Francisco J. Morera-Ocón

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

Objective: To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. Background: EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. Methods: Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. Results: These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. Conclusions: EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Invaginación intestinal en el adulto: presentación de un caso y revisión de la literatura médica española

INTRODUCTION Intestinal invagination in the adult is an uncommon condition, often manifested by non-specific chronic or sub-acute symptoms. In the majority of occasions there is an organic lesion. There are currently no large patient series published in the literature to help define the management of these patients. MATERIAL AND METHOD A review of case series published in the Spanish literature. A data base of patients over 15 years old was designed. Data was extracted from national clinical cases using Internet resources. Our own recent clinical case is added. RESULTS A series of 30 adults with intestinal invagination was obtained (29 cases from the review and one own). The median age was 45 years (19-84 years) and 17/30 (57%) were males. A total of 27/30 patients had abdominal pain and 8/30 (28%) cases had established intestinal obstruction. The preoperative diagnosis of invagination was made in 25/30 (83%) of patients. The invaginations were; enteroenteric, 61%; colocolic, 12%; enterocolic, 21%; and gastrojejunal, 6%. A total of 85% of the invaginations were associated with a proliferative lesion and 43% of the latter were malignant. CONCLUSIONS The diagnosis of invagination in the adult is usually made preoperatively. There are no data to support intestinal resection without performing a reduction. Resection must be the norm and the presence of lymph nodes is no argument to perform large resections.

Considerations on pancreatic exocrine function after pancreaticoduodenectomy

The pancreaticoduodenectomy (PD) procedure may lead to pancreatic exocrine and endocrine insufficiency. There are several types of reconstruction for this kind of operation. Pancreaticogastrostomy (PG) was introduced to reduce the rate of postoperative pancreatic fistula. Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy (PJ), recently some reports reveal benefits from the PG over the PJ. Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice, and the detrimental results over the exocrine pancreatic function. The pancreatic exocrine function can be measured with direct and indirect tests. Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement. Among the tubeless indirect tests, the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption. The patient compliance and time consuming makes it not so suitable for its clinical use. Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency, is not cumbersome, and has been used to study pancreatic function after resection. We analyze the FE1 levels in our patients after the PD with two types of reconstruction, PG and PJ, and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.

Implicaciones pronósticas del estudio estandarizado de los márgenes de resección en el cáncer de páncreas

INTRODUCTION Involvement of surgical resection margins is a fundamental prognostic factor in pancreatic oncological surgery. However, there is a lack of standardized histopathology definition. The aims of this study are to investigate the real rate of R1 resections when surgical specimens are evaluated according to a standardized protocol and to study its survival implications. PATIENTS Y METHODS One hundred consecutive surgically resected patients with pancreatic ductal adenocarcinoma were included in the study. They were further divided in 2 groups: pre-protocol, evaluated before the introduction of the standardized protocol and post-protocol, analyzed with the standardized protocol. RESULTS R0 resection rate in the pre-protocol group was 78%, falling to 47% after the introduction of the standardized protocol (p=0,003). The posterior retroperitoneal margin was the most frequently involved margin. In cases with tumors located at the pancreatic head and analyzed according to the standardized protocol R1 involvement negatively affected survival. Median survival in the R0 group was 22 months versus 16 in those with the margin involved (HR: 2.044; IC 95% 1,00-4,16; P=.043). CONCLUSIONS Standardized evaluation of the retroperitoneal margins in pancreatic cancer increases the rate of R1 patients. In cases with pancreatic cancer located at the pancreatic head involvement of posterior retroperitoneal margin significantly decreases survival.

Intestinal invagination in adults: Presentation of a case and a review of the Spanish literature

Abstract Introduction Intestinal invagination in the adult is an uncommon condition, often manifested by non-specific chronic or sub-acute symptoms. In the majority of occasions there is an organic lesion. There are currently no large patient series published in the literature to help define the management of these patients. Material and method A review of case series published in the Spanish literature. A data base of patients over 15 years old was designed. Data was extracted from national clinical cases using Internet resources. Our own recent clinical case is added. Results A series of 30 adults with intestinal invagination was obtained (29 cases from the review and 1 own). The median age was 45 years (19–84 years) and 17/30 (57%) were males. A total of 27/30 patients had abdominal pain and 8/30 (28%) cases had established intestinal obstruction. The preoperative diagnosis of invagination was made in 25/30 (83%) of patients. The invaginations were; enteroenteric, 61%; colocolic, 12%; enterocolic, 21%; and gastrojejunal, 6%. A total of 85% of the invaginations were associated with a proliferative lesion and 43% of the latter were malignant. Conclusions The diagnosis of invagination in the adult is usually made preoperatively. There are no data to support intestinal resection without performing a reduction. Resection must be the norm and the presence of lymph nodes is no argument to perform large resections.

Indicaciones quirúrgicas en los pólipos de vesícula biliar

INTRODUCTION The surgery of gallbladder polyps is not well defined due to the lack of evidence-based clinical guidelines. OBJECTIVE To analyse the management of polyps in Spain, and a review of the literature and treatment standards. MATERIAL AND METHODS The reports on cholecystectomy with gallbladder polyps (GBP) were extracted from the Pathology data base. Patients subjected to surgery with a diagnosis of GBP were identified in the Surgery data base. A single list was prepared and a review was made of the clinical histories, including, age, gender, clinical data, ultrasound report, and histopathology report. RESULTS A total of 30 patients, with a median age of 51 years (range 22-83), 21 of whom were female, were included. The ultrasound diagnosis was GBP in 19 patients, GBP and calculi in 7 cases, and calculi with no polyps in 4 cases. Other diagnoses concurrent with GBP were multiple haemangiomas (3), large single simple cyst (1), and multiple simple cysts (1). Eleven patients had typical pain (biliary origin), 5 of which showed no calculi on ultrasound. Eight had non-specific pain, which persisted in 3 cases after the cholecystectomy. Pseudopolyps were found in 20 gallbladders, and true polyps in 4 cases. In 3 cases, polyps were not found in the pathology study. CONCLUSIONS The ultrasound report must specify the size, shape, and number of polyps. Patients with biliary type pain would benefit from a cholecystectomy. The probability of malignancy is minimum if the GBP is less than 10mm and aged under 50 years, and a cholecystectomy is not required. A GBP greater than 10mm should be an indication of cholecystectomy.

Síndrome del ducto pancreático desconectado: transección completa del páncreas secundaria a pancreatitis aguda

Disconnected pancreatic duct syndrome is a serious complication of acute pancreatitis which is defined by a complete discontinuity of the pancreatic duct, such that a viable side of the pancreas remains isolated from the gastrointestinal tract. This pancreatic disruption is infrequently observed in the clinical practice and its diagnostic and therapeutic management are controversial. We present an extreme case of disconnected pancreatic duct syndrome with complete duct disruption and pancreatic transection following acute pancreatitis, as well as the diagnostic and therapeutic processes carried out.

Sobre la experiencia fast-track en la duodenopancreatectomía cefálica

Hay que felicitar a los autores del artı́culo sobre fast-track en la duodenopancreatectomı́a cefálica por los resultados quirúrgicos obtenidos. La lectura del trabajo plantea una serie de consideraciones que quizá los autores podrı́an puntualizar. Según describen en «Pacientes y método», su grupo está empleando neoadyuvancia con quimiorradioterapia en todos los casos de adenocarcinoma. ? Todos los pacientes tienen una biopsia preoperatoria positiva? ? La ecoendoscopia es el método empleado para obtener dicha biopsia? Para definir una fı́stula pancreática, al no dejar drenaje abdominal, ? realizan ecografı́a/TC y punción a todos los pacientes en el postoperatorio? Refieren que en algunos pacientes de su serie realizaron resecciones hepáticas, la mayorı́a por metástasis. ? La presencia demetástasis de adenocarcinoma pancreático no es un criterio de irresecabilidad para su grupo? En cuanto a los diagnósticos de la duodenopancreatectomı́a cefálica de la serie presentada, llama la atención la presencia de un tumor de la estroma gastrointestinal (GIST). ? Era pancreático? Encontramos muy pocos casos de GIST pancreáticos descritos en la literatura, y añadir otro caso serı́a interesante para aumentar la experiencia sobre este tipo de tumores.

Controversias en la cirugía del cáncer de páncreas

Hay que felicitar a Fabregat et al por su trabajo sobre el adenocarcinoma pancreático, siendo un centro de referencia nacional. Nos gustarı́a plantear algunas cuestiones: La irresecabilidad ante invasión arterial, ? es por criterio técnico u oncológico? Si la resección ante invasión portomesentérica o arterial esplénica está aceptada, el oncológico no será el argumento. Los autores definen invasión arterial como la presencia de contacto directo entre tumor y vaso arterial. Frecuentemente la sospecha de invasión arterial se desmiente en la histologı́a ? Cuál es el criterio de no resección, la invasión arterial o su posible atrapamiento? ? Linfadenectomı́a curativa o pronóstica? Los autores practican una linfadenectomı́a radical (según Yeo et al), y sugieren que aumentando las adenopatı́as resecadas aumentará la supervivencia, pero no resecan cuando el estudio intraoperatorio de adenopatı́as preaortocava resulta positivo. La resección es mejor paliación que la derivación; la contraindicación de resección ante adenopatı́as preaortocava positivas es controvertida, entonces ? por qué no resecar nunca? En sus conclusiones hacen hincapié en la conveniencia de alcanzar 20 o más resecciones por año para ser considerado centro capacitado. Su serie es de 12, con resultados excelentes. En un estudio multicéntrico de 25 grupos reputados ningún centro participante alcanzó más de 20 resecciones/año, 5 realizaron más de 5, y 20 cinco o menos. Según Brennan el 93% de los hospitales americanos tendrı́an que dejar de operar estos pacientes si se cumpliera el dintel impuesto.

What guidelines tell us about acute pancreatitis. A review of the last international guidelines

BackgroundSince the Atlanta Symposium several guidelines and consensus conferences have been published to improve the management and understanding of patients with acute pancreatitis. Herein, a review of the most recent guidelines on acute pancreatitis is carried out, trying to find differences and similarities.MethodsFive of the last international guidelines on acute pancreatitis as well as the last consensus conference are critically reviewed.ConclusionsThere is more consensus than disagreement between guidelines, which is why the knowledge of them is of great importance when treating AP.