Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study.

INTRODUCTION: Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS: Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS: Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS: Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.

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

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

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

Análisis de factores de riesgo de vaciamiento gástrico lento tras la duodenopancreatectomía cefálica / Study of risk factors for delayed gastric emptying after partial pancreatoduodenectomy

Introducción: El vaciamiento gástrico lento (VGL) es una de las complicaciones más frecuentes tras la duodenopancreatectomía cefálica. El objetivo del actual estudio es analizar los factores de riesgo de su aparición. Métodos: Análisis de factores de riesgo de VGL sobre una base de datos prospectiva de 390 pacientes intervenidos entre 2013 y 2021. Se realizó un estudio retrospectivo comparativo entre pacientes con y sin VGL y posteriormente un estudio de factores de riesgo de VGL mediante modelos de regresión logística univariante y multivariante. Resultados: La incidencia de VGL en el global de la serie fue del 28%. Un 63% de los pacientes presentaron alguna complicación y la mortalidad postoperatoria fue del 3,1%. Se evidenció que la edad mediana (73 años vs. 68 años, p<0,001) y la creatinina preoperatorias (75 vs. 68.5, p<0,001) eran superiores en el grupo VGL. El estudio de factores de riesgo evidenció que la edad superior a 60 años (p=0,002) y la fístula pancreática (p<0,001) eran factores de riesgo de VGL. Conclusiones: La presencia de fístula pancreática se confirma como factores de riesgo de VGL tras la duodenopancreatectomía. Además, se demuestra que la edad superior a 60 años es un factor de riesgo de VGL. (AU)

Introduction: Delayed gastric emptying is one of the most frequent complications after pancreatoduodenectomy. Methods: We performed an analysis of risk factors for delayed gastric emptying on a prospective database of 390 patients operated on between 2013 and 2021. A comparative retrospective study was carried out between patients with and without delayed gastric emptying and subsequently a study of risk factors for delayed gastric emptying using univariate and multivariate logistic regression models. Results: The incidence of delayed gastric emptying in the overall series was 28%. The morbidity of the group was 63% and postoperative mortality was 3.1%. Focusing in delayed gastric emptying, it was shown that the median age (73 years vs. 68 years, p<0.001) and preoperative creatinine (75 vs. 65.5, p<0.001) were higher in the group with this complication. The study of risk factors showed that age over 60 years (p=0.002) and pancreatic fistula (p<0.001) were risk factors for delayed gastric emptying. Conclusions: The presence of pancreatic fistula is confirmed as risk factor for slow gastric emptying after pancreaticoduodenectomy. In addition, age over 60 years is shown to be a risk factor for slow gastric emptying. (AU)

Hypoalbuminemia and advanced age are risk factors for delayed gastric emptying after pancreaticoduodenectomy / La hipoalbuminemia y la edad avanzada son factores de riesgo de vaciamiento gástrico lento tras duodenopancreatectomía cefálica

Background: delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. It could be related to some baseline patient-related characteristics. This study aims to assess the predictive factors associated to DGE in the cohort of patients included in the PAUDA clinical trial. Methods: this study was a retrospective analysis based on the 80 patients included in a randomized clinical trial conducted and published by our group. A descriptive analysis and a bivariate regression model were carried out. Some factors were further scrutinized for associations using the Pearson correlation coefficient and, finally, a multiple regression model using a stepwise selection of variables was conducted. Results: DGE was diagnosed in 36 (45 %) out of 80 patients (DGE group). The number of patients older than 60 years old in the DGE group was greater than in the group without DGE (32 vs 28 patients, p = 0.009]. Likewise, the number of patients with a preoperative albumin < 35 g/L (18 vs 11 patients, p = 0.036); preoperative bilirubin > 200 µmol/L (14 vs 8 patients, p = 0.039); postoperative haemorrhage (7 vs 1 patients, p = 0.011); postoperative intraabdominal abscess (12 vs 5 patients, p = 0.017); and postoperative biliary fistula (5 vs 0 patients, p = 0.011), was also greater in the DGE group. Two risk factors were associated with DGE: the patient's age at the time of surgery and preoperative hypoalbuminemia (serum albumin concentration ≤ 35g/L). Conclusions: the patient's age at the time of surgery and the preoperative nutritional status are independent risk factors to the development of DGE after pancreatoduodenectomy. (AU)

Introducción: el vaciamiento gástrico lento (VGL) es una complicación frecuente tras la duodenopancreatectomía cefálica (DPC) y puede relacionarse con algunas características basales del paciente. El objetivo es evaluar los factores predictivos de VGL en la cohorte de pacientes incluidos en el ensayo clínico aleatorizado PAUDA. Métodos: se realizó un análisis retrospectivo basado en los 80 pacientes incluidos en el ensayo PAUDA. Se realizaron un análisis descriptivo y un modelo de regresión bivariante. Posteriormente, algunos factores se examinaron mediante el coeficiente de correlación de Pearson y, finalmente, se llevó a cabo un modelo de regresión multivariante. Resultados: se diagnosticó VGL en 36 (45 %) pacientes. El número de pacientes mayores de 60 años en el grupo VGL fue mayor que en el grupo sin VGL (p = 0,009). El número de pacientes con albúmina preoperatoria < 35 g/L (p = 0,036); bilirrubina preoperatoria > 200 µmol/L (p = 0,039); hemorragia (p = 0,011); absceso intraabdominal (p = 0,017); y fístula biliar (p = 0,011), fue mayor en el grupo VGL. Dos factores de riesgo se asociaron con el VGL: la edad del paciente y la hipoalbuminemia preoperatoria. Conclusiones: la edad del paciente en el momento de la cirugía y el estado nutricional preoperatorio son factores de riesgo independientes de VGL tras DPC. (AU)

Hypoalbuminemia and advanced age are risk factors for delayed gastric emptying after pancreaticoduodenectomy.

Introduction: Background: delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. It could be related to some baseline patient-related characteristics. This study aims to assess the predictive factors associated to DGE in the cohort of patients included in the PAUDA clinical trial. Methods: this study was a retrospective analysis based on the 80 patients included in a randomized clinical trial conducted and published by our group. A descriptive analysis and a bivariate regression model were carried out. Some factors were further scrutinized for associations using the Pearson correlation coefficient and, finally, a multiple regression model using a stepwise selection of variables was conducted. Results: DGE was diagnosed in 36 (45 %) out of 80 patients (DGE group). The number of patients older than 60 years old in the DGE group was greater than in the group without DGE (32 vs 28 patients, p = 0.009]. Likewise, the number of patients with a preoperative albumin < 35 g/L (18 vs 11 patients, p = 0.036); preoperative bilirubin > 200 µmol/L (14 vs 8 patients, p = 0.039); postoperative haemorrhage (7 vs 1 patients, p = 0.011); postoperative intraabdominal abscess (12 vs 5 patients, p = 0.017); and postoperative biliary fistula (5 vs 0 patients, p = 0.011), was also greater in the DGE group. Two risk factors were associated with DGE: the patient's age at the time of surgery and preoperative hypoalbuminemia (serum albumin concentration ≤ 35g/L). Conclusions: the patient's age at the time of surgery and the preoperative nutritional status are independent risk factors to the development of DGE after pancreatoduodenectomy.

Introducción: Introducción: el vaciamiento gástrico lento (VGL) es una complicación frecuente tras la duodenopancreatectomía cefálica (DPC) y puede relacionarse con algunas características basales del paciente. El objetivo es evaluar los factores predictivos de VGL en la cohorte de pacientes incluidos en el ensayo clínico aleatorizado PAUDA. Métodos: se realizó un análisis retrospectivo basado en los 80 pacientes incluidos en el ensayo PAUDA. Se realizaron un análisis descriptivo y un modelo de regresión bivariante. Posteriormente, algunos factores se examinaron mediante el coeficiente de correlación de Pearson y, finalmente, se llevó a cabo un modelo de regresión multivariante. Resultados: se diagnosticó VGL en 36 (45 %) pacientes. El número de pacientes mayores de 60 años en el grupo VGL fue mayor que en el grupo sin VGL (p = 0,009). El número de pacientes con albúmina preoperatoria < 35 g/L (p = 0,036); bilirrubina preoperatoria > 200 µmol/L (p = 0,039); hemorragia (p = 0,011); absceso intraabdominal (p = 0,017); y fístula biliar (p = 0,011), fue mayor en el grupo VGL. Dos factores de riesgo se asociaron con el VGL: la edad del paciente y la hipoalbuminemia preoperatoria. Conclusiones: la edad del paciente en el momento de la cirugía y el estado nutricional preoperatorio son factores de riesgo independientes de VGL tras DPC.

Study of risk factors for delayed gastric emptying after partial pancretoduodenectomy.

INTRODUCTION: Delayed gastric emptying is one of the most frequent complications after pancreatoduodenectomy. METHODS: We performed an analysis of risk factors for delayed gastric emptying on a prospective database of 390 patients operated on between 2013 and 2021. A comparative retrospective study was carried out between patients with and without delayed gastric emptying and subsequently a study of risk factors for delayed gastric emptying using univariate and multivariate logistic regression models. RESULTS: The incidence of delayed gastric emptying in the overall series was 28%. The morbidity of the group was 63%, and postoperative mortality was 3.1%. Focusing on delayed gastric emptying, the median age (73 years vs 68 years, P < 0.001) and preoperative creatinine (75 vs 65.5, P < 0.001) were higher in the group with this complication. The study of risk factors showed that age over 60 years (P = 0.002) and pancreatic fistula (P < 0.001) were risk factors for delayed gastric emptying. CONCLUSION: The presence of pancreatic fistula is confirmed as a risk factor for slow gastric emptying after pancreaticoduodenectomy. In addition, age over 60 years is shown to be a risk factor for slow gastric emptying.

Reporte de un caso de tratamiento de gastroparesia pediátrica con prucaloprida: una terapia novedosa / A case report of prucalopride treatment in pediatric gastroparesis: a novel therapy

La prucaloprida acelera el vaciamiento gástrico en adultos con gastroparesia. No existen estudios con este medicamento en niños con gastroparesia. Se presenta un niño de 8 años que consultó por síntomas posprandiales de un mes de duración, con diagnóstico de gastroparesia por gammagrafía de vaciamiento gástrico. No mejoró con metoclopramida, domperidona, eritromicina y esomeprazol. Recibió prucaloprida durante dos períodos (durante 178 y 376 días) a dosis de 0,03-0,04 mg/kg/día. Presentó mejoría en el seguimiento con el índice cardinal de síntomas de gastroparesia y gammagrafías de vaciamiento gástrico. Por la buena respuesta, la prucaloprida podría ser una opción terapéutica en la gastroparesia pediátrica.

Prucalopride has been used in adults with gastroparesis, accelerating gastric emptying. There are no studies with this drug in gastroparetic children. An 8-year-old boy is presented who consulted for a month of postprandial symptoms, with a diagnosis of gastroparesis by gastric emptying scintigraphy. He did not improve with metoclopramide, domperidone, erythromycin, and esomeprazole. He received prucalopride for two periods (for 178 and 376 days) at doses: 0.03 - 0.04 mg/kg/day, presenting improvement in the follow-up with the cardinal gastroparesis symptom index and gastric emptying scintigraphy. Due to the good response, prucalopride may be a therapeutic option in pediatric gastroparesis.

Diagnóstico y tratamiento actual de la gastroparesia: una revisión sistemática de la literatura / Current diagnosis and treatment of gastroparesis: A systematic literature review

Resumen El vaciamiento gástrico normal refleja un esfuerzo coordinado entre diferentes regiones del estómago y el duodeno, y también una modulación extrínseca por parte del sistema nervioso central y factores del intestino distal. Los principales eventos relacionados con el vaciamiento gástrico normal incluyen el fondo de relajación para acomodar la comida, contracciones antrales para triturar partículas grandes de comida, contracción pilórica para permitir la liberación de comida del estómago y coordinación antropiloroduodenal de los fenómenos motores de relajación. La dismotilidad gástrica incluye el vaciamiento tardío del estómago (gastroparesia), vaciamiento gástrico acelerado (síndrome de dumping) y otras disfunciones motoras, como el deterioro del fondo de distensión, que se encuentra con mayor frecuencia en la dispepsia funcional. Los síntomas de la gastroparesia son inespecíficos y pueden simular otros trastornos estructurales.

Abstract Normal gastric emptying reflects a coordinated effort between different regions of the stomach and the duodenum, and also an extrinsic modulation by the central nervous system and distal bowel factors. The main events related to normal gastric emptying include relaxation of the fundus to accommodate food, antral contractions to triturate large food particles, the opening of the pyloric sphincter to allow the release of food from the stomach, and anthropyloroduodenal coordination for motor relaxation. Gastric dysmotility includes delayed emptying of the stomach (gastroparesis), accelerated gastric emptying (dumping syndrome), and other motor dysfunctions, e.g., deterioration of the distending fundus, most often found in functional dyspepsia. The symptoms of gastroparesis are nonspecific and may mimic other structural disorders.

Radiologic assessment of gastric emptying of water-soluble contrast media: New data security from a longitudinal study. / Evaluación radiológica del vaciamiento gástrico de medio de contraste hidrosoluble: nuevos datos de seguridad de un estudio longitudinal.

BACKGROUND AND OBJECTIVES: Practice guidelines for preoperative fasting have not clearly established the fasting time needed after oral administration of water-soluble contrast media. The aim of this study was to determine the time required for the gastric emptying during the water-soluble contrast media in patients with acute abdominal pain. METHODS: This prospective longitudinal study included sixty-eight patients older than 18 years of age with acute abdominal pain, who required a water-soluble contrast media enhanced abdominal computed tomography study. Plain radiographs were obtained hourly until complete the gastric emptying. Patients with probable bowel obstruction were not included in the study. RESULTS: A total of 31 (45,6%), 54 (79,4%), and 64 (94,1%) patients achieved a complete gastric clearance of barium in 1, 2 and 3 hours, respectively. All patients achieved complete emptying of water-soluble contrast media within 6 hours. Gastric emptying time was not associated with gender (P=0,44), body mass index (P=.35), fasting time prior to water-soluble contrast media intake (P=0,12), administration of opioids in the emergency room (P=0,7), and the presence of comorbidities (P=0,36). CONCLUSION: Ninety-four percent of the patients with acute abdominal pain achieved complete gastric emptying within 3hours after the administration of water-soluble contrast media. All of them achieved complete gastric emptying within 6hours. The results suggested 6hours after oral intake of the contrast media is enough to complete transit of water-soluble contrast media through the stomach and avoid unnecessary risks.

Aferição do volume residual gástrico: retrato da prática clínica de enfermeiros / Assessing gastric residual volume: a description of nurses' clinical practice / Verificación del volumen gástrico residual: retrato de la práctica clínica de enfermeros

RESUMO Objetivo Verificar diferenças na prática de aferição do volume residual gástrico entre enfermeiros clínicos e identificar a fundamentação teórica que subsidia a prática. Método Estudo transversal realizado por meio do envio de questionário online aos e-mails dos enfermeiros cadastrados no Conselho Regional de Enfermagem do Estado de São Paulo. Resultados Participam do estudo 598 profissionais de enfermagem, dos quais 484 prestavam assistência apenas a adultos e 114 exclusivamente à crianças. O teste do volume residual gástrico é realizado por 83,4% dos profissionais da enfermagem, sendo que, em sua maioria, a suspensão e a liberação da terapia nutricional enteral são realizadas pelo médico. A suspensão da terapia nutricional enteral entre adultos ocorre, predominantemente, quando o volume residual gástrico é igual a 200 ml e, entre crianças, se valores menores do que 100 ml. A conduta após a suspensão da dieta envolve a devolução do conteúdo gástrico aspirado e a manutenção do cateter fechado até o próximo horário, em 48,3% dos atendimentos entre adultos e 68,4% entre crianças. Dos participantes da pesquisa, 42,9% desconhecem a fundamentação teórica que subsidia a prática do teste. Conclusão Evidenciou-se a necessidade de capacitação dos enfermeiros e de novas investigações sobre a prática de aferição do volume residual gástrico.

ABSTRACT Objective To analyze the differences in nurses' clinical practice for assessing residual gastric volume and identifying the theoretical framework which supports their practice. Method A cross-sectional study carried out by sending an online questionnaire by e-mail to nurses registered at the Regional Nursing Council of the State of São Paulo. Results This study included 598 nursing professionals, with 484 only providing care to adults and 114 exclusively to children. The gastric residual volume test is performed by 83.4% of nursing professionals; in most cases the suspension and prescription of enteral nutritional therapy are performed by the physician. Suspension of enteral nutritional therapy among adults predominantly occurs when the gastric residual volume is equal to 200 ml, and in children when values are less than 100 ml. Procedure after diet suspension involves the return of aspirated gastric contents and maintaining the catheter closed until the next hour in 48.3% of the procedures among adults, and 68.4% among children. 42.9% of the participants in this study were not aware of the theoretical basis that supports the test performance. Conclusion We can highlight the need for nurses' training and further studies focused on the practice for assessing gastric residual volume.

RESUMEN Objetivo Verificar diferencias en la práctica de verificación del volumen gástrico residual entre enfermeros clínicos e identificar la fundamentación teórica que subsidia la práctica. Método Estudio transversal realizado mediante el envío de cuestionario en línea a los emails de los enfermeros registrados en el Consejo Regional de Enfermería del Estado de São Paulo. Resultados Participaron en el estudio 598 profesionales enfermeros, de los que 484 prestaban asistencia solo a adultos y 114 exclusivamente a niños. La prueba del volumen gástrico residual la lleva a cabo el 83,4% de los profesionales enfermeros, siendo que, en su mayoría, la suspensión y la liberación de la terapia de nutrición enteral la realiza el médico. La suspensión de la terapia de nutrición enteral entre adultos ocurre, predominantemente, cuando el volumen gástrico residual es igual a 200 ml y, entre niños, si los valores son menores que 100 ml. La conducta después de la suspensión de la dieta involucra la devolución del contenido gástrico aspirado y el mantenimiento del catéter cerrado hasta el próximo horario, en el 48,3% de las atenciones entre adultos y el 68,4% entre niños. De los participantes de la investigación, el 42,9% desconocen la fundamentación teórica que subsidia la práctica de la prueba. Conclusión Se evidenció la necesidad de capacitación de los enfermeros y de nuevas investigaciones acerca de la práctica de verificación del volumen gástrico residual.

Relación entre gastrectomía de tipo manga y reflujo gastroesofágico / Relationship between sleeve gastrectomy and gastroesophageal reflux

La enfermedad por reflujo gastroesofágico es una entidad muy frecuente en la población general, con secuelas significativas, como esofagitis péptica, esófago de Barrett y carcinoma de esófago. La obesidad, por su parte, es una condición que se ha incrementado en el mundo en las últimas tres décadas y es uno de los principales factores de riesgo para reflujo gastroesofágico y esófago de Barrett. En los últimos años, la cirugía bariátrica se ha convertido en el mejor tratamiento para la obesidad mórbida y algunas de sus técnicas son reconocidas por ser procedimientos esencialmente antirreflujo como, por ejemplo, la derivación gástrica laparoscópica en Y de Roux. Sin embargo, la relación entre la manga gástrica por laparoscopia y el reflujo gastroesofágico, sigue siendo un tema controvertido. El propósito de esta revisión es presentar la información disponible sobre los mecanismos fisiopatológicos asociados a la presentación de reflujo gastroesofágico después de manga gástrica por laparoscopia y la influencia de la técnica quirúrgica en la prevención de esta complicación.

Gastroesophageal reflux disease (GERD) is a very common disease in the general population with significant consequences like peptic esophagitis, Barrett's esophagus (BE), and esophageal carcinoma. On the other hand, obesity is a condition that has increased in the world in the last three decades and is one of the major risk factors for GERD and BE. In recent years, bariatric surgery has become the best treatment option for morbid obesity and some of these techniques are recognized as being essentially anti-reflux procedures like laparoscopic Roux-en-Y gastric bypass (LRYGB). However, the relationship between laparoscopic sleeve gastrectomy (LSG) and GERD remains controversial. The purpose of this review is to present the available evidence about the pathophysiological mechanisms associated with the presentation of GERD after LSG and the influence of surgical technique in preventing this complication.

Outcomes of pancreatogastrostomy with gastric partition after pylorus-preserving pancreaticoduodenectomy with gastric partition.

INTRODUCTION: Pylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated to a better postoperative outcome than conventional pancreaticojejunostomy in the setting of a prospective-randomized study. The aim of this study is to further evaluate the surgical outcome in a series of 129 consecutive patients. METHODS: Between 2007 and June 2013, 129 patients with periampullary tumors surgically treated with PPPD-GP were retrospectively analyzed. Surgical complications (Clavien-Dindo score), as well as pancreatic and non-pancreas related complications were analyzed. RESULTS: Overall postoperative complication rate was 77%, although 50% of complications were graded I-II by the Clavien-Dindo classification. Incidence of clinically relevant pancreatic fistula was 18%: ISGFP type B: 12%, and type C: 6%. Other pancreas specific complications such as delayed gastric emptying and pospancreatectomy haemorrhage were 27 and 15%, respectively, similar to results published in the literature. Overall perioperative mortality rate was 4.6%. CONCLUSION: PPPD-GP results show that it is a technique with an acceptable morbidity, low mortality and pancreatic fistula rate similar to other techniques currently described of pancreaticoenteric reconstruction.

Vaciamiento gástrico y diabetes mellitus tipo 2 / Gastric emptying and Type 2 diabetes mellitus

El adecuado control de la diabetes mellitus tiene una gran importancia desde muchos puntos de vista. En los últimos años, se ha destacado el impacto que tienen los niveles de la glucemia postprandial sobre el manejo y las complicaciones de esta enfermedad. Controlar la hiperglucemia postprandial y, por lo tanto, su participación en el deterioro clínico de los pacientes con diabetes puede conseguirse retardando el vaciamiento gástrico y estimulando el efecto incretina, los cuales se pueden promover utilizando los análogos del péptido similar al glucagón tipo 1 (GLP-1). En este artículo se revisa el concepto del efecto incretina y la utilidad de los análogos GLP-1 en el control de la glicemia en los pacientes con diabetes mellitus tipo 2.

Proper control of diabetes mellitus is very important from many points of view. In recent years, the impact of postprandial blood glucose levels on the treatment and complications of this disease has been highlighted. Controlling postprandial hyperglycemia-and, therefore, its participation in the clinical deterioration of patients with diabetes-can be achieved by delaying gastric emptying and stimulating the incretin effect, which can be promoted using the analogues of glucagon-like peptide-1 (GLP-1). In this article, the concept of the incretin effect and usefulness of GLP-1 analogues for glycemic control in patients with type 2 diabetes mellitus is reviewed.

Estudio centellográfico del vaciamiento gástrico con estaño coloidal / Scintigraphic study of colloidal tin gastric emptying

INTRODUCCIÓN: la gastroparesia se define como un retardo en el vaciamiento gástrico, en ausencia de obstrucción mecánica, asociado a síntomas como náusea y/o vómitos, sensación de plenitud gástrica posprandial, saciedad precoz o dolor epigástrico por más de 3 meses. Las causas que más frecuentemente se relacionan son la diabetes mellitus y la idiopática. La prueba de oro en el diagnóstico del retardo del vaciamiento gástrico es la gammagrafía y el radiofármaco que más se ha utilizado el 99mTc-sulfuro coloidal. OBJETIVO: evaluar el vaciamiento gástrico y mostrar los resultados obtenidos con el uso del estaño coloidal en el estudio centellográfico del vaciamiento gástrico. MÉTODOS: se realizó un estudio descriptivo en 64 pacientes de más de 18 años utilizando como radiofármaco 99mTc-Sn coloidal. RESULTADOS: el 31 % del total de pacientes presentó síntomas. El tiempo de vaciamiento fue normal en 44 casos y la asociación de síntomas y gastroparesia se observó en 20 (15 diabéticos y 5 no diabéticos), 9 pacientes tuvieron un vaciamiento retardado, pero no referían síntomas. La gastroparesia fue más frecuente en mujeres que en hombres (35 % versus 21 %). El 21 % de los casos tenían un retardo moderado del vaciamiento gástrico. CONCLUSIONES: los resultados obtenidos con 99mTc-Sn coloidal son comparables con los reportados por otros autores que utilizan el 99mTc-SC en la evaluación gammagráfica del vaciamiento gástrico.

INTRODUCTION: gastroparesis is defined as a delay in gastric emptying in the absence of mechanical obstruction, associated with symptoms such as nausea and/or vomiting, postprandial gastric fullness feeling, early satiety or epigastric pain for more than 3 months. Diabetes mellitus and idiopathic are the most frequent causes related. The gold standard in the diagnosis of delayed gastric emptying is gammagraphy and 99mTc-sulfur colloid is the most widely used radiopharmaceutical. OBJECTIVE: assess gastric emptying and show the results obtained with the use of colloidal tin in the gammagraphy study of gastric emptying. METHODS: a descriptive study was conducted in 64 patients older than 18 years using 99mTc-sulfur colloid radiopharmaceutical. RESULTS: 31 % of patients had symptoms. The emptying time was normal in 44 cases and the association of gastroparesis symptoms was observed in 20 (15 diabetics and 5nondiabetics), 9 patients had delayed emptying, but they did not report symptoms. Gastroparesis was more frequent in women than in men (35 % versus 21 %). 21 % of patients had moderate delayed gastric emptying. CONCLUSIONS: results obtained with colloidal Tc-Sn 99m are comparable with those reported by other authors using 99mTc-SC in gammagraphy assessment of gastric emptying.

Causas poco frecuentes de obstrucción en la salida gástrica en pediatría: Utilidad de la ecografía / Unusual causes of pediatric gastric oulet obstruction. Utility of ultrasound

Las causas de obstrucción en el vaciamiento gástrico (OVG) pueden ser intrínsecas, de la pared o extrínsecas. En Pediatría, la más frecuente es la estenosis hipertrófica del píloro. El objetivo de este trabajo es mostrar la utilidad del ultrasonido (US) en el diagnóstico de OVG de causa poco común. El estómago es fácilmente visualizable con US, cuando la luz se distiende adecuadamente con líquido. El protocolo de estudio incluye la realización de cortes en los planos transversal y longitudinal, evaluando la pared (normalmente de 3mm aprox.) y el vaciamiento gástrico. Presentamos una serie de 7 pacientes, entre los 9 meses y 12 años de edad, con síntomas de OVG, que fueron estudiados en nuestro hospital entre 2009 y 2012. El US mostró engrosamiento de la pared, ocupación de la cavidad gástrica o alguna imagen en íntimo contacto con la pared, sin plano de clivaje. Los diagnósticos fueron: enfermedad granulomatosa crónica, duplicación con heterotopia gástrica y metaplasia intestinal focal, gastritis crónica, linfoma de Burkitt, quiste de duplicación con ectopia pancreática y tricobezoar. En los niños con vómitos alimenticios y sospecha de OVG debemos hacer un estudio ecográfico minucioso de la región antropilórica para valorar la pared, el contenido y las relaciones extrínsecas, de modo de orientar el diagnóstico y sugerir en cada caso qué estudios realizar para confirmarlo. La endoscopia con biopsia generalmente es concluyente, evitando la seriada esófago gastroduodenal (SEGD) y, en muchos casos, se utiliza la tomografía computada (TC), por lo menos antes del diagnóstico histológico de certeza.

The stomach is easily observed in an ultrasound (US) exam when is filled with liquid. The US scan protocol includes longitudinal and transversal views of the stomach, evaluating the muscular wall thickness (normal up to 3mm) and the gastric outlet. Causes of gastric outlet obstruction can be intrinsic, extrinsic or from the stomach wall. In children, the commonest cause is the hypertrophic pyloric stenosis.The aim of this work is to show the usefulness of ultrasonography (US) in the diagnosis of gastric outlet obstruction of uncommon cause. We present 7 patients from 9 months to 12 years old, studied in our hospital between 2009 and 2012, who presented gastric outlet obstruction symptoms. US showed thickening of the stomach muscular wall, filling of the stomach lumen or a mass in close relationship with the stomach wall. Granulomatous disease, gastric duplication with heterotopy, focal intestinal metaplasia, chronic gastritis, Burkitt lymphoma, duplication cyst, pancreatic ectopic tissue and bezoar were found in our serie. Gastric outlet obstruction (nonbilius emesis) in children is an entity that must be studied with detail through US including the pyloric channel and the gastric antrum. Endoscopy guided biopsy is conclusive in most of the cases avoiding the need for an Upper GI study and, in many cases, the need for a CT scan.

Causas poco frecuentes de obstrucción en la salida gástrica en Pediatría: Utilidad de la ecografía

Las causas de obstrucción en el vaciamiento gástrico (OVG) pueden ser intrínsecas, de la pared o extrínsecas. En Pediatría, la más frecuente es la estenosis hipertrófica del píloro. El objetivo de este trabajo es mostrar la utilidad del ultrasonido (US) en el diagnóstico de OVG de causa poco común. El estómago es fácilmente visualizable con US, cuando la luz se distiende adecuadamente con líquido. El protocolo de estudio incluye la realización de cortes en los planos transversal y longitudinal, evaluando la pared (normalmente de 3mm aprox.) y el vaciamiento gástrico. Presentamos una serie de 7 pacientes, entre los 9 meses y 12 años de edad, con síntomas de OVG, que fueron estudiados en nuestro hospital entre 2009 y 2012. El US mostró engrosamiento de la pared, ocupación de la cavidad gástrica o alguna imagen en íntimo contacto con la pared, sin plano de clivaje. Los diagnósticos fueron: enfermedad granulomatosa crónica, duplicación con heterotopia gástrica y metaplasia intestinal focal, gastritis crónica, linfoma de Burkitt, quiste de duplicación con ectopia pancreática y tricobezoar. En los niños con vómitos alimenticios y sospecha de OVG debemos hacer un estudio ecográfico minucioso de la región antropilórica para valorar la pared, el contenido y las relaciones extrínsecas, de modo de orientar el diagnóstico y sugerir en cada caso qué estudios realizar para confirmarlo. La endoscopia con biopsia generalmente es concluyente, evitando la seriada esófago gastroduodenal (SEGD) y, en muchos casos, se utiliza la tomografía computada (TC), por lo menos antes del diagnóstico histológico de certeza.(AU)

The stomach is easily observed in an ultrasound (US) exam when is filled with liquid. The US scan protocol includes longitudinal and transversal views of the stomach, evaluating the muscular wall thickness (normal up to 3mm) and the gastric outlet. Causes of gastric outlet obstruction can be intrinsic, extrinsic or from the stomach wall. In children, the commonest cause is the hypertrophic pyloric stenosis.The aim of this work is to show the usefulness of ultrasonography (US) in the diagnosis of gastric outlet obstruction of uncommon cause. We present 7 patients from 9 months to 12 years old, studied in our hospital between 2009 and 2012, who presented gastric outlet obstruction symptoms. US showed thickening of the stomach muscular wall, filling of the stomach lumen or a mass in close relationship with the stomach wall. Granulomatous disease, gastric duplication with heterotopy, focal intestinal metaplasia, chronic gastritis, Burkitt lymphoma, duplication cyst, pancreatic ectopic tissue and bezoar were found in our serie. Gastric outlet obstruction (nonbilius emesis) in children is an entity that must be studied with detail through US including the pyloric channel and the gastric antrum. Endoscopy guided biopsy is conclusive in most of the cases avoiding the need for an Upper GI study and, in many cases, the need for a CT scan.(AU)

Estudio centellográfico del vaciamiento gástrico con estaño coloidal / Scintigraphic Study of Colloidal Tin Gastric Emptying

Introducción: la gastroparesia se define como un retardo en el vaciamiento gástrico, en ausencia de obstrucción mecánica, asociado a síntomas como náusea y/o vómitos, sensación de plenitud gástrica posprandial, saciedad precoz o dolor epigástrico por más de 3 meses. Las causas que más frecuentemente se relacionan son la diabetes mellitus y la idiopática. La prueba de oro en el diagnóstico del retardo del vaciamiento gástrico es la gammagrafía y el radiofármaco que más se ha utilizado el 99mTc-sulfuro coloidal.Objetivo: evaluar el vaciamiento gástrico y mostrar los resultados obtenidos con el uso del estaño coloidal en el estudio centellográfico del vaciamiento gástrico.Métodos: se realizó un estudio descriptivo en 64 pacientes de más de 18 años utilizando como radiofármaco 99mTc-Sn coloidal.Resultados: el 31 por ciento del total de pacientes presentó síntomas. El tiempo de vaciamiento fue normal en 44 casos y la asociación de síntomas y gastroparesia se observó en 20 (15 diabéticos y 5 no diabéticos), 9 pacientes tuvieron un vaciamiento retardado, pero no referían síntomas. La gastroparesia fue más frecuente en mujeres que en hombres (35 por ciento versus 21 por ciento). El 21 por ciento de los casos tenían un retardo moderado del vaciamiento gástrico.Conclusiones: los resultados obtenidos con 99mTc-Sn coloidal son comparables con los reportados por otros autores que utilizan el 99mTc-SC en la evaluación gammagráfica del vaciamiento gástrico(AU)

Introduction: gastroparesis is defined as a delay in gastric emptying in the absence of mechanical obstruction, associated with symptoms such as nausea and/or vomiting, postprandial gastric fullness feeling, early satiety or epigastric pain for more than 3 months. Diabetes mellitus and idiopathic are the most frequent causes related. The gold standard in the diagnosis of delayed gastric emptying is gammagraphy and 99mTc-sulfur colloid is the most widely used radiopharmaceutical.Objective: assess gastric emptying and show the results obtained with the use of colloidal tin in the gammagraphy study of gastric emptying.Methods: a descriptive study was conducted in 64 patients older than 18 years using 99mTc-sulfur colloid radiopharmaceutical.Results: 31 percent of patients had symptoms. The emptying time was normal in 44 cases and the association of gastroparesis symptoms was observed in 20 (15 diabetics and 5nondiabetics), 9 patients had delayed emptying, but they did not report symptoms. Gastroparesis was more frequent in women than in men (35 percent versus 21 percent). 21 percent of patients had moderate delayed gastric emptying.Conclusions: results obtained with colloidal Tc-Sn 99m are comparable with those reported by other authors using 99mTc-SC in gammagraphy assessment of gastric emptying(AU)

[The physiology of glucagon-like peptide-1 and its role in the pathophysiology of type 2 diabetes mellitus]. / Fisiología del GLP-1 y su papel en la fisiopatología de la diabetes mellitus tipo 2.

The hormone glucagon-like peptide-1 (GLP-1) is synthesized and secreted by L cells in the small intestine in response to food ingestion. After reaching the general circulation it has a half-life of 2-3 minutes due to degradation by the enzyme dipeptidyl peptidase-4. Its physiological role is directed to control plasma glucose concentration, though GLP-1 also plays other different metabolic functions following nutrient absorption. Biological activities of GLP-1 include stimulation of insulin biosynthesis and glucose-dependent insulin secretion by pancreatic beta cell, inhibition of glucagon secretion, delay of gastric emptying and inhibition of food intake. GLP-1 is able to reduce plasma glucose levels in patients with type 2 diabetes and also can restore beta cell sensitivity to exogenous secretagogues, suggesting that the increasing GLP-1 concentration may be an useful therapeutic strategy for the treatment of patients with type 2 diabetes.

[Modulation of the incretin effect in the treatment of diabetes]. / Modulación del efecto incretina en el tratamiento de la diabetes.

Modulation of the incretin effect has opened up a new strategy in the treatment of diabetes mellitus type 2 (DM2). To date, this physiological mechanism has been boosted in two ways: firstly, by pharmacological inhibition of the enzyme that physiologically degrades glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP4); secondly, through the development of GLP-1 agonists (GLP-1a) that are resistant to the action of DPP-4. Several clinical trials have shown the clinical superiority of GLPa, which seems to be linked to higher circulating levels of GLP-1. On the other hand, this higher efficacy also seems to be associated with the higher rate of adverse effects associated with aGLP-1 therapy compared with DPP-4 inhibition. These and other differentiating characteristics of the two drug families will determine the choice of drug therapy in the personalized treatment of hyperglycemia in patients with DM2.

[The physiology of glucagon-like peptide-1 and its role in the pathophysiology of type 2 diabetes mellitus]. / Fisiología del GLP-1 y su papel en la fisiopatología de la diabetes mellitus tipo 2.

The hormone glucagon-like peptide-1 (GLP-1) is synthesized and secreted by L cells in the small intestine in response to food ingestion. After reaching the general circulation it has a half-life of 2-3 minutes due to degradation by the enzyme dipeptidyl peptidase-4. Its physiological role is directed to control plasma glucose concentration, though GLP-1 also plays other different metabolic functions following nutrient absorption. Biological activities of GLP-1 include stimulation of insulin biosynthesis and glucose-dependent insulin secretion by pancreatic beta cell, inhibition of glucagon secretion, delay of gastric emptying and inhibition of food intake. GLP-1 is able to reduce plasma glucose levels in patients with type 2 diabetes and also can restore beta cell sensitivity to exogenous secretagogues, suggesting that the increasing GLP-1 concentration may be an useful therapeutic strategy for the treatment of patients with type 2 diabetes.