Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico.

BACKGROUND: Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy. METHODS: We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival. RESULTS: A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients. CONCLUSIONS: SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.

Peritoneal carcinomatosis index and overall survival in patients taken to cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy.

BACKGROUND: The peritoneal carcinomatosis (PC) secondary to gastrointestinal or gynecological cancer has increased its incidence. It has a worse prognosis compared to other sites of metastasis. The peritoneal carcinomatosis index (PCI) establishes overall survival in patients with gastrointestinal or gynecological tumors and carcinomatosis. OBJECTIVE: To evaluate the relationship of PCI to overall survival (OS) and recurrence-free survival (RFS) in patients treated with cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC). METHOD: A descriptive, retrolective study of 80 charts of patients with CP was conducted. We included patients with colon, ovarian, appendicular, pseudomyxoma and gastric tumors with CP treated with CRS plus HIPEC. The OS and RFS were determined according to the type of adenocarcinoma and the degree of differentiation. The OS and RFS were determined in months in patients with PCI > 15 PCI as well as in patients with PCI < 15 considering the tumor of origin. RESULTS: Patients with ovarian tumors and pseudomyxoma with PCI < 15 presented OS > 70 months, compared to patients with gastric tumors (4 months). CONCLUSIONS: The PCI and histology are predictors of OS. Patients with ovarian tumors and PCI < 15 have higher OS, similar to pseudomyxomas. RFS was also higher in patients with PCI < 15.

ANTECEDENTES: La incidencia de carcinomatosis peritoneal (CP) secundaria a cáncer gastrointestinal o ginecológico ha aumentado y tiene peor pronóstico en comparación con otros sitios de metástasis. El índice de carcinomatosis peritoneal (ICP) establece la supervivencia global en pacientes con tumores gastrointestinales o ginecológicos y carcinomatosis. OBJETIVO: Evaluar la relación del ICP con la supervivencia global (SG) y la supervivencia libre de recurrencia (SLR) en pacientes tratados con cirugía citorreductora (CCR) más quimioterapia intraperitoneal e hipertemia (HIPEC). MÉTODO: Estudio descriptivo, retrolectivo, de 80 expedientes de pacientes con CP. Se incluyeron tumores de colon, ovario, apendicular, pseudomixomas y gástricos con CP tratados con CCR + HIPEC. Se determinaron la SG y la SLR de acuerdo con el tipo de adenocarcinoma y el grado de diferenciación, en meses, en pacientes con ICP > 15 y con ICP < 15 considerando el tumor de origen. RESULTADOS: Los pacientes con tumores de ovario y pseudomixoma con ICP < 15 tenían una SG > 70 meses, frente a 4 meses con tumores gástricos. CONCLUSIONES: El ICP y la histología son predictores de la SG. Las pacientes con tumores ováricos con ICP < 15 tienen mayor SG, igual que los pseudomixomas. La SLR fue mayor en los pacientes con ICP < 15.

Solid and papillary neoplasm of the pancreas (SPNP): a case report.

Background: Solid and papillary neoplasm of the pancreas (SPNP) is a rare pancreatic tumor, well known for its predilection for young women and large volume. The tumor has a favorable prognosis and differentiating it from other pancreatic tumors with aggressive behavior is necessary. Case Description: We present the case of a 34-year-old female without relevant background. She presented with abdominal pain and by fine needle biopsy was diagnosed as ductal carcinoma. During the evaluation, an abdominal ultrasound revealed a pancreatic growth that was "bulky, solid, with irregular margins, in homogeneously hypoechoic, with anechoic areas of necrosis, located lateral to the tail of the pancreas and medial to the upper pole of the left kidney and the lower splenic pole". The patient was admitted, and surgery was performed. At the laparotomy, a tumor of 15 cm in diameter was detected. The tumor was located in the tail of the pancreas, was well encapsulated, and of solid consistency. Caudal pancreatectomy with a splenectomy was carried out. The final pathology diagnosis was a SPNP. Conclusions: In the presence of a large abdominal mass of pancreatic relevance, even in older women, the possibility of having an SPNP should always be evaluated. Given the low malignancy potential of this tumor and the excellent prognosis with radical surgical treatment, the preoperative diagnosis should always be particularly accurate. Surgical resection is recommended as the treatment of choice.

Role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of gastric cancer.

Patients with peritoneal carcinomatosis (PC) of gastric origin have a poor prognosis of life with an average survival of 1-3 months. Systemic chemotherapy has improved the survival of those patients with gastric metastatic cancer at 7-10 months. However, this benefit could not be reproduced in those patients with PC. The current literature for the use of hyperthermic intraperitoneal chemotherapy (HIPEC) for gastric PC has significant variation related to patient selection, treatment intent (palliative vs. attempt at curative treatment), surgical technique, intraperitoneal chemotherapy agent utilized, and systemic chemotherapy administered adjuvantly. From the perspective of patient selection for cytoreduction and HIPEC, patients with extensive PC are not candidates. In addition, unresectable location would make a patient a poor candidate for cytoreduction and HIPEC. Optimally, those with positive peritoneal cytology alone could benefit most. However, the role of cytoreductive surgery and HIPEC in patients with PC of gastric origin has not yet been clarified.

Los pacientes con carcinomatosis peritoneal (CP) de origen gástrico tienen un mal pronóstico de vida, con una supervivencia media de 1 a 3 meses. La quimioterapia sistémica ha mejorado la supervivencia de los pacientes con cáncer gástrico metastásico a los 7-10 meses. Sin embargo, este beneficio no se ha podido reproducir en los pacientes con CP. En cuanto a lo relacionado con la literatura actual para el uso de HIPEC (hyperthermic intraperitoneal chemotherapy) en la CP de origen gástrico, existe una variación significativa en la selección de pacientes, la intención de tratamiento (paliativo frente a intento de tratamiento curativo), la técnica quirúrgica, el agente quimioterapéutico intraperitoneal utilizado y la quimioterapia sistémica adyuvante administrada. Desde la perspectiva de la selección de pacientes para citorreducción y tratamiento con HIPEC, los pacientes con CP extensa no son candidatos. Además, lesiones irresecables por su localización harían al paciente un pobre candidato para citorreducción y tratamiento con HIPEC. De manera óptima, aquellos pacientes con citología peritoneal positiva en ausencia de CP son quienes más podrían beneficiarse. Sin embargo, el papel de la cirugía citorreductora y del tratamiento con HIPEC en los pacientes con CP de origen gástrico aún no ha sido esclarecido.

Prognostic importance of lymph node ratio after resection of ampullary carcinomas.

BACKGROUND: The prognosis of the lymph node ratio (LNR) in Vater's ampulla carcinomas (VACs) is recently studied. However, there are not enough data in several populations like Latin American people. Our aim is to demonstrate the prognosis significance of the LNR in this setting. METHODS: Pancreaticoduodenectomies for VACs were identified (n=128) from 1980 through 2015. Based on a ROC curve, a cut-off point of 0.1 was assigned for the LNR and the population was divided into two groups for comparison. RESULTS: The LNR ≥0.1 group was statistically significant associated with recurrence (38.5% vs. 19.5%), pT3-T4 tumors (69.2% vs. 29.3%), poorly differentiated tumors (46.2% vs. 17.5%), lymphovascular invasion (61.5 vs. 17.1%), perineural invasion (38.5% vs. 19.5%), and positive margins (15.4% vs. 2.4%). In the multivariate analysis, LNR (HR 2.891; CI: 1.987-3.458, P=0.02), LNM (HR 2.945; CI: 2.478-3.245, P=0.002), perineural invasion (HR 3.327; CI: 3.172-4.156, P=0.003), and recurrence (HR 3.490; CI: 2.896-4.122, P=0.001) were associated with lower survival. CONCLUSIONS: The LNR is a good predictor of survival and worse oncological outcomes for VACs after resection.

Metastatic pheochromocytoma to liver without elevation of metanephrines and catecholamines.

INTRODUCTION: Malignant pheochromocytoma represents 10% of all patients with pheochromocytoma. Of these cases, only 5-9% presents without elevation of metanephrines and catecholamines. PRESENTATION OF CASE: A 43-year-old female patient presented with an abdominal tumor. An exploratory laparotomy was performed and the final report was a pheochromocytoma. After ten years, multiple liver lesions were detected and surgical treatment was performed. Pathological evaluation revealed a malignant pheochromocytoma with negative margins after 5 years of follow-up without evidence of disease. DISCUSSION: The recurrence rate of malignant pheochromocytoma is 15-20% at ten years and a 5-year survival rate that ranges from 50% to 80%. The presence of synchronous metastases is rare (10-27%), but have been reported until 20 years later with the most common metastatic sites being the local lymph nodes, bone (50%), liver (50%) and lung (30%). The prognostic factor such as size >6cm, age over 45 years, synchronous metastasis and no tumor excision are related with poor prognosis. CONCLUSION: Surgical treatment offers the best survival rate and the only chance of cure so far and the goal is an R0 resection as in our case. So it should be the treatment of choice.

Primary retroperitoneal Merkel cell carcinoma: Case report and literature review.

BACKGROUND: Merkel cell carcinoma (MCC) is an aggressive cutaneous neuroendocrine carcinoma that affects elderly patients and typically arises in sun-exposed skin. The disease is very rare and only few cases present with no apparent skin lesion. In the retroperitoneum there are only two cases reported in the literature. CASE PRESENTATION: We report a case of a 54-year-old Mexican male with MCC, which presented as a large retroperitoneal mass. Pathological and immunohistochemical analysis of the transabdominal CT-guided biopsy specimen revealed a MCC. The patient underwent preoperative chemotherapy followed by a laparotomy and the mass was successfully excised. DISCUSSION: There are two possible explanations for what occurred in our patient. The most plausible theory is the retroperitoneal mass could be a massively enlarged lymph node where precursor cells became neoplastic. This would be consistent with a presumptive diagnosis of primary nodal disease. Moreover, metastasis to the retroperitoneal lymph nodes has been reported as relatively common when compared to other sites such as liver, bone, brain and skin. The less probable theory is the non-described "regression" phenomena of a cutaneous MCC, but we are not found a primary skin lesion. CONCLUSION: Preoperative chemotherapy and excision of the primary tumor is the surgical treatment of choice for retroperitoneal MCC. We propose that further studies are needed to elucidate the true efficacy of chemotherapy in conventional and unconventional patients with MCC.