Hidatidosis pancreática en una niña de 5 años / Pancreatic echinococcosis in a 5-year-old girl

La hidatidosis pancreática representa el 0,2-0,6 % de los casos, siendo la población pediátrica la de mayor riesgo. Las lesiones suelen localizarse en cabeza del páncreas (50-58 %); la localización en cuerpo y cola del páncreas se encuentra en el 24-34 % y el 19 %, respectivamente. Dada la posibilidad de complicaciones, suele realizarse tratamiento quirúrgico. Se sugiriere indicar albendazol antes y después del acto quirúrgico por los riesgos de ruptura y diseminación de los protoescólices. Se presenta el caso de una niña de 5 años de edad con dolor abdominal progresivo y lesión quística en páncreas compatible con hidatidosis en la ultrasonografía. En la tomografía computada se observa compresión de la vía biliar. La hemoaglutinación indirecta fue negativa. Presentó elevación de la bilirrubina total, con franco predominio de bilirrubina directa, y aumento de enzimas hepáticas. Se realizó laparotomía exploradora, colecistectomía y destechamiento del quiste. Evolucionó favorablemente, continuó con albendazol durante 3 meses luego de la cirugía.

Pancreatic echinococcosis accounts for 0.2­0.6% of cases, with the pediatric population being at a higher risk. Most commonly, pancreatic lesions occur in the head of the pancreas (50­58%); and in the body and tail in 24­34% and 19% of cases, respectively. Given the potential complications, surgery is usually performed. Albendazole is recommended before and after the surgery due to the risks for rupture and dissemination of protoscolices. Here we describe the case of a 5-year-old girl with progressive abdominal pain and cystic lesion in the pancreas compatible with echinococcosis in the ultrasound. The computed tomography showed bile duct compression. Indirect hemagglutination was negative. She had elevated total bilirubin, with a clear predominance of direct bilirubin, and high liver enzymes. Exploratory laparotomy, cholecystectomy, and unroofing of the cyst were performed. The patient had a favorable course and continued with albendazole for 3 months after the surgery.

Resultados iniciales de un programa de cirugía hepato-bilio-pancreática laparoscópica en el Hospital Regional de Talca / Initial results of a laparoscopic hepato-biliary-pancreatic surgery program at the Regional Hospital of Talca

Resumen Introducción: La cirugía laparoscópica es la vía de abordaje de elección para el tratamiento de múltiples patologías abdominales, sin embargo, su desarrollo en la cirugía hepato-bilio-pancreática (HBP) ha sido más lento y heterogéneo. Objetivo: Presentar los resultados de la implementación y desarrollo de un programa de cirugía HBP laparoscópica en el Hospital de Regional de Talca. Materiales y Método: Estudio de serie de casos que incluye a todos los pacientes operados por una patología HBP por vía laparoscópica como acceso a la cavidad abdominal en el Hospital Regional de Talca entre el 1 de junio de 2014 y el 30 de junio de 2016. Resultados: Fueron 42 pacientes, 25 (59,5%) de sexo femenino. La mediana de edad fue 58 años (IQ25-75 38-64 años). 22 (52,4%) tuvo una cirugía abdominal previa en la mayoría de ellos por vía abierta. 22 (52,4%) pacientes fueron intervenidos por patología maligna. La indicación más frecuente fue la cirugía radical por cáncer de vesícula biliar en 10 (23,8%) casos y la hidatidosis hepática (HH) en 7 (16,7%). 1 (2,4%) paciente portador de una HH requirió de una conversión a laparotomía. 5 (11,9%) presentaron alguna morbilidad posoperatoria, 2 de ellos > III de Clavien. La mediana de recuperación funcional fue de 1 día (1-2) y la de estadía posoperatoria de 3 días (3-4). No hubo mortalidad a 90 días. Con una mediana de seguimiento de 26,5 (18-33) meses, 4 (19%) de los 21 pacientes oncológicos intervenidos con intención curativa presentaron recurrencia de la enfermedad, la mayoría de ellos sistémica y el 95% está libre de recurrencia a los 24 meses. Conclusiones: La implementación y el desarrollo de la cirugía hepato-bilio-pancreática (HBP) por vía laparoscópica puede efectuarse en hospitales de referencia regional con los mismos estándares y resultados internacionales.

Introduction: Laparoscopic surgery is the preference access for the treatment of various abdominal pathologies, however, its development in hepato-biliary-pancreatic (HBP) surgery has been slower and heterogeneous. Aim: Present the results of the implementation and development of a laparoscopic HBP surgery program at the Regional Hospital of Talca. Materials and Method: Case series study in which were included all patients submitted to laparoscopic surgery for treatment of HPB pathology as access to the abdominal cavity in the Regional Hospital of Talca between June 1, 2014 and June 30, 2016. Results: There were 42 patients, 25 (59.5%) female. The median age was 58 years (IQ25-75 38-64 years). 22 (52.4%) had previous abdominal surgery in most of them by open route. 22 (52.4%) patients were operated on for malignant pathology. The most frequent indication was radical surgery for gallbladder cancer in 10 (23.8%) cases and hepatic hydatidosis (HH) in 7 (16.7%). 1 (2.4%) patient carrying a HH required a conversion to laparotomy. 5 (11.9%) presented some postoperative morbidity, 2 of them > Clavien III. The median functional recovery was 1 day (1-2) and the postoperative stay was 3 days (3-4). There was no mortality at 90 days. With a median follow-up of 26.5 (18-33) months, 4 (19%) of the 21 oncological patients operated on with curative intent presented recurrence of the disease, most of them systemic and 95% free from recurrence at 24 months. Conclusions: Implementation and development of HBP surgery by laparoscopy is feasible and it can be performed in regional referral hospitals with the same international standards and results.

Seguridad y eficacia del drenaje guiado por endosonografía de colecciones pancreáticas usando prótesis plásticas y metálicas tipo LAMS / Safety and efficacy of EUS-guided drainage of pancreatic fluid collections using plastic and lumen apposing metal stents (LAMS)

Background: Pancreatic fluid collections (PFC) are associated with severe acute pancreatitis. After maturation (after 4 weeks) they are classified as pancreatic pseudocyst (PP) and walled-off necrosis (WON). Endoscopic management is associated with lower morbidity and mortality compared with surgery. Aim: To describe the experience of EUS-guided drainage PFC drainage using plastic stent (PS) or metal stent (lumen apposing metal stents, or "LAMS"). Methods: Retrospective, observational study, between 2016-2019. Results: 17 patients in total. 8 cases were symptomatic PP and 9 were WON. Age 12-72 years. 12 cases in men. Indications: abdominal pain 5 cases and infection 11. The 8 cases of PFC were drained successfully using PS, without adverse effects. Regarding WON drainage, 3 cases were managed with PS and 6 with LAMS. In 5 cases, complementary endoscopic necrosectomy was required. A patient with LAMS required complementary surgical cleaning ("step-up") to treat collections far from the LAMS. Complications: one case of PS presented pigment occlusion with superinfection and another case presented migration to the stomach. Regarding LAMS, one case presented self-limited bleeding, another case presented obstruction of the stent with infection, which was managed endoscopically and with antibiotics. Conclusion: The endoscopic management of PFC is effective and safe, with plastic and metal stent (LAMS). The choice of type of stent depends on the characteristics of PFC (liquid vs solid), center experience and costs.

Introducción: Las colecciones pancreáticas (CP) se asocian a pancreatitis agudas graves. Luego de su maduración (después de las 4 semanas) se clasifican en pseudoquistes (PQ) y necrosis encapsulada (NE). El manejo endoscópico se asocia a menor morbimortalidad comparado con el quirúrgico. Objetivo: Describir la experiencia del drenaje de CP mediante el uso de prótesis plásticas (PP) o metálicas (lumen apposing metal stents, o "LAMS") mediante endosonografía. Método: Estudio retrospectivo, observacional, entre 2016-2018. Resultados: 17 pacientes en total. Ocho casos fueron PQ sintomáticos y 9 NE. Edad 12-72 años (12 casos en hombres). Indicaciones: dolor abdominal 5 casos e infección 11. Los 8 casos de PQ fueron drenados exitosamente con PP, sin efectos adversos. En relación con el drenaje de NE, 3 casos fueron manejados con PP y 6 con LAMS. En 5 casos se requirió necrosectomía endoscópica complementaria. Un paciente con LAMS requirió aseo quirúrgico complementario por colecciones alejadas al LAMS. En relación con las complicaciones, un caso de PP presentó oclusión del pigtail con sobreinfección y otro presentó migración al estómago. Respecto a LAMS, un caso presentó sangrado autolimitado y otro caso obstrucción de la prótesis con sobreinfección, que fue manejada endoscópicamente y con antibióticos. Conclusión: El manejo endoscópico de las CP es efectiva y segura, tanto con prótesis plásticas como metálicas (LAMS). La elección de la prótesis depende de las características de la lesión (líquido vs sólido), experiencia del centro y costos.

O valor da amilase, obtido precocemente nos drenos abdominais, é teste útil em prever a ocorrência de fístula pancreática após duodenopancreatectomia: lições aprendidas de um centro do Sul do Brasil / Early drain fluid amylase is useful to predict pancreatic fistula after pancreatoduodenectomy: lessons learned from a southern brazilian center

ABSTRACT BACKGROUND: Pancreatic fistula represents the most feared complication after pancreatoduodenectomies, being the major responsible for the high morbidity and mortality after this operation. Its incidence remains around 10% to 30%. In recent years, several authors have studied the value of amylase in abdominal drains fluid, measured at an early stage after the surgical procedure, as a useful tool to identify patients at risk of developing pancreatic fistula. OBJECTIVE: To analyze the value of early drain fluid amylase as a method to predict the occurrence and severity of postoperative pancreatic fistula in patients undergoing pancreatoduodenectomies. METHODS: We evaluated 102 prospective patients submitted to pancreatoduodenectomies from January 2013 to June 2017. The mensuration of amylase in abdominal drains was performed on days 1, 3, 5 and 7 in all patients. Patients were divided into three groups according to postoperative day 1 (POD1) results: values <270 U/L (group 1); between 271 and 5.000 U/L (group 2); and values >5.000 U/L (group 3). RESULTS: The incidence of pancreatic fistula was 25.5%, being 3.33%, 27.3% and 41.02% in the three groups, respectively. Compared with group 1, the risk of developing pancreatic fistula increased with increasing amylase values on POD1. Amylase values on POD1 and POD3 of patients with pancreatic fistula were higher than in the other ones without this complication (P<0.001). In addition, in group 3, 37.5% of patients with pancreatic fistula evolved to death (P<0.001). Finally, in this group, patients who died had drain fluid amylase values on POD1 significantly higher than the others in the same group (P<0.001). CONCLUSION: Early drain fluid amylase value is a useful test to stratify patients in relation to the risk of developing pancreatic fistula after pancreatoduodenectomies, in addition to correlate with the severity of this complication.

RESUMO CONTEXTO: A fístula pancreática representa a complicação mais temida após as duodenopancreatectomias, sendo a grande responsável pela elevada morbi-mortalidade após esta operação. Sua incidência permanece em torno de 10% a 30%. Nos últimos anos, diversos trabalhos têm estudado o valor da amilase nos drenos abdominais, medido de forma precoce após o procedimento cirúrgico, como ferramenta útil para a identificação dos pacientes sob risco de desenvolver fístula pancreática. OBJETIVO: Avaliar o valor da amilase no fluido dos drenos abdominais, obtido precocemente no pós-operatório, como método para prever a ocorrência e severidade da fístula pancreática nos pacientes submetidos a duodenopancreatectomias. MÉTODOS: Foram avaliados 102 pacientes prospectivos submetidos a duodenopancreatectomias no período de janeiro de 2013 a junho de 2017. A dosagem da amilase nos drenos abdominais foi realizada nos dias 1, 3, 5 e 7 em todos os pacientes. Os pacientes foram divididos em três grupos conforme os resultados do 1o PO: valores <270 U/L (grupo 1); entre 271 e 5.000 U/L (grupo 2); e valores >5.000 U/L (grupo 3). RESULTADOS: A incidência de fístula pancreática foi de 25,5%, sendo 3,33%, 27,3% e 41,02% nos três grupos, respectivamente. Comparados ao grupo 1, o risco de desenvolver fístula pancreática foi crescente com o aumento da amilase no 1o PO. Os valores das amilases no 1o PO e 3o PO dos pacientes com fístula pancreática foram maiores do que nos pacientes sem essa complicação (P<0,001). Além disso, no grupo 3, 37,5% dos pacientes com fístula pancreática evoluíram para óbito (P<0,001). Por fim, neste grupo, os pacientes que evoluíram para óbito tiveram valores de amilase no 1o PO significativamente maiores do que os demais pacientes (P<0,001). CONCLUSÃO: O valor da amilase, medido de forma precoce nos drenos abdominais no pós-operatório de duodenopancreatectomias, é teste útil para estratificar pacientes em relação ao risco de apresentar fístula pancreática, além de se correlacionar com a severidade dessa complicação.

Páncreas divisum y pancreatitis: su importancia en la práctica cotidiana / Pancreas divisum and pancreatitis: its importance in everyday practice

Pancreas divisum (PD) is the most common congenital anatomical variant of the pancreas. Its etiological implication in recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) has been recurrently questioned. Normal anatomy and variants: 80-90% of the population has normal anatomy, with excretion of exocrine pancreatic secretion to the duodenum by the major papilla. Three anatomical variants of PD have been described: classic PD with visible ventral duct, but total absence of fusion; PD with absence of ventral duct; and incomplete PD, with a rudimentary connection between the ventral and dorsal ducts. Clinical implication: This anatomical variant is symptomatic in less than 5% of the carriers, being associated to higher prevalence in patients with RAP However, the relationship between PD and RAP is considered probable, only in cases of association with mutation of the CFTR gene. Obstructive CP can develop in the segment drained by the dorsal duct. Diagnosis: Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive diagnostic method. Other non-invasive diagnostic methods are endosonography and computed tomography (CT), the latter with lower performance. Treatment: The current trend in acute pancreatitis (AP) where PD is assumed as an etiological factor, is endoscopic resolution, with papillotomy with or without a pancreatic stent.

El páncreas divisum (PD) es la variante anatómica congénita más frecuente del páncreas. Su implicancia etiológica en pancreatitis aguda recurrente (PAR) y pancreatitis crónica (PC) ha sido frecuentemente cuestionada. Anatomía normal y variantes: 80-90% de la población presenta anatomía normal, con salida de secreción pancreática exocrina al duodeno por la papila mayor. Se han descrito 3 variantes anatómicas: PD clásico con conducto ventral visible, pero ausencia total de fusión; PD con ausencia de conducto ventral; y PD incompleto, con conexión rudimentaria entre los conductos ventral y dorsal. Implicancia clínica: Esta variante anatómica da síntomas en menos de 5% de los portadores, asociándose a mayor prevalencia en pacientes con PAR. Sin embargo, se considera probable la relación entre PD y PAR, solo en casos de asociación con mutación del gen CFTR. Pancreatitis crónica (PC) obstructiva se puede desarrollar en el segmento drenado por el conducto dorsal. Diagnóstico: La colangiopancreatografía por resonancia magnética (CPRM) es el método diagnóstico más sensible. Otros métodos diagnósticos no invasivos son la endosonografía y tomografía computada (TC), este último de menor rendimiento. Tratamiento: La tendencia actual en PA donde se asume PD como factor etiológico, es la resolución endoscópica, con papilotomía con o sin stent.

Intrapancreatic accessory spleen / Baço acessório intrapancreático

ABSTRACT An asymptomatic 79-year-old woman, with incidental finding on abdominal ultrasound of a solid nodule in the tail of the pancreas. Magnetic resonance imaging showed a 12mm solid tumor. The suggested diagnosis was pancreatic neuroendocrine tumor. The pathological examination showed an intrapancreatic splenic tissue. This is a rare ectopic location of spleen tissue and it should be considered in the differential diagnosis of pancreatic solid tumors.

RESUMO Mulher de 79 anos, com achado incidental em ultrassonografia de abdome de lesão sólida em cauda de pâncreas. Em ressonância magnética, foi confirmada lesão de 12mm. Foi aventada a hipótese diagnóstica de tumor neuroendócrino não secretor, sendo realizada pancreatectomia distal laparoscópica. Em estudo anatomopatológico, diagnosticou-se tecido esplênico, configurando baço acessório intrapancreático. Este tipo de manifestação topográfica de baço é rara, mas deve fazer parte dos diagnósticos diferenciais em tumores sólidos do pâncreas.

Critical analysis and systematization of rat pancreatectomy terminology

ABSTRACT PURPOSE: To critically analyze and standardize the rat pancreatectomy nomenclature variants. METHODS: It was performed a review of indexed manuscripts in PUBMED from 01/01/1945 to 31/12/2015 with the combined keywords "rat pancreatectomy" and "rat pancreas resection". The following parameters was considered: A. Frequency of publications; B. Purpose of the pancreatectomy in each article; C. Bibliographic references; D. Nomenclature of techniques according to the pancreatic parenchyma resection percentage RESULTS: Among the 468, the main objectives were to surgically induce diabetes and to study the genes regulations and expressions. Five rat pancreatectomy technique references received 15 or more citations. Twenty different terminologies were identified for the pancreas resection: according to the resected parenchyma percentage (30 to 95%); to the procedure type (total, subtotal and partial); or based on the selected anatomical region (distal, longitudinal and segmental). A nomenclature systematization was gathered by cross-checking information between the main surgical techniques, the anatomic parameters descriptions and the resected parenchyma percentages. CONCLUSION: The subtotal pancreatectomy nomenclature for parenchymal resection between 80 and 95% establishes a surgical parameter that also defines the total and partial pancreatectomy limits and standardizes these surgical procedures in rats.

Fifty consecutive pancreatectomies without mortality / Cinquenta pancreatectomias consecutivas sem mortalidade

Objective: to report the group's experience with a series of patients undergoing pancreatic resection presenting null mortality rates. Methods: we prospectively studied 50 consecutive patients undergoing pancreatic resections for peri-ampullary or pancreatic diseases. Main local complications were defined according to international criteria. In-hospital mortality was defined as death occurring in the first 90 postoperative days. Results: patients' age ranged between 16 and 90 years (average: 53.3). We found anemia (Hb < 12g/dl) and preoperative jaundice in 38% and 40% of cases, respectively. Most patients presented with peri-ampullary tumors (66%). The most common surgical procedure was the Kausch - Whipple operation (70%). Six patients (12%) needed to undergo resection of a segment of the mesenteric-portal axis. The mean operative time was 445.1 minutes. Twenty two patients (44%) showed no clinical complications and presented mean hospital stay of 10.3 days. The most frequent complications were pancreatic fistula (56%), delayed gastric emptying (17.1%) and bleeding (16%). Conclusion : within the last three decades, pancreatic resection is still considered a challenge, especially outside large specialized centers. Nevertheless, even in our country (Brazil), teams seasoned in such procedure can reach low mortality rates.

Objetivo: apresentar uma série de casos consecutivos de ressecções pancreáticas com mortalidade nula, discutindo os aspectos relacionados ao preparo pré-operatório, técnica cirúrgica e cuidados pós-operatórios. Métodos: foram analisados prospectivamente 50 pacientes consecutivos submetidos à ressecções pancreáticas para o tratamento de doenças pancreáticas ou periampulares. As principais complicações locais foram definidas segundo critérios internacionais. A mortalidade intra-hospitalar foi considerada quando o óbito ocorreu nos primeiros 90 dias do pós-operatório. Resultados: a faixa etária variou entre 16 e 90 anos (média: 53,3 anos). Anemia (Hb<12g/dl) e icterícia pré-operatória estavam presentes, respectivamente, em 38% e 40% dos casos. A maior parte dos pacientes era portadora de tumor periampular (66%). O procedimento cirúrgico mais realizado foi a operação de Kausch-Whipple (70%). Em seis pacientes (12%) houve necessidade de ressecção de segmento do eixo mesentericoportal. O tempo cirúrgico médio foi 445,1 minutos. Vinte e dois pacientes (44%) evoluíram sem nenhuma complicação clínica e tiveram tempo médio de internação de 10,3 dias. As complicações mais frequentes foram: fístula pancreática (56%), retardo do esvaziamento gástrico (17,1%) e sangramento (16%). Conclusão: nas últimas três décadas a ressecção pancreática ainda é considerada um desafio, principalmente fora dos grandes centros especializados. Apesar disso, com uma equipe habituada com esse procedimento, um baixo índice de mortalidade é possível.

Efficacy and Safety of Pancreatobiliary Endoscopic Procedures during Pregnancy

BACKGROUND/AIMS: Endoscopic therapy with endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective diagnostic and therapeutic tool for biliary and pancreatic disorders during pregnancy. In this report, we describe our experiences with pancreatobiliary endoscopic procedures during pregnancy. METHODS: We reviewed ERCP and endoscopic ultrasonography (EUS) procedures that were performed at a single tertiary care referral center between January 2002 and October 2013. Medical records were reviewed for the procedure indication, the duration of fluoroscopy, postprocedure complications, etc. Pregnancy outcomes and fetal complications were identified by chart review and phone calls to patients. RESULTS: A total of 10 ER-CPs and five EUSs were performed in 13 pregnant patients: four of whom underwent the procedure in the first trimester, eight in the second trimester, and one in the third trimester. Indications for endoscopic therapy included gallstone pancreatitis, obstructive jaundice with common bile duct (CBD) stone, asymptomatic CBD stone, pancreatic cyst, choledochal cyst, and acute cholecystitis. Only one patient had a complication, which was postprocedural hyperamylasemia. Two patients underwent an artificial abortion, one according to her own decision and the other due to an adverse drug reaction. CONCLUSIONS: ERCP seems to be effective and safe for pregnant women. Additionally, EUS can be an alternative to ERCP during pregnancy.

Endoscopic Retrograde Cholangiopancreatography during Pregnancy: Really Guarantee to Safety?

No abstract available.

Endoscopic Ultrasound-Guided Transluminal Drainage for Peripancreatic Fluid Collections: Where Are We Now?

Endoscopic drainage for pancreatic and peripancreatic fluid collections (PFCs) has been increasingly used as a minimally invasive alternative to surgical or percutaneous drainage. Recently, endoscopic ultrasound-guided transluminal drainage (EUS-TD) has become the standard of care and a safe procedure for nonsurgical PFC treatment. EUS-TD ensures a safe puncture, avoiding intervening blood vessels. Single or multiple plastic stents (combined with a nasocystic catheter) were used for the treatment of PFCs for EUS-TD. More recently, the use of covered self-expandable metallic stents (CSEMSs) has provided a safer and more efficient approach route for internal drainage. We focused our review on the best approach and stent to use in endoscopic drainage for PFCs. We reviewed studies of EUS-TD for PFCs based on the original Atlanta Classification, including case reports, case series, and previous review articles. Data on clinical outcomes and adverse events were collected retrospectively. A total of 93 patients underwent EUS-TD of pancreatic pseudocysts using CSEMSs. The treatment success and adverse event rates were 94.6% and 21.1%, respectively. The majority of complications were of mild severity and resolved with conservative therapy. A total of 56 patients underwent EUS-TD using CSEMSs for pancreatic abscesses or infected walled-off necroses. The treatment success and adverse event rates were 87.8% and 9.5%, respectively. EUS-TD can be performed safely and efficiently for PFC treatment. Larger diameter CSEMSs without additional fistula tract dilation for the passage of a standard scope are needed to access and drain for PFCs with solid debris.

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas / Predictive factors of morbidity in distal pancreatic resections

OBJETIVO: Avaliar a morbidade pós-operatória e investigar a existência de seus fatores preditivos. MÉTODOS: O estudo foi realizado de forma retrospectiva, a partir de uma base de dados mantida de forma prospectiva. De 1994 a 2008, 100 pacientes consecutivos foram submetidos à ressecções pancreaticas esquerdas. A principal variável de interesse foi a morbidade pós-operatória, tendo diversas outras características da população sido registradas simultaneamente. Posteriormente, para a análise de fatores preditivos de morbidade pós-operatória o subgrupo de pacientes que foi submetido aos procedimentos de pancreatectomia distal com preservação do baço (n=65) foi analisado separadamente quanto à relevância das diferentes técnicas de secção do parênquima pancreático, assim como, outros possíveis fatores preditivos à ocorrência de morbidade pós-operatória. RESULTADOS: Considerando-se juntamente todas as ressecções pancreáticas esquerdas realizadas, a ocorrência de complicações globais, de complicações relevantes e graves foi 55%, 42% e 20%, respectivamente. Os fatores que se mostraram preditivos à ocorrência de morbidade pós-operatória após pancreatectomia distal com preservação do baço foram a técnica de secção do parênquima pancreático, idade, índice de massa corporal e a realização de operação abdominal concomitante. CONCLUSÃO: A morbidade associada às ressecções pancreáticas, à esquerda dos vasos mesentéricos superiores, foi importante. De acordo com a estratificação adotada baseada na gravidade das complicações, alguns fatores preditivos foram identificados. Estudos futuros com coortes maiores de pacientes são necessários para confirmar tais resultados.

OBJECTIVE: To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS: The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS: Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION: The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Encuesta nacional sobre tratamiento quirúrgico de patología del hígado, vía biliar y páncreas / An enquiry about liver, biliary and pancreatic surgery in Chile

Background: Chile has a high incidence of cholelithiasis and associated complications, that usually require surgical treatment. Aim: Lo carry out an enquiry about biliary diseases and their surgical treatment in public and prívate surgical services in Chile. Material and Methods: An enquiry about liver and biliary diseases and their treatment was designed and sent by electronic mail to 35 surgical services. Results: Lhe enquiry was answeredby 17 services. A total of 9.505 cholecystectomies were reported. Between21 and 98 percent of the procedures were laparoscopic. Iatrogenic lesions of the biliary tree were reported in 0.3 percent of the procedures. Choledocolithiasis was found associated to cholelithiasis in 0 to 21 percent of procedures. However, the use of intraoperative cholangiography was incidental. Lhe incidence of gallbladder cancer in cholecystectomies for cholelithiasis fluctuated between 0.2 and 8.9 percent. Liver metastases derived from colorectal cancer were the most common liver tumor operated. Hydatidosis was more common in southern Chile. Pancreatic excision was almost exclusively performed in Metropolitan Santiago. Conclusions: This information will allow the establishment of information and collaboration channels among the surgical services throughout Chile.

Se trata de una encuesta realizada con el objeto de conocer la frecuencia e incidencia de las principales patologías y técnicas quirúrgicas de la esfera hepato-bilio-pancreática atendida en centros de salud públicos y privados del país durante el año 2007. La encuesta fue respondida por 17 instituciones nacionales. Entre los resultados resaltan el total de colecistectomías reportadas de 9.505, de las cuales entre un 21 y 98 por ciento son realizadas por vía laparoscópica. Lesiones iatrogénicas de vía biliar ocurrieron dentro de un rango de 0 a 1,5 por ciento, con una mediana de 0,3 por ciento. La frecuencia de coledocolitiasis asociada a la colelitiasis ocurrió entre un 0 a 21 por ciento, aunque el empleo de colangiografía intraoperatoria es en general de ocurrencia incidental. La incidencia de cáncer vesicular en colecistectomías por colelitiasis es claramente distinta según se trate de instituciones de centro-norte y sur del país, con incidencias que varían entre 0,2 y 8,9 por ciento. Las metástasis hepáticas operadas son principalmente de origen colorrectal, y son los tumores hepáticos más frecuentemente tratados. La hidatidosis hepática manifiesta en esta encuesta su conocida distribución geográfica, siendo más frecuentemente tratada en los centros del sur del país. La cirugía pancreática resectiva tiende a estar concentrada en las instituciones de la región metropolitana.

Pancreatoduodenectomía totalmente laparoscópica: técnica quirúrgica y experiencia inicial / Totally laparoscopic pancreaticoduodenectomy: surgical technique and initial experience

Introduction: Nowadays the utility of laparoscopic pancreatic surgery is accepted for a wide variety of indications. However pancreaticoduodenectomy has been considered beyond the possibilities of laparoscopy by the majority of surgeons. The objective of this report is to show our surgical technique and initial experience with totally laparoscopic pancreaticoduodenectomy. Material and Methods: Between November of 2007 and June of 2008, a laparoscopic technique was offered to patients with indication of pancreaticoduodenectomy for different pathologies. We describe the surgical technique, perioperative care, intraoperative complications, need for conversion to open technique, mortality, and early postoperative complications. Results: A total of three patients were subjected to laparoscopic pancreaticoduodenectomy. The surgical indication was an ampullar adenocarcinoma in a 52 years old woman, a pseudopapilar tumor of the pancreatic head in a 17 years oíd woman, and a duodenal gastrointestinal stromal tumor in a 63 years oíd man. There was no need for conversion to open technique. There was no mortality. The operative time ranged from 300 to 360 min. The first patient presented an upper gastrointestinal bleeding, from pancreatic anastomoses requiring surgical hemostasis. The last patient developed a self-limited biliary fistula, managed successfully with drains. The hospital stay varied from 8 to 25 days. Discussion: Totally laparoscopic pancreaticoduodenectomy is a feasible procedure, replicating the same steps of open surgery in a reasonable operative time, and with surgical results comparable with open technique.

Introducción: Actualmente la utilidad de la laparoscopía en la cirugía pancreática es ampliamente aceptada en diversas áreas; sin embargo, la pancreatoduodenectomía había sido considerada un procedimiento fuera de las posibilidades de laparoscopía por la mayoría de los cirujanos. El objetivo de este trabajo es dar a conocer la técnica quirúrgica y nuestra experiencia inicial con la pancreatoduodenectomía totalmente laparoscópica. Material y Métodos: Desde noviembre del 2007 hasta junio del 2008, se ofreció la vía de abordaje laparoscópica a pacientes con indicación de pancreatoduodenectomía curativa por diversas patologías. Se describe la técnica quirúrgica utilizada, el manejo perioperatorio, complicaciones intraoperatorias, necesidad de conversión a técnica abierta, mortalidad y complicaciones precoces. Resultados: Total = 3 pacientes. La indicación de cirugía fue por un adenoma ampular en una mujer de 52 años, un tumor pseudopapilar de cabeza de páncreas en una mujer de 17 años y un tumor estromal gastrointestinal duodenal en un hombre de 63 años. No se requirió de conversión a técnica abierta en ningún caso. No hubo mortalidad postoperatoria. Los tiempos operatorios variaron entre 300-360 min. La primera paciente presentó una hemorragia digestiva alta por sangrado del muñón pancreático, requiriendo reoperación. El último paciente presentó una fístula biliar autolimitada, manejada con drenajes. La estadía hospitalaria varió entre 8 y 25 días. Discusión: La pancreatoduodenectomía totalmente laparoscópica es técnicamente factible de realizar, replicando los mismos pasos de la técnica abierta, en un tiempo operatorio razonable, y obteniendo resultados quirúrgicos comparables a la técnica abierta.

Endoscopic Pancreatic Sphincterotomy: Indications and Complications

BACKGROUND/AIMS: Although a few recent studies have reported the effectiveness of endoscopic pancreatic sphincterotomy (EPST), none has compared physicians' skills and complications resulting from the procedure. Thus, we examined the indications, complications, and safety of EPST performed by a single physician at a single center. METHODS: Among 2,313 patients who underwent endoscopic retrograde cholangiopancreatography between January 1996 and March 2008, 46 patients who underwent EPST were included in this retrospective study. We examined the indications, complications, safety, and effectiveness of EPST, as well as the need for a pancreatic drainage procedure and the concomitant application of EPST and endoscopic sphincterotomy (EST). RESULTS: Diagnostic indications for EPST were chronic pancreatitis (26 cases), pancreatic divisum (4 cases), and pancreatic cancer (8 cases). Therapeutic indications for EPST were removal of a pancreaticolith (10 cases), stent insertion for pancreatic duct stenosis (9 cases), nasopancreatic drainage (7 cases), and treatment of sphincter of Oddi dysfunction (1 case). The success rate of EPST was 95.7% (44/46). Acute complications of EPST included five cases (10.9%) of pancreatitis and one of cholangitis (2.2%). EPST with EST did not reduce biliary complications. Endoscopic pancreatic drainage procedures following EPST did not reduce pancreatic complications. CONCLUSIONS: EPST showed a low incidence of complications and a high rate of treatment success; thus, EPST is a relatively safe procedure that can be used to treat pancreatic diseases. Pancreatic drainage procedures and additional EST following EPST did not reduce the incidence of procedure-related complications.

Seven years experience of pancreaticoduodenectomy at Sawanpracharak Hospital.

BACKGROUND: Pancreaticoduodenectomy is a major procedure with significant mortality and morbidity. Pancreaticoduodenectomy is a safe procedure for a variety of periampullary conditions at Sawanpracharak Hospital. OBJECTIVE: To evaluate complications, morbidity, and mortality. The effects of clinical and variables related to patient mortality. MATERIAL AND METHOD: Retrospective medical records review of 52 patients who underwent pancreaticoduodenectomy at Sawanpracharak Hospital between February 2000 and November 2006 was conducted. Of these, 12 patients who died after pancreaticoduodenectomy were studied. RESULTS: Of 52 cases, 29 males and 23 females, the median age was 64 years (age range, 32-82 years). Median operative time was 3.70 hours (range, 2.0-9.5 hours). Pathological examination demonstrated 38.46% ampullary cancer 26.92% pancreatic cancer, 1.92% duodenal cancer, 11.54% periampullary cancer, 3.85% gastric cancer, 1.92% gastrointestinal stromal tumor, 5.77% chronic pancreatitis, 1.92% cystadenoma of pancreas, 1.92 chronic gastric ulcer, 1.92% leiomyoma of duodenum, and 3.85% no pathologic report. Fifty percent of patients underwent pylorus preservation pancreaticoduodenectomy. Postoperative complications occurred in 40.38% of patients, including intraabdominal abscess (19.05%), pancreatic fistula (14.29%), bowel fistula (9.52%), internal bleeding (9.52,%), sepsis (9.52%), superior mesenteric occlusion (4.76%), bile fistula (4.76%), cholangitis (4.76%), acute renal failure (14.29%), pneumonia (4.76%), acute myocardial infarction (4.76%), and additional surgery was required in 13.46% of patients. Overall perioperative mortality was 23.08% with only one patient with benign disease (chronic pancreatitis) died postoperatively. Underlying medical disease conditions did not influence postoperative morbidity or mortality. Natures of surgical complications were indicated as causes of significant higher mortality. The median follow-up for patients was 3.37 months (range, 0.5-65.7 months, mean 8.71 +/- 13.66 months). CONCLUSION: Pancreaticoduodenectomy still causes considerable morbidity and mortality. With careful patient selection, preoperative assessment of respectability, surgical technique, critical care anesthesia, and postoperative care, pancreaticoduodenectomy can be performed safely and improve the results to an acceptable level.

Quiste hidatídico pancreático: reporte de un caso / Pancreatic hydatid cyst: report of one case

Se presenta el caso de un paciente con dolor epigástrico de intensidad progresiva, cuyos estudios de imágenes revelaron la presencia de una lesión quística de la cabeza de páncreas. Se realizó una pancreato-duodenectomía. El estudio anatomopatológico reveló un quiste hidatídico de la cabeza de páncreas, siendo el primer caso publicado en nuestra literatura nacional.

We report a 56 years old male consulting for a progressive epigastric pain lasting eight months. An abdominal ultrasound and a magnetic resonance showed a cystic lesion in the head of the pancreas and bile duct dilatation. He was operated, performing a pancreatoduodenectomy with a Roux en Y gastrojejunoanastomosis. The patient has a postoperative pneumonia but the rest of the evolution was uneventful and was discharged at the tenth postoperative day. The pathological diagnosis of the surgical piece was a pancreatic hydatid cyst.

Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts

BACKGROUND: Surgery is the traditional treatment for symptomatic pancreatic pseudocysts, but the morbidity is still too high. Minimally invasive endoscopic approaches have been encouraged. AIMS: To evaluate the efficacy of endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. METHODS: From January, 2003 to August, 2006, 31 consecutive symptomatic patients submitted to 37 procedures at the same endoscopic unit were retrospectively analysed. Chronic and acute pancreatitis were found in, respectively, 17 (54.8 percent) and 10 (32.3 percent) cases. Bulging was present in 14 (37.8 percent) cases. Cystogastrostomy or cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control. By protocol, only a single plastic stent, without nasocystic drain, was used. Straight or double pigtail stents were used in, respectively, 22 (59.5 percent) and 15 (40.5 percent) procedures. RESULTS: Endoscopic ultrasound-guided transmural drainage was successful in 29 (93.5 percent) patients. Two cases needed surgery, both due to procedure-related complications. There was no mortality related to the procedure. Twenty-four patients were followed-up longer than 4 weeks. During a mean follow-up of 12.6 months, there were six (25 percent) symptomatic recurrences due to stent clogging or migration, with two secondary infections. Median time for developing complications and recurrence of the collections was 3 weeks. These cases were successfully managed with new stents. Complications were more frequent in patients treated with straight stents and in those with a recent episode of acute pancreatitis. CONCLUSIONS: Endoscopic transmural drainage provides an effective approach to the management of pancreatic pseudocysts.

RACIONAL: A abordagem cirúrgica é o tratamento tradicional para os pseudocistos sintomáticos de pâncreas, contudo a morbidade permanece elevada. Terapêuticas endoscópicas minimamente invasivas têm sido encorajadas. OBJETIVO: Avaliar a eficácia da drenagem endoscópica transmural de pseudocistos de pâncreas guiada por ecoendoscopia. MÉTODOS: De janeiro de 2003 a agosto de 2006, 31 pacientes sintomáticos submetidos a 37 procedimentos no mesmo centro de referência foram analisados retrospectivamente. Pancreatite crônica e aguda foram detectadas em, respectivamente, 17 (54,8 por cento) e 10 (32,3 por cento) pacientes. Abaulamento da parede esteve presente em 14 (37,8 por cento) casos. Cistogastrostomias ou cistoduodenostomias foram criadas com um ecoendoscópio linear sob controle endosonográfico e fluoroscópico. Como rotina, apenas uma única prótese plástica foi empregada, sem dreno nasocístico. Próteses retas ou " double pigtail" foram empregadas em, respectivamente, 22 (59,5 por cento) e 15 (40,5 por cento) procedimentos. RESULTADOS: A drenagem endoscópica foi adequada em 29 (93,5 por cento) pacientes. Dois casos necessitaram intervenção cirúrgica por complicações do procedimento. Não houve mortalidade relacionada ao procedimento. Vinte e quatro pacientes contaram com seguimento superior a 4 semanas. Durante seguimento médio de 12,6 meses, ocorreram seis (25 por cento) recurrências sintomáticas por obstrução ou migração da prótese, com infecção secundária em dois casos, todos manejados com novas próteses. O tempo mediano para ocorrência de complicações foi de 3 semanas. Complicações tardias foram mais freqüentes em pacientes tratados com próteses retas e naqueles com história recente de pancreatite aguda. CONCLUSÔES: A drenagem endoscópica transmural constitui abordagem efetiva para o manejo dos pseudocistos de pâncreas.