Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

The beginnings and evolution of a pancreatic surgeon: a technical morphological analysis in first 5 years / 中华外科杂志

Objective: To explore the development of the pancreatic surgeon technique in a high-volume center. Methods: A total of 284 cases receiving pancreatic surgery by a single surgeon from June 2015 to December 2020 were retrospectively included in this study. The clinical characteristics and perioperative medical history were extracted from the medical record system of Zhongshan Hospital,Fudan University. Among these patients,there were 140 males and 144 females with an age (M (IQR)) of 61.0 (16.8) years(range: 15 to 85 years). The "back-to-back" pancreatic- jejunal anastomosis procedure was used to anastomose the end of the pancreas stump and the jejunal wall. Thirty days after discharge,the patients were followed by outpatient follow-up or telephone interviews. The difference between categorical variables was analyzed by the Chi-square test or the CMH chi-square test. The statistical differences for the quantitative data were analyzed using one-way analysis of variance or Kruskal-Wallis H test and further analyzed using the LSD test or the Nemenyi test,respectively. Results: Intraoperative blood loss in pancreaticoduodenectomy between 2015 and 2020 were 300,100(100),100(100),100(0),100(200) and 150 (200) ml,respectively. Intraoperative blood loss in distal pancreatectomy was 250 (375),100 (50),50 (65), 50 (80),50 (50),and 50 (100) ml,respectively. Intraoperative blood loss did not show statistical differences in the same operative procedure between each year. The operative time for pancreaticoduodenectomy was respectively 4.5,5.0(2.0),5.5(0.8),5.0(1.3),5.0(3.3) and 5.0(1.0) hours in each year from 2015 to 2020,no statistical differences were found between each group. The operating time of the distal pancreatectomy was 3.8 (0.9),3.0 (1.5),3.0 (1.8),2.0 (1.1),2.0 (1.5) and 3.0(2.0) hours in each year,the operating time was obviously shorter in 2018 compared to 2015 (P=0.026) and 2020 (P=0.041). The median hospital stay in 2020 for distal pancreatectomy was 3 days shorter than that in 2019. The overall incidence of postoperative pancreatic fistula gradually decreased,with a incident rate of 50.0%,36.8%,31.0%,25.9%,21.1% and 14.8% in each year. During this period,in a total of 3,6,4,2,0 and 20 cases received laparoscopic operations in each year. The incidence of clinically relevant pancreatic fistula (grade B and C) gradually decreased,the incident rates were 0,4.8%,7.1%,3.4%,4.3% and 1.4%,respectively. Two cases had postoperative abdominal bleeding and received unscheduled reoperation. The overall rate of unscheduled reoperation was 0.7%. A patient died within 30 days after the operation and the overall perioperative mortality was 0.4%. Conclusion: The surgical training of a high-volume center can ensure a high starting point in the initial stage and steady progress of pancreatic surgeons,to ensure the safety of pancreatic surgery.

Chinese expert consensus on minimally invasive radical surgery for pancreatic ductal adenocarcinoma (version 2022) / 中华外科杂志

Although there are still controversies over the efficiency and safety of minimally invasive radical surgery for pancreatic ductal adenocarcinoma (PDAC), most available studies have suggested a promising application of minimally invasive radical surgery. This consensus, referring to Chinese expert opinions and worldwide researches, aimed to discuss the related issues on minimally invasive radical surgery for PDAC to ensure the perioperative and oncological outcomes. Quality of evidence and strength of recommendations were evaluated based on the GRADE approach. The 15 recommendations covered 5 topics: oncological outcomes and patient safety of laparoscopic and robotic pancreatoduodenectomy, left-side pancreatectomy for PDAC, learning curve, safety of neoadjuvant therapy, and vascular resection in minimally invasive radical surgery for PDAC. This consensus gives reference and guidance to surgeons on the use of minimally invasive radical surgery for PDAC. Although this consensus is not sufficient to answer all the questions about minimally invasive radical surgery for PDAC, it represents the current consensus on the application of the techniques in the treatment of PDAC on the Chinese mainland.

Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer / 中华外科杂志

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ2 test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ2=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ2=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.

Neoplasia quística mucinosa gigante del páncreas tratada con pancreatectomía corporocaudal y preservación esplénica / Giant mucinous cystic neoplasm of the pancreas undergoing pancreatectomy with splenic preservation

RESUMEN: La neoplasia quística mucinosa del páncreas (NQMP) es un tumor infrecuente, que afecta predominantemente a mujeres (90-95 %), afectando especialmente entre la quinta y séptima década de la vida; cuyo descubrimiento suele ser incidental. Por lo general, son lesiones solitarias, sin compromiso del conducto pancreático principal; poco sintomáticas y asociadas a malignidad (10 % a 40 %). El objetivo de este manuscrito fue reportar un caso de neoplasia quística mucinosa gigante del páncreas intervenida quirúrgicamente y revisar la evidencia existente respecto de sus características morfológicas, terapéuticas y pronósticas. Mujer de 29 años, con masa abdominal poco sintomática. El diagnóstico se verificó por medio de ultrasonografía, tomografía axial computarizada y resonancia nuclear magnética. Se intervino quirúrgicamente, realizándose pancreatectomía corporocaudal con preservación esplénica, sin incidentes. La paciente fue dada de alta al quinto día, sin complicaciones, y evolucionó de forma adecuada, sin complicaciones postoperatorias. La NMQP es una lesión compleja, que puede asociarse a malignidad, pero el diagnóstico preoperatorio de malignidad no puede establecerse con seguridad. El pronóstico depende de un diagnóstico precoz y un tratamiento oportuno.

SUMMARY: Mucinous cystic neoplasm of the pancreas (MCNP) are variable types of tumors, which predominantly affect women (90-95 %), and usually appear incidentally in the 5th to 7th decade of life. They are generally solitary lesions, with no involvement of the main pancreatic duct, rarely symptomatic and are associated with malignancy (10 % to 40 %). The aim of this manuscript was to report a case of giant mucinous cystic neoplasm of the pancreas surgically treated and review the existing evidence regarding its morphological, therapeutic and prognosis characteristics. Patient: A 29-year-old woman with a slightly symptomatic abdominal mass. The diagnosis was verified with ultrasound, computed axial tomography and magnetic nuclear resonance. The patient underwent surgery; an uneventful corporocaudal pancreatectomy with splenic preservation was performed. She was discharged on the fifth day, and has evolved adequately, without postoperative complications. MCNP is a complex lesion, which can be associated with malignancy, but the preoperative diagnosis of malignancy cannot be established with certainty. Its prognosis depends on early diagnosis and timely treatment.

Hipoglucemia hiperinsulínica en un adulto con nesidioblastosis / Hyperinsulinic Hypoglycemia in an Adult with Nesidioblastosis

RESUMEN Introducción: La Nesidioblastosis es una rara afección pancreática que provoca hipoglucemia por hipersinsulinismo endógeno en la infancia. Es poco habitual en el adulto; solo se han publicado casos aislados desde su descripción. Objetivo: Caracterizar la presentación de una hipoglucemia hiperinsulínica en un paciente adulto con Nesidioblastosis. Caso clínico: Paciente adulto de 35 años, blanco, sexo masculino, sospecha de insulinoma, con episodios de hipoglucemia en ayunas o tras un ejercicio que revertía con la ingesta de alimentos o soluciones glucosadas. Se le realizó pancreatectomía de un 85 por ciento y en el estudio histológico se detectó una Nesidioblastosis. Conclusiones: Es infrecuente en el adulto, realizar su diagnóstico es difícil, se llega a la cirugía con el conocimiento de un estado hiperinsulínico endógeno, sin la certeza de su origen(AU)

ABSTRACT Introduction: Nesidioblastosis is a rare pancreatic condition that causes hypoglycemia due to endogenous hypersinsulinism in childhood. It is unusual in adults; only isolated cases have been published including its description. Objective: To characterize a case of hyperinsulinic hypoglycemia, in an adult patient with nesidioblastosis. Clinical case: A 35-year-old, white, male, adult patient with suspected insulinoma, with episodes of hypoglycemia in the fasting state or after exercise that was reversed with ingestion of food or glucose solutions. 85 percent pancreatectomy was performed and nesidioblastosis was detected in the histological study. Conclusions: It is rare in adults, making its diagnosis is difficult, and surgery is reached with the knowledge of an endogenous hyperinsulinic state, without the certainty of its origin(AU)

Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery / Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas

Abstract Purpose: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume. Methods: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-WhitneyU-test. Results: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09). Conclusion: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Resumo Justificativa: O presente estudo teve como objetivo examinar os fatores associados à Lesão Renal Aguda (LRA) no pós-operatório, centrando-se na hipotensão e perda de sangue intraoperatórias. Método: Estudo de coorte retrospectivo de pacientes submetidos a cirurgia de pâncreas entre Janeiro de 2013 e Dezembro de 2018. O desfecho primário foi ocorrência de LRA em até 7 dias após a cirurgia e o secundário, o tempo de hospitalização. A análise multivariada foi usada para determinar os fatores explicativos associados à LRA; a interação entre o valor integrado da hipotensão e volume de perda de sangue foi avaliada. As diferenças no tempo de hospitalização foram comparadas pelo teste U de Mann-Whitney. Resultados: Dos 274 pacientes, 22 pacientes apresentaram LRA. A raiz cúbica da área sob a pressão arterial média intraoperatória < 65 mmHg (Odds Ratio = 1,21; Intervalo de Confiança de 95% 1,01-1,45; p = 0,038) e volume de perda sanguínea > 500 mL (Odds Ratio = 3,81; Intervalo de Confiança de 95% 1,51-9,58; p = 0,005) estavam independentemente associados à lesão renal aguda. A interação entre hipotensão arterial média e volume de perda sanguínea em relação à lesão renal aguda apontou o modelo como significante (p < 0,0001) com efeito de interação (p = 0,0003). A LRA não apresentou relação significante com o tempo de hospitalização (19 vs. 28 dias, p = 0,09). Conclusões: A área sob hipotensão arterial e o volume de perda sanguínea > 500 mL no intraoperatório apresentaram associação com LRA no pós-operatório. Entretanto, se a pressão arterial média se mantém, mesmo em pacientes com grande volume de perda sanguínea, o risco de desenvolver LRA no pós-operatório é comparável ao risco dos pacientes com pequeno volume de perda sanguínea.

Hiperplasia de células neuroendocrinas que simula tumor sólido de páncreas / Neuroendocrine cell hyperplasia mimicking a solid pancreatic tumor

RESUMEN La hiperplasia de células neuroendocrinas pancreáticas es una patología donde se produce un aumen to en el número de células de los islotes de Langerhans y a veces puede simular un proceso tumoral. Caso clínico: presentamos el caso de un paciente con tumor sólido de cola de páncreas, sintomático, al que se le realizó esplenopancreatectomía corporocaudal laparoscópica. El resultado anatomopatoló gico posterior informó una hiperplasia neuroendocrina. Conclusión: la hiperplasia de células neuroen docrinas debería considerarse en el diagnóstico diferencial de tumores sólidos de páncreas. La alterna tiva quirúrgica laparoscópica es factible cuando no es posible establecer el diagnóstico prequirúrgico con estudios de imágenes o biopsia.

ABSTRACT Pancreatic endocrine cell hyperplasia is defined as an increase in the number of cells of Langerhans islets and can sometimes mimic a tumoral process. Case report: a male patient with a symptomatic solid tail of pancreas tumor underwent laparoscopic distal pancreatectomy and splenectomy. The pathological examination reported neuroendocrine cell hyperplasia. Conclusion: pancreatic endocrine cell hyperplasia should be considered in the differential diagnosis of solid pancreatic tumors. Laparoscopic surgery is feasible when the preoperative diagnosis with imaging tests of biopsy is not possible.

Robotic pancreatic resection. Personal experience with 105 cases / Ressecção pancreática robótica. Experiência pessoal com 105 casos

ABSTRACT Objective: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. Methods: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Results: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. Conclusions: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

RESUMO Objetivo: a primeira ressecção pancreática robótica no Brasil foi realizada por nossa equipe em 2008. Desde março de 2018, uma nova política nos levou a empregar sistematicamente o robô em todas cirurgias pancreáticas minimamente invasivas. O objetivo deste artigo é revisar nossa experiência com a ressecção pancreática robótica. Métodos: todos os pacientes submetidos a ressecção pancreática robótica de 2018 a 2019 foram incluídos. Variáveis pré- e intraoperatórias como idade, sexo, indicação, tempo cirúrgico, sangramento, diagnóstico, tamanho do tumor foram analisados. Resultados: 105 pacientes foram submetidos a pancreatectomia robótica. A idade mediana dos pacientes foi de 60,5 anos. 55 pacientes eram do sexo feminino. 51 pacientes foram submetidos a pancreatoduodenectomia, 34 pancreatectomia distal. A morbidade foi de 23,8% e ocorreu um óbito (mortalidade de 0,9%). Três pacientes (2,8%) tiveram a operação convertida para aberta. Quatro pacientes apresentaram retardo no esvaziamento gástrico e dois apresentaram sangramento. Vinte e quatro pacientes apresentaram fístula pancreática tratada de forma conservadora com remoção tardia do dreno pancreático. Nenhum paciente necessitou de drenagem percutânea, reintervenção ou readmissão hospitalar. Conclusões: a plataforma robótica é útil para a reconstrução do trato alimentar após pancreatoduodenectomia ou após pancreatectomia central. Pode aumentar a preservação do baço durante pancreatectomias distais. Técnicas poupadoras de pâncreas, como enucleação, ressecção de processo uncinado e pancreatectomia central, devem ser usadas para evitar insuficiência exócrina e/ou endócrina. A ressecção robótica do pâncreas é segura e viável para pacientes selecionados. Deve ser realizada em centros especializados por cirurgiões com experiência em cirurgia pancreática aberta e minimamente invasiva.

Características de la neoplasia quística mucinosa del páncreas en pacientes atendidos en un Hospital Nacional del Perú / Characteristics of pancreatic mucinous cystic neoplasm in patients treated at a National Hospital in Peru

RESUMEN Con el objetivo de analizar las características clínico, patológicas y quirúrgicas de la Neoplasia Quística Mucinosa de páncreas (NQM), se realizó un análisis de los pacientes del servicio de Cirugía de Páncreas, Bazo y Retroperitoneo del Hospital Nacional Guillermo Almenara Irigoyen en Lima, Perú desde enero del 2009 hasta octubre del 2018. La presencia del estroma ovárico se usó como criterio diagnóstico de NQM. De diez pacientes con edad promedio de 47,8 años, nueve fueron mujeres, las lesiones estuvieron localizadas en el páncreas distal, el tamaño tumoral promedio fue de 88,6 mm. En todos los pacientes se realizó una pancreatectomía distal siendo tres laparoscópicas, no hubo reoperaciones ni fallecidos, dos pacientes tuvieron carcinoma invasor asociado. En conclusión, la presentación de NQM es mayor en mujeres de edad media siendo la localización en el páncreas distal y el porcentaje de malignidad bajo. La cirugía laparoscópica es una alternativa de manejo.

ABSTRACT In order to analyze the clinical, pathological, and surgical characteristics of pancreatic mucinous cystic neoplasm (MCN), an analysis of the patients from the Pancreas, Spleen, and Retroperitoneal Surgery Service of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, was performed from January 2009 to October 2018. The presence of ovarian stroma was used as a diagnostic criterion for MCN. From ten patients with an average age of 47.8 years, nine were women; the lesions were located in the distal pancreas, and the average tumor size was 88.6 mm. All patients underwent a distal pancreatectomy, three of which were laparoscopic; there were no reoperations or deaths; two patients had associated invasive carcinoma. In conclusion, the frequency of MCN is higher in middle-aged women, being the location in the distal pancreas and the percentage of malignancy is low. Laparoscopic surgery is a disease management option.

Pancreatectomía corpo-caudal con resección en bloque de tronco celíaco: reporte de 2 casos / Corporal caudal pancreatectomy with celiac trunk block resection: report of 2 cases

INTRODUCCIÓN: El adenocarcinoma de cuerpo y cola de páncreas corresponde a cerca de un tercio del total de cánceres pancreáticos. Evoluciona en forma silenciosa hasta alcanzar estadios avanzados, llegando a comprometer muchas veces grandes vasos como tronco celíaco y sus ramas, y la arteria mesentérica superior. La resolución quirúrgica parece ser la única alternativa en estos casos. OBJETIVO: Presentar dos casos de adenocarcinoma de cuerpo y cola de páncreas tratados en nuestro hospital con pancreatectomía corpo-caudal y resección en bloque de tronco celíaco (procedimiento de Appleby modificado). DISCUSIÓN: Este procedimiento ha demostrado aumentar la sobrevida de estos pacientes, además de generar un alivio inmediato y duradero del dolor. Sin embargo, corresponde a una intervención con una alta morbilidad, siendo la fístula pancreática y la gastropatía isquémica las complicaciones más frecuentes. La evaluación del flujo de los vasos colaterales es un paso crítico para evitar las complicaciones isquémicas. CONCLUSIONES: La pancreatectomía corpo-caudal con resección en bloque de tronco celíaco, es una alternativa factible en adenocarcinoma de cuerpo y cola de páncreas localmente avanzado. Su indicación debe ser cuidadosa debido a que corresponde a un procedimiento con alta morbilidad.

INTRODUCTION: Adenocarcinoma of the body and tail of the pancreas corresponds to about one third of all pancreatic cancers. It evolves silently to reach advanced stages, often involving large vessels such as the celiac trunk and its branches, and the superior mesenteric artery. Surgical resolution seems to be the only alternative in these cases. AIM: To present two cases of adenocarcinoma of the body and tail of the pancreas treated in our hospital with distal pancreatectomy and celiac trunk en block resection (modified Appleby procedure). DISCUSSION: This procedure has been shown to increase the survival of these patients, in addition to generating immediate and lasting pain relief. However, it corresponds to an intervention with a high morbidity, being the pancreatic fistula and the ischemic gastropathy the most frequent complications. The evaluation of the flow of the collateral vessels is a critical step to avoid ischemic complications. CONCLUSIONS: Distal pancreatectomy with en bloc resection of the celiac trunk is a feasible alternative in locally advanced adenocarcinoma of the body and tail of the pancreas. Its indication must be careful since is a procedure with high morbidity.

Congenital hyperinsulinism in two siblings with ABCC8 mutation: same genotype, different phenotypes

SUMMARY Congenital hyperinsulinism (CHI) is a heterogenous disease caused by insulin secretion regulatory defects, being ABCC8/KCNJ11 the most commonly affected genes. Therapeutic options include diazoxide, somatostatin analogues and surgery, which is curative in focal CHI. We report the case of two siblings (born two years apart) that presented themselves with hypoketotic hyperinsulinemic persistent hypoglycemias during neonatal period. The diagnosis of diffuse CHI due to an ABCC8 compound mutation (c.3576delG and c.742C>T) was concluded. They did not benefit from diazoxide therapy (or pancreatectomy performed in patient number 1) yet responded to somatostatin analogues. Patient number 1 developed various neurological deficits (including epilepsy), however patient number 2 experienced an entirely normal neurodevelopment. We believe this case shows how previous knowledge of the firstborn sibling's disease contributed to a better and timelier medical care in patient number 2, which could potentially explain her better neurological outcome despite their same genotype.

A technical note on low cost rat laparoscopy an initial experience

Abstract Purpose: To evaluate a novel and adapted low-cost set model for laparoscopic surgery in rats. Methods: Nine Wistar rats underwent two different laparoscopic procedures, splenectomy (n=3) and distal pancreatectomy with splenectomy (n = 6), after assembling a low-cost set replacing the conventional one (monitor, micro camera, image processor, light source, laparoscope and insufflator). The new set included an Android Tablet 10.5 ", a 5mm USB Endoscope and semiautomatic sphygmomanometer monitor. Results: The same surgeon performed the laparoscopic procedures. Total surgical time ranged from 36 to 60 minutes with a mean of 45.8 minutes. Three rats died during the distal pancreatic and splenectomy procedure (33.3%), due to respiratory failure (n = 1), uncontrolled abdominal hemorrhage (n=1) and iatrogenic gastric perforation (n = 1). We followed the other six rats (66.6%) for seven days with no further evidence of complications. Conclusions: The laparoscopic partial pancreatectomy and splenectomy can be performed with the novel low-cost set assembled in the present experimental study. Both specific training and skills development are required to validate more advanced laparoscopic procedures and achieve a desirable outcome.

Laparoscopic distal pancreatectomy with spleen preservation / Pancreatectomia distal laparoscópica com preservação esplênica

ABSTRACT Background: Laparoscopic distal pancreatectomy has been the choice for resection of distal pancreas lesions due many advantages over open approach. Spleen preservation technique seems minimizes infectious complications in long-term outcome. Aim: To present the results of laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique (preservation of spleen blood vessels) performed by single surgical team. Methods: Retrospective case series aiming to evaluate both short and long-term outcomes of laparoscopic distal pancreatectomies with spleen preservation. Results: A total of 54 laparoscopic distal pancreatectomies were performed, in which 26 were laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique. Mean age was 47.9 years-old (21-75) where 61.5% were female. Mean BMI was 28.5 kg/m² (18-38.8). Mean diameter of lesion was 4.3 cm (1.8-7.5). Mean operative time was 144.1 min (90-200). Intraoperative bleeding was 119.2 ml (50-600). Conversion to laparotomy 3% (n=1). Postoperative morbidity was 11.5%. Postoperative mortality was null. Mean of hospital stay was 4.8 days (2-14). Mean time of follow-up period was 19.7 months (2-60). There was no neoplasm recurrence or mortality on evaluated period. There was no infectious complication. Conclusion: Laparoscopic distal pancreatectomy with spleen and splenic vessels preservation is feasible, safe, and effective procedure. This technique presented both low morbidity and null mortality on this sample. There were neither infectious complications nor neoplasm recurrence on long-term follow-up period.

RESUMO Racional: A pancreatectomia distal laparoscópica tem sido a abordagem de escolha para ressecção de tumores em pâncreas distal devido a muitas vantagens sobre a abordagem laparotômica. A técnica com preservação esplênica parece minimizar complicações infecciosas em longo prazo. Objetivo: Analisar os resultados das pancreatectomias distais laparoscópicas com preservação esplênica e dos vasos esplênicos. Método: Série de casos com 26 doentes operados para avaliar os resultados em curto e longo prazo. Resultados: Cinquenta e quatro pancreatectomias distais laparoscópicas foram realizadas nesse período, onde 26 foram pancreatectomias distais laparoscópicas com preservação esplênica pela técnica de Kimura. A média de idade foi 47,9 anos (21-75), onde 61,5% eram mulheres. A média do IMC foi 28,5 kg/m² (18-38,8). O diâmetro médio das lesões foi 4,3 cm (1,8-7,5). O tempo cirúrgico médio foi 144,1 min (90-200). A média de sangramento intra-operatório foi 119,2 ml (50-600). O índice de conversão foi 3% (n=1). A morbidade pós-operatória foi 11,5%, e a mortalidade nula. A média de internação hospitalar foi 4,8 dias (2-14). A média de seguimento foi 19,7 meses (2-60). Não houve recorrência de neoplasias e nem mortalidade durante esse período e também não houve complicações infecciosas em longo prazo. Conclusão: A pancreatectomia distal laparoscópica com preservação esplênica e dos vasos esplênicos é procedimento factível, seguro e eficaz no tratamento de neoplasias pancreáticas. Esta técnica apresentou baixa morbidade e mortalidade. Não houve complicações infecciosas e nem recidiva neoplásica em longo prazo.

Laparoscopic uncinatectomy: a more conservative approach to the uncinate process of the pancreas / Uncinectomia laparoscópica: uma operação mais conservadora que pode ser a melhor opção para acesso ao processo uncinado do pâncreas

ABSTRACT Background: The isolate resection of the uncinate process of the pancreas is a rarely described procedure but is an adequate surgery to treat benign and low grade malignancies of the uncinate process of the pancreas. Aim: To detail laparoscopic uncinatectomy technique and present the initial results. Method: Patient is placed in supine position with the surgeon between legs. Three 5-mm, one 10-mm and one 12-mm trocars were used to perform the isolated resection of the uncinate process of the pancreas. Parenchymal transection is performed with harmonic scalpel. A hemostatic absorbable tissue is deployed over the area previously occupied by the uncinate process. A Waterman drain is placed. Result: This procedure was applied to an asymptomatic 62-year-old male with biopsy proven low grade neuroendocrine tumor of the pancreatic uncinate process. A laparoscopic pancreaticoduodenectomy was proposed. During the initial surgical evaluation, intraoperative sonography was performed and disclosed that the lesion was a few millimeters away from the Wirsung. The option was to perform a laparoscopic uncinatectomy. Postoperative period until full recovery was swift and uneventful. Conclusion: Laparoscopic uncinatectomy is a safe and efficient procedure when performed by surgical teams with large experience in minimally invasive biliopancreatic procedures.

RESUMO Racional: A ressecção isolada do processo uncinado do pâncreas é procedimento raramente relatado na literatura, mas consiste em operação adequada para o tratamento de tumores benignos e malignidades não-invasivas de baixo grau do processo uncinado do pâncreas. Objetivo: Detalhar a técnica da uncinectomia laparoscópica e apresentar os resultados iniciais. Método: Paciente é colocado em posição supina com o cirurgião entre as pernas. São utilizados três trocárteres de 5 mm, um de 10 mm e um de 12 mm para realizar a ressecção isolada do processo uncinado. A transecção parenquimatosa é realizada com bisturi harmônico. Tecido absorvível hemostático é implantado sobre a área anteriormente ocupada pelo processo uncinado. Dreno de Waterman é colocado sobre a área de superfície cruenta pancreática. Resultado: Este procedimento foi utilizado em um caso de tumor neuroendócrino de processo uncinado de pâncreas de baixo grau comprovado por biópsia guiada por ultrassonografia endoscópica. Ultrassonografia intra-operatória evidenciou lesão distando alguns milímetros do ducto de Wirsung, e assim optou-se pela realização de uncinectomia laparoscópica. A evolução pós-operatória até recuperação completa foi rápida e sem intercorrências. Conclusão: A uncinectomia por via laparoscópica é procedimento eficaz e seguro em equipes com experiência em cirurgia biliopancreática minimamente invasiva.

Hiperinsulinismo congénito del recién nacido: A propósito de un caso clínico / Congenital hyperinsulinism of the newborn: a case report

El hiperinsulinismo congénito (HC) es la causa más frecuente de hipoglicemia persistente del recién nacido (RN), y se caracteriza por secreción no regulada de insulina frente a hipoglicemia. El manejo inicial es médico, pero en caso de fracaso, la pancreatectomía parcial es el tratamiento quirúrgico de elección. Objetivo: Comunicar el caso de un RN con HC con énfasis en el estudio genético, de imágenes y manejo quirúrgico, incluyendo la cirugía laparoscópica. Caso clínico: RN de término, con hipoglicemia prolongada por HC que no respondió al tratamiento médico. La ultrasonografía y resonancia nuclear magnética abdominal fueron normales. PET/CT Galio 68 evidenció aumento de metabolismo glucídico focalizado en el cuerpo pancreático. Se realizó pancreatectomía córporo-caudal laparoscópica sin incidentes, con mejoría de la hipoglicemia. El estudio genético fue compatible con HC focal, confirmado luego por biopsia. Conclusión: Se expone acerca de las características clínicas y diagnóstico del HC, en particular el rol de la cirugía y ventajas del abordaje laparoscópico.

Congenital hyperinsulinism (CH) is the most frequent cause of persistent hypoglycemia in the newborn and it is characterized by an inappropriately elevated insulin level in presence of hypoglycemia. Initial management is medical treatment, but if it fails, partial pancreatectomy is the surgical procedure of choice. Objective: To report a case of a newborn with CH to aware on this condition and update its multidisciplinary management. Case report: The case of a full term newborn with severe symptomatic hypoglycemia unresponsive to medical treatment is reported . Ultrasonography and abdominal MRI were normal, Gallium 68 PET/CT showed uptake in the body of the pancreas. Laparoscopic corporocaudal pancreatectomy was performed. The patient resolved hypoglycemia and was discharged without incidents. Genetic study was consistent with focal CH, confirmed later by biopsy. Discussion: This case report exposes the clinical presentation of CH and its diagnosis. It emphasizes on the surgical treatment and the advantages of minimally invasive technique.

Solid pseudopapillary tumor of the pancreas: Clinical features, diagnosis and treatment / Tumor sólido pseudopapilífero do pâncreas: características clínicas, diagnóstico e tratamento

Summary Introduction: Solid pseudopapillary tumor of the pancreas (SPTP) is a rare neoplasm of low malignant potential with uncertain behavior, diagnosed mainly in young women. Method: Our report comprises a series of cases of SPTP reviewed retrospectively, highlighting clinical, tomographic and immunohistochemical features, treatment performed and outcomes. Results: Thirteen patients were found to have pancreatic [solid] masses on computed tomography scan measuring a mean diameter of 8.8 cm. All patients underwent complete surgical excision. Immunohistochemistry confirmed diagnosis in all cases. Conclusion: SPTP occurs more frequently in young women. Diagnostic suspicion lies on the finding of a bulky, solid and cystic pancreatic mass. Imaging findings might provide diagnostic information before resection. Conservative approaches can be used in selected cases and survival rates are usually excellent following complete resection.

Resumo Introdução: O tumor sólido pseudopapilífero do pâncreas é uma neoplasia rara de baixo potencial de malignidade e com comportamento incerto, diagnosticado principalmente em mulheres jovens. Método: Uma série de casos dessa patologia é revisada retrospectivamente, focalizando os aspectos clínicos, tomográficos e imuno-histoquímicos, o tratamento realizado e o desfecho. Resultados: Foram avaliadas 13 pacientes com massas pancreáticas, por meio de tomografia computadorizada, com diâmetro médio de 8,8 cm. Todas as pacientes submeteram-se a ressecção cirúrgica completa. A imuno-histoquímica confirmou o diagnóstico em todos os casos. Conclusão: Esses tumores ocorrem frequentemente em mulheres jovens. Suspeita-se do diagnóstico ao encontrar uma volumosa tumoração sólido-cística no pâncreas. As imagens podem fornecer informações diagnósticas antes da ressecção. Podem-se empregar abordagens conservadoras em pacientes selecionados, e a sobrevida geralmente é excelente com a ressecção completa.

Pancreatectomía córporo-caudal con resección del tronco celíaco por adenocarcinoma de cuerpo pancreático: intervención de Appleby modificada / Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: the modified Appleby procedure

La resección oncológica completa es el único procedimiento que permite la sobrevida a largo plazo en cáncer de páncreas. La afectación de la arteria hepática, tronco celíaco o arteria mesentérica superior constituyen una contraindicación quirúrgica porque se asocia a mal pronóstico y por las dificultades técnicas que implica conseguir la resección oncológica completa. Solo un grupo seleccionado de pacientes con buena respuesta a la quimioterapia y pasibles de resección R0 se benefician de la cirugía de resección del tronco celíaco. A partir de un caso clínico de un adenocarcinoma de páncreas con infiltración de la arteria hepática común y tronco celíaco que tras una buena respuesta a la neoadyuvancia y embolización de la arteria hepática común fue sometido a una esplenopancreatectomía córporo-caudal con resección del tronco celíaco, se realiza una revisión de la literatura sobre el tema y sus aspectos técnicos relevantes. El análisis realizado permite sugerir que en casos debidamente seleccionados la pancreatectomía córporo-caudal con resección del tronco celíaco en bloque es un procedimiento factible, seguro, y con buenos resultados quirúrgicos y oncológicos. En condiciones de respuesta a la quimioterapia neoadyuvante y experiencia del equipo quirúrgico pareciera que esta cirugía podría mejorar el pronóstico y calidad de vida de estos enfermos.

Abstract Complete oncologic resection is the only procedure that enables survival in pancreatic cancer. Compromise of the liver artery, the celiac artery or the superior mesenteric artery constitute a surgical contraidication since it is associated to a bad prognosis and it is technically hard to achieve a complete surgical resection. Only a selected group of patients who respond well to chemotherapy and may be subject to resection benefit from celiac artery resection surgery. A clinical case of adenocarcinoma of the pancreas with infiltration of the common liver artery and the celiac artery underwent a corporeo-caudal pancreatosplenectomy with celiac artery resection after a good response to neoadjuvant therapy and hepatic arterial embolization. Based on this, a review of literature on this issue and its relevant technical aspects was conducted. The analysis performed may suggest that in duly selected cases, corporeo-caudal pancreatosplenectomy with bloc celiac artery resection is a feasible and safe procedure with good surgical and oncologic results. Upon good response to neoadjuvant chemotherapy and an experienced surgical team, this surgery seems to improve prognosis and the quality of life of these patients.

Resumo A ressecção oncológica completa é o único procedimento que permite uma sobrevida em longo prazo a pacientes com câncer de pâncreas. O comprometimento da artéria hepática, tronco celíaco ou artéria mesentérica superior é uma contraindicação cirúrgica porque está associado a um prognóstico ruim e, devido às dificuldades técnicas que implica conseguir a ressecção oncológica completa. Somente um grupo selecionado de pacientes com boa resposta à quimioterapia e que possa ser submetido à ressecção R.0 pode se beneficiar da cirurgia de ressecção do tronco celíaco. A partir de um caso clínico de um adenocarcinoma de pâncreas com infiltração da artéria hepática comum e do tronco celíaco, que depois de apresentar boa resposta à quimioterapia e a embolização da artéria hepática comum, foi submetido a uma esplenopancreatectomia corpo-caudal com ressecção do tronco celíaco, realizou-se uma revisão da literatura sobre o tema e seus aspectos técnicos relevantes. A análise realizada permite sugerir que nos casos devidamente selecionados, a pancreatectomia corpo-caudal com ressecção em bloco do tronco celíaco é um procedimento factível, seguro, com bons resultados cirúrgicos e oncológicos. Quando se reúnem as condições de resposta adequada à quimioterapia neoadjuvante e a experiência da equipe de cirurgia, pareceria que esta intervenção poderia melhorar o prognóstico e a qualidade de vida destes pacientes.

Minimally invasive surgery for pseudopapillary neoplasm of the pancreas / Cirurgia minimamente invasiva para tratamento da neoplasia pseudopapilar do pâncreas

ABSTRACT Background: Solid pseudopapillary pancreatic neoplasia is usually a large well-circumscribed pancreatic mass, with cystic and solid areas more frequently found in young women. It is a benign pancreatic neoplasia in most cases, therefore minimally invasive surgery could be an interesting approach. Aim: Evaluate the results of minimally invasive surgery for this neoplasia. Methods: Patients with this tumor who underwent minimally invasive pancreatectomies between 2009 and 2015 in a single institution, were analyzed regarding demographic, clinical-pathological futures, post-operative morbidity and disease-free survival. Results: All were women, and their median age was 39 (18-54) years. Two patients with tumor in the head of the pancreas underwent laparoscopic pancreaticoduodenectomy, and another one underwent laparoscopic enucleation. Two patients with tumor in the neck underwent central pancreatectomy. Distal pancreatectomies were performed in the other five, one with splenic preservation. None required blood transfusion or conversion to open surgery. Two (20%) developed clinical relevant pancreatic fistulas, requiring readmission. Median length of postoperative hospital stay was five days (2-8). All resection margins were negative. Patients were followed for a median of 38 months (14-71), and there was no recurrence. Conclusions: Minimally invasive surgery for solid pseudopapillary pancreatic neoplasia is feasible for tumors in different locations in the pancreas. It was associated with acceptable morbidity and respected the oncologic principles for treatment.

RESUMO Racional: Tumores sólidos pseudopapilíferos do pâncreas são em geral massas circunscritas, com componentes sólidos e císticos, mais frequentemente encontrados em mulheres jovens. Na maioria dos casos, são neoplasias benignas e portanto, a abordagem minimamente invasiva pode ser considerada vantajosa. Objetivo: Avaliar os resultados das pancreatectomias laparoscópicas em pacientes com esses tumores. Métodos: Foram avaliados pacientes submetidos à pancreatectomias minimamente invasivas em um única instituição. Foram analisadas variáveis demográficas, clinicopatológicas, complicações pós-operatórias e sobrevida. Resultados: Todos os pacientes eram mulheres e a idade mediana foi de 39 (18-54) anos. Duas pacientes com tumores na cabeça do pâncreas foram submetidas à duodenopancreatectomia e outra à enucleação. Duas pacientes com tumores no colo do pâncreas realizaram pancreatectomia central. Outras cinco com neoplasias no corpo e cauda foram submetidas à pancreatectomia distal, uma delas com preservação do baço. Nenhuma necessitou de conversão para laparotomia. Houve duas fístulas pancreáticas clinicamente relevantes (20%). O tempo mediano de internação foi de cinco (2 a 8) dias e duas pacientes foram reinternadas (20%). Todas as margens de ressecção foram negativas e após seguimento mediano de 38 (14-71) semanas, todas estavam livres de doença. Conclusão: As ressecções pancreáticas minimamente invasivas de tumores sólidos pseudopapilíferos são factíveis para tumores em diferentes localizações no pâncreas, com morbidade aceitável obedecendo-se os princípios oncológicos para o tratamento dessas neoplasias.