Clinicopathological characteristics and prognosis of patients with small bowel tumors: A single center analysis of 220 cases / 中华胃肠外科杂志

Objective: To analyze the clinicopathological characteristics and prognosis of patients with small bowel tumors. Methods: This was a retrospective, observational study. We collected clinicopathological data of patients with primary jejunal or ileal tumors who had undergone small bowel resection in the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University between January 2012 and September 2017. The inclusion criteria included: (1) older than 18 years; (2) had undergone small bowel resection; (3) primary location at jejunum or ileum; (4) postoperative pathological examination confirmed malignancy or malignant potential; and (5) complete clinicopathological and follow-up data. Patients with a history of previous or other concomitant malignancies and those who had undergone exploratory laparotomy with biopsy but no resection were excluded. The clinicopathological characteristics and prognoses of included patients were analyzed. Results: The study cohort comprised 220 patients with small bowel tumors, 136 of which were classified as gastrointestinal stromal tumors (GISTs), 47 as adenocarcinomas, and 35 as lymphomas. The median follow-up for all patient was 81.0 months (75.9-86.1). GISTs frequently manifested as gastrointestinal bleeding (61.0%, 83/136) and abdominal pain (38.2%, 52/136). In the patients with GISTs, the rates of lymph node and distant metastasis were 0.7% (1/136) and 11.8% (16/136), respectively. The median follow-up time was 81.0 (75.9-86.1) months. The 3-year overall survival (OS) rate was 96.3%. Multivariate Cox regression-analysis results showed that distant metastasis was the only factor associated with OS of patients with GISTs (HR=23.639, 95% CI: 4.564-122.430, P<0.001). The main clinical manifestations of small bowel adenocarcinoma were abdominal pain (85.1%, 40/47), constipation/diarrhea (61.7%, 29/47), and weight loss (61.7%, 29/47). Rates of lymph node and distant metastasis in patients with small bowel adenocarcinoma were 53.2% (25/47) and 23.4% (11/47), respectively. The 3-year OS rate of patients with small bowel adenocarcinoma was 44.7%. Multivariate Cox regression-analysis results showed that distant metastasis (HR=4.018, 95%CI: 2.108-10.331, P<0.001) and adjuvant chemotherapy (HR=0.291, 95% CI: 0.140-0.609, P=0.001) were independently associated with OS of patients with small bowel adenocarcinoma. Small bowel lymphoma frequently manifested as abdominal pain (68.6%, 24/35) and constipation/diarrhea (31.4%, 11/35); 77.1% (27/35) of small bowel lymphomas were of B-cell origin. The 3-year OS rate of patients with small bowel lymphomas was 60.0%. T/NK cell lymphomas (HR= 6.598, 95% CI: 2.172-20.041, P<0.001) and adjuvant chemotherapy (HR=0.119, 95% CI: 0.015-0.925, P=0.042) were independently associated with OS of patients with small bowel lymphoma. Small bowel GISTs have a better prognosis than small intestinal adenocarcinomas (P<0.001) or lymphomas (P<0.001), and small bowel lymphomas have a better prognosis than small bowel adenocarcinomas (P=0.035). Conclusions: The clinical manifestations of small intestinal tumor are non-specific. Small bowel GISTs are relatively indolent and have a good prognosis, whereas adenocarcinomas and lymphomas (especially T/NK-cell lymphomas) are highly malignant and have a poor prognosis. Adjuvant chemotherapy would likely improve the prognosis of patients with small bowel adenocarcinomas or lymphomas.

Clinical Research Advances of Duodenal-Type Follicular Lymphoma--Review / 中国实验血液学杂志

Duodenal-type follicular lymphoma (DFL) is a unique subtype of follicular lymphoma (FL), which often involves the second portion of duodenum (descending part of duodenum). Due to its specific pathological features, such as lack of follicular dendritic cells meshwork and disappearance of activation-induced cytidine deaminase expression, DFL presents an inert clinical course and is often confined to the intestinal tract. Inflammation-related biomarkers suggest that the microenvironment may play a likely role in the pathogenesis and favorable prognosis of DFL. Since patients generally have no obvious clinical symptoms and low progression rate, the treatment regimen for DFL is mainly observation and waiting (W&W) strategy. This study will review the latest research progress of epidemiology, diagnosis, treatment and prognosis of DFL in recent years.

Resección duodenal distal: análisis de nuestra experiencia con una cirugía infrecuente / Distal duodenal resection: analysis of our experience with infrequent surgery

Resumen Introducción: La resección duodenal distal (RDD) es una técnica quirúrgica compleja e infrecuente usada para el tratamiento de patologías duodenales o extraduodenales, que no comprometen la papila duodenal mayor, siendo su indicación más frecuente la patología neoplásica. Objetivo: Dar a conocer nuestra experiencia con esta técnica quirúrgica. Materiales y Método: Serie de pacientes sometidos a RDD entre 2009-2020 en el Hospital Clínico UC. Resultados: Total 12 pacientes, mediana de edad 56 años. Diagnóstico preoperatorio: tumores primarios duodenales (4), tumores con compromiso duodenal por contigüidad (5) y patologías de urgencia (3). El abordaje fue abierto en 9 pacientes y laparoscópico en 3 (1 caso convertido). En 9 pacientes se resecó D3-D4, en 1 paciente incluyó parte de D2 y en 2, sólo D4. La anastomosis duodenoyeyunal fue manual en 10 casos, todas con ascenso transmesocólico del asa yeyunal. Hubo 33% (n: 4) de morbilidad, todos Clavien Dindo II y 8% de mortalidad (n: 1). No hubo filtración de la anastomosis duodenoyeyunal. En el seguimiento ninguno presentó complicaciones y 4 pacientes fallecieron por progresión oncológica. Conclusión: La principal indicación quirúrgica fue patología neoplásica y en nuestra serie no hubo morbilidad mayor ni filtración anastomótica.

Introduction: Distal duodenal resection is a complex and infrequent surgical technique used for the treatment of duodenal or extraduodenal pathologies that do not compromise the greater duodenal papilla, the most frequent indication being the neoplastic cause. Aim: To publicize our experience with this surgical technique. Materials and Method: Series of patients undergoing a distal duodenal resection between 2009-2020 at the UC Clinical Hospital. Results: Total 12 patients, median age 56 years. Preoperative diagnosis: primary duodenal tumors (4), tumors with duodenal involvement due to contiguity (5), and emergency pathologies (3). The approach was open in 9 patients and laparoscopic in 3 (1 converted). D3-D4 was resected in 10 patients, 1 included part of D2 and 2 only D4. The duodenojejunal anastomosis was manual in 10 cases, all with transmesocolic ascending of the jejunal loop. There were 33% (n: 4) morbidity, all Clavien Dindo II, and 8% mortality (n: 1). There was no leakage of the duodenojejunal anastomosis. During followup, none presented complications and 4 patients died of oncological progression. Conclusion: The main surgical indication was neoplastic pathology and in our series, there was no major morbidity or anastomotic leak.

Seguimento de longo prazo de pacientes com tumor neuroendócrino da papila duodenal submetidos à papilectomia endoscópica: série de casos e revisão da literatura / Long-term follow-up of patients undergoing endoscopic papillectomy for papillary neuroendocrine tumor: a case series and literature review

ABSTRACT BACKGROUND: Duodenal papilla neuroendocrine tumors (DP-NET) are rare. Surgical therapy may be recommended for their treatment. However, they have high rates of morbidity and mortality. Endoscopic papillectomy (EP) is safe and effective for complete resection of tumors at this site. OBJECTIVE: This study aimed to describe a case series of DP-NETs resected by EP and perform a literature review. METHODS: A series of patients with DP-NETs underwent EP as primary treatment between Jan/2008 and Mar/2020 at a tertiary referral center. A comprehensive search was made on the MEDLINE primary electronic database. The search strategy was designed to find all articles related to DP-NETs published in the literature. RESULTS: Six patients underwent EP for presenting DP-NETs, four of whom were women (mean age, 63 years). The mean diameter of DP-NETs was 1.6±0.3 cm. Four of six patients were followed up, one of whom suffered relapse at the resection site after 3 months and was referred to surgery (pT3n1b) and the remaining three patients experienced no endoscopic or histological recurrence during follow-up periods of 10, 7, and 4 years, respectively. Eighteen articles were found in the literature search in MEDLINE. The articles included case reports of endoscopically treated DP-NETs. CONCLUSION: EP is safe and effective for DP-NETs that are ≤20 mm, confined to the submucosal layer, well-differentiated, and without local or remote metastasis. Adequate endoscopic follow-up and definitive surgical treatment in the presence of relapse are necessary.

RESUMO CONTEXTO: Tumores neuroendócrinos da papila duodenal (TNE-PD) são raros. A cirurgia deve ser recomendada para o tratamento. No entanto, apresentam altas taxas de morbimortalidade. A papilectomia endoscópica (PE) é segura e eficaz para a ressecção completa de tumores nesta região. OBJETIVO: Descrever uma série de casos de TNEs-PD ressecados por PE e realizar uma revisão da literatura. MÉTODOS: Pacientes com TNEs-PD submetidos a PE como tratamento primário com intenção curativa entre jan/2008 e mar/2020 em um centro de referência terciário foram estudados. Uma pesquisa abrangente foi feita no MEDLINE. A estratégia de busca foi desenhada para encontrar todos os artigos relacionados a TNEs-PD publicados na literatura, que haviam sido submetidos a PE. RESULTADOS: Seis pacientes foram submetidos a PE por apresentar TNEs-PD, sendo quatro mulheres, com média de idade de 66 anos (22-96). O diâmetro médio dos TNEs-PD foi de 1,8±0,4 cm. Quatro dos seis pacientes foram acompanhados, um dos quais sofreu recidiva no local da ressecção após 3 meses e foi encaminhado para cirurgia (pT3n1b), e os três pacientes restantes não apresentaram recorrência endoscópica ou histológica durante os períodos de acompanhamento de 10, 7 e 4 anos, respectivamente. Dezoito artigos foram encontrados no MEDLINE. Os artigos incluíram relatos de casos de TNEs-PD tratados pela PE. CONCLUSÃO: A PE é segura e eficaz para TNEs-PD ≤20 mm, confinados à camada submucosa, bem diferenciados e sem metástases locais ou remotas. Acompanhamento endoscópico adequado e tratamento cirúrgico definitivo na vigência de recidiva são necessários.

Caracterización de lesiones duodenales y su sobrevida / Characterization of duodenal lesions and their survival

Resumen Introducción: Las lesiones duodenales son infrecuentes. Objetivo: Caracterizar a los pacientes con lesiones duodenales observados entre enero de 2008 y diciembre de 2013 en el Servicio de Salud Metropolitano Sur, en Santiago de Chile. Materiales y Método: Se obtuvieron los datos de los registros del Hospital Barros Luco Trudeau y Hospital El Pino. Los pacientes incluidos fueron los observados entre enero de 2008 y diciembre de 2013. Se analizaron edad, género, características clínicas, localización, métodos diagnósticos, hallazgos anatomopatológicos y tratamiento. El 24 de abril de 2019 se obtuvo la fecha de fallecimiento de todos los pacientes del Registro Civil. El análisis estadístico se realizó con el software STATA 15.1. Resultados: Se encontraron 157 pacientes con lesiones duodenales, 65 presentaron adenocarcinoma duodenal y 71 pacientes pólipos duodenales, 25 de ellos fueron adenomas. Análisis univariado de sobrevida evidenció que los pacientes con pólipos asociado a carcinoma y los adenocarcinomas duodenales, presentaron una sobrevida inferior (p = 0,013, HR 6,584 y p < 0,001, HR 7,604, respectivamente). En los pacientes con adenocarcinoma duodenal, aquellos que se sometieron a una cirugía con intención curativa, y aquellos que recibieron quimioterapia tuvieron una sobrevida global mejor que aquellos que no recibieron terapia (p < 0,001, HR 0,351 y p = 0,001, HR 0,276, respectivamente. Discusión: La incidencia estimada del adenocarcinoma duodenal en nuestra población es de 1,1 por cada 100.000 habitantes, la que es más alta que otras publicadas. Proponemos estudio endoscópico en poblaciones de riesgo y tratamiento con intención curativa para los pacientes con adenocarcinoma duodenal sin metástasis a distancia.

Introduction: Duodenal lesions are infrequent. Aim: To characterize patients with duodenal lesions observed between January 2008 and December 2013 at the Southern Metropolitan Health Service, in Santiago, Chile. Materials and Method: Data were obtained from the Barros Luco Trudeau Hospital and El Pino Hospital records. The patients included were those observed between January 2008 and December 2013. Age, gender, clinical characteristics, location, diagnostic methods, anatomopathological findings and treatment were analyzed. On April 24th 2019 was obtained the date of death of all patients at the National Civil Registry. The statistical analysis was performed with the software STATA 15.1. Results: 157 patients with duodenal lesions were found, 65 presented duodenal adenocarcinoma and 71 patients had duodenal polyps, 25 of them were adenomas. Univariate analysis of survival showed that patients with polyps associated with carcinoma and duodenal adenocarcinomas had a lower survival rate (p = 0.013, HR 6.584 y p < 0.001, HR 7.604, respectively). In patients with duodenal adenocarcinoma, those who underwent surgery with curative intent, and those who receive chemotherapy had a better overall survival than those who did not received therapy (p < 0.001, HR 0.351 y p = 0.001, HR 0.276, respectively). Discussion: We propose endoscopic study in at-risk populations and treatment with curative intent for patients with duodenal adenocarcinoma without distant metastases. The estimated incidence of duodenal adenocarcinoma in our population is 1.1 per 100,000 inhabitants and seem to be higher than other published.

Tubulovillous adenoma of the duodenal papilla: radiological-endoscopic and anatomopathological correlation in the surgical proposal

SUMMARY Tubulovillous adenomas of the duodenal ampulla are rare neoplasms. The present report describes a case with radiological-endoscopic and pathological correlation in which the patient underwent duodenal pancreatectomy with good postoperative progression. With advanced imaging methods, especially magnetic resonance and endoscopic ultrasound, locoregional aspects and extraluminal, lymphovascular, and metastatic invasion have been increasingly discussed as contributors to therapeutic decision making. This progression improves lesion staging and is especially useful in selecting eligible candidates for endoscopic treatment.

RESUMO Os adenomas túbulo-vilosos da ampola duodenal são neoplasias raras. Neste trabalho apresentamos um caso com correlação radiológico-endoscópica e patológica, tendo a paciente sido submetida à duodenopancreatectomia com boa evolução pós-operatória. Com os avanços dos métodos de imagem, em especial da ressonância magnética e ultrassonografia endoscópica, aspectos locorregionais, além da invasão extraluminal, linfovascular e metastática, têm sido discutidos de maneira crescente como contribuintes na decisão terapêutica. Essa evolução contribui para o melhor estadiamento destas lesões e é especialmente útil para selecionar candidatos elegíveis ao tratamento endoscópico.

Pancreaticoduodenectomy: impact of the technique on operative outcomes and surgical mortality / Duodenopancreatectomia: impacto da técnica nos resultados operatórios e mortalidade cirúrgica

ABSTRACT Background: Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. Aim: To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. Method: Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. Results: Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). Conclusion: There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

RESUMO Racional : A duodenopancreatectomia (DP) é procedimento associado com significativa morbimortalidade. Inicialmente descrita como gastroduodenopancreatectomia (GDP), a possibilidade de preservação do antro gástrico e piloro foi descrita na década de 1970. Objetivo : Avaliar a mortalidade e variáveis operatórias da DP com ou sem preservação pilórica e correlacioná-las com a técnica adotada e indicação cirúrgica. Método: Estudo de coorte histórica, baseado em análise de dados de registros médicos de indivíduos submetidos à DP entre os anos de 2012 a 2017. Foram analisadas variáveis demográficas, antropométricas e operatórias e correlacionadas com a técnica adotada (GDP vs. DP) e a indicação cirúrgica. Resultados : Dos 87 indivíduos avaliados, 38 (43,7%) foram submetidos à GDP e 49 (53,3%) à DP. A frequência de realização da GDP (62,5%) foi significativamente maior entre os pacientes com neoplasia de pâncreas (p=0,04). O tempo de internação total foi significativamente menor entre os indivíduos submetidos à ressecção por neoplasias de comportamento menos agressivo (p=0,04). A mortalidade cirúrgica foi de 10,3%, não havendo diferença entre GDP e DP. A mortalidade foi significativamente maior entre os indivíduos submetidos à ressecção por pancreatite crônica (p=0,001). Conclusão : Não houve diferenças na morbimortalidade, tempo cirúrgico, sangramento ou tempo de internação entre GDP e DP. A neoplasia de cabeça de pâncreas associou-se mais com indicação de GDP. A ressecção de neoplasias menos agressivas associou-se a menor morbimortalidade.

Melanoma duodenal: reporte de caso y revisión de la literatura / Duodenal melanoma: a case report and review of the literature

Se presenta el caso de un paciente varón de 75 años que acude por dolor abdominal, hiporexia, llenura precoz, malestar general y deposiciones líquidas, ingresando a emergencia por un episodio de síncope. Al examen físico se palpa borde hepático 6 cm por debajo del reborde costal derecho. Por ello se solicita estudios de imagen, hallando lesiones compatibles con metástasis hepáticas múltiples. Posteriormente se solicita endoscopía digestiva alta, hallando lesiones hiperpigmentadas múltiples en la segunda porción duodenal. El estudio histopatológico e inmunohistoquímico concluyó melanoma duodenal. El examen físico no reveló lesiones neoplásicas dérmicas u oculares asociadas.

We report the case of a male patient of 75 years old who presents with abdominal pain, hyporexia, early satiety, general malaise and watery stools, admitted in emergency for an episode of syncope. On physical examination, hepatomegaly of 6cm below the right costal margin was detected. CT scan showed multiple liver metastases. An upper endoscopy found multiple hyperpigmented lesions on the second portion of the duodenum. Histology and immunohistochemistry studies concluded it was duodenal melanoma. Skin and ocular examination did not reveal associated neoplastic lesions

Linfoma duodenal asociado a infección por Strongyloides stercoralis. Dos manifestaciones de la infección por HTLV-1 / Duodenal Lynphoma associated to Strongyloides stercoralis infection. Two types of HTLV-1 infection

La infección por el virus linfotrópico de células T humanas tipo 1 (HTLV-1), es causante de la leucemia/linfoma de células T del Adulto (ATLL), siendo la afectación duodenal poco usual. La coinfección de HTLV-1 con Strongyloides stercolaris es común en los pacientes con HTLV- 1 debido a la inadecuada respuesta TH2 que presentan estos sujetos. Describimos a una paciente mujer de 48 años de edad, natural y procedente de la selva del Perú con historia familiar de infección por HTLV- 1 quien acude con diarrea crónica y baja de peso. Se le diagnosticó infección por HTLV-1 así como ATLL duodenal y estrongiloidiasis. Se inició tratamiento con ivermectina y quimioterapia, siendo estabilizada y dada de alta. Reportamos el presente caso debido a la poca frecuencia de coexistencia en duodeno de ATLL y estrongiloidiasis.

Infection by the Human T- Lymphotropic virus I (HTLV-1) causes Adult T cell Leukemia-lymphoma (ATLL), being the duodenal involvement rare. Commonly, patients co-infected with HTLV-1 and Strongyloides stercoralis are seen due to the lack of TH2 response found on these patients. We describe a 48-year-old woman, from the jungle of Peru, with a family history of HTLV-1 infection, who presented with a History of chronic diarrhea and weight loss. HTLV-1 infection with ATLL and strongyloidiasis were diagnosed. Ivermectin treatment and chemotherapy were initiated, being stabilized, and discharged. We report this case because of the unusual coexistence in the duodenum of ATLL and strongyloidiasis.

Adenocarcinoma duodenal: un diagnóstico poco frecuente / Duodenal adenocarcinoma: a rare diagnosis

El adenocarcinoma duodenal es una entidad poco prevalente que suele cursar con clínica de vómitos, pérdida de peso e hiporexia; presentándose más frecuentemente en varones en la sexta década de la vida. La endoscopia digestiva alta supone la técnica de elección para el diagnóstico, siendo útiles para el estudio de extensión tanto la ecoendoscopia como la tomografía computarizada (TC). En relación a esta rara patología presentamos el caso de un paciente diagnosticado de neoplasia de bulbo duodenal en nuestro centro...

Duodenal adenocarcinoma is a rare disease whose symptoms are usually vomit, weight loss and lack of appetite; appearing more frequently in men in their sixties. Upper gastrointestinal endoscopy is the technique chosen for its diagnosis, also relying on other techniques such as endoscopic ultrasonography or computed tomography for the extension study. In this regard we report the case of a patient diagnosed of bulbar duodenal adenocarcinoma in our hospital...

Se justifica el seguimiento después de una colectomía en pacientes con poliposis adenomatosa familiar / The follow up after colectomy in patients with familial adenomatous polyposis is justified

phenotypic expression is the presence of múltiple colorectal adenomatous polyps (more than 100), with high probability developing colorrectal cancer (CRC) before the fifth decade of life. Prophylactic surgery (total colectomy or restorative proctocolectomy) reduces the risk of developing CRC. However, the risk of developing tumors in other organs remains present. Objetive: Analyze the frequency and type of tumors associated with classic familial adenomatous polyposis syndrome (FAPc) patients undergoing prophylactic colectomy. Material and Methods: Cohort study. From the registry of hereditary colorrectal cancer (CRC) at our institution, we identified patients with FAPc who underwent total colectomy with ileorrectal anastomosis (TC-IRA) or restorative proctocolectomy (RTPC), from 1999 to 2014. In the follow-up we analyzed related tumors and mortality. Results: 27 patients, of whom 18 (66.7%) underwent TC-IRA and 9 (33.3%) underwent RTPC. At the time of surgery, 4 patients had CRC (15%) and 5 had extracolonic tumors (osteomas). In a mean follow-up of 49, 4 months (i: 2 y 178) the following lesions were diagnosed: digestive tract adenomas in 17 (63%) patients, of these 2 required a proctectomy and 3 resection of duodenal adenomas. Eight patients developed desmoid tumors (30%), and 3 of them underwent surgery. One patient had an extradigestive tumor (thyroid cancer) and only 8/27 (29.6%) did not develop other tumors. One patient died due to progression of his CCR. Discussion: In this series it is confirmed that most patients will develop neoplasms FAPc after colectomy. conclusion: The removal of the colon and/or rectum is able to prevent the development of CRC. However, two thirds of the patients develop other tumors in which systematic surveillance allowed early detection and treatment.

Objetivo: Analizar la frecuencia y tipo de tumores asociados en pacientes con poliposis adenomatosa familiar clásica (PAFc) sometidos a una colectomía profiláctica. Materiales y Métodos: Estudio de cohorte. Desde el registro de cáncer colorrectal (CCR) hereditario, se identificaron las familias con PAFc, y de estas a los pacientes que se les practicó una colectomía total con anastomosis íleorrectal (CT-AIR) o proctocolec-tomía restauradora (PCTR), desde 1999 al 2014. En el seguimiento se analizaron los tumores asociados y su mortalidad. Resultados: Se identificaron 27 pacientes, de los cuales 18 (66,7%) fueron sometidos a CT-AIR y 9 (33,3%) a PCTR. Al momento de la cirugía, 4 pacientes presentaban CCR (15%) y 5 tenían tumores extracolónicos (osteomas). En un seguimiento promedio de 49,4 meses (i: 2 y 178) se diagnosticaron: adenomas del tracto digestivo en 17 (63%) pacientes, de éstos 2 requirieron una proctectomía y 3 resecciones de adenomas duodenales. Ocho pacientes desarrollaron tumores desmoides (30%), y 3 de ellos fueron sometidos a una cirugía. Un paciente presentó un tumor extradigestivo (cáncer de tiroides) y sólo 8/27 (29,6%) pacientes no desarrollaron otros tumores. Un paciente falleció por progresión de su CCR. Discusión: En esta serie se confirma que la mayoría de los pacientes con PAFc seguirán desarrollando neoplasias después de su colectomía. conclusiones: La extirpación del colon y/o recto permitió evitar el desarrollo de CCR. Sin embargo, dos tercios de los pacientes presentaron otros tumores en quienes su seguimiento permitió una detección y tratamiento temprano.

The largest western experience with hepatopancreatoduodenectomy: lessons learned with 35 cases / A maior experiência ocidental com hepatopancreatoduodenectomia: lições aprendidas com 35 casos

Background : Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma. Aim : To present 10-year experience performing this operation in advanced malignant tumors. Methods : This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%). Results: Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%. Conclusion : Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.

Racional : Hepatoduodenopancreatectomia é uma das operações abdominais mais complexas indicadas principalmente no carcinoma biliar avançado. Objetivo : Apresentar experiência de 10 anos executando esta operação em tumores malignos avançados. Métodos : Trata-se de estudo descritivo e retrospectivo. De 2004 a 2014, 35 hepatopancreatoduodenectomias foram realizadas em três diferentes instituições. A indicação mais comum foi carcinoma biliar avançado em 24 pacientes (68,5%). Resultados : Dezoito tinham câncer de vesícula biliar, oito tumores de Klatskin, cinco tumores neuroendócrinos com metástase hepática, uma metástase colorretal invadindo a cabeça do pâncreas, uma neoplasia mucinosa papilar intraductal com metástase hepática, uma recorrência do câncer gástrico com comprometimento hepático e um melanoma ocular com metástase na cabeça do pâncreas e no lobo direito do fígado. Todos os pacientes foram submetidos a duodenopancreatectomia com ressecção hepática da seguinte forma: oito triseccionectomias direitas, cinco lobectomias direitas, quatro lobectomias esquerdas, e 18 lobectomias centrais (IVb, V e VIII). A mortalidade global foi de 34,2% (12/35) e a taxa de morbidade global foi de 97,4%. Conclusão : Alta mortalidade é vista quando grande ressecção hepática é realizada junto à duodenopancreatectomia, incluindo lobectomia e triseccionectomia direita. Insuficiência hepática em combinação com deiscência do pâncreas é invariavelmente letal. Esforços para garantir fígado remanescente em 40-50% do volume total são a chave para obter sobrevida.

Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

Laparoscopic pancreaticoduodenectomy: right-inferior-posterior "artery first" approach / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To discuss the application of right-inferior-posterior "artery first" approach in laparoscopic pancreaticoduodenectomy.</p><p><b>METHODS</b>Clinical data of 17 patients who underwent laparoscopic pancreaticoduodenectomy through right-inferior-posterior "artery first" approach in our department from February 2014 to April 2015 were retrospectively analyzed. The operation began at the inferior flexure of duodenum. After entering the Toldt's space, the left renal vein (LRV) was revealed and the root of superior mesenteric artery (SMA) was exposed just above the LRV. SMA was dissected along its trunk till the horizontal part of duodenum.</p><p><b>RESULTS</b>Of these 17 cases, adenocarcinoma of pancreatic head was observed in 5 cases, adenosquamous carcinoma in 2 cases, mucinous cycstic neoplasm in 1 case, adenocarcinoma of lower common bile duct in 4 cases, and duodenal papilla cancer in 5 cases. Fifteen cases were accomplished successfully with laparoscopy and 2 cases were converted to open approach. The average operating time was (320 ± 85) min and mean intraoperative blood loss was (305 ± 175) ml. The cutting margins were tumor negative in all the patients. The average number of harvested lymph node was 15.4 ± 6.5. Postoperative complication occurred in 5 cases. Two cases of bile leakage and 2 cases of pancreatic fistula were cured with conservative treatment. One case of delayed abdominal hemorrhage was resolved with reoperation.</p><p><b>CONCLUSION</b>Right-inferior-posterior "artery first" approach is safe and feasible in laparoscopic pancreaticoduodenectomy.</p>

Malignant gastroduodenal obstruction: An endoscopic approach

Malignant gastric outlet obstruction describes a constellation of symptoms that can result as a common endpoint from a variety of primary tumours, particularly those of the upper gastrointestinal tract and pancreas. Affected patients face a dismal, undignified and rapid decline in health secondary to malnutrition, dehydration and constant nausea with associated vomiting. Palliative treatment has traditionally involved a gastrojejunostomy—a major undertaking given the functional status of these patients. More recent advances in the endoscopic placement of metal stents to relieve obstruction have clear benefits over the surgical method. We look at the factors involved in patient selection, the techniques and considerations involved in stent deployment and the potential complications associated with this method.

Endoscopic Resection of Sporadic Non-ampullary Duodenal Neoplasms: A Single Center Study / 대한소화기학회지

BACKGROUND/AIMS: Sporadic non-ampullary duodenal neoplasms are rare and optimal treatment for these lesions remains undefined. Endoscopic resection of duodenal neoplasms is widely used recently and it is an alternative treatment strategy to surgical excision. This study aimed to evaluate the safety and efficacy of endoscopic resection of duodenal neoplasms and to determine its outcomes. METHODS: Patients who underwent endoscopic resection for non-ampullary duodenal neoplasms between January 2005 and December 2014 were analyzed retrospectively. Data including size, morphology, histology, location and endoscopic procedural technique were reviewed. The main outcome measurements were success rate, complication, recurrence and follow-up assessments. RESULTS: The study included 33 patients with duodenal neoplasms. The mean size of resected lesion was 8.58 mm. The results of histologic examination were as follows: 23 (69.7%) adenomas, 2 (6.1%) adenocarcinoma, 3 (9.1%) Brunner's gland tumor and 3 (9.1%) neuroendocrine tumor. Tubular adenoma wase the most common type (63.6%) of non-ampullary duodenal neoplasms. Eighteen (54.5%) lesions were found in the second portion of the duodenum, and 10 (30.3%) lesions on bulb and 3 (9.1%) lesions on superior duodenal angle. Of the 33 cases, 32 (97.0%) were managed by endoscopic mucosal resection technique during a single session and one case was managed by endoscopic submucosal dissection (ESD). One episode of perforation occurred after ESD. During a median follow-up period of 5.76 months, recurrence was observed in only one case of in a patient with tubular adenoma. CONCLUSIONS: Endoscopic resection of duodenal neoplasm is a safe and effective treatment modality that can replace surgical resection in many cases. Careful endoscopic follow-up is essential to manage recurrence or residual lesions.

Hemorragia digestiva alta como primera manifestación clínica de neoplasia de bulbo duodenal. Presentación de caso / High digestive hemorrhages as first clinical manifestation of neoplasia from the duodenal bulb. Case presentation

Fundamentación: Las neoplasias malignas del intestino delgado son poco comunes y su diagnóstico es tardío porque suelen ser asintomáticas o los síntomas son intermitentes e inespecíficos Objetivo: Ofrecer una enseñanza clínico-endoscópica y radiológica de la forma de presentación de la neoplasia del bulbo duodenal que hizo su debut con hemorragia digestiva alta. Presentación de caso: Paciente masculino de 75 años de edad que ingresó por presentar sangrado digestivo alto en forma de vómitos oscuros, se le realizaron varios exámenes, entre ellos esofagogastroduodenoscopia así como toma de biopsia para estudio histológico cuyo diagnóstico definitivo fue adenocarcinoma del bulbo duodenal. Conclusiones: En las enfermedades que afectan el tracto gastrointestinal es necesario tener presente como diagnóstico nosológico este tipo de tumor maligno ya que un tratamiento oportuno puede asegurar una evolución satisfactoria y una supervivencia mayor para el paciente.

Background: Malignant neoplasias of the small intestine are not very common and the diagnosis is late because they are usually asymptomatic or the symptoms are intermittent and inespecific. Objective: To offer a clinical-endoscopical and radiological teaching of the way of the presentation of the neoplasia of the duodenal bulb that made its debut with high digestive hemorrhage. Case presentation: A 75 years old male patient who was admitted due to a high digestive bleeding in a way of dark vomits, several exams were performed, such as esophagogastroduodenoscopy as well as biopsy taking for histological study whose definite diagnosis was adenocarcinoma of the duodenal bulb. Conclusions: In the diseases that affect the gastrointestinal tract it is necessary to bear in mind as a nosologic diagnosis this type of malignant tumor since an timely treatment can assure a satisfactory evolution and a major survival for the patient.