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ABSTRACT: Cephalic duodenopancreatectomy (CDP) is the treatment of choice in cancer of the head of the pancreas. However, it continues to have a high post-surgical morbidity and mortality. The aim of this article is to define variables that influence post-surgical morbidity and mortality after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma (PA) cancer of the head of the pancreas (CHP).
The variables were prospectively collected form patients operated on between 1991 and 2007, in order to investigate the factors of higher morbidity.
A total of 204 patients had been intervened due to PA, of whom 57 were older than 70 years. Of these patients, 119 had a CPD, 11 extended lymphadenectomy, 66 with pyloric conservation, and 8 with extension to total pancreatectomy due to involvement of the section margin. Portal or mesenteric vein resection was included in 35 cases. Post-surgical complications were detected in 45% of cases, the most frequent being: slow gastric emptying (20%), surgical wound infection (17%), pancreatic fistula (10%), and serious medical complications (8%). Further surgery was required in 13%, and the over post-surgical mortality was 7%. A patient age greater than 70 years, post-surgical haemoperitoneum, gastroenteric dehiscence, and the presence of medical complications were post-surgical mortality risk factors in the multivariate analysis. Pancreatic fistula was not a factor associated with post-surgical mortality.
Cephalic duodenopancreatectomy is a safe technique but with a considerable morbidity. Patients over 70 years of age must be carefully selected before considering surgery. Serious medical complications must be treated aggressively to avoid an unfavourable progression.
Cirugía Española 11/2010; 88(5):299-307. · 0.87 Impact Factor
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Juan Fabregat,
Juli Busquets,
Núria Peláez, Rosa Jorba,
Francisco García-Borobia,
Cristina Masuet,
Carlos Valls,
Sandra Ruiz-Osuna,
Teresa Serrano,
Maica Galán,
María Cambray,
Berta Laquente,
Emilio Ramos,
Antoni Rafecas
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ABSTRACT: Surgery is the accepted treatment in adenocarcinoma of the head of the pancreas; however, the long-term survival continues to be low. The aim of this study is to define prognostic factors of long-term survival after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma.
We have collected data on the treatment of adenocarcinoma of the head of the pancreas (ADHP) by means of a cephalic duodenopancreatectomy (CDP) performed n the Bellvitge University Hospital (Barcelona) from 1991 to 2007.
A total of 204 CDP due to ADHP were performed. The histology showed that the resected tumour was larger than 3cms in 70 cases, with lymphatic infiltration in 73%, perineural invasion in 89%, and lymphatic involvement in 89%. More than 15 lymph nodes were resected in 120 patients. A total of 113 (60%) patients received adjuvant treatment after surgery. There were 148 (73%) deaths, of which 55 (27%) were alive at closure. The actual mean survival was 2.54 years (95% CI; 2.02-3.07) and an actuarial survival at 5 years of 13.55% (95% CI; 7.69-19.41). The study of mortality risk factors showed that, female gender, absence of peri-operative transfusion (p=0.003), the resection of more than 15 lymph nodes during the operation (P=0.004), and the administration of adjuvant treatment (p=0.004) had a better long-term prognosis. The multivariate analysis showed that transfusion and gender were the most significant variables.
Surgery of head of the pancreas adenocarcinoma must include an adequate lymphadectomy, and must be performed with a low morbidity and without the need of a peri-operative transfusion.
Cirugía Española 10/2010; 88(6):374-82. · 0.87 Impact Factor
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ABSTRACT: Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS). RESULTS: The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23). Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). CONCLUSIONS: Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.
Cirugía Española 06/2010; 87(6):364-71. · 0.87 Impact Factor
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ABSTRACT: To compare the postoperative results of various preservative surgery (PS) techniques with those of two types of pancreatoduodenectomy (PD).
The subjects of this study were 65 patients treated surgically for chronic pancreatitis, or benign or borderline tumors. We defined PS as any of the following: duodenum-preserving pancreatic head resection (DPPHR), uncinatectomy (UC), and cystic tumor enucleation (EN). The two types of PD were Whipple pancreatoduodenectomy (WPD) and pylorus-preserving pancreatoduodenectomy (PPPD).
Benign lesions were treated with PD in 41 patients and PS in 24 patients. Whipple pancreatoduodenectomy was performed in 17 patients, PPPD in 24, DPPHR in 20, EN in 3, and UC in 1. The main indication for surgery was chronic pancreatitis (66%). Delayed gastric emptying (DGE) was seen in 41% of patients in the PD group but none in the PS group (P = 0.04). However, there were no differences between the two groups in the incidence of pancreatic fistulas or other complications. Reoperation was required in five of the PD patients, but none of the PS patients.
Surgical techniques for preserving pancreatic tissue are effective for carefully selected patients with benign pancreatic disorders.
Surgery Today 01/2010; 40(2):125-31. · 1.22 Impact Factor
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ABSTRACT: Management of the cystic lesions of the pancreas is of interest to general and pancreatic surgeons and physicians of other disciplines: gastroenterology, internal medicine, endoscopy, radiology, pathology, etc. The majority of cystic lesions are inflammatory pseudo-cysts. Cystic neoplasms represents only 10% of cystic lesions of the pancreas and 1% of pancreatic tumours. Preoperative diagnosis is crucial given the differences in natural history of the spectrum of benign, malignant, and borderline lesions. Serous cystadenoma is a benign lesion that requires non-surgical management if there are no symptoms. Mucinous neoplasms are premalignant lesions that mainly require pancreatic resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the resection sample. The pancreatic surgical risk is a problem for the appropriate management of these patients.
Cirugía Española 01/2009; 84(6):296-306. · 0.87 Impact Factor
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ABSTRACT: The reported prevalence rate of bile duct cysts is very low. However, the clinical presentation of bile duct cysts is common to other hepatobiliary diseases. In this article, we report on a series of patients who have been surgically treated over the last 15 years.
All the patients who had undergone bile duct cyst-related surgery at this hospital had their clinical history reviewed retrospectively from 1990 to 2002. Data were obtained prospectively from 2002 to 2005. The following variables were taken into account in our analysis: diagnosis data, surgical procedure, morbidity, post-surgery mortality rates, and follow-up.
Over the last 15 years, 18 patients have undergone surgery at our hospital (6 male, 12 female). The most common clinical presentation was that of abdominal pain and the usual symptoms associated with acute cholangitis. As for surgical procedure, a complete cyst resection with biliary derivation was performed in all 15 cases. The histopathological diagnosis was choledochal cyst in 12 cases, Caroli's disease in 5 cases and a malignant choledochal cyst (adenocarcinoma) in 1 case. The most frequent post-surgical complication was bile leak (3 cases, 16.6%). There was no post-surgical mortality (0%). There were no relapses in the subsequent follow-up
Our preferred surgical procedure is that of complete cyst resection with biliary derivation. Our overall results are similar to those of medical teams who practise a radical resective procedure, and better than those who practise partial resections.
Cirugía Española 12/2008; 84(5):256-61. · 0.87 Impact Factor
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ABSTRACT: Introducción El diagnóstico de las lesiones quísticas del páncreas ha ido en aumento, de forma que en algunos centros la proporción de resecciones pancreáticas por neoplasias quísticas del páncreas ha pasado del 16 al 30% 1 . Este aumento de la frecuencia puede atribuirse a varias razo-nes, como el aumento de la longevidad y la calidad de vida de los pacientes, la mejor resolución de las técnicas diagnósticas de imagen o el mejor conocimiento por ra-diólogos, clínicos y patólogos de este tipo de lesiones. Además, la mejoría de los resultados de la cirugía pan-creática en centros especializados probablemente haya comportado un aumento de las indicaciones quirúrgicas. El diagnóstico y el manejo de estas lesiones son com-plejos, incluso para especialistas de centros de referencia./n. 08907 L'Hospitalet de Llobregat. Barcelona. España. Correo electrónico: rjorba@csub.scs.es Manuscrito recibido el 29-11-2007 y aceptado el 16-7-2008. Resumen El manejo de las lesiones quísticas del páncreas in-teresa tanto al cirujano general y pancreático como a los especialistas en otras disciplinas: gastroenterolo-gía, medicina interna, endoscopia, radiología, anatomía patológica, etc. La mayoría de estas lesiones son seu-doquistes inflamatorios. Las neoplasias quísticas su-ponen sólo un 10% del total de las lesiones quísticas del páncreas y un 1% de los tumores pancreáticos. El diagnóstico preoperatorio es crucial, dadas las diferencias en la historia natural del espectro de las lesiones: benignas, malignas y borderline. El cistadenoma seroso es una lesión benigna que no precisa resección quirúrgica, salvo cuando es sin-tomática. Las neoplasias mucinosas son lesiones premalignas que requieren mayoritariamente resec-ción pancreática. A pesar de los avances en las técnicas de imagen, el diagnóstico definitivo se establece únicamente tras el estudio histológico de la pieza de resección. El riesgo que comporta la cirugía pancreática es un problema asociado al manejo apropiado de estos pa-cientes. Palabras clave: Neoplasia quística del páncreas. Re-sección pancreática. Cistadenoma seroso. Neoplasia quística mucinosa. Neoplasia intraductal papilar mucinosa. Tumor sólido seudopapilar.
Cir Esp. 10/2008;
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Emilio Ramos,
Laura Martínez,
Cristina Gámez,
Jaume Torras,
Carles Valls,
Antoni Rafecas,
Laura Lladó, Rosa Jorba,
Sandra Ruiz,
Teresa Serrano,
Joan Fabregat
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ABSTRACT: Unsuspected intrahepatic and extrahepatic metastases are frequently discovered at laparotomy in patients with resectable colorectal liver metastases (CLM), and 60% of these patients will develop a recurrent tumour within 3 years, after a "curative" liver resection. These findings strongly support the need for more effective preoperative staging. The combined positron emission tomography-computed tomography technique (PET-CT) has emerged as a promising diagnostic modality for determining whether patients with recurrent disease in the liver are suitable candidates for curative resection.
The aim of this study was to assess the additional value of information provided by PET-CT compared to that of conventional radiological studies (CT and MR) in patients with resectable CLM.
Between June 2006 and August 2007, 63 patients evaluated for a first resection of CLM were entered into a prospective database. Each patient received a CT-MR and a PET-CT. Forty-three patients underwent a laparotomy and 42 a hepatectomy. The main end point of the study was to assess the impact of the PET-CT findings on the therapeutic strategy.
New findings in the PET-CT resulted in a change in the therapeutic strategy in 9 (14%) of the patients. However, PET-CT provided additional information was true positive by revealing abdominal extrahepatic metastases only in 4 (6.4%) patients, and falsely over-staged four patients and under staged one patient. Lesion-by-lesion sensitivity and predictive positive value for liver lesions were 78,4% and 96% for CT-MR alone, and 55% and 100% for PET-CT respectively. PET-CT was superior to CT-MR for the detection of local recurrence at the site of the initial colorectal surgery.
In the selection of patients with CLM being considered for surgical therapy, PET-CT provided useful information only in 6.4% of cases. Possibly longer follow-up will increase this percentage. Our findings support the use of PET-CT mainly in patients with high risk of local recurrence.
Cirugía Española 09/2008; 84(2):71-7. · 0.87 Impact Factor
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ABSTRACT: The objective of the study is to review our experience in the surgical treatment of Klatskin tumours, after the systematic application of the current concepts of radicalism. Sixty-one patients resected using these criteria are presented.
We have studied 154 patients. Surgery was ruled out in 59 (41%) of them, and a liver transplant was performed on 9; of the 86 patients operated on, 25 were resectable. Resectability was 71% (of the 86 patients operated on) and was 39% of the total patients. The results during two periods are compared, 1989-1998 (pre-99) and 1999-2007 (post-99).
On comparing the two periods, resectability increased from 26% to 53% (p = 0.01), the percentage of exploratory laparotomies decreasing (pre: 45% vs post: 22%; p = 0.04). Hepatectomy was performed in 53 cases (87%), being most frequent post-99 (pre: 66% vs post: 91%; p = 0.02). Resection of the caudate was performed in 48 cases (90%), being most frequent in the post-99 period (pre: 40% vs pos: 89%; p = 0.005). Post-operative morbidity was 77%, with 28% the patients being re-operated on, and the post-operative mortality was 16.4%, with no significant differences between the periods. Actuarial survival at 5 years increases in the post-99 period (pre: 26% vs post: 51%; p = 0.06).
Adequate staging, associated with an aggressive surgical strategy can achieve a greater than 50% resectability rate. The post-operative morbidity and mortality of this strategy is high, but the survival that it achieves justifies this.
Cirugía Española 04/2008; 83(3):139-44. · 0.87 Impact Factor
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ABSTRACT: Surgery that preserves the duodenopancreatic region has become well-established in chronic pancreatitis (CP) and some groups have begun to use these techniques to treat benign tumors and even those with uncertain potential malignancy. However, the technical complexity of this type of intervention may be greater than that of cephalic duodenopancreatectomy and complications may be even more frequent and consequently the indications for these procedures are debated. The aim of this study was to evaluate the experience accumulated at our center over the past few years in the use of pancreatic surgery preserving the duodenopancreatic region (PS). MATERIAL AND METHODS. Between 1996 and 2006, we carried out PS in 24 patients with disease localized in the head of the pancreas. PS was defined as any of the following techniques: resection of the head of the pancreas with duodenal preservation (RHPDP), uncinatectomy (UC) and cystic tumor enucleation (EN).
RHPDP was performed in 20 patients (83%), UC in 1 (4%) and EN in 3 (13%). Surgery was performed for CP in 11 patients, serous cystoadenoma in 4, intraductal papillary mucinous tumor in 5 and miscellaneous injuries in the four remaining patients. Overall, the series showed 54% morbidity with no post-operative mortality. The median length of postoperative hospital stay was 11 days (7-43).
After analyzing the experience accumulated over the years, showing nil mortality and acceptable morbidity, we believe that the use of these 3 techniques for preserving the pancreatic parenchyma is useful when their suitability is rigorously indicated. Subsequent studies should look in depth at improving quality of life and physiological effects, depending on the technique used.
Cirugía Española 09/2007; 82(2):105-11. · 0.87 Impact Factor
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ABSTRACT: Splanchnic thrombosis is a surgical challenge in liver transplantation (LT). The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution.
The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution.
Between 1999 and 2004, 366 liver transplants were performed in 335 patients. Forty-two patients [12.5%: portal vein thrombosis (PVT) group] had portal thrombosis at the time of LT. We analyzed the technical aspects and compared their evolution with a group of patients without portal thrombosis (n = 293; no-PVT group). Retransplantations were excluded.
Of the 42 patients with thrombosis, 18 had partial thrombosis and 16 complete thrombosis [six included the proximal superior mesenteric vein (SMV) and in two the whole splanchnic system]. In 12 cases, usual T-T anastomosis was performed and in 16 cases a thrombectomy was carried out; there were five cases of anastomosis at confluence of the SMV, five cases of anastomosis to a collateral vein, three cases of venous graft, and one case of cavoportal hemitransposition. The operative time was higher in PVT group (417 +/- 103 min vs. 363 +/- 83; p = 0.0005), as RBC transfusion (2.4 +/- 3.1 vs. 1.9 +/- 2.3; p = 0.04), and hospital stay (20.9 +/- 14.9 d vs. 15.1 +/- 10.6; p = 0.002). However, there were no differences in hospital mortality (4% vs. 7.8%; p = 0.98), primary dysfunction (4.8% vs. 7.8%; p = 0.44), or three-yr-actuarial survival (75% vs. 77%; p = 0.95). The incidence of post-transplant thrombosis was higher in the PVT group (15% vs. 2.4%; p = 0.0005).
Portal thrombosis is associated with greater operative complexity and rethrombosis, but has no influence on overall morbidity and mortality.
Clinical Transplantation 06/2007; 21(6):716-21. · 1.67 Impact Factor
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ABSTRACT: The aim of our study was to prospectively evaluate the accuracy of dual-phase helical CT in the preoperative assessment of resectability in patients with suspected pancreatic cancer using surgical and histopathologic correlation.
Between January 1999 and December 2000, 76 patients with suspected pancreatic cancer underwent preoperative evaluation and staging with dual-phase helical CT (3-mm collimation for pancreatic phase, 5-mm collimation for portal phase). Iodinated contrast material was injected IV (170 mL at a rate of 4 mL/sec); acquisition began at 40 sec during the pancreatic phase and at 70 sec during the portal phase. Three radiologists prospectively evaluated the imaging findings to determine the presence of pancreatic tumor and signs of unresectability (liver metastasis, vascular encasement, or regional lymph nodes metastasis). The degree of tumor-vessel contiguity was recorded for each patient (no contiguity with tumor, contiguity of < 50%, or contiguity of > or =50%).
Thirty-nine patients with pancreatic adenocarcinoma were surgically explored. Curative resections were attempted in 34 patients and were successful in 25. The positive predictive value for resectability was 73.5%. Nine patients considered resectable on the basis of CT findings were found to be unresectable at surgery because of liver metastasis (n = 5), vascular encasement (n = 2), or lymph node metastasis (n = 2). We found that the overall accuracy of helical CT as a tool for determining whether a pancreatic adenocarcinoma was resectable was 77% (30/39 patients).
Dual-phase helical CT is a useful technique for preoperative staging of pancreatic cancer. The main limitation of CT is that it may not reveal small hepatic metastases.
American Journal of Roentgenology 04/2002; 178(4):821-6. · 2.78 Impact Factor
