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: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. We sought to evaluate the incidence of and identify risk factors for the development of PL in patients undergoing distal pancreatectomy (DP) at a single high-volume institution. All patients who underwent primary open DP (excluding completion pancreatectomy and debridement) between January 1, 1984 and July 1, 2006 were identified, and their medical records were reviewed. chi and multivariable logistic regression analyses were performed to identify risk factors for PL. In a cohort of 704 patients undergoing primary DP, the indications for DP were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and both stapled and sutured in 9% of cases. Ligation of the pancreatic duct was performed in 22% of cases. Perioperative mortality was <1%, but overall morbidity was 33%, most commonly PL (12% clinically significant, 21% biochemical). Multivariable logistic regression analysis revealed that neither the method of closure of the pancreatic remnant (P = 0.41) nor ligation of the pancreatic duct (P > 0.05) affected the risk of clinically significant PL. This largest reported series of DP demonstrates that this procedure can be performed with low mortality but still carries a substantial risk of morbidity, particularly PL. In contrast to some previous studies, this analysis found that surgical management of the pancreatic remnant has no effect on the incidence of clinically significant PL.
    Annals of surgery 08/2009; 250(2):277-81. DOI:10.1097/SLA.0b013e3181ae34be · 7.19 Impact Factor