Comportamiento clínico-epidemiológico de los tumores periampulares malignos diagnosticados en Gastroenterología

Introducción: Los tumores malignos ubicados en la región periampular pueden ser: ampular, biliar, pancreático o duodenal, y constituyen un problema de salud por su alta mortalidad. En su etiopatogenia se involucran múltiples factores de riesgo, cuyo comportamiento clínico y epidemiológico se desconoce en la población matancera. Objetivo: Determinar el comportamiento clínico y epidemiológico de los tumores periampulares malignos. Materiales y métodos: Se realizó un estudio descriptivo, prospectivo en 34 pacientes con diagnóstico de tumores periampulares malignos, atendidos en el Servicio de Gastroenterología del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas, de enero a diciembre de 2021. Se estudiaron variables como: grupos de edad, sexo, factores de riesgo y antecedentes patológicos personales, tiempo de evolución de los síntomas y localización del tumor. Los resultados fueron recogidos en una planilla de recolección de datos. Resultados: Predominó el sexo masculino y el grupo de 50 a 69 años. Los factores de riesgo más frecuentes fueron el consumo de café, tabaquismo y diabetes mellitus. El íctero fue el síntoma más frecuente. La mayoría de los pacientes iniciaron los síntomas de 1 a 3 meses antes del diagnóstico. El cáncer de páncreas fue el más frecuente. Conclusiones: Los tumores periampulares predominaron en la población mayor de 50 años. Los hábitos tóxicos fueron los factores de riesgo más frecuentes. El cáncer de páncreas tuvo mayor incidencia. El comportamiento clínico estuvo relacionado con la localización de la lesión, el tiempo de evolución de los síntomas, y los factores de riesgo que predominaron.

Introduction: Malignant tumors located in the periampullary region can be ampullary, biliary, pancreatic or duodenal and are a health problem due to their high mortality. Their etio-pathogenesis involves many risk factors, whose clinic and epidemiological behavior is unknown by the population of Matanzas. Objective: To determine the clinical-epidemiological behavior of malignant periampullary tumors. Materials and methods: A descriptive, prospective study was conducted in 34 patients with diagnosis of malignant periampullary tumors, treated in the Gastroenterology Service of the Clinical-Surgery University Hospital Comandante Faustino Perez Hernandez, of Matanzas, from January to December 2021. Variables such as age group, sex, risk factors and personal pathological history, time of evolution of symptoms and tumor location were studied. The results were collected in a data collection form. Results: Male sex and the 50-69 years age group predominated. The most frequent risk factors were coffee consumption, smoking and diabetes mellitus. Jaundice was the most frequent symptom. Most of the patients started symptoms one to three months before the diagnosis. Pancreatic cancer was the most frequent. Conclusions: Periampullary tumors predominated in the population older than 50 years. Toxic habits were the most common risk factors. Pancreatic cancer had a higher incidence. Clinical behavior was related to the location of the lesion, the time of evolution of the symptoms, and the risk factors that predominated.

Manejo de los tumores periampulares malignos en pacientes evaluados en consulta multidisciplinaria

Introducción: Los tumores malignos ubicados en la región periampular pueden ser: ampular (carcinoma ampular), biliar (colangiocarcinoma), pancreático (tumores de la cabeza del páncreas) o duodenal (cáncer de la segunda porción duodenal), y constituyen un problema de salud por su alta mortalidad, y un motivo frecuente de consulta multidisciplinaria por oncología digestiva. Objetivo: Describir los procederes diagnósticos y resultados histopatológicos asociados al manejo de tumores periampulares en pacientes atendidos en consulta multidisciplinaria. Materiales y métodos: Se realizó un estudio descriptivo y prospectivo en 34 pacientes con diagnóstico de estas neoplasias, en el Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández. La fecha comprende de enero a diciembre del año 2021. Se estudiaron variables como: grupos de edad, sexo, resultados imagenológicos, endoscópicos e histológicos, vía para la realización de la biopsia y tratamiento definitivo. Los resultados fueron recogidos en una planilla de recolección de datos. Resultados: Predominaron el sexo masculino y el grupo de 50 a 69 años. La tomografía axial computarizada abdominal mostró mayor sensibilidad en el diagnóstico respecto al ultrasonido. La colangiopancreatografía endoscópica retrograda fue el método diagnóstico y terapéutico más utilizado, seguido del tratamiento quirúrgico paliativo. Conclusiones: El manejo de los tumores, al igual que su tratamiento definitivo, estuvo relacionado con su localización. Como todos no pudieron ser estadificados, fue necesario el estudio histológico.

Introduction: Malignant tumors located in the periampullary region may be: ampullary (ampullary carcinoma), biliary (chollangiocarcinoma), pancreatic (tumors of the pancreas head) or duodenal (cancer of the second duodenal portion). They constitute a health problem due to their high mortality and a reason of frequent multidisciplinary consultation by digestive oncology. Objective: To describe the diagnostic procedures and the histopathological results associated to the management of periampullary tumors in patients treated in multidisciplinary consultations. Materials and methods: A descriptive and prospective study was conducted in 34 patients diagnosed with these neoplasms at the Clinical-Surgical University Hospital Comandante Faustino Perez. The date ranges from January to December 2021. Variables such as age groups, sex, imaging, endoscopic and histological results, pathway for biopsy and definitive treatment were studied. The results were collected in a data collection form. Results: Male sex and the age group from 50 to 69 years predominated. Abdominal computed axial tomography showed higher sensitivity in the diagnosis than ultrasound. Retrograde endoscopic cholangiopancreatography was the most widely used diagnostic and therapeutic method, followed by palliative surgical treatment Conclusions: The management of the tumors, as well as their definitive treatment, was related to their location. Since all of them could not be staged, histological study was necessary.

The effect of biliary stents implanted before pancreaticoduodenectomy in periampullary tumors on postoperative results: a retrospective analysis of 106 consecutive cases at a single medical center.

PURPOSE: The present study evaluated the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes and presented the details of a surgeon's 6 years of experience. METHODS: All consecutive pancreatoduodenectomies performed from 2015 to 2021 were retrospectively analyzed. The study population was divided into two groups: the stented group (Group I) and the nonstented group (Group II). Patient demographic data and clinical characteristics were compared between the two groups. RESULTS: This study comprised 106 individuals who underwent pancreaticoduodenectomy for periampullary tumors. The median age of the patients was 64.41 ± 11.67 years, and 65 (61.3%) were males. Sixty-seven patients (63.2%) received biliary drains (stented group), and 39 (36.8%) patients did not (nonstented group). Total bilirubin values (6.39 mg/dl) were higher in the nonstented patient group than in the stented group. The rate of total complications was significantly higher in the stented group than in the nonstented group [please check this carefully] (p < 0.05). The length of stay, operation time and pancreatic fistula were found to be higher in the stented group than in the nonstented group. CONCLUSIONS: Although the total bilirubin value was higher in the nonstented patient group than in the stented group, preoperative biliary drainage increased postoperative complication rates, operation time, and hospital stay. An advanced age and the presence of stents were independent risk factors influencing morbidity development according to the multivariate analysis.

Hepatic artery lymph node relevance in periampullary tumors: A retrospective analysis of survival outcomes.

Background: The Periampullary area comprehends a heterogeneous and complex structure with different histological tissues. Surgical standards include the peripancreatic regional lymphadenectomy, and during pancreatoduodenectomy (PD) the hepatic artery lymph node HALN(8a) is dissected. We aimed to describe the prognostic significance of the HALN(8a) lymph node metastasis in terms of disease-free survival (DFS) and overall survival (OS) in a specific cohort of patients in limited economic and social conditions. Methods: A retrospective study was conducted based on a prospective database from the HPB department of patients who underwent pancreaticoduodenectomy (PD) due to periampullary tumors during 2014-2021. Overall survival (OS) and disease-free survival (DFS) were estimated to be associated with positive HALN(8a) using Kaplan-Meier analysis. Log Rank test and Cox proportional hazards regression analysis was used. Results: 111 patients were included, 55,4% female. The most frequent pathology was ductal adenocarcinoma (60.3%). The positive rate of the HALN(8a) node was 21.62%. The Median OS time was 25.5 months, and the median DFS time was 13,8 months. Positive HLAN(8a) node, the cutoff of lymph node ratio resection (LNRR), and vascular invasion showed a strong association with OS. (CoxRegression p = 0.03 HR 0.5, p 0.003 HR = 1.8, p = 0.02 HR 0.4 CI 95%). In terms of DFS, lymph node ratio cutoff, tumoral size, and vascular invasion showed a statistically significant association with the outcome (p = 0.008, HR = 1.5; p = 0.04 HR = 2.1; p = 0.02 HR = 0.4 CI 95%). Conclusion: In this series of PD, OS was reduced in patients with HALN(8a) compromise in patients with pancreatic cancer, however without statistical significance in DFS. In multivariate analysis, lymph node status remains an independent predictor of OS and DFS. Further studies are needed.

The Spectrum of Postoperative Complications and Outcomes After Pancreaticoduodenectomy: A Retrospective Outlook From a Developing Country.

Background Pancreaticoduodenectomy is an extremely complex surgical procedure that mandates aggressive postoperative management. Unfortunately, in developing countries, the limited resources and poor postoperative care lead to multiple complications and abysmal outcomes. Therefore, our study aimed to evaluate the spectrum of postoperative complications and outcomes among patients undergoing pancreaticoduodenectomy. Methods This retrospective study involved a total of 97 patients who underwent pancreaticoduodenectomy for ampullary, periampullary, or pancreatic tumors. Patients with advanced metastasis and unresectable tumors were excluded from the study. Patients were studied for various parameters including the demographic details, postoperative outcomes, characteristics of the tumor, and postoperative complications. Results Out of 97 patients, 59 (60.8%) patients were males. The mean age of the study participants was 53.43 ± 17.89 years. Jaundice and abdominal pain were the most common presenting symptoms among the study participants. Of the 97 patients, 58 (59.8%) had malignant tumors. A total of 49 patients developed various postoperative complications including surgical site infections (10.3%), anastomosis leakage (9.27%), pancreatic fistula (9.27%), cholangitis (7.2%), and biliary leakage (4.1%). A total of 29 (29.9%) patients expired due to postoperative complications. Conclusions Surgical site infections, anastomosis leakage, pancreatic fistula, cholangitis, and biliary leakage are common but preventable postoperative complications after pancreaticoduodenectomy. These lead to morbidity and mortality, especially in the setting of a resource-deprived developing country. Aggressive postoperative management, improved surgical technique, better intraoperative hemostasis management, and a multi-disciplinary approach for the management of such patients can help in preventing postoperative complications and improving the postoperative outcomes.

Does Preoperative Acute Pancreatitis Inevitably Delay Pancreatoduodenectomy in Patients with Periampullary Tumors?

Preoperative acute pancreatitis (PAP) in patients with periampullary tumor can cause technical difficulties when performing pancreatoduodenectomy (PD) but perioperative risks of PAP remain unclear. The purpose of this study was to investigate the impact of PAP on surgical outcomes and determine the optimal timing of PD. Patients undergoing surgery for periampullary tumors between 2009 and 2018 were included. Simple random sampling (1:4) was performed to compare outcomes between the PAP group and the control group. Operative failure was defined as exploration-only or unwanted total pancreatectomy. The rate of operative failure was higher in the PAP group than in the control group (6.6% vs. 0%, p < 0.001). There was no significant difference in postoperative outcomes including complications or in-hospital mortality between the two groups. Surgical outcomes were compared after dividing PAP groups by intervals (2, 3, or 4 weeks) between the onset of PAP and surgery, and there were no differences between the groups. In conclusion, in spite of the increased risk of operation failure, PD could be performed in PAP patients at comparable rates of postoperative complications. Further study is needed to select patients with PAP in proper conditions for performing PD.

[Surgery for periampullary pancreatic cancer]. / Chirurgie periampullärer Pankreaskarzinome.

Periampullary neoplasms are a heterogeneous group of different tumor entities arising from the periampullary region, of which pancreatic ductal adenocarcinoma (PDAC) is the most common subgroup with 60-70%. As typical for pancreatic adenocarcinomas, periampullary pancreatic cancer is characterized by an aggressive growth and early systemic progression. Due to the anatomical location in close relationship to the papilla of Vater symptoms occur at an earlier stage of the disease, so that treatment options and prognosis are overall more favorable compared to pancreatic carcinomas at other locations. Nevertheless, the principles of treatment for periampullary pancreatic cancer are not substantially different from the standards for pancreatic cancer at other locations. A potentially curative approach for non-metastatic periampullary pancreatic cancer is a multimodal therapy concept, which includes partial pancreatoduodenectomy as a radical oncological resection in combination with a systemic adjuvant chemotherapy. As a result, long-term survival can be achieved in patients with favorable prognostic factors. In addition, with the continous development of surgery and systemic treatment potentially curative treatment concepts for advanced initially nonresectable tumors were also established, after completion of neoadjuvant treatment. This article presents the current surgical principles of a radical oncological resection for periampullary pancreatic cancer in the context of a multimodal treatment concept with an outlook for future developments of treatment.

A Case of Peutz-Jeghers Syndrome Presenting With an Inoperable Periampullary Tumor.

Peutz-Jeghers syndrome (PJS) is a syndrome characterized by multiple hamartomatous polyps in the gastrointestinal system and melanin pigments accumulating in the skin and mucous membranes. Patients with PJS have an increased risk of gastrointestinal malignancies. In this syndrome, pancreatic cancer is primarily detected in older ages. In this article, we present a case of a patient with an unresectable periampullary tumor and PJS.

Synchronous Periampullary Tumors in a Patient With Pancreas Divisum and Neurofibromatosis Type 1.

INTRODUCTION: In this study, we describe for the first time a Neurofibromatosis type 1 patient with pancreas divisum, multiple periampullary tumors and germline pathogenic variants in NF1 and CFTR genes. CASE REPORT: A 62-year-old female NF1 patient presented with weakness, choluria, nausea, and diffuse abdominal pain to an emergency room service. Magnetic resonance imaging revealed an abdominal mass involving the periampullary region and pancreas divisum. After surgical resection, three synchronous neoplasms were detected including two ampullary tumors (adenocarcinoma of the major ampulla and a neuroendocrine tumor of the minor ampulla) and a gastrointestinal stromal tumor (GIST). Germline multigene panel testing (MGPT) identified two pathogenic heterozygous germline variants: NF1 c.838del and CFTR c.1210-34TG[12]T[5]. CONCLUSION: This is the first report of a Neurofibromatosis type 1 patient with pancreas divisum and multiple periampullary tumors harboring pathogenic germline variants in NF1 and CFTR genes. The identification of two germline variants and a developmental anomaly in this patient may explain the unusual and more severe findings and underscores the importance of comprehensive molecular analyses in patients with complex phenotypes.

[Comparative analysis of radical surgical treatment of periampullary tumors]. / Sravnitel'nyi analiz radikal'nogo khirurgicheskogo lecheniya opukholei periampulyarnoi zony.

OBJECTIVE: Retrospective analysis of patients with periampullary tumors undergoing pancreatoduodenectomy. MATERIAL AND METHODS: A retrospective review included 48 patients with resectable periampullary tumors. Patients were divided into two groups according to the localization of cancer. Group 1 - pancreatic head tumors (n=27), group 2 - tumors of major duodenal papilla (n=21). Survival was analyzed depending on chemotherapy and vascular resection. All patients underwent standard pancreatoduodenectomy with anastomosis on a single intestinal loop and D2 lymph node dissection. RESULTS: Annual survival rate in patients with pancreatic head tumors was significantly higher compared with patients with tumors of major duodenal papilla (69.1% vs. 95.6%, p<0.05). Moreover, vascular resection (PV/SMV) was significant predictor of survival (p<0.01). There was a noticeable tendency to impaired survival if adjuvant chemotherapy was absent. CONCLUSION: Pancreatoduodenectomy is preferred for periampullary tumors since this procedure significantly increases life expectancy. Postoperative adjuvant chemotherapy is recommended in all patients regardless histological data because combined approach is associated with improved survival.

Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma.

BACKGROUND AND AIMS: There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality. METHODS: Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index. RESULTS: A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category. CONCLUSION: To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.

Endoscopic Ultrasound-Guided Choledochoduodenostomy as Palliative Treatment: A Challenging Case Report.

We report the case of an 88-year-old female with obstructive jaundice due to a periampullary tumor. The patient developed acute cholangitis and consequent clinical deterioration, so it was decided to perform palliative biliary drainage. Due to duodenal tumor invasion, it was not possible to perform endoscopic retrograde cholangiopancreatography. A different approach was attempted and it was decided to carry out an endoscopic ultrasound-guided choledochoduodenostomy. This procedure was performed with a linear echoendoscope, and using a duodenal bulbar approach, a fistula was created between the bulb and the common bile duct. A self-expandable fully covered metal biliary stent was placed in the common bile duct under endoscopic and fluoroscopic guidance, allowing biliary drainage. The patient presented clinical improvement. However, 3 weeks after being discharged, she was readmitted to our department with hematemesis associated with the migration of the biliary stent to the duodenal bulb. Endoscopic hemostasis was performed but the patient had multiple bleeding relapses that were controlled through arterial embolization. Despite the migration of the biliary stent, the fistula between the duodenum and the common bile duct remained patent, allowing a successful palliation of the obstructive jaundice. Therefore, despite the occurred complication, we admitted a technical and clinical success of the endoscopic ultrasound-guided choledochoduodenostomy. This is an emerging technique and a valuable alternative for palliative biliary drainage in cases of malignant distal obstruction. This clinical report supports this finding, reporting technical aspects of the procedure, associated complications and their management as well as the clinical outcomes.

Apresentamos o caso de uma doente do sexo feminino, de 88 anos de idade, com icterícia obstrutiva devido a um tumor periampular, complicada com colangite aguda. Foi proposta drenagem biliar paliativa através da colocação de uma prótese biliar por colangiopancreatografia retrógrada endoscópica. No entanto, devido a invasão tumoral do duodeno, não foi possível realizar esta abordagem e como alternativa foi efetuada uma coledocoduodenostomia guiada por ecoendoscopia. Este procedimento foi realizado com um ecoendoscópio linear e, utilizando uma abordagem através do bulbo duodenal, foi criada uma fístula entre o bulbo e a via biliar principal. Uma prótese metálica auto-expansível totalmente coberta foi colocada na via biliar principal com apoio endoscópico e fluoroscópico, permitindo a drenagem biliar. A doente apresentou melhoria do estado clínico com resolução do quadro de colangite aguda. No entanto, tr's semanas após a alta, ela foi novamente internada no nosso serviço por hematemeses associadas à migração da prótese biliar para o bulbo. Foi realizada hemostase endoscópica, no entanto, por apresentar várias recidivas da hemorragia optou-se pela embolização arterial, verificando-se controlo definitivo da hemorragia. Apesar da migração da prótese biliar, a fístula entre o duodeno e o a via biliar principal permaneceu patente, permitindo uma paliação da icterícia obstrutiva. Portanto, admitimos o sucesso técnico e clínico da coledocoduodenostomia guiada por ecoendoscopia. Esta é uma técnica emergente e uma alternativa valiosa para a drenagem biliar paliativa em casos de obstrução distal maligna. O presente caso clínico é representativo desse valor, relatando os aspetos técnicos do procedimento efetuado, complicações associadas e a sua abordagem, bem como a evolução clinica da doente.

Retrospective cohort of pancreatic and Vater ampullary adenocarcinoma from a reference center in Mexico.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) and ampulla of Vater adenocarcinomas (AVAC) are periampullary tumors. These tumors have overlapping symptoms and a common treatment, but present differences in their survival and biology. No recent studies in Mexico have been published that describe the clinicopathological characteristics of these tumors. Therefore, the aim of this study was to describe the clinicopathological characteristics of PDAC and AVAC in patients at a reference center in Mexico. METHODS: A retrospective cohort of patients with PDAC or AVAC was analyzed at our institution (July 2007 to June 2016). Inferential analysis of the clinical data was performed with Student's t-test or a χ2 test with odds ratios (OR) and confidence intervals (CI), depending on the variables. Overall survival was compared using Kaplan-Meier curves with log-rank p values. RESULTS: Forty patients with PDAC and 76 with AVAC were analyzed, including 77 females and 39 males with a mean age of 60.6 years and a mean evolution time of 5.7 months. PDAC patients had more abdominal pain, a larger tumor size and more advanced stages than AVAC patients. In contrast, AVAC patients had more jaundice, a higher percentage of complete resections and higher overall survival. Up to 70% of patients were overweight. PDAC cohort included a higher proportion of smokers. CONCLUSIONS: Our cohort was slightly younger, had a larger percentage of females, and a greater percentage of obese patients than those in many international reports. A high proportion of PDAC patients are diagnosed in advanced stages and have a low likelihood of resectability.

One hundred and forty five total laparoscopic pancreatoduodenectomies: A single centre experience.

INTRODUCTION: Laparoscopic pancreatoduodenectomy (LPD) remains one of the most challenging minimal invasive operations today. PATIENTS AND METHODS: Between January 2007 and December 2016, 197 patients were scheduled for LPD but 162 patients (from January 2007 to July 2016) were analysed in this cohort series. RESULTS: Total LPD concerned for 162 patients (five patients did not undergo PD and 12 underwent conversion): standard LPD in 104 patients (66%), and laparoscopic pylorus-preserving PD in 41 patients (26%). Median operative time was 415 (240-765) min. Median blood loss was 200 (50-2100) ml. Twelve patients required blood transfusion. Clinically relevant pancreatic fistula (ISGPF grades B and C) occurred in 21 (13%) patients: 16 (10.0%) grade B, and 5 (3%) grade C. Grades B and C delayed gastric emptying occurred in five patients each. Grades B and C post-pancreatectomy bleeding occurred in 9 (5.7%) and 3 (1.9%) patients, respectively. LPD was performed for 18 (11.4%) benign and 139 (88.5%) malignant lesions. Superior mesenteric and/or portal vein involvement required major venous resection in eight patients. The 90-day mortality 5.0%. The median overall survival for pancreatic ductal adenocarcinoma was 22.5 months. CONCLUSION: Morbidity and mortality for LPD are comparable to open procedures rates in the literature. Laparoscopic major venous resection is feasible and safe.

Frecuencia de tratamiento quirurgico curativo de las neoplasias periampulares. Experiencia en base a 122 casos / Frequency in curative surgical treatment of periampullary tumors. Experience based on 122 cases

Introducción Los tumores periampulares son aquellos que se desarrollan en un área de 2 cm próxima de la papila de Vater; en este grupo se encuentran los tumores de cabeza de páncreas, los de la ampolla de Vater, los del colédoco intrapancreático y duodenales. Objetivo: Determinar la frecuencia de tratamiento quirúrgico curativo de los tumores de la región periampular en el servicio de Cirugía General del Hospital Central del Instituto de Previsión Social. Metodología: Investigación retrospectiva, observacional descriptiva y de corte transverso en el periodo 2009-2015. Resultados Se estudiaron 122 casos, la frecuencia de tumores periampulares resecables intraoperatoriamente, y por tanto sometidos a duodeno pancreatectomía cefálica fue de 38.52%, que corresponde a 47 casos del total. La relación de varón/mujer fue de 1,3/1. El promedio de edad fue 64,67 años. La ictericia fue el signo y síntoma prevalente y el primero en aparecer. Se realizó ecografía y tomografía en todos los pacientes. Ningún paciente fue sometido a ecoendoscopia. El tipo histológico más frecuente fue adenocarcinoma ductal de páncreas con 89 casos (72,95%). Conclusión: La estatificación quirúrgica determinando la resecabilidad o no de dichos tumores es fundamental para evitar procedimientos cruentos innecesarios, la ecografía y tomografía son estudios necesarios para la determinación de resecabilidad, pero que muchas veces necesitan ser reforzados con otros estudios como la eco endoscopia que evitaría los falsos resecables que ingresan a quirófano innecesariamente. Situación encontrada muy frecuentemente en este estudio.

Introduction: Periampullary tumors are most often localizated in a 2 cm area next to the ampulla of Vater, and this group included the head of pancreas carcinoma, Vater´s ampulla carcinoma, intrapancreatic cholangiocarcinoma and duodenal carcinoma. Objective: to define the frequency of curative surgical treatment in tumors of periampullar region at the Service of General Surgery of Instituto de Previsión Social. Patients and Method: a retrospective, observational and descriptive study between 2009 and 2015. Results: In 122 cases, 47 of them (38,5%) had a resectability criteria and was performed a CDP surgery in these cases. There wasn´t difference of presentation according to gender. The average age was 64,67 years old. Jaundice was the first symptom showed and the most common. It was performed ultrasonography and CT scan in all patients. The most common histological type was the pancreatic ductal adenocarcinoma in 89 patients. Conclusion: The staging of the periampullar tumors and the resectabilty criteria are very important parameters to avoid an unnecessary surgical procedure. Ultrasonography and CT scan are important tools to clarify the resectability criteria, even better if they are accompanied by endoscopic ultrasound.

Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors.

BACKGROUND: Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms. METHODS: We conducted a bibliographic research using the National Library of Medicine's PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests. RESULTS: One RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (p < 0.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, p = 0.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups. CONCLUSIONS: Although the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.

Unexpected benign histopathology after pancreatoduodenectomy for presumed malignancy: accepting the inevitable.

BACKGROUND: Differentiating malignant and benign disease in the pancreatic head and periampullary region is difficult. The aim of this retrospective study was to analyze patients with unexpected "benign" disease after pancreatoduodenectomy (PD) to evaluate the incidence, possible discriminating factors, and outcome. The role of preoperative pathology interpretation in diagnosing malignancy was also assessed. METHODS: Patients with unexpected benign disease were identified from a prospectively maintained database of 446 PDs for presumed malignancy from April 2006 to December 2013. Clinical, radiological, and pathological features were reviewed. Positive predictive values (PPVs) of preoperative pathology interpretation were analyzed. Short-term outcomes were compared. RESULTS: Incidence of unexpected benign disease was 6.5 % (29/446). Radiological diagnostic signs (except the double duct sign) suggestive of malignancy were seen in more than half of the benign cases. Preoperative pathology 'positive' or 'suspicious for malignancy' had a PPV of 97.6 % and 'indeterminate disease' and had a PPV of 90 % for malignancy. 'Benign' or 'negative' pathology had a PPV of 19 % for benign disease in strongly suspected malignancy. There was no significant difference in outcomes in PD for benign versus malignant disease except for a decreased rate of POPFs and a higher trend toward mortality. However, both outcomes were not independently associated with benign disease. CONCLUSIONS: A small percentage of benign disease after PD for "strongly suspected malignancy" is inevitable. No radiological or pathological features can reliably discriminate benign from malignant in these patients. Trend toward higher mortality after PD for unexpected benign disease exists. Detailed preoperative pathological subclassifications are helpful in malignancy.

Factors affecting survival in patients who underwent pancreaticoduodenectomy for periampullary cancers.

OBJECTIVE: The purpose of this study was to determine the factors affecting survival in patients who underwent pancreaticoduodenectomy for periampullary cancers and to discuss the outcomes of our findings. MATERIAL AND METHODS: This retrospective study included 79 patients who underwent pancreaticoduodenectomy for periampullary cancers between September 1987 and October 2011 in the Department of General Surgery at Ondokuz Mayis University School of Medicine. The factors of age, tumor localization, tumor size, lymphovascular invasion, status of lymph node metastasis, tumor differentiation, preoperative CA 19-9 levels, preoperative total bilirubin levels, preoperative albumin levels, and preoperative biliary drainage were investigated to determine their influence on survival. The survival periods were calculated using the Kaplan-Meier method. The log-rank test was used for comparison of the prognostic factors. The independent prognostic factors affecting survival were determined by Cox hazard regression analysis and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. P<0.05 was considered as significant. RESULTS: The following were identified as independent prognostic factors adversely affecting survival: tumor size ≥2 cm (HR: 2.0, 95% CI: 0.27-0.90), lymphovascular invasion (HR: 2.9, 95% CI: 0.18-0.60), CA 19-9 levels ≥100 U/mL (HR: 2.0, 95% CI: 0.26-0.90), and albumin levels <2.5 mg/dL (HR: 2.7, 95% CI: 1.14-6.66). CONCLUSION: The independent prognostic factors identified in this study can be used for selection of patients for whom pancreaticoduodenectomy should be applied for periampullary cancers. These factors could help us to estimate survival rates.

Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy.

AIM: To determine predictors of clinically relevant pancreatic fistulas (CRPF) by measuring drain fluid amylase (DFA) in the early postoperative period. METHODS: This prospective clinical study included 382 patients with periampullary tumors that were surgically resected at our department between March 2005 and October 2012. A cephalic duodenopancreatectomy (DP) was performed on all patients. Two closed suction drains were placed at the end of the surgery. The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer. Pancreatic fistula (PF) was classified according to the International Study Group of Pancreatic Fistula (ISGPF) criteria. Postoperative complications were defined according to the Dindo-Clavien classification. All data were statistically analyzed. The optimal thresholds of DFA levels on the first, second and third postoperative days were estimated by constructing receiver operating curves, generated by calculating the sensitivities and specificities of the DFA levels. The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula (BPF) and CRPF. RESULTS: Pylorus-preserving duodenopancreatectomy was performed on 289 (75.6%) patients, while the remaining patients underwent a classic Whipple procedure (CW). The total incidence of PF was 37.7% (grade A 22.8%, grade B 11.0% and grade C 3.9%). Soft pancreatic texture (SPT) was present in 58.3% of patients who developed PF. Mortality was 4.2%. The median DFA value on the first postoperative day (DFA1) in patients who developed PF was 4520 U/L (range 350-99000 U/L) for grade A fistula (BPF) with a SPT and a diameter of the main pancreatic duct (MPD) of ≤ 3 mm. For grade B/C (CRPF), the median DFA1 value was 8501 U/L (range 377-92060 U/L) with a SPT and MPD of ≤ 3 mm. These values were significantly higher when compared to the patients who did not have PF (122; range 5-37875 U/L). The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were: DFA1 1200 U/L for the BPF and CRPF; DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF. The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF. CONCLUSION: DFA1 ≥ 1200 U/L is an important predictive factor for PF of any degree. The trend of DFA3 (decrease of < 50%) compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.