VIPoma pancreático tratado com pancreatectomia distal e preservação esplênica com ligadura da artéria esplênica / Pancreatic VIPoma treated with distal pancreatectomy and splenic preservation with ligature of splenic artery

O VIPoma é um tumor neuroendócrino de baixa malignidade derivado das células das ilhotas não-beta do pâncreas, apresenta incidência de 1:10.000.000 pessoas na população e sua localização mais comum é no corpo e cauda do pâncreas. Seu tratamento curativo é cirúrgico, sendo geralmente realizada a pancreatectomia distal com esplenectomia. O caso relatado foi o de uma paciente do sexo feminino, de 31 anos, diagnosticada com VIPoma pancreático. O tratamento realizado foi a pancreatectomia distal com preservação esplênica e ligadura da artéria esplênica. A preservação esplênica diminui a morbidade perioperatória, sem prejudicar o resultado oncológico nos tumores de baixo grau de malignidade.

VIPoma is a low grade malignancy neuroendocrine tumor derived from non-beta pancreatic islet cells, it has an incidence of 1:10.000.000 individuals in the general population and its commoner location is in the body and tail of the pancreas. The curative treatment is surgery, and distal pancreatectomy with splenectomy is usually the employed technique. The case reported was of a female patient, 31 years-old, diagnosed with pancreatic VIPoma. The chosen treatment was distal pancreatectomy with splenic preservation and ligature of the splenic artery. Splenic preservation reduces the perioperatory morbidity, with no prejudice to the oncologic effect in the low grade malignancy tumors.

Conducta conservadora ante el traumatismo esplénico / Conservative behavior in case of splenic traumatism

INTRODUCCIÓN. El bazo es el órgano que más frecuentemente se lesiona en los traumatismos abdominales. Fueron objetivos de este trabajo describir la conducta conservadora ante el traumatismo esplénico y determinar su frecuencia en el Hospital Pediátrico Juan Manuel Márquez, centro provincial de atencion al niño politraumatizado, donde se preconiza esta conducta por los beneficios que ofrece la preservación del bazo a la función inmunolópgica. MÉTODOS. Se realizó un estudio prospectivo con 36 pacientes con traumatismo esplénico que fueron tratados de forma conservadora teniendo como criterio principal la estabilidad hemodinámica del paciente. Se analizó edad, sexo, causa de lesión esplénica, lesiones asociadas, tratamiento conservador realizado, complicaciones y estadía hospitalaria. RESULTADOS. El traumatismo esplénico estuvo presente en el 66,6 por ciento de los traumatismos abdominales. Las causas más frecuentes fueron los accidentes de tránsito (50 por ciento), seguidos de las caídas desde alturas (33 por ciento). En el 89 por ciento de los pacientes se siguió una conducta conservadora: en el 88 por ciento de los casos se aplicó tratamiento médico conservador y en el 11 por ciento, métodos quirúrgicos de conservación esplénica. CONCLUSIONES. Todas las lesiones ocurrieron por traumatismos contusos. Las técnicas quirúrgicas utilizadas fueron dos esplenorrafias y una esplenectomía parcial. No hubo fallecidos y las complicaciones fueron mínimas, por lo que consideramos que la conducta conservadora del traumatismo esplénico es una modalidad de tratamiento segura en la infancia

INTRODUCTION. The spleen is the more frequent involved organ in the abdominal traumata. The aims of present paper were to describe the conservative behavior in case of splenic traumatism and to determine its frequency in the Juan Manuel Márquez Children University Hospital, provincial children center of care for poli-traumatism child, where this type of behavior is emphasized due to benefits offered by spleen preservation to the immunologic function. METHODS. A retrospective study was conducted in 36 patients presenting with splenic traumatism treated in a conservative way taking into account as main criterion the hemodynamic patient's stability. The age, sex, cause of splenic lesion, associated lesions, and conservative treatment, applied complications and hospital stay. RESULTS. Splenic traumatism was present in the 66,6 percent of abdominal traumata. The more frequent causes were the road accidents (50 percent), followed by falls from heights (33 percent). In the 89 percent of patients there was a conservative behavior: in the 88 percent a conservative medical treatment was applied and in the 11 percent surgical methods of splenic conservation were used. CONCLUSIONS. Total of lesions occurred due to bruise traumatisms. Surgical techniques used were two splenorrhaphies and a partial splenectomy. There were not deceased and complications were minimal, thus, we considered that conservative behavior of splenic traumatism is a safe treatment modality in childhood

Preservação do baço na pancreatectomia distal por trauma / Distal pancreatectomy with splenic preservation in traumatic injuries of pancreas

OBJETIVOS: A esplenectomia simplifica a pancreatectomia distal no trauma mas tem o inconveniente de aumentar a vulnerabilidade do paciente às infecções. O objetivo é avaliar se a preservação do baço na referida cirurgia é exeqüível e segura. MÉTODOS: A preservação do baço foi feita em 52 pacientes (48 por cento) entre 108 submetidos à pancreatectomia distal. Quarenta e cinco (86,5 por cento) do sexo masculino e sete (13,5 por cento) do sexo feminino. Idade variou de seis a 42 anos com média de 22,1 anos. Trauma penetrante foi a causa da lesão em 35 (67 por cento) com 27 (77 por cento) por arma de fogo e oito (23 por cento) por arma branca. Contusão foi responsável pela lesão em 17 (33 por cento). RESULTADOS: Não houve óbito. Fístula pancreática ocorreu em seis (11,5 por cento) pacientes; coleção subfrênica em seis (11,5 por cento); pancreatite em dois (3,8 por cento); abcesso de parede em quatro (8 por cento); pneumonia em quatro (8 por cento). Quarenta pacientes tiveram lesões associadas. O ISS médio foi de 19,3. O baço apresentava lesão em 13 pacientes. Sete foram submetidos à esplenorrafia e seis à ressecção parcial. Em 51 pacientes o baço foi conservado com os vasos esplênicos. Em um caso foi feita a ligadura proximal e distal dos vasos esplênicos (técnica Warschaw). Permanência hospitalar média de 12 dias. CONCLUSÃO: A pacreatectomia distal com preservação do baço mostrou ser segura nos pacientes estáveis, mesmo na presença de lesões associadas. A ausência de óbitos e a participação de cirurgiões em fase de treinamento confirmam sua segurança.

OBJECTIVES: Splenectomy simplifies distal pancreatectomy in trauma but has the inconvenience of increasing vulnerability to infection. The objective of this study is to assess whether spleen preservation in the aforementioned surgical procedure is feasible and safe. METHODS: Spleen preservation was performed in 52 patients (48 percent) of 108 undergoing distal pancreatectomy. Forty-five (86.5 percent) were males and 7 (13,5 percent) were females. The mean age was 22.1 years, varying from 6 to 42 years. Penetrating trauma was the cause of injury in 35 cases (67 percent), 27 of which (77 percent) due to gunshot wounds and 8 (23 percent) due to stab wounds. Blunt trauma was the cause of injury in 17 cases (33 percent). RESULTS: There were no deaths. Pancreatic leaks occurred in 6 (11.5 percent) patients, fluid collection in the splenic fossa in 6 (11.5 percent), pancreatitis in 2 (3.8 percent), surgical wound abscesses in 4 (8 percent) and pneumonia in 4 (8 percent) patients. Forty patients had associated injuries. The average ISS was 19.3. The spleen was injured in 13 patients. Seven underwent splenorrhaphy and 6 required partial splenic resection. The spleen and splenic vessels were preserved in 51 patients. In one case, proximal and distal ligation of the splenic vessels (Warschaw technique) was performed. Hospital stay averaged 12 days. CONCLUSION: Distal pancreatectomy with spleen preservation was shown to be a safe procedure in stable patients, even with associated injuries. The absence of deaths and the co-participation of surgeons in training confirms the safety of this procedure.

Splenic Preservation in Rats

Despite the recognized desirability of spenic salvage,forced splenectomy remains the rule in many operative situations,including trauma and pancreatic cancer. The aim of this study was to evaluate the phagocytic function,histologic finding and anatomic change when the perfusion of preserved spleen was done only through short gastric vessels after splenic vessel ligation. In this situation, we evaluate the necessity of mass reduction to improve the perfusion into the residual spleen by 2/3 patial splenectomy. We studied 41 Sprague-Dawley rats by subdiving them into 3 main groups.In HL(;Hilar ligation)group, splenic vessel ligation was done(n=18). In HLS(Hilar ligation + 2/3partial splenectomy), splenic vessel ligation and partial splenectomy were done(n=18), and the others(n=5) were used as a control group. The changes of anatomy,histologic findings, and phagocytic functions in the preserved splenic tissue were observed at 1hour,2weeks, and 5months postoperatively,based on results of the India ink technique for demonstrating phagocytic function and on results of regular histologic examination. In all rats,at least 1 upper short gastric vessel was noted without direct connection to splenic vessel.In HL group,at 2weeks postoperatively,the size and weight of the preserved spleens were severely decreased to 1/3 of those of control group(p=0.0002). But,after 5months,the size and weight recovered to about 70-80% of those of initial spleen parameters.In HLS group,the size and weight changes were not found.At 1hour postoperatively phagocytic activity decreased to 35% in the control group,10% at 2weeks and not improved at 5months in both groups.The white pulps didn't show any specific change. We concluded that in spite of splenic mass reduction,the white pulp did not change, and phagocytic function was not improved.Therefore,the splenic mass reduction is not essential for the recovery of phagocytic function at the preserved spleen.