Ismael Domínguez

Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients.

Objective:Mucinous cystic neoplasms (MCNs) of the pancreas have often been confused with intraductal papillary mucinous neoplasms. We evaluated the clinicopathologic characteristics, prevalence of cancer, and prognosis of a large series of well-characterized MCNs in 2 tertiary centers. Methods:Analysis of 163 patients with resected MCNs, defined by the presence of ovarian stroma and lack of communication with the main pancreatic duct. Results:MCNs were seen mostly in women (95%) and in the distal pancreas (97%); 25% were incidentally discovered. Symptomatic patients typically had mild abdominal pain, but 9% presented with acute pancreatitis. One hundred eighteen patients (72%) had adenoma, 17 (10.5%) borderline tumors, 9 (5.5%) in situ carcinoma, and 19 (12%) invasive carcinoma. Patients with invasive carcinoma were significantly older than those with noninvasive neoplasms (55 vs. 44 years, P = 0.01). Findings associated with malignancy were presence of nodules (P = 0.0001) and diameter ≥60 mm (P = 0.0001). All neoplasms with cancer were either ≥40 mm in size or had nodules. There was no operative mortality and postoperative morbidity was 49%. Median follow-up was 57 months (range, 4–233); only patients with invasive carcinoma had recurrence. The 5-year disease-specific survival for noninvasive MCNs was 100%, and for those with invasive cancer, 57%. Conclusions:This series, the largest with MCNs defined by ovarian stroma, shows a prevalence of cancer of only 17.5%. Patients with invasive carcinoma are older, suggesting progression from adenoma to carcinoma. Although resection should be considered for all cases, in low-risk MCNs (≤4 cm/no nodules), nonradical resections are appropriate.

Mucin-Producing Neoplasms of the Pancreas: An Analysis of Distinguishing Clinical and Epidemiologic Characteristics

BACKGROUND & AIMS Mucin-producing neoplasms (MPNs) of the pancreas include mucinous cystic neoplasms (MCNs) and main-duct, branch-duct, and combined intraductal papillary mucinous neoplasms (IPMNs). MCNs and branch-duct IPMNs are frequently confused; it is unclear whether main-duct, combined, and branch-duct IPMNs are a different spectrum of the same disease. We evaluated their clinical and epidemiologic characteristics. METHODS Patients who underwent resection for histologically confirmed MPNs were identified (N = 557); specimens were reviewed and eventually reclassified. RESULTS One hundred sixty-eight patients (30%) had MCNs, 159 (28.5%) had branch-duct IPMNs, 149 (27%) had combined IPMNs, and 81 (14.5%) had main-duct IPMNs. Patients with MCNs were significantly younger and almost exclusively women; 44% of patients with main-duct or combined IPMNs and 57% of those with branch-duct IPMNs were women. MCNs were single lesions located in the distal pancreas (95%); 11% were invasive. IPMNs were more frequently found in the proximal pancreas; invasive cancer was found in 11%, 42%, and 48% of branch-duct, combined, and main-duct IPMNs, respectively (P = .001). Patients with invasive MCN and those with combined and main-duct IPMNs were older than those with noninvasive tumors. The 5-year disease-specific survival rate approached 100% for patients with noninvasive MPNs. The rates for those with invasive cancer were 58%, 56%, 51%, and 64% for invasive MCNs, branch-duct IPMNs, main-duct IPMNs, and combined IPMNs, respectively. CONCLUSIONS MPNs comprise 3 different neoplasms: MCNs, branch-duct IPMNs, and main-duct IPMNs, including the combined type. These tumors have specific clinical, epidemiologic, and morphologic features that allow a reasonable degree of accuracy in preoperative diagnosis.

Implications and Management of Pancreatic Fistulas Following Pancreaticoduodenectomy: The Massachusetts General Hospital Experience

OBJECTIVE To describe the management and impact of pancreatic fistulas in a high-volume center. DESIGN Retrospective case series. SETTING Tertiary academic center. PATIENTS Five hundred eighty-one consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006. MAIN OUTCOME MEASURES Development of a pancreatic fistula (defined as > 30 mL of amylase-rich fluid from drains on or after postoperative day 7, or discharge with surgical drains in place, regardless of amount); the need for additional interventions or total parenteral nutrition; other morbidity; and mortality. RESULTS Seventy-five patients (12.9%) developed a pancreatic fistula. Fistulas were managed with gradual withdrawal of surgical drains. This allowed for patient discharge and eventual closure at a mean of 18 days in 38.7% of cases; these were classified as low-impact fistulas. The remaining 46 patients (61.3%) had an associated abscess, required percutaneous drainage or total parenteral nutrition, or developed bleeding; these were classified as high-impact fistulas and closed a mean of 35 days after surgery. Standard 30-day in-hospital mortality was 1.9% for all pancreaticoduodenectomies and 6.7% for those who developed a pancreatic fistula. The overall fistula-related mortality was 9.3% (7 patients), all but 1 of which was related to major hemorrhage. CONCLUSIONS More than one-third of pancreatic fistulas are clinically insignificant (low impact). The remaining 60% of fistulas have a high clinical impact and nearly an 8-fold increase in overall mortality.

Long-term evaluation of biliary reconstruction after partial resection of segments IV and V in iatrogenic injuries.

Roux-en-Y hepatojejunostomy is the procedure of choice for biliary reconstruction after complex iatrogenic injury that is usually associated with vascular injuries and concomitant ischemia of the ducts. To avoid the ischemic component, our group routinely performs a high repair to assure an anastomosis in noninflamed, nonscarred, and nonischemic ducts. If the duct bifurcation is preserved, the Hepp-Couinaud approach for reconstruction is an excellent choice. Partial liver resection of segments IV and V allows adequate exposure of the bile duct at its bifurcation with an anterior approach of the ducts (therefore not jeopardizing the circulation), allowing a high quality anastomosis. Long-term results of bile duct reconstruction using this approach are described. Two hundred eighty-five bile duct reconstructions were done between 1989 and 2004 in a tertiary care university hospital. The first partial-segment IV resection was done in 1994; 94 cases have been reconstructed since then using this approach. All of them had a complex injury (Strasberg E1-E5), and although in many cases the bifurcation was preserved (E1-E3), a high bilioenteric anastomosis was done to facilitate the reconstruction. In 70 cases, the bifurcation was identified, and in the 24 in which the confluence was not preserved, the right and left ducts were found except in one case. In three patients, the right duct was found unsuitable for anastomosis, and a liver resection was done. In the remaining 21, an anastomosis was done using a stent (transhepatic, transanastomotic) through the right duct. According to Lillemoe’s criteria, 86 cases had good results (91%). In four of the eight remaining patients, there was the need to operate again due to the presence of an obstruction and/or cholangitis. In the rest, radiological instrumentation was done. Four of these cases have developed secondary biliary cirrhosis, two of which have died while waiting for a liver transplant, four and six years after reconstruction. Partial segments IV and V resection allows adequate exposure of the confluence and the isolated left or right hepatic ducts. Anterior exposure of the ducts allows an anastomosis in well-preserved, nonischemic, nonscarred, or noninflamed ducts. Parenchyma removal also allows the free placement of the jejunal limb, without external compression and tension, obtaining a high quality anastomosis with excellent long-term results.

Transition from a low- to a high-volume centre for bile duct repair: changes in technique and improved outcome

BACKGROUND Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City. METHODS A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken. RESULTS Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group. CONCLUSIONS Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.

967 Main-Duct and Combined IPMNs Are the Same Clinical Entity and Distinct from Branch-Duct IPMNs

G A A b st ra ct s reported abdominal complaints as opposed to 7.6% of those without PC(s) (p = 0.589). None of the individuals with PC(s) had pancreatic disease in their medical history. Conclusion: In individuals undergoing preventive medical examination with MRI, the prevalence of PCs was 2.2%. Of these PCs, 5.3% were ≥30 mm, 8% were multilocular and in 10% of cases may represent side-branch IPMN. Cyst presence correlated with increasing age, no difference of prevalence by sex was found. Abdominal complaints did not correlate with PC presence.