EMC - Técnicas Quirúrgicas - Aparato Digestivo 01/2011; 27(4):1–3. DOI: 10.1016/S1282-9129(11)71186-2

ABSTRACT Las pancreatectomías son resecciones parciales o totales del páncreas que están indicadas en circunstancias diversas, como carcinomas y lesiones benignas, tumorales o inflamatorias. Debido a esta variedad de indicaciones, existe una serie de técnicas de pancreatectomías, a las que pueden asociarse las enucleaciones pancreáticas (ablación de un tumor sin resección parenquimatosa adyacente) y las ampulectomías (resección limitada del aparato ampular). El tipo de pancreatectomía se escoge sobre todo dependiendo de la localización de la lesión, su carácter benigno o maligno y la posible coexistencia de fenómenos inflamatorios. La mayor parte de las pancreatectomías exponen a una morbimortalidad significativa que ha justificado el desarrollo de variantes técnicas destinadas a disminuir su gravedad y que debe sopesarse con el pronóstico de la enfermedad subyacente.

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    ABSTRACT: To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD). Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging. From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed. Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy. Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.
    Annals of surgery 02/2009; 249(1):111-7. DOI:10.1097/SLA.0b013e3181930249 · 7.19 Impact Factor
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    ABSTRACT: OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts. Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily. Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively. The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.
    Annals of Surgery 11/1994; 220(4):492-504; discussion 504-7. DOI:10.1097/00000658-199410000-00008 · 7.19 Impact Factor
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    ABSTRACT: The purpose of this study was to analyze the short-term outcome and to determine risk factors after distal pancreatectomy (DP). This prospective single-center study included 61 patients undergoing DP with splenic preservation in 6 (10%). The diagnoses included pancreatic adenocarcinoma (n = 9), neuroendocrine neoplasms (n = 17), benign neoplasm (n = 26), pseudocyst (n = 4), chronic pancreatitis (n = 2), and other diagnoses (n = 3). Twelve clinical factors were studied. The chi-square test was used for univariate analysis. The median duration of the postoperative hospital stay was 10 days (range, 5-155 days). Two patients (3%) died postoperatively; 12 patients (20%) had one or more intra-abdominal complications with reoperation necessary in 3 patients (5%): 6 pancreatic fistula (10%), 11 intra-abdominal collections (18%), 1 postoperative hemorrhage (2%). Univariate analysis showed that a body mass index >25 kg/m 2 was the only risk factor for intra-abdominal complication ( P = .003). DP is associated with an intra-abdominal morbidity rate of 20%, which is increased for patients with a body mass index >25 kg/m 2 .
    Surgery 03/2005; 137(2):180-5. DOI:10.1016/j.surg.2004.06.063 · 3.11 Impact Factor