, hipertensión arterial y diabetes mellitus, así como tiempo prolongado de ser fumadores y consumidores de alcohol. Los signos de obstrucción biliar son de importancia capital en el diagnóstico clínico.

Introduction: The cephalic pancreaticoduodenectomy continues being a complex surgical intervention. Objective: To characterize patients operated on cephalic duodenopancreatectomy according to selected epidemiological, clinical and histologic variables. Methods: An observational, descriptive and retrospective study of a series of 15 cases operated on cephalic pancreaticoduodenectomy was carried out in the General Surgery Service of Saturnino Lora Teaching Provincial Hospital in Santiago de Cuba, during the five year period 2016-2020. The analyzed variables were age, sex, comorbidities, toxic habits, symptoms and signs, as well as histologic type of the lesions. Results: There was a prevalence of the male sex patients (80.0 %) and the 50 to 55 age group (40.0 %). The most frequent comorbidities were hypertension in 80.0 % of the case material, followed by the diabetes mellitus in 53.3 %. Nicotine addiction (66.7 %) and alcoholism (60.0 %) prevailed, as well as the signs of biliary obstruction (73.3 %). The main histologic diagnosis was pancreas adenocarcinoma in 60.1 % of those affected. Conclusions: The cephalic pancreaticoduodenectomy is carried out predominantly in patients with pancreas adenocarcinomas and, to a lesser extent, in patients with duodenum adenocarcinomas and other benign affections; in those affected of the male sex, with intermediate and advanced ages of life, hypertension and diabetes mellitus, as well as long time of being smokers and alcohol consumers. The signs of biliary obstruction are of capital importance in the clinical diagnosis.

Resección vascular mayor por adenocarcinoma pancreático ductal: reporte del primer caso registrado en Paraguay / Major vascular resection for pancreatic ductal adenocarcinoma: case report, of first case reported in Paraguay

El adenocarcinoma pancreático ductal (APD) es la cuarta causa de muerte por cáncer y se proyecta que para el 2030 ocupe el segundo lugar. El pronóstico es sombrío, siendo la sobrevida menor a 9% en 5 años. Se consideró durante mucho tiempo a la resección quirúrgica como el único tratamiento curativo, sin embargo, sólo el 15 a 20% de los pacientes pueden ser beneficiados con la misma. La clasificación pre terapéutica más utilizada es la del National Comprehensive Cáncer Network (NCCN), basada en la relación del tumor con estructuras vasculares, clasificándolos en tumores "resecables", de resección límite "Borderlines" y "localmente avanzados". Se presenta el primer caso registrado en Paraguay de APD con infiltración de la Vena Mesentérica Superior (VMS) tratado con duodenopancreatectomía cefálica (DPC) asociada a resección vascular mayor.

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer death and is projected to rank second by 2030. The prognosis is bleak, with survival being less than 9% in 5 years. For a long time, surgical resection was considered the only curative treatment, however, only 15 to 20% of patients can benefit from it. The most widely used pre-therapeutic classification is that of the National Comprehensive Cancer Network (NCCN), based on the relationship of the tumor with vascular structures, classifying them into "resectable", "borderline" and "locally advanced" tumors. We present the first registered case in Paraguay of PDA with infiltration of the Superior Mesenteric Vein (SMV) treated with cephalic duodenopancreatectomy (CPD) associated with major vascular resection.

Resección Duodenopancreática Cefálica: Patología, Complicaciones, Seguimiento (Parte II) / Cephalic Duodenopancreatic Resection: Pathology, Complications, Follow-up (Part II)

Antecedentes: La duodenopancreatectomía cefálica (D.P.C.) es el procedimiento quirúrgico aceptado para el tratamiento de los tumores malignos y benignos del confluente bilio-duodenopancreático. Lugar de aplicación: Hospital Nacional de Clínicas y Clínica privada. Diseño: Estudio protocolizado y prospectivo. Material y método: Entre diciembre 2000 y diciembre 2014 se operaron 96 DPC. Las indicaciones de la cirugía fueron: 39 cánceres de la cabeza de páncreas, 19 cánceres de papila, 9 cáncer de duodeno, 10 de colédoco distal, 5 tumores quísticos del páncreas, 4 pancreatitis crónica, 3 tumores funcionantes de páncreas, 3 tumores no funcionantes, finalmente 3 tumores de otra etiología. Resultados: Con respecto a la mortalidad dentro de los 30 días, fallecieron 5 pacientes (4, 80 %). Posteriormente, fallecieron dentro de los 90 días 5 pacientes más (9,3 %). En las complicaciones quirúrgicas, nosotros encontramos: la fistula pancreática hubo en 32 pacientes. Con respecto al Vaciamiento gástrico estuvo presente en 19 enfermos y finalmente en 5 pacientes tuvieron una hemorragia intra peritoneal que fueron re intervenidos y uno de los cuales falleció. Por otro lado, hubo 11 colecciones abdominales, donde se re operaron 4 pacientes y a los 7 restantes se les colocó un drenaje en dicha colección. Se re intervinieron 4 pacientes con evisceración, CONCLUSIONES: Los resultados de nuestro trabajo, apoyan el concepto que cirujanos con bajo volumen de D.P.C. anuales, pero con una estricta formación en Instituciones con infraestructura adecuada y un equipo multidisciplinario, pueden también obtener buenos resultados en las lesiones malignas y benignas del confluente bilio-duodeno-pancreático

Background: Cephalic duodenopancreatectomy (CDP) (pancreaticoduodenectomy of the head of the pancreas) is the surgical option accepted as the procedure of choice for the management of both malignant and benignant tumours of the duodenal-pancreatic biliary confluence. Setting: National Clinical Hospital and private practice. Desing: Protocoled and prospective study. Methods: Between December 2000 through December 2014, 96 CDP have been operated upon: 39 cancers of the head of the pancreas, 19 cancers of the papilla, 9 cancers of the duodenum, 10 of the distal common bile ducts, 5 cystic tumours of the pancreas, 4 chronic pancreatitis, 3 functioning pancreas, 3 non-functioning tumours, and finally 3 tumours of different ethiologies: 1 GIST of duodenum, 1 metastasis from a renal cancer, and 1 colon cancer of the hepatic flexure who invaded the duodenum. Results: Pancreatic fistulas were observed in 32 patients. With reference to gastric emptying it was present in 19 patients, and finally in 5 patients an intra peritoneal haemorrhage was present which were re- intervened, and one of them died. On the other hand, 11 abdominal collections were present, of whom 4 patients were re-operated, and to the remaining 7 ,a drainage was placed in the collection. Four patients were re-operated with evisceration. Conclusions: The results of our study support the concept that surgeons with low volume of annual CDP, but with strict training in institutions with adequate infrastructure and a multidisciplinary team, can obtain also good results.

RESECCIÓN DE PANCREATODUODENECTOMÍA CEFÁLICA. TÉCNICA, MORBILIDAD Y MORTALIDAD (PARTE 1) / Cephalic pancreatoduodenectomy resection Technique, morbidity and mortality (Part 1)

Antecedentes: La duodenopancreatectomía cefálica (D.P.C.) es el procedimiento quirúrgico aceptado para el tratamiento de los tumores malignos y benignos del confluente bilio-duodenopancreático. Lugar de aplicación: hospital nacional de clínicas y clínica privada. Diseño: estudio protocolizado y prospectivo. Material y método: entre diciembre 2000 y diciembre 2014 se operaron 96 dpc. De ellos, 54 del sexo masculino y 42 del femenino, cuyas edades oscilaron entre 27 y 79 años de edad (media de 59 años). El promedio del período de tiempo entre el inicio de los síntomas y la primera consulta fue de 81 días (rango 10 a 129 días). A todos los pacientes se les llevo a cabo ecografía y tac de abdomen. Resultados: con respecto a la mortalidad dentro de los 30 días, fallecieron 5 pacientes (4, 80 %). Posteriormente, fallecieron dentro de los 90 días 5 pacientes más (9,3 %). Con respecto a la morbilidad, las dividimos en clínicas que fueron 17 pacientes (16,32 %) y 50 fueron quirúrgicas (48 %). Dentro de ellas la fistula pancreática estuvo en 32 pacientes (30,72 %). Con respecto al vaciamiento gástrico estuvo presente en 19 (18,24 %) y finalmente 5 (4,80 %) tuvieron una hemorragia intra peritoneal. Ocho pacientes tuvieron una fistula biliar (7,62 %). Conclusiones: los resultados de nuestro trabajo, apoyan el concepto que cirujanos con bajo volumen de d.P.C. Anuales, pero con una estricta formación en instituciones con infraestructura adecuada y un equipo multidisciplinario, pueden también obtener buenos resultados en las lesiones malignas y benignas del confluente bilio-duodeno-pancreático

Background: Cephalic pancreatoduodenectomy (CPD) is the surgical procedure of choice accepted for the management of both the malignant and the benign tumors of the bilio- duodeno pancreatic confluence. Setting: Clinico- National Hospital and private practice. Desing: protocoled and prospective study. Methods: between december 2000 and december 2014, 96 cpd have been operated. Of these, 54 were men and 42 were women, with ages ranged between 27 to 79 years (average 59 years). The time between the onset of symptoms and the first consultation period. Averaged 81 days (range 10-129 days). All the patients were submitted to ultrasound and ct of the abdomen. Results: with reference to mortality within 30 days, 5 patients (4, 80%) died. Subsequently, 5 more patients died within 90 days (9.3%). With reference to morbidity, we divided them in two, clinicals that were 17 patients (16.32%) And 50 were surgical (48%). Within pancreatic fistula included 32 patients (30, 72%). With reference to the gastric emptying, it was present in 19 (18.24%) And finally 5 (4.80%) Had intra peritoneal bleeding. In addition, 8 patients had a biliary fistula (7.62%). Conclusions: the results of our study support the concept that surgeons with low volume of cpd annually, but with strict training in institutions with adequate infraestructure and a multidisciplinary team, can also obtain good results in the malignant and benign lesions of the biliary-duodeno-pancreatic confluence.

Efectos de la curva de aprendizaje en los resultados de la duodenopancreatectomía cefálica en un hospital de nivel II / Effects of the learning curve on the results of cephalic pancreaticoduodenectomy in a level II hospital

Resumen Introducción: La duodeno pancreatectomía cefálica es una operación compleja cuyos resultados a corto plazo son multifactoriales. Objetivo: Evaluar el impacto de la curva de aprendizaje en los resultados a corto plazo de la duodenopancreatectomía cefálica en un hospital de nivel II. Materiales y Método: Se analizaron los datos obtenidos a partir de una base de datos mantenida prospectivamente desde 2005. Se definieron dos periodos de tiempo: de 2005 a 2011 y de 2012 a 2017. Se compararon la morbilidad, mortalidad y estancia postoperatoria de ambos períodos. Resultados: Durante el período de tiempo estudiado se hicieron 126 duodenopancreatectomías cefálicas, 61 durante la primera etapa y 65 durante la segunda. La tasa de transfusión intraoperatoria se redujo de 33% a 15% (p = 0,011). La tasa de transfusión postoperatoria se redujo de 39 a 23% (p = 0,021). No hubo diferencias significativas con respecto a la incidencia global de complicaciones postoperatorias (59% y 52,3%). La incidencia de abscesos intraabdominales fue significativamente menor en el segundo período (18% y 4,6%, respectivamente; p = 0,038). La tasa de reintervenciones se redujo significativamente, de 22% a 9% (p = 0,049). También se redujo significativamente la tasa de mortalidad, de 6,56% a 0% (p = 0,032). La estancia media postoperatoria disminuyó significativamente en el segundo período, pasando de 19,6 a 15,8 días (p = 0,001), con una mayor proporción de pacientes dados de alta en los 8 primeros días de postoperatorio (11,5% y 38,5%, respectivamente; p = 0,001). Conclusión: La curva de aprendizaje es un factor que permite mejorar los resultados de la duodenopancreatectomía cefálica, en un hospital de nivel II, hasta alcanzar valores similares a los de un hospital de nivel III.

Introduction: The duodenum pancreatectomy cephalic is a complex operation whose short-term results are multifactorial. Aim: To assess the impact of the learning curve on the short-term outcomes of cephalic duodenopancreatectomy at a level II hospital. Materials Method: We analyze the data obtained from a database maintained prospectively since 2005. Two time periods were defined: from 2005 to 2011 and from 2012 to 2017. The morbidity, mortality and postoperative stay of both periods were compared. Results: 126 cephalic duodenopancreatectomies were performed, 61 during the first period and 65 during the second. The intraoperative transfusion rate was reduced from 33% to 15% (p = 0.011). The postoperative transfusion rate was reduced from 39 to 23% (p = 0.021). There were no significant differences with respect to the overall incidence of postoperative complications (59% and 52.3%, respectively). However, the incidence of intra-abdominal abscesses was significantly lower in the second period (18% and 4.6%, respectively, p = 0.038). The rate of reoperations was significantly reduced, from 22% to 9% (p = 0.049). The mortality rate was also significantly reduced, from 6.56% to 0% (p = 0.032). The mean postoperative stay decreased significantly in the second period, from 19.6 to 15.8 days (p = 0.001), with a higher proportion of patients discharged in the first 8 postoperative days (11.5% and 38.5%, respectively, p = 0.001). Conclusion: The learning curve is a factor allows improving the results of cephalic pancreaticoduodenectomy, in a level II hospital, until reaching values similar to those of a level III hospital.

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

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

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

Pancreatoduodenectomy for solid pseudopapillary tumor of the pancreas: a multi-institution study / Duodenopancreatectomia para o tumor pseudopapilar sólido do pâncreas: estudo multi-institucional

ABSTRACT Background: Solid pseudopapillary tumor of the pancreas is a rare low-grade malignant neoplasm. Most patients present with nonspecific symptoms until the tumor becomes large. Complete surgical resection by pancreatoduodenectomy is the treatment of choice for tumors located in the head of the pancreas Aim: To analyzed the clinicopathologic features, management, and outcomes of patients who had solid pseudopapillary tumor of the head pancreas and underwent surgical resection. Methods: Were analyzed 16 patients who underwent pancreatoduodenectomy for this condition. Results: Mean age was 25.7 years old, and 15 patients were female (93.7%). Nonspecific abdominal pain was present in 14 (87.5%). All underwent computed tomography and/or magnetic resonance imaging as part of diagnostic workup. The median diameter of the tumor was 6.28 cm, and surgical resection was performed with open or laparoscopic pancreatoduodenectomy without neoadjuvant chemotherapy. Postoperative complications occurred in six patients (37.5%) and included pancreatic fistula without mortality. The mean of hospital stay was 10.3 days. Median follow-up was 3.6 years, and no patient had local recurrence or metastatic disease. Conclusion: For these patients surgical resection with pancreatoduodenectomy is the treatment of choice showing low morbidity, no mortality, and good long-term survival.

RESUMO Racional: Tumor sólido pseudopapilar do pâncreas é neoplasia maligna rara, de baixo grau de malignidade. A maioria dos pacientes apresenta sintomas inespecíficos até que o tumor aumente de tamanho. A ressecção cirúrgica completa através a duodenopancreatectomia é o tratamento de escolha para os localizados na cabeça do pâncreas. Objetivo: Analisar as características clinicopatológicas, tratamento e resultados de pacientes com tumor sólido pseudopapilar do pâncreas localizado na cabeça do pâncreas submetidos à ressecção cirúrgica. Método: Foram analisados 16 pacientes com duodenopancreatectomia devido a esse tumor localizado na cabeça do pâncreas. Resultados: Havia 15 mulheres (93,7%) e a média de idade era de 25,7 anos. Dor abdominal não específica esteve presente em 14 pacientes (87,5%). Todos realizaram tomografia computadorizada do abdome e/ou ressonância nuclear magnética como parte da investigação. O diâmetro médio do tumor era de 6,28 cm e a ressecção cirúrgica foi realizada por duodenopancreatectomia, tanto por laparotomia quanto por videolaparoscopia, com ou sem quimioterapia neoadjuvante. As complicações pós-operatórias ocorreram em seis pacientes (37,5%) e incluíram fístula pancreática, sem mortalidade. O tempo médio de internação hospitalar foi de 10,3 dias. O tempo médio de seguimento foi de 3,6 anos e nenhum paciente apresentou recorrência local ou doença metastática. Conclusões: A ressecção cirúrgica através da duodenopancreatectomia é o tratamento de escolha para estes pacientes. Os resultados mostraram baixa morbidade, nenhuma mortalidade e boa sobrevida em longo prazo.

Modified heidelberg technique for pancreatic anastomosis / Anastomose pancreática pela técnica de heidelberg modificada

ABSTRACT Background : Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described. Aim: To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results. Method: The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o'clock, 4 o'clock, 6 o'clock, 8 o'clock, 10 o'clock, and 12 o'clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied. Results : Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed. Conclusion : Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

RESUMO Racional: Fístula pancreática é a principal causa de morbidade e mortalidade após duodenopancreatectomia. Muitos procedimentos técnicos têm sido descritos para prevenir esta complicação. Objetivo: Apresentar uma nova técnica baseada em pequenas modificações sobre a técnica original de Heidelberg para pancreatojejunostomia na reconstrução do coto pancreático após duodenopancreatectomia e apresentar os resultados iniciais. Método: Esta técnica foi utilizada para pacientes com pancreas de consistência firme ou amolecida e ducto pancreático maior ou menor que 3 mm. Os pontos são realizados com prolene 5-0, duas agulhas nas posições de 2, 4, 6, 8, 10 e 12 h, com espessura total no parênquima pancreático. Uma sutura continua é realizada com prolene 4-0 de agulha única na parede posterior e anterior do pâncreas com a camada seromuscular do jejuno. Uma sonda de silicone de 20 cm de comprimento é inserida no ducto pancreático em direção ao jejuno. As duas suturas hemostáticas previamente colocadas nas bordas superior e inferior do remanescente pancreático são passadas e amarradas com a camada seromuscular do jejuno. Resultados: Dezessete pacientes foram submetidos a pancreatojejunostomia após duodenopancreatectomia por diferentes causas. Nenhum desenvolveu fístula pancreática graus B ou C. Vazamento bioquímico, de acordo com a nova definição do Grupo Internacional de Estudo em Cirurgia do Pâncreas (ISGPS), foi observado em quatro pacientes (23,5%). Não houve mortalidade. Conclusão: Os resultados iniciais desta técnica confirmam que é simples, confiável, fácil de realizar e de aprender. Ela é útil para reduzir a incidência de fistula pancreática após duodenopancreatectomia.

Pancreatoduodenectomy: brazilian practice patterns / Duodenopancreatectomia: prática padrão do brasil

ABSTRACT Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

RESUMO Racional: A duodenopancreatectomia é um procedimento cirúrgico tecnicamente desafiador, com uma incidência de complicações pós-operatórias variando de 30% a 61%. O procedimento requer experiência de alto nível, e para minimizar complicações relacionadas à cirurgia uma padronização de alta qualidade é imperativa. Objetivo: Compreender o padrão da prática brasileira para duodenopancreatectomia. Método: Um questionário foi elaborado com a finalidade de obter uma visão geral da prática cirúrgica em câncer do pâncreas, treinamento específico e experiência em duodenopancreatectomia. O questionário foi enviado para cirurgiões com declarado interesse em cirurgia pancreática. Resultados: Um total de 60 questionários foi enviado e 52 retornaram (86,7%). A região sudeste foi a que mais respondeu, com 25 cirurgiões (48,0%). Apenas dois cirurgiões (3,9%), realizaram mais do que 50% das duodenopancreatectomia por videolaparoscopia. O procedimento clássico de Whipple foi realizado por 24 cirurgiões (46,2%) e a linfadenectomia padrão do Grupo Internacional de Estudo em Cirurgia Pancreática foi realizada por 43 cirurgiões (82,7%). Para a reconstrução, a pancreatojejunostomia foi realizada por 49 cirurgiões (94,2%), em alça única por 41 (78,9%), com anastomose do tipo ducto-mucosa por 38 (73,1%). O cateter transanastomose foi realizado por 26 cirurgiões (50%), reconstrução gástrica antecólica por 39 (75%) e enteroanastomose tipo Braun apenas por seis cirurgiões (11,5%). A drenagem abdominal profilática foi realizada por todos os cirurgiões e o uso de análogos da somatostatina por seis cirurgiões (11,5%). Nutrição enteral precoce no pós-operatório foi utilizada de rotina por 22 cirurgiões (42,3%) e 34 cirurgiões (65,4%), usaram sonda nasogástrica de rotina. Conclusão: Heterogeneidade foi observada na prática padrão da duodenopancreatectomia pelos cirurgiões no Brasil e, algumas delas em contraste com evidências estabelecidas na literatura.

Tumor de colédoco distal vs. coledocolitíase: desafio no diagnóstico pré-operatório / Distal bile duct cancer vs. choledocholithiasis: challenge in preoperative evaluation

O diagnóstico do paciente ictérico, por vezes, pode ser uma tarefa árdua. Dentre as causas principais, destacam-se a doença litiásica, como a coledocolitíase. Por outro lado, doenças neoplásicas como neoplasias peri-ampulares e da via biliar principal apresentam grande relevância, com destaque para o tumor de via colédoco. Apresentamos relato de caso de um paciente que apresentou dúvida diagnóstica nos exames pré-operatórios de imagem (US abdominal, TC multislice e Colangiorressonância). Realizada a abordagem através da exploração transcística das vias biliares para a confirmação do diagnóstico e posterior duodenopancreatectomia laparoscópica. Este relato ilustra a dificuldade em realizar o diagnóstico diferencial desta patologia. Mesmo com exames laboratoriais e de imagem, associados à anamnese e ao exame físico detalhado, nem sempre é possível confirmar o diagnóstico no pré-operatório, muitas vezes só confirmado durante o procedimento cirúrgico.

The diagnosis of jaundiced patient can sometimes be difficult task. Among the most important causes are common bile duct and its complications. By the other side, periampullary tumors and the main biliary duct tumor also have great relevance, especially cholangiocarcinoma. In this paper, we present the case report of patient that presented doubt diagnostic in preoperative in ultrasound, multislice CT and magnetic resonance. The patient underwent a laparoscopic trancystic common bile exploration, than decide to perform the laparoscopic pancreaticoduodenectomy. This report show the difficulty to make the diagnosis in pre operative evaluation. Even with laboratory and image, associate detailed case history and physical examination, not always is possible and confirm the diagnosis, many times the diagnostic is confirm during the surgical procedure.

Técnica de reconstrucción laparoscópica en la duodenopancreatectomía cefálica / Laparoscopic reconstructon technique of cephalic duodenopancreatectomy

Antecedentes: la duodenopancreatectomía cefálica (DPC) es la cirugía indicada para el tratamiento de los tumores ampulares y periampulares. El abordaje totalmente laparoscópico es técnicamente dificil de realizar pues requiere mucha destreza y experiencia por parte del equipo quirúrgico. La dificultad técnica de la pancreato-yeyuno anastomosis es quizás el factor limitante para confeccionar la duode-nopancreatectomía cefálica enteramente por vía laparoscópica. Objetivo: mostrar la técnica de reconstrucción laparoscópica con la pancreato-yeyuno anastomosis ductomucosa con la técnica de Blumgart modificada. Lugares de aplicación: Sanatorio de la Trinidad Mitre, Hospital Luciano y Mariano de la Vega, Hospital Argerich. Material y Métodos: se analizaron los pacientes operados enteramente por vía laparoscópica. Dichos pacientes fueron reconstruidos con una sola asa, realizando una pancreato-yeyuno anastomosis con la técnica de Blumgart modificada. Resultados: en los pacientes con DPC totalmente laparoscópica, el páncreas fue de textura intermedia en 3 pacientes y en 2 con textura blanda. El tempo operatorio medio fue 384 minutos. La estadía hospitalaria media fue 12 días. Dos pacientes desarrollaron fistula pancreática tipo A. Un paciente presentó retardo del vaciamiento gástrico que resolvió espontáneamente. Conclusiones: la reconstrucción completa por vía laparoscópica es factble y totalmente reproducible con la misma técnica que se utliza por vía laparotómica.

Background: pancreatoduodenectomy is the procedure indicated for the treatment of ampullary and periampullary tumors. The total laparoscopic approach for pancreatoduodenectomy is technically dificult to perform requiring skill and great experience of the surgical team. The technical dificulty of the pancreatojejunostomy is perhaps the limiting factor to perform the pancreatoduodenectomy totally laparoscopic. Objective: to describe the technique of the laparoscopic reconstructon using the pancreatojejunos-tomy according to the Blumgart modifed technique. Material and methods: patentis operated entrely by totally laparoscopic approach were analyzed. These patentis were reconstructed performing a pancreatojejunostomy with the Blumgart modifed technique. Resultis: in patentis with totally laparoscopic approach, pancreas texture was intermediatein 3 pa-tentis and 2 had sof texture. The average operating tme was 384 minutes. The average hospital stay was 12 days. Two patentis developed pancreatic fistula type A. One patent had delayed gastric emp-tying which resolved spontaneously. Conclusion: total laparoscopic reconstructon is feasible and reproducible with the same technique used by laparotomy.

Morbilidad y mortalidad en 1028 duodenopancreatectomías cefálicas / Morbidity and mortality afer 1028 cephalic duodenopancreatectomies

Antecedentes: en las últmas décadas se han extendido las indicaciones de duodenopancreatectomía cefálica (DPC). Sin embargo, las series con más de 1000 DPC provienen de unos pocos centros de los Estados Unidos y Europa y ninguna de Latinoamérica. Objetivo: evaluar la morbilidad y mortalidad de 1028 DPC consecutivas realizadas por un mismo equipo quirúrgico. Material y métodos: se analizaron los datos de una base prospectiva de 1028 DPC consecutivas. Se determinaron los datos demográficos, la indicación de la cirugía, el intervalo de tempo entre el inicio de los síntomas y la primera consulta, la clasificación de la American Society of Anesthesiologistis (ASA), el tipo de técnica quirúrgica, el tempo operatorio, la colocación de drenaje biliar previo, el diagnóstico anatomopatológico, la morbilidad y la mortalidad. Se compararon la morbilidad y la mortalidad de la DPC en dos centros de salud. Resultados: las 1028 DPC se realizaron en un período comprendido entre julio de 1994 y diciembre de 2014. La edad promedio fue 59,6 años y 565 pacientes (55%) fueron de sexo masculino. Las indicaciones más frecuentes fueron tumor de páncreas (n=262) y tumor de papila (n=249). En 670 casos se diagnosticó patología maligna. El promedio de tempo entre el inicio de los síntomas y la primera consulta fue de 71 días (rango 10 a 123 días). En 461 pacientes (44%) se drenó la vía biliar antes de la cirugía. En 399 pacientes (35,3%) se registraron una o varias complicaciones. La fistula pancreática (21%) y el vaciamiento gástrico retardado (11%) fueron las complicaciones más frecuentes. Se registró una mortalidad del 3,1% (32 pacientes). Todas las DPC fueron realizadas en dos centros, uno público (n=642) y el otro privado (n=386). Los pacientes operados en el centro público tuvieron en forma signi-ficativa mayor morbilidad (46% vs. 27%, p> 0,001) y mortalidad (4% vs. 1,5%, p< 0,001). Conclusión: la DPC realizada por cirujanos de alto volumen en cirugía pancreática tene elevada morbilidad, pero baja mortalidad. A pesar de los buenos resultados globales, la morbimortalidad de la DPC en un centro público fue significativamente mayor que la del centro privado.

Background: in recent decades the indicatons for pancreaticoduodenectomy (PD) has been extended. However, series of patentis with more than 1000 PD come from a few center in the USA and Europe and none from Latin America. Objective: to evaluate the morbidity and mortality of 1028 consecutive PD performed by the same surgical team. Material and methods: we analyzed data from a prospective data base of 1028 consecutive PD. The demographic data, the indicaton of surgery, the tme interval between the onset of symptoms and the frst consultaton, the classificaton of the ASA, the type of surgical technique, operative tme, placement of biliary drainage, the anatomopathological diagnosis, the morbidity and the mortality was determined. We compared the morbidity and mortality of the PD at two diferent health centers Resultis: the 1028 PD were performed in a period between July 1994 and December 2014. The mean age was 59.6 years and 565 (55%) were male. The most frequent indicatons were pancreatic tumor (n = 262) and ampullary tumor (n = 249). Malignant tumors were found in 670 patentis. The average tme between onset of symptoms and the frst consultaton was 71 days (range 10-123 days). Preoperative biliary drainage were performed in 461 (44%) patentis. Morbility was 35.3% (399 patentis). Pancreatic fistula (21%) and delayed gastric emptying (11%) were the most frequent complicatons. All PD were performed at two centers, one public (n = 642) and the other private (n = 386). Patentis operated at the private center had significantly lower morbidity (27% vs 46%, p <0.001) and mortality (1.5% vs 4%, p <0.001) Conclusion: the DPC performed by high-volume surgeons in pancreatic surgery has high morbility, but low mortality. Despite the overall good performance, morbidity and mortality of the DPC in a public center was significantly higher than the private center.

Outcomes from mesenteric-portal axis resection during pancreatectomy / Resultados da ressecção do eixo mesentérico-portal durante a pancreatectomia

BACKGROUND: Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers. AIM: To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy. METHOD: Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment. RESULTS: Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case). CONCLUSION: Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient's cancer prognosis. .

RACIONAL: Devido à complexidade e riscos, a ressecção e reconstrução do eixo mesentérico-portal durante pancreatectomia até o início dos anos noventa não era recomendada. Entretanto, com o aprimoramento técnico e redução da morbimortalidade ela tem sido indicada de forma rotineira nos grandes centros. OBJETIVO: Demostrar os resultados de uma série de casos submetida à ressecção do eixo mesentérico-portal durante a pancreatectomia. MÉTODO: Foram avaliados prospectivamente e consecutivamente pacientes submetidos à ressecção do eixo mesentérico-portal durante pancreatectomias. A indicação do procedimento baseou-se em critérios anatômicos definidos por exames de imagem ou por avaliação intra-operatória. RESULTADOS: Foram incluídos 10 pacientes, metade do sexo masculino, com idade média de 55,7 anos (40-76). As doenças de base mais frequentes foram o adenocarcinoma de pâncreas e o tumor de Frantz. O tipo de ressecção e reconstrução vascular mais realizado foi respectivamente a ressecção circunferencial da veia porta associada à veia mesentérica superior com ligadura da veia esplênica (4 casos=40%) e a anastomose primária dos cotos vasculares (5 casos=50%). O tempo operatório variou entre 480 e 600 minutos (média=556 minutos) e o tempo de internação pós-operatória variou de 9 a 114 dias (média=34,8 dias). A morbidade foi de 60%, sendo a fístula pancreática clínica (grau B e C) a complicação mais frequente (3 casos=30%). A mortalidade foi de 10% (um caso). CONCLUSÃO: A ressecção do eixo mesentérico-portal é artifício técnico válido. Deve ser considerada após consideração que contemple não apenas as condições clínicas dos pacientes, as condições técnicas e anatômicas da infiltração tumoral do eixo mesentérico-portal, mais também, e de forma não menos importante, a expectativa de sobrevida com base no prognóstico oncológico do paciente. .

Evolução histórica do tratamento cirúrgico do câncer de pâncreas / Historical evolution of the surgical treatment of pancreatic cancer

Objetivos: Revisar os principais aspectos históricos da evolução do tratamento do câncer de pâncreas.Fonte de dados: Revisão bibliográfica através do PubMed. Foram analisados artigos selecionados sobre a história do tratamento do câncer de pâncreas.Síntese dos dados: Ressecção cirúrgica completa é a única alternativa terapêutica que pode possibilitar a cura dos pacientes com câncer de pâncreas. Entretanto, a duodenopancreatectomia é um dos procedimentos cirúrgicos mais desafiadores, necessitando cirurgiões com alto nível de treinamento para sua execução com segurança. Diversos personagens estiveram envolvidos na evolução da técnica operatória na cirurgia pancreática até que o procedimento atingisse os níveis de segurança atuais.Conclusões: Apesar da segurança com a qual a duodenopancreatectomia é realizada atualmente, a sobrevida pós-operatória no câncer de pâncreas ainda é insuficiente, sugerindo que as questões técnicas operatórias representam apenas uma das etapas necessárias para progresso dos resultados. Melhora no sistema de rastreamento, diagnosticando tumores mais precoces, identificação de pacientes de alto risco e aperfeiçoamento no tratamento adjuvante são necessários para aumentar a taxa de cura dessa neoplasia.

Aims: To review the main historical aspects of the evolution of the treatment of pancreatic cancer.Source of data: Literature review through PubMed. Selected articles on the history of the treatment of pancreatic cancer were analyzed.Summary of findings: Complete surgical resection is the only therapeutic alternative that may allow cure of patients with pancreatic cancer. However, pancreaticoduodenectomy is one of the most challenging surgical procedures, requiring surgeons with a high level of training for its secure implementation. Several protagonists were involved in the evolution of the surgical technique in pancreatic surgery until the procedure reached current levels of security.Conclusions: Despite the safety with which pancreaticoduodenectomy is currently performed, postoperative survival in pancreatic cancer is still insufficient, suggesting that technical issues are just one of the steps needed to improve outcome. Better screening methods to diagnose earlier tumors, identification of high risk patients and improvement in adjuvant treatment are needed to increase the cure rate of this neoplasm.

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

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

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

Impacto de la duodenopancreatectomía en los pacientes adultos mayores / Impact of duodenopancreatectomy in elder patients

La incidencia de las neoplasias peri ampulares se incrementa sustancialmente con la edad, teniendo en cuenta que la incidencia de estas neoplasias se presenta mucho más en pacientes mayores y que la expectativa de vida cada vez es más alta es muy difícil cuestionar la cirugía en este grupo de pacientes. Objetivo: Evaluar la conveniencia de realizar una duodenopancreatectomía en los pacientes adultos mayores y si ésta presenta mayores complicaciones y mortalidad en este grupo de pacientes. Materiales y métodos: Durante el periodo comprendido entre octubre del 2002 hasta junio del 2012 se realizó un estudio retrospectivo en 314 pacientes sometidos a una duodenopancreatectomía para evaluar si los pacientes ancianos presentaban una mayor morbilidad y mortalidad luego de esta cirugía. Se distribuyó a los pacientes en dos grupos de acuerdo a la edad. En el primero se incluyeron a 240 pacientes que eran menores de 75 años y en el segundo se incluyeron a 74 pacientes mayores de 75 años. No existió diferencia significativa en la morbilidad de los dos grupos. Resultados: La mortalidad general en toda la serie fue de 4%. En el primer grupo la mortalidad fue de 2,9% mientras que en el segundo grupo subió a 9,4% ,siendo esta diferencia significativa. Sin embargo, cuando redujimos la edad de comparación a 65 años y a 70 años pudimos comprobar que la diferencia ya no fue significativa. Conclusion: Luego de este estudio podemos afirmar que la edad mayor de 75 años aumenta el riesgo de mortalidad de manera significativa en los pacientes sometidos a una duodenopancreatectomía, pero no contraindica la cirugía ya que es la única opción para tratar de curar a una paciente con este tipo de cáncer.

The incidence of periampullary neoplasms substantially increases with age. If we take into account that this incidence is higher in the elder patient and that life expectancy is nowadays longer, questioning surgical approach in this group of patients turns out to be controversial. Objetive: Asses if in the elder patients the duodenopancreatectomy has a higher mortality and complications. Materials and methods: A retrospective study including patients who underwent duodenopancreatectomy between October 2002 and June 2012 was undertaken to assess whether the elder ones had a higher morbidity and mortality after surgery. Patients were distributed in two groups according to age. The first group included 240 patients younger than 75 years, and the second one included 74 patients older than 75 years. There wasn't NO significant difference in morbidity between the two groups. Results: General mortality for the whole series was 4%. The first group had a 2.9% mortality whereas in the second one mortality reached 4.9%, a significant difference. However, when we changed the reference age from 75 years to 65 or 70 years the difference was not significant any more. Conclusion: From this study we can ascertain that an age more than 75 years significantly increases the mortality risk in duodenopancreatectomy patients. This age, however, doesn't proscribe surgical approach, since surgery is the only choice for curative treatment in patients with this type of cancer.

Hepatectomía derecha tras extirpación de tumor de la ampolla de Vater / Right hepatectomy after excision of a carcinoma of the ampulla of Vater: report of one case

Occasionally hepatectomy for metastases of ampulla of Vater carcinoma can result in a better survival and quality of life of patients. We report a 67 years old male subjected to a duodenopancreatectomy for a carcinoma of the ampulla of Vater that required afterwards a right hepatectomy for metastases. Twenty one months after the second operation and 42 months after the first operation, that patient is asymptomatic and without evidences of relapse.

El tratamiento quirúrgico del carcinoma de ampolla de Vater presenta mejores resultados oncológicos que los del resto de los tumores periampulares. En casos seleccionados, la resección hepática por metástasis de carcinoma de ampolla de Vater extirpado previamente, puede proporcionar supervivencias prolongadas y con buena calidad de vida. Presentamos un paciente de 67 años tratado con duodenopancreatectomía por cáncer de la ampolla de Vater y posteriormente con hepatectomía derecha por metástasis. A los 42 y 21 meses de la primera y segunda intervención respectivamente, permanece asintomático y sin evidencia de enfermedad.