The Financial Implications of Pancreatic Surgery: The Hospital Is the Big Winner, Not the Surgeon!

Background: High-volume pancreatic surgery centers require a significant investment in expertise, time, and resources to achieve optimal patient outcomes. A detailed understanding of the economics of major pancreatic surgery is limited among many clinicians and hospital administrators. A greater consideration of these financial aspects may in fact have implications for enhancing clinical care and for a broader sustainability of high-volume pancreatic surgery programs. Methods: In this retrospective observational study, patients who underwent pancreaticoduodenectomy (PD), total pancreatectomy, or distal pancreatectomy at one academic medical center during the fiscal year 2021 were evaluated. Detailed hospital charges and professional fees were obtained for patients using the Qlik perioperative database. Clinical data for the study cohort were gathered from a prospectively maintained, IRB-approved pancreatic surgery database. Charges for the 91-day perioperative period were included. A P < 0.05 was considered significant. Results: During the study period, 159 evaluable patients underwent 1 of 3 designated pancreatic resections included in the analysis. Ninety-seven patients (61%) were diagnosed with adenocarcinoma and 70% (n = 110) underwent PD. The total charges (combined professional and hospital charges) for the cohort encompassing the entire perioperative period were $20,661,759. The median charge per patient was $130,306 (interquartile range [IQR], $34,534). The median direct cost of care was $23,219 (IQR, $6321) and the median contribution margin per case was $10,092 (IQR, $22,949). The median surgeon professional fee charges were $7700 per patient (IQR, $1296) as compared to $3453 (IQR, $1,144) for professional fee receipts (45% of the surgeon charge). The differences between the professional fee charges and receipts per patient were also considerable for other health care professionals such as anesthesiologists ($4945 charges vs $1406 receipts [28%]) and pathologists ($3035 charges vs $680 receipts [22%]). The surgeon professional fees were only 6% of the total charges, while the professional fees for anesthesiology and pathology were 4% and 2% of the total charges, respectively. Supply charges were 3% of the total charges. Longer operative time was correlated with increased hospital and anesthesia charges, without a significant increase in surgeon charges (P < 0.001, P < 0.001, and P = 0.2, respectively). Male sex, diabetes, and low serum albumin correlated with greater total hospital charges (P = 0.01, P = 0.01, and P = 0.03, respectively). Conclusions: The role of the surgeon in the perioperative clinical care of major pancreatic resection patients is crucial and important and is by no means limited to the operative day. Nevertheless, in the context of the current US health care system, the reimbursement to the surgeon in the form of professional fees is a relatively small fraction of the total health care receipts for these patients. This imbalance necessitates a substantial financial partnership between hospitals and their pancreatic surgery units to ensure the long-term viability of these programs.

Lyme disease and Whipple's disease: a comprehensive review for the rheumatologist.

Despite their rarity, Lyme disease and Whipple's disease are of significant importance in rheumatology, as both can manifest as chronic arthritis, presenting challenges in the differential diagnosis of inflammatory arthropathies. In Lyme disease, arthritis typically emerges as a late manifestation, usually occurring six months after the onset of erythema migrans. The predominant presentation involves mono- or oligoarthritis of large joints, with a chronic or remitting-recurrent course. Even with appropriate antimicrobial treatment, arthritis may persist due to inadequate immunological control triggered by the disease. In contrast, Whipple's disease may present with a migratory and intermittent seronegative poly- or oligoarthritis of large joints, preceding classic gastrointestinal symptoms by several years. Both disorders, particularly Whipple's disease, can be misdiagnosed as more common autoimmune rheumatic conditions such as rheumatoid arthritis and spondyloarthritis. Epidemiology is crucial in suspecting and diagnosing Lyme disease, as the condition is transmitted by ticks prevalent in specific areas of the United States, Europe, and Asia. On the contrary, the causative agent of Whipple's disease is widespread in the environment, yet invasive disease is rare and likely dependent on host genetic factors. In addition to erythema migrans in Lyme disease and gastrointestinal manifestations in Whipple's disease, neurological and cardiac involvement can further complicate the course of both. This article offers a comprehensive review of the epidemiological, pathophysiological, clinical, and therapeutic aspects of both diseases.

[Surgical resection and survival of clear cell renal cancer metastases to the pancreas]. / Resección quirúrgica y sobrevida de metástasis de cáncer renal de células claras a páncreas.

Introduction: Pancreas is considered one of the organs most frequently affected by recurrence after nephrectomy secondary to renal cell carcinoma reporting an incidence of 20%, 85% of these occur within the first 3 years. Objective: The objective of the study is to evaluate overall survival and disease-free survival in patients with renal cancer and pancreatic metastases who underwent surgical treatment. Methods: A retrospective cross-sectional study of patients with histological diagnosis of renal cancer associated with pancreatic metastasis was performed and included those treated by pancreatoduodenectomy or distal pancreatectomy during the period 1987-2020. Results: 14 patients with pancreatic metastasis were included. Two groups of patients were obtained: those who underwent pancreatic surgery for metastasis and those who did not undergo surgical procedure. According to the location of the metastasis, 71.4% corresponded to a single location and 28.6% to multiple locations. 57.1% underwent Whipple and 42.9% distal pancreatectomy. Survival after the surgical procedure was 1150 days versus 499 days in non-operated patients. Conclusion: Pancreatic metastases due to RCC can be curable, improve morbidity, and increase disease-free survival with surgical treatment.

Introducción: El páncreas es considerado de los órganos más frecuentemente afectados por recurrencia después de la nefrectomía secundaria a carcinoma de células renales notificándose una incidencia de 20%, 85% de estas ocurren dentro de los primeros 3 años. Objetivo: Evaluar la sobrevida general y sobrevida libre de enfermedad en pacientes con cáncer renal y metástasis pancreáticas sometidos a tratamiento quirúrgico. Métodos: Se realizó un estudio retrospectivo transversal de pacientes con diagnóstico histológico de cáncer renal asociado a metástasis pancreática y se incluyeron aquellos tratados mediante cirugía de tipo pancreatoduodenectomía o pancreatectomía distal durante el periodo de tiempo 1987-2020. Resultados: Se incluyeron 14 pacientes con metástasis a páncreas. Se obtuvieron dos grupos de pacientes: sometidos a cirugía pancreática por metástasis y aquellos que no se les realizó procedimiento quirúrgico. De acuerdo a la localización de la metástasis 71.4% correspondía a ubicación única y 28.6% a ubicación múltiple. Al 57.1% se les realizó Whipple y 42.9% pancreatectomía distal. La sobrevida tras el procedimiento quirúrgico, fue de 1150 días vs. 499 días en no operados. Conclusión: Las metástasis a páncreas por CCR pueden ser curables, mejorar la morbilidad y aumentar la sobrevida libre de enfermedad con tratamiento quirúrgico.

Whipple's Disease: A Systematic Review of the Literature

Introduction: Whipple's disease is a chronic systemic disease with a predilection for the digestive system, especially the small intestine. It was first described in 1907 by George H. Whipple, who named it intestinal lipodystrophy. It is caused by a gram-positive bacterium belonging to the Actinomycetaceae family called Tropheryma whipplei. Objective: To characterize patients with Whipple's disease. Materials and methods: A systematic literature review was carried out using the DeCS terms enfermedad de Whipple (Whipple's disease) or (Tropheryma whipplei) in the Pubmed/Medline, Scopus, Scielo, Science Direct, Embase, Cochrane Library, BIREME, Proquest, and Redalyc databases; 123 articles were analyzed. Results: 123 published articles corresponding to case reports and series were examined, noting a higher prevalence in males (70.6%). The most frequent manifestations were joint symptoms (61%), followed by weight loss (47.1%) and diarrhea (43.4%). The most used diagnostic method was polymerase chain reaction (PCR) (63.2%), followed by biopsy (50.7%) and pathological examination with PAS (periodic acid Schiff) granules (47.8%). The management most used was antibiotic therapy with a predominance of trimethoprim/sulfamethoxazole and ceftriaxone. Conclusions: Whipple's disease has a low prevalence, occurs more frequently in white people, mainly affects the elderly, has a predilection for the male sex, and is characterized as a chronic systemic disease with a predilection for the digestive system, especially the small intestine.

Introducción: la enfermedad de Whipple es una enfermedad crónica sistémica con predilección por el aparato digestivo, especialmente el intestino delgado. Fue descrita por vez primera en 1907 por George H. Whipple, quien la denominó lipodistrofia intestinal. Es causada por una bacteria grampositiva perteneciente a la familia de los Actinomycetaceae denominada Tropheryma whipplei. Objetivo: caracterizar a los pacientes con enfermedad de Whipple. Materiales y métodos: se realizó una revisión sistemática de la literatura, de los términos DeCS enfermedad de Whipple (whipple Disease) o (Tropheryma whipplei) en las bases de datos Pubmed/Medline, Scopus, Scielo y Science Direct, Embase, Cochrane Library, BIREME, Proquest y Redalyc; se analizaron 123 artículos. Resultados: se analizaron 123 artículos publicados que correspondían a reportes y series de casos en los cuales se evidenció una mayor prevalencia en varones (70,6%). Las manifestaciones más frecuentes fueron los síntomas articulares (61%), seguidos de pérdida de peso (47,1%) y diarrea (43,4%). El método diagnóstico más usado fue la reacción en cadena de la polimerasa (PCR) (63,2%), seguido por la biopsia (50,7%) y, por último, examen anatomopatológico con gránulos PAS (ácido peryódico de Schiff) (47,8%). El manejo más empleado fue la antibioticoterapia con predominio de trimetoprima/sulfametoxazol y ceftriaxona. Conclusiones: la enfermedad de Whipple tiene una baja prevalencia, se presenta con mayor frecuencia en personas de raza blanca, afecta principalmente a los adultos mayores, tiene predilección por el sexo masculino y se caracteriza por ser una enfermedad crónica sistémica con predilección por el aparato digestivo, especialmente el intestino delgado.

Duodenopancreatectomía laparoscópica: evolución de los primeros casos en Venezuela / Laparoscopic duodenopancreatectomy: evolution of the first cases in Venezuela

La duodenopancreatectomía cefálica es la única opción con criterio curativo de los tumores periampulares y cabeza de páncreas. El abordaje mínimamente invasivo ha mostrado sus beneficios en la duodenopancreatectomía cefálica lo cual ha llevado a un mayor interés a nivel mundial por esta técnica. El objetivo es describir la técnica utilizada y analizar la evolución que presentaron los primeros casos realizados en Venezuela de duodenopancreatectomía laparoscópica y así dar a conocer nuestra experiencia, es un estudio retrospectivo, descriptivo, de corte transversal; se revisaron 106 historias clínicas, obteniendo 8 casos para este estudio: 5 femeninos y 3 masculinos, los promedios de edad y tiempo de evolución de la enfermedad fueron de 54,15 años y de 7 meses respectivamente, la indicación fue 4 tumores de cabeza de páncreas y 4 periampulares, el índice de masa corporal promedio fue de 23,44 kg/mt2, el tiempo quirúrgico osciló entre 315 ­ 475 min, la estancia hospitalaria de 4 ­ 24 días, las perdidas hemáticas fueron de 200cc ± 20cc, tres pacientes presentaron complicaciones post operatorias mediatas. En conclusión, los resultados que hemos observado en nuestro reporte inicial de casos de duodenopancreatectomía laparoscópica reúnen las características de otras publicaciones similares y se ratifica los beneficios de este abordaje, la clave para la duodenopancreatectomía laparoscópica de rutina es que sea realizada en centros especializados, con protocolos estandarizados, ejecutado por cirujanos hepatobiliar y pancreática con experiencia en laparoscopia avanzada(AU)

Duodenopancreatectomy is the only option with curative criteria of the periampullary tumors and pancreatic head. The minimally invasive approach has shown its benefits in cephalic duodenopancreatectomy which has led to greater interest worldwide in this technique. The objective is to describe the technique used and analyze the evolution presented by the first cases of laparoscopic duodenopancreatectomy and thus publicize our experience, it is a retrospective, descriptive, cross-sectional study; 106 medical records were reviewed, obtaining 8 cases for this study: 5 women and 3 men, the average age and the time of evolution of the disease were 54.15 years and 7 months, the indication was 4 pancreas head and 4 periampullary tumors, the average body mass index was 23, 44 kg/mt2, assisted surgery was performed in 4 patients and 4 totally laparoscopic, the surgical time ranged between 315 - 475 min, and the hospital stay was 4 - 24 days, the blood loss was 200cc ± 20cc, three patients presented mediated postoperative complications. In conclusion, the results we have observed in our initial case report of laparoscopic duodenopancreatectomy meet the characteristics of other similar publications and the benefits of this approach are ratified, the key to routine laparoscopic duodenopancreatectomy is that it is performed in specialized centers, with standardized protocols, executed by surgeons with experience in advanced laparoscopy in addition to hepatobiliary and pancreatic surgery(AU)

Whipple's pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago.

BACKGROUND: Many authorities advocate for Whipple's procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple's procedures were performed in a low-volume, resource-poor setting in the West Indies. AIM: To study outcomes of Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. METHODS: This was a retrospective study of all patients undergoing Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. RESULTS: This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple's procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths. CONCLUSION: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

Whipple's operation with a modified centralization concept: A model in low-volume Caribbean centers.

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors' opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy.

Background: The incidence of Grade C postoperative pancreatic fistula ranges from 2 to 11% depending on the type of pancreatic resection. This complication may frequently require early relaparotomy and the surgical approach remains technically challenging and is still associated with a high mortality. Infectious complications and post-operative hemorrhage are the two most common causes of reoperation. Summary: The best management of grade C pancreatic fistulas remains controversial and ranges from conservative approaches up to completion pancreatectomy. The choice of the technique depends on the patient's conditions, intraoperative findings, and surgeon's discretion. A pancreas-preserving strategy appears to be attractive, including from simple to more complex procedures such as debridement and drainage, and external wirsungostomy. Completion pancreatectomy should be reserved for selected cases, including stable patients with severe infection complication or hemorrhage after pancreatic fistula who do not respond to pancreas-preserving procedures. Key Messages: This review describes the current options for management of grade C pancreatic fistula after pancreatoduodenectomy with regard to indication, choice of procedure and outcomes of the different approaches.

Multiple Biliary Stones: a Rare Long-term Complication after Whipple Procedure / Múltiplos cálculos biliares: uma complicação rara a longo prazo após o procedimento de Whipple

A hypertensive, diabetic woman underwent a successful Whipple procedure at the age of 84 due to carcinoma of the ampulla of Vater. She presented an extremely rare complication 24 months after the surgery, consisting of acute cholangitis due to multiple biliary lithiases associated with a bilioenteric anastomotic stricture. The diagnosis was confirmed with computed tomography, magnetic resonance cholangiopancreatography, and cholangiography. The patient was successfully treated with multiple percutaneous transhepatic cholangioplasties (AU)

Uma mulher hipertensa e diabética foi submetida a um procedimento bem-sucedido de Whipple aos 84 anos devido a um carcinoma da ampola de Vater e apresentou uma complicação extremamente rara 24 meses após da cirurgia, consistindo em colangite aguda devido à presença de litíase biliar múltipla associada com estenose da anastomose bilio-entérica. O diagnóstico foi confirmado com tomografia computadorizada, colangiopancreatografia por ressonância mag-nética e colangiografia.O paciente foi tratado com sucesso com múltiplas colangioplastias transhepáticas percutâneas (AU)

Whipple's disease: a case report in Santa Catarina, Brazil.

Whipple's disease is a rare systemic infection caused by a diastase-resistant and Gram-positive bacillus called Tropheryma whipplei. The diagnosis of the disease is difficult and often late due to the variety of the symptoms. The objective of this study was to report a rare case of Whipple's disease treated at the Internal Medicine service of a hospital in the Midwest of Santa Catarina, Brazil. The patient was invited for an interview to describe the history of symptoms and previous treatments. Additionally, test results and treatments performed during hospitalization were assessed through the medical records. The case report describes a 39-year-old white male who presented, at the time of diagnosis, severe diarrhea, hematochezia, weight loss, fever, and inguinal adenomegaly, in addition to preceding migratory polyarthritis. After investigation, the diagnosis of Whipple's disease was achieved in conjunction with antibiotic treatment, with improvement of clinical and laboratory symptoms after 15 days. This case highlights the broad array of symptoms and the non-specific features of the Whipple's disease. Establishing an early diagnosis is essential for the success of the treatment, avoiding a long-lasting escalation of symptoms, which lead to cachexia and a devastating loss of the patient's quality of life.

Hyperinsulinemic hypoglycemia in adolescents: case report and systematic review.

BACKGROUND: Hyperinsulinemic hypoglycemia is the most common cause of severe and persistent hypoglycemia in neonates and children. It is a heterogeneous condition with dysregulated insulin secretion, which persists in the presence of low blood glucose levels. CASE PRESENTATION: We report a case of a 15 year-old male with hyperinsulinemic hypoglycemia, who underwent a subtotal pancreatectomy after inadequate response to medical therapy. Pathological examination was positive for nesidioblastosis (diffuse ß-cell hyperplasia by H-E and immunohistochemical techniques). The patient's blood glucose levels normalized after surgery and he remains asymptomatic after 1 year of follow-up. The systematic review allowed us to identify 41 adolescents from a total of 205 cases reported in 22 manuscripts, from a total of 454 found in the original search done in PubMed and Lilacs. CONCLUSIONS: Although very well reported in children, hyperinsulinemic hypoglycemia can occur in adolescents or young adults, as it happens in our reported case. These patients can be seen, treated and reported by pediatricians or adult teams either way due to the wide age range used to define adolescence. Most of them do not respond to medical treatment, and subtotal distal pancreatectomy has become the elected procedure with excellent long-term response in the vast majority.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres.

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon's peri-operative experience.

Adult pancreatoblastoma: A rare malignant tumor of the pancreas.

Pancreatoblastoma (PB) is a rare malignant tumor in adults. It has an overall incidence of 0.004 per 100,000 inhabitants. Its diagnosis with fine-needle aspiration (FNA) is difficult due to multiple differentiation lines present on PB that overlap with other tumors. A 76-year-old male patient presented with jaundice, weight loss of 10 kg in 6 months, and appetite loss. Abdominal computed tomography scan showed a tumor in the pancreas head. Transendoscopic ultrasound with FNA biopsy revealed a malignant epithelial neoplasia compatible with PB with immunohistochemistry CK19 (+), P63(+), synaptophysin (-), and Ki67 50%. The patient underwent surgical resection and adjuvant chemotherapy. Currently, the patient is in follow-up with the latest imaging showing no evidence of disease at 32 months after his initial diagnosis. PB is an uncommon malignant neoplasia with an aggressive behavior. Its diagnostic and therapeutic protocols are unclear. Its preoperative diagnosis may be difficult since its imaging features and serological markers are non-specific. However, FNA may be useful in some situations. Surgical resection is currently the recommended treatment that is associated with the best long-term survival.

Enfermedad de whipple e hipertensión pulmonar reversible / Whipple's disease and reversible pulmonary hypertension

Resumen La enfermedad de Whipple es una enfermedad multisistémica crónica, causada por la bacteria Tropherima whipplei. Se han descripto aproximadamente 1200 casos en la literatura. La incidencia mundial se estima en 9.8 casos por millón de personas. Los datos provenientes de Sudamérica y Europa muestran que afecta a varones de mediana edad. Se cree que los factores inmunológicos del huésped son los que influyen en el curso de la infección y no el genotipo del agente. Dado que las características clínicas no suelen ser específicas y el espectro de manifestaciones en órganos individuales puede ser subestimado, el diagnóstico sigue siendo muy difícil. Presentamos un caso confirmado por histopatología con compromiso multisistémico. Consideramos importante su difusión dados los escasos casos documentados en Sudamérica y la relevancia de tener presente la sospecha diagnóstica para el abordaje terapéutico precoz que mejora el pronóstico de esta rara enfermedad.

Abstract Whipple's disease is a chronic mutisystem disease caused by the bacteria Tropherima whipplei. Approximately 1200 cases have been described in the literature. The worldwide incidence is estimated at 9.8 cases per million people. Data from South America and Europe show that it affects middle-aged males. It is believed that host immunological factors rather than agent genotypic traits influence the course of the infection. Since the clinical characteristics are usually nonspecific and the wide spectrum of manifestations in individual organs may be underestimated, the diagnosis remains challenging. We present a case with multisystem compromise confirmed by histopathology. We consider its publication important given the few cases documented in South America and the relevance of bearing in mind the importance of an early diagnosis for a prompt treatment that improves the prognosis of this rare disease.

[Whipple's disease and reversible pulmonary hypertension]. / Enfermedad de Whipple e hipertensión pulmonar reversible.

Whipple's disease is a chronic mutisystem disease caused by the bacteria Tropherima whipplei. Approximately 1200 cases have been described in the literature. The worldwide incidence is estimated at 9.8 cases per million people. Data from South America and Europe show that it affects middle-aged males. It is believed that host immunological factors rather than agent genotypic traits influence the course of the infection. Since the clinical characteristics are usually nonspecific and the wide spectrum of manifestations in individual organs may be underestimated, the diagnosis remains challenging. We present a case with multisystem compromise confirmed by histopathology. We consider its publication important given the few cases documented in South America and the relevance of bearing in mind the importance of an early diagnosis for a prompt treatment that improves the prognosis of this rare disease.

La enfermedad de Whipple es una enfermedad multisistémica crónica, causada por la bacteria Tropherima whipplei. Se han descripto aproximadamente 1200 casos en la literatura. La incidencia mundial se estima en 9.8 casos por millón de personas. Los datos provenientes de Sudamérica y Europa muestran que afecta a varones de mediana edad. Se cree que los factores inmunológicos del huésped son los que influyen en el curso de la infección y no el genotipo del agente. Dado que las características clínicas no suelen ser específicas y el espectro de manifestaciones en órganos individuales puede ser subestimado, el diagnóstico sigue siendo muy difícil. Presentamos un caso confirmado por histopatología con compromiso multisistémico. Consideramos importante su difusión dados los escasos casos documentados en Sudamérica y la relevancia de tener presente la sospecha diagnóstica para el abordaje terapéutico precoz que mejora el pronóstico de esta rara enfermedad.

Qualidade da declaração de idade nos dados de óbito do Censo demográfico brasileiro de 2010 / Quality of age statement in 2010 brazilian demographic Census death data

Resumo Introdução O debate em torno do quesito de óbito no Censo Demográfico brasileiro foi retomado pela proximidade do Censo Demográfico de 2020. Há certa vantagem em obter informações de óbito por meio do Censo, mas é importante garantir a qualidade dessa informação. Objetivo Analisar a qualidade da declaração de idade para os dados de óbito do Censo Demográfico de 2010. Método Foram utilizadas as informações acerca dos óbitos nos domicílios, coletadas no questionário do universo do Censo Demográfico de 2010 do IBGE. A análise foi realizada a partir dos índices de Whipple e Myers. Resultados Para o Brasil como um todo, os resultados observados atestam uma boa qualidade dos dados de declaração de idade dos óbitos. No entanto, quando é estratificada a análise ao âmbito de unidades federativas, algumas distorções foram verificadas, sobretudo nas unidades pertencentes às regiões Norte e Centro-Oeste. Conclusão O uso dos dados de mortalidade para as análises em âmbito macro, do país como um todo, não requer ajustes para adequar as qualidades das informações, assim como para as análises em termos das grandes regiões.

Abstract Background The debate on deaths in the Brazilian population census has been resumed by the proximity of the next 2020 census. There are some advantages in obtaining death information through the census, but it is important to ensure the quality of this information. Objective To analyze the quality of the age declaration for the 2010 demographic census death data. Method Information on household deaths collected from the 2010 IBGE demographic census questionnaire was used. The analysis was performed from the Whipple and Myers indices. Results For Brazil as a whole, the observed results attest to a good quality of the death declaration data. However, when the analysis at the state level is stratified, some distortions were found, especially in the North and Midwest areas. Conclusion The use of mortality data for macro-level analyzes of the country as a whole does not require adjustments to suit the quality of the information, as well as for analysis in terms of large regions.

Procedimiento de Whipple: experiencia de un centro en fase de crecimiento en cirugía hepato-bilio-pancreática / Whipple procedure: hepatic-bilio-pancreatic single center experience

La operación de Whipple es el procedimiento quirúrgico de mayor complejidad en cirugía abdominal, este se realiza en pacientes con tumores de la encrucijada pancreatoduodenal, es la única alternativa para tratamiento curativo en fases tempranas de la enfermedad. Objetivo: Determinar los resultados del procedimiento Whipple, en pacientes intervenidos con tumores de la encrucijada pancreatoduodenal en el Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social, en el periodo de enero 2,015 a enero 2,020. Método: Descriptivo, observacional, retrospectivo. Resultados: Se incluyeron 42 procedimientos de Whipple, 29 (69%) casos del género masculino y 13 (31%) para el género femenino. La edad media fue de 61.5 años, el 54% presentaban comorbilidad asociada. El 24% utilizo transfusión transoperatoria de hemoderivados, el tiempo quirúrgico de 5.5 horas. La reintervención fue del 4.7%. Complicaciones postoperatorias tempranas 18%. La histología más común fue el carcinoma de cabeza de páncreas en el 43%. La mortalidad postoperatoria temprana fue del 4.7%. El OR de complicaciones asociadas a comorbilidades fue de 1.7 con un IC 0.3046-7.20 y un valor de P: 0.9251 que no es estadísticamente significativo. Conclusiones: Los tumores pancreatoduodenales en nuestra población se presentan en edades más tempranas a lo reportado. La morbimortalidad es similar a lo reportado en otros estudios a nivel latinoamericano, sin embargo las complicaciones están más elevadas que las mejores series internacionales. No existe asociación entre el riesgo de complicaciones con comorbilidades del paciente. (AU)

Whipple operation is the most complex surgical procedure in abdominal surgery, it's performed in patients with tumors of the pancreaticoduodenal crossroads, it is the only alternative for curative treatment in early stages of the disease. Objective: To determine the results of the Whipple procedure in patients operated on with tumors of the ancreaticoduodenal crossroads at the Hospital General de Enfermedades del IGSS in the period from January 2015 to January 2020. Method: Descriptive, observational, retrospective. Results: fourtytwo Whipple procedures were included, 29 (69%) cases of the male gender and 13 (31%) for the female gender. The mean age was 61.5 years, 54% had associated comorbidity. Twentyfour percent used intraoperative transfusion of blood products and surgical time of 5.5 hours. Reoperation was 4.7% with early postoperative complications of 18%. The most common histology was carcinoma of the head of the pancreas in 43%. Early postoperative mortality was 4.7%. The OR of complications associated with comorbidities was 1.7 with a CI 0.3046-7.20 and a P value: 0.9251, which is not statistically significant. Conclusions: Pancreaticoduodenal tumors in our population present at an earlier age than reported. Morbidity and mortality is similar to that reported in other studies. There is no association between the risk of complications with patient comorbidities. (AU)

Whipple disease diagnosed by enteroscopy: first case report in Colombia of an underdiagnosed disease and literature review.

BACKGROUND: Whipple's disease is a rare systemic disease caused by a gram-positive bacillus called Tropheryma whipplei. First described in 1907 as an intestinal lipodystrophy with histological finding of vacuoles in the macrophages of the intestinal mucous. Usually the symptoms are localized according to the compromised organ. The differential diagnosis is wide. It can be fatal without proper treatment. Recurrence can occur in up to 33% of the cases and usually compromises the neurological system. CASE PRESENTATION: This article reports the case of a 46-year-old female patient with a history of a 6-month hypochromic microcytic anemia of unknown cause. She consulted for a 6-months oppressive abdominal pain located in the mesogastrium as well as abdominal distention associated with nausea and liquid stools; in addition, she had an 8-month small and medium joint pain, without edema or erythema. Physical examination without relevant findings. Multiple esophagogastroduodenoscopies with normal gastric and duodenal biopsies findings and a normal colonoscopy were performed. Endoscope capsule showed red spots in the duodenum and ulcerations in the jejunum and proximal ileum covered by fibrin; histological report showed macrophages with positive periodic acid-schiff reaction staining (PAS staining), disgnosing Whipple's disease. Antibiotics were initiated. The patient is currently in the second phase of treatment without gastrointestinal and joint symptoms. CONCLUSION: This is the first case reported in Colombia. It is a rare entity and difficult to diagnose reason why it is important to continue with clinical investigations to give more clarity about the onset and appropriate diagnose to avoid the delay in treatment of this entity.

Laparoscopic pancreatoduodenectoy.

BACKGROUND: Pancreatoduodenectomy or Whipple's operation, is the elective surgical procedure to treat different periampullary diseases. Through the years this surgery has been doing open, but in the lasts decades thanks to the improve technology and trained surgeons, today is feasible doing it laparoscopic with good results. OBJECTIVE: To present the initial experience and results in totally laparoscopic pancreatoduodenectomy in Hospital Regional ISSSTE Puebla, reporting the second number of cases in México. METHOD: Since July 2014-July 2018, 8 patients has been operated by totally laparoscopic pancreatoduodenectomy, 7 in Hospital Regional ISSSTE Puebla and 1 in a private Hospital. RESULTS: Evaluating all the patients, not one had mortality during operation, no morbidity or immediate reoperation, so the results are favourable. CONCLUSION: Laparoscopic pancreatoduodenectomy is a very complex procedure but feasible, and good results depends on various factors, like the appropriate patient selection.

ANTECEDENTES: La pancreatoduodenectomía o cirugía de Whipple es el procedimiento de elección en el tratamiento de las enfermedades periampulares. A través de los años se ha realizado de manera abierta, y actualmente, gracias a la mejora de los recursos humanos y tecnológicos, se realiza este procedimiento por mínima invasión con buenos resultados. OBJETIVO: Presentar la experiencia inicial en la pancreatoduodenectomía totalmente laparoscópica en el Hospital de Alta Especialidad del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) de Puebla, dando a conocer la segunda serie de casos reportada en México. MÉTODO: De julio de 2014 a julio de 2018 se han realizado ocho pancreatoduodenectomías totalmente laparoscópicas, siete en el hospital de alta especialidad ISSSTE Puebla y una en un hospital privado. RESULTADOS: En todos los pacientes intervenidos los resultados son favorables, sin mortalidad transoperatoria y sin presentar complicaciones graves ni reintervención. CONCLUSIÓN: La pancreatoduodenectomía laparoscópica es un procedimiento de alta complejidad que, teniendo una adecuada selección de pacientes y un manejo multidisciplinario, se puede llevar a cabo con excelentes resultados.

Adenocarcinoma de papila duodenal maior - Um relato de caso / Adenocarcinoma of the major duodenal papilla - A case report

Tumores periampulares (TP) são originados a partir de estruturas próximas a Ampola de Vater e correspondem a um grupo heterogêneo de neoplasias. O adenocarcinoma da papila duodenal maior faz parte desse grupo de neoplasias. As principais manifestações são a icterícia do tipo obstrutiva, prurido, colúria, acolia fecal, além de perda ponderal e dor abdominal, associado a elevação dos níveis séricos de bilirrubina e enzimas hepáticas. O prognóstico é obscuro, sendo os carcinomas do tipo pancreaticobiliar aqueles com pior prognóstico. A ecografia endoscópica é o método mais sensível para diagnóstico e estadiamento e o tratamento de escolha é pancreaticoduodenectomia, conhecida como cirurgia de Whipple, frequentemente associada à quimioterapia adjuvante ou terapia de quimiorradiação. O presente trabalho propõe descrever um caso de adenocarcinoma da ampola de Vater em paciente de 38 anos atendida no Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF), abrangendo desde a sintomatologia inicial, processo diagnóstico até a conduta terapêutica. Sua relevância está em alertar os profissionais da saúde sobre a importância de elencar os tumores periampulares entre os possíveis diagnósticos diferenciais para pacientes com síndrome colestática, dado que o diagnóstico e a ressecção cirúrgica precoce são os fatores decisivos para um melhor prognóstico. (AU)

Periampular tumors (PT) originate from structures close to Vater's Ampulla and correspond to a heterogeneous group of cancers. The adenocarcinoma of the major duodenal papilla is part of this group of cancers. The main manifestations are obstructive jaundice, pruritus, choluria, fecal acholia, weight loss and abdominal pain, associated with elevated serum levels of bilirubin and liver enzymes. The prognosis is poor, with pancreaticobiliar type carcinomas having the worst prognosis. Endoscopic ultrasound is the most sensitive method for diagnosis and staging, and the best treatment is pancreaticoduodenectomy, known as Whipple surgery, often associated with adjuvant chemotherapy or chemoradiation therapy. The article proposes to describe a case of adenocarcinoma of the Vater's ampulla in a 38-year-old patient treated at the University Hospital of the Federal University of Juiz de Fora (HU-UFJF), covering from the initial symptoms, the diagnostic process and the therapeutic conduct. Its relevance is to alert health professionals about the importance of listing periampular tumors among the possible differential diagnoses for patients with cholestatic syndrome, considering that the diagnosis and early surgical resection are decisive factors for a better prognosis. (AU)