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BACKGROUND: Mucinous cysts of the pancreas (MCN) are infrequent, usually unilocular tumors which occur in postmenopausal women and are located in the pancreatic body/tail. The risk of malignancy is low. The objective is to define preoperative risk factors of malignancy in pancreatic MCN and to assess the feasibility of the laparoscopic approach. METHODS: Retrospective multicenter observational study of prospectively recorded data regarding distal pancreatectomies was carried out at seven hepatopancreatobiliary (HPB) Units between 01/01/08 and 31/12/18 (the ERPANDIS Project). RESULTS: Four hundred and forty-four distal pancreatectomies were recorded including 47 MCN (10.6%). Thirty-five were non-invasive tumors (74.5%). In all, 93% of patients were female, and 60% were ASA (American Society of Anaesthesiology) II. The mean preoperative size was 46 mm. Patients with invasive tumors were older (54 vs. 63 years). Invasive tumors were larger (6 vs. 4 cm), although the difference was not significant (P=0.287). Sixty percent was operated via laparoscopic approach, which was used in 74.6% of non-invasive tumors and in 16.7% of the invasive ones. The spleen was not preserved in 93.6% of the patients. R0 resection was obtained in all patients. Two patients with invasive tumors died. CONCLUSIONS: In our surgical series of MCN, patients with malignancy were older and presented larger tumors, although the difference was not statistically significant. Laparoscopy is a safe and feasible approach for MCN. Prospective studies are now needed to define risk factors that can guide the decision whether to administer conservative treatment or to operate.

fifty to 70 percent of pancreatic neuroendocrine tumors are diagnosed incidentally. The objective of this study was to compare the phenotype and oncological outcomes of incidental versus symptomatic pancreatic neuroendocrine tumors.a retrospective study was performed, identifying all incidental and symptomatic tumors resected between 2000 and 2019. Baseline characteristics, symptoms, operative variables and pathological stage were all recorded. Patterns of recurrence and overall and disease-free survival were analyzed in both groups.fifty-one incidental and 45 symptomatic pancreatic tumor resections were performed. Symptomatic tumors were more frequent in females (29 vs 17; p = 0.005) and younger patients (median years; 50 vs 58; p = 0.012) and were detected at a more advanced stage (p = 0.027). There were no differences in location and most resections (n = 49; 51 %) were performed laparoscopically. There were no operative mortalities and 17 (17.7 %) severe complications (≥ IIIb on the Clavien-Dindo classification) were recorded with no differences between the two groups. With a median follow-up of 64.4 months (range 13.5-90), overall survival at five and ten years was 89.7 % and 72.8 % for the non-incidental tumors and 80.9 % and 54.6 % for the incidental tumors (p = ns), respectively. Disease-free survival in both groups (excluding M1a) was 71.2 % and 47.5 %, and 93.7 % and 78.1 %, respectively (p = ns).symptomatic tumors are more frequent in females and present at more advanced pathological stages. There were no significant differences in overall and disease-free survival between the two groups. Resection of incidental tumors ≥ 1.5-2 cm seems advisable, although each case should be assessed on an individual basis.

Ampuero J et al. analyzed the relationship between liver injury and clinical progression of the disease in a meta-analysis of over 5,000 COVID-19 patients. The authors reported an association between increased aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin levels with mortality, admission to Intensive Care and the development of complications, respectively.

Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue.A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated.After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

COVID-19 is associated with severe coagulopathy. We present three cases of colonic ischemia that can be attributed to the hypercoagulable state related with SARS-CoV2 and disseminated intravascular coagulation. Three males aged 76, 68 and 56 with respiratory distress presented episodes of rectal bleeding, abdominal distension and signs of peritoneal irritation. Endoscopy (case 1) and computed tomography angiography revealed colonic ischemia. One patient (case 2) in which a computed tomography (CT) scan showed perforation of the gangrenous cecum underwent surgery. D-dimer levels were markedly increased (2,170, 2,100 and 7,360 ng/ml) in all three patients. All three patients died shortly after diagnosis.

Background Multivisceral resection (MVR) is sometimes necessary to achieve disease-free margins in cancer surgery. In certain patients with pancreatic tumors that invade neighboring organs these must be removed to perform an appropriate oncological surgery. In addition, there is an increasing need to perform resections of other organs like liver not directly invaded by the tumor but which require synchronous removal. The results of MVR in pancreatic surgery are controversial. Material and methods A distal pancreatectomy retrospective multicenter observational study using prospectively compiled data carried out at seven HPB Units. The period study was January 2008 to December 2018. We excluded DP with celiac trunk resection. Results 435 DP were performed. In 62 (14.25%) an extra organ was resected (82 organs). Comparison of the preoperative data of MVR and non-MVR patients showed that patients with MVR had lower BMI, higher ASA and larger tumor size. In the MVR group, the approach was mostly laparotomic and spleen preservation was performed only in 8% of the cases, Blood loss and the percentage of intraoperative transfusion were higher in MVR group. Major morbidity rates (Clavien > IIIa) and mortality (0.8vs.4.8%) were higher in the MVR group. Pancreatic fistula rates were practically the same in both groups. Mean hospital stay was twice as long in the MVR group and the readmission rate was higher in the MVR group. Histology study confirmed a much higher rate of malignant tumors in MVR group. Conclusions In order to obtain free margins or treat pathologies in several organs we think that DP + MVR is a feasible technique in selected patients; the results obtained are not as good as those of DP without MVR but are acceptable nonetheless. Clinicaltrials.gov identifier NCT04317352.

Purpose Liver metastases are the most common malignant solid liver lesions, approximately 40% of which stem from colorectal tumors. Liver resection is currently the only curative treatment for colorectal cancer liver metastases (CRLM). However, there is a lack of consensus criteria to assess the results of this treatment. In order to evaluate the quality of surgical outcomes, it is necessary to identify quality indicators (QIs) and their corresponding quality standards (QS). We propose a simple method to determine QI and QS in CRLM surgery (CRLMS) and establish acceptable quality limits (AQL) for each QI. Material and methods A systematic review of CRLMS results published from 2006 to 2016. Clinical guidelines, consensus conferences, and publications related to the CRLMS were reviewed to identify and select QIs. Once selected, a new review of the papers including the results of at least one of the QIs was performed. Statistical process control (SPC) method was applied to calculate the QS and AQL of each QI. The limits of variability were established from mean and confidence intervals at 95% and 99.8%. Results The most relevant QIs and its AQLs were postoperative mortality (2%, < 4.5%), overall postoperative morbidity (33%, < 41%), liver failure (5%, < 8%), postoperative hemorrhage (1%, < 3%), biliary fistula (6%, < 10%), reoperation (3%, < 6%), R1 resection margins (18%, < 25%), and overall survival at 12 and 60 months (84%, > 77%; and 34%, > 25%, respectively). Conclusions Despite its limitations, the present study constitutes the most extensive scientific evidence to date on QI and AQL in CRLMS and may constitute a reference in future studies.

espanolIntroduccion: la trombosis portal (TP) es una complicacion relativamente frecuente de la cirrosis avanzada que aumenta el riesgo perioperatorio de los receptores de trasplante hepatico. La hemos caracterizado en una cohorte de pacientes, los factores de riesgo y su influencia sobre la supervivencia. Material y metodos: estudio retrospectivo de los receptores de trasplante hepatico en la Clinica Universidad de Navarra entre los anos 2000 y 2015. Se analizaron las diferencias clinicas y biologicas en sujetos con y sin trombosis portal, la supervivencia y el desarrollo de un indice predictivo. Resultados: se incluyeron un total de 288 pacientes. De ellos, se registro trombosis portal en 46 (16%), de los que siete (15,2%) presentaron estadios 3-4 de Yerdel. Se identificaron como factores asociados la presencia de varices esofagicas/gastricas (OR = 3,7; p = 0,03), la ligadura u escleroterapia de las mismas (OR = 2,3; p = 0,01), el sobrepeso/obesidad (OR = 2,1; p = 0,04) y la trombocitopenia (OR = 3,6; p = 0,04). En el analisis de supervivencia mediante curvas de Kaplan-Meier no se encontraron diferencias significativas entre los grupos con y sin trombosis portal (p = 0,7), si bien la mortalidad fue superior en los estadios 3-4 de Yerdel (p EnglishIntroduction: portal vein thrombosis is a relatively common complication of advanced cirrhosis that increases perioperative risk in liver transplant recipients. This condition was characterized in a cohort of patients, including risk factors and their influence on survival. Material and methods: a retrospective study of liver transplant recipients at the Clinica Universidad de Navarra was performed between 2000 and 2015. Differences in clinical and biological characteristics and survival were analyzed in subjects with and without portal vein thrombosis. A predictive index was also developed. Results: a total of 288 patients were included in the study, portal vein thrombosis was recorded in 46 (16%) cases and seven (15.2%) had stage 3/4 disease according to Yerdel’s classification. Factors associated with the presence of esophageal/gastric varices (OR = 3.7; p = 0.03) included variceal ligation or sclerotherapy (OR = 2.3; p = 0.01), being overweight/obesity (OR = 2.1; p = 0.04) and thrombocytopenia (OR = 3.6; p = 0.04). There were no significant differences between the groups with and without portal vein thrombosis in terms of survival according to Kaplan-Meier curve analysis (p = 0.7). However, the mortality rate was higher for Yerdel stages 3-4 (p

Background: Although surgical resection is the only potentially curative treatment for pancreatic cancer (PC), long-term outcomes of this treatment remain poor. The aim of this study is to describe the feasibility of a neoadjuvant treatment with induction polychemotherapy (IPCT) followed by chemoradiation (CRT) in resectable PC, and to develop a machine-learning algorithm to predict risk of relapse. Methods: Forty patients with resectable PC treated in our institution with IPCT (based on mFOLFOXIRI, GEMOX or GEMOXEL) followed by CRT (50 Gy and concurrent Capecitabine) were retrospectively analyzed. Additionally, clinical, pathological and analytical data were collected in order to perform a 2-year relapse-risk predictive population model using machine-learning techniques. Results: A R0 resection was achieved in 90% of the patients. After a median follow-up of 33.5 months, median progression-free survival (PFS) was 18 months and median overall survival (OS) was 39 months. The 3 and 5-year actuarial PFS were 43.8% and 32.3%, respectively. The 3 and 5-year actuarial OS were 51.5% and 34.8%, respectively. Forty-percent of grade 3-4 IPCT toxicity, and 29.7% of grade 3 CRT toxicity were reported. Considering the use of granulocyte colony-stimulating factors, the number of resected lymph nodes, the presence of perineural invasion and the surgical margin status, a logistic regression algorithm predicted the individual 2-year relapse-risk with an accuracy of 0.71 (95% confidence interval [CI] 0.56&ndash, 0.84, p = 0.005). The model-predicted outcome matched 64% of the observed outcomes in an external dataset. Conclusion: An intensified multimodal neoadjuvant approach (IPCT + CRT) in resectable PC is feasible, with an encouraging long-term outcome. Machine-learning algorithms might be a useful tool to predict individual risk of relapse. A small sample size and therapy heterogeneity remain as potential limitations.

Resumen Introduccion La Fast-track surgery se ha planteado recientemente como un programa eficaz en la cirugia pancreatica. Aunque la morbimortalidad tras la duodenopancreatectomia cefalica ha mejorado en la ultima decada, la prevalencia de complicaciones postoperatorias continua siendo elevada. El objetivo de este trabajo es examinar los resultados de un programa de Fast-track en este tipo de intervenciones. Resultados Ochenta y dos pacientes fueron intervenidos de duodenopancreatectomia cefalica dentro de un protocolo de recuperacion precoz. La mediana de edad fue 63 anos. El 65% fueron varones. La mediana de estancia hospitalaria fue de 9 dias, con un 14,6% de reingresos. Se aplico la clasificacion de Clavien-DeOliveira para evaluar la severidad de las complicaciones. La morbilidad global fue del 47,6%. La complicacion mas frecuente correspondio al grupo que englobaba las generales, seguidas por la infeccion de la herida quirurgica y complicaciones cardiorrespiratorias. Teniendo en cuenta que solo el 32% de los pacientes tuvieron drenaje desde la cirugia, la frecuencia de fistula pancreatica fue del 8,5%, y esta se situaba en los grupos de mayor morbilidad (grados III, IV y V). La mortalidad postoperatoria fue del 4,9%. La cirugia asociada constituyo un factor de riesgo para la mortalidad. Conclusiones La Fast-track surgery en la duodenopacreatectomia cefalica realizada en centros de alto volumen es un programa seguro y eficaz que permite ademas mejorar los resultados de morbimortalidad.

The surgical treatment of benign tumors of the neck of the pancreas usually consists of enucleation or formal pancreatectomy. Central pancreatectomy has been put forward because it has fewer major complications and can preserve endocrine and exocrine function. Between January 1999 and march 2003, three patients with benign tumors of the neck of the pancreas underwent central pancreatectomy. all patients underwent computed tomography scans, intraoperative ultrasound and frozen-section analysis. pathologic examination showed two mucinous cystadenomas and one serous cystadenoma. after a mean follow-up of 34 months, none of the patients has shown major complications or local recurrence, or has developed diabetes. In conclusion, central pancreatectomy is a useful technique for selected benign or low-grade malignant pancreatic tumors of the neck of the pancreas.

Introduction Fast-track surgery has been proposed as a valid method in pancreatic surgery. Although morbidity and mortality has improved in the last decade, the prevalence of postoperative complications is still high. The aim of this study is to analyse the results of a programme of Fast-track surgery in this context. Results A total of 82 patients who underwent a cephalic pancreatoduodenectomy with a programme of early recovery after surgery, were analysed. There were 53 men, with a median age of 63 years old. The median hospital stay was 9 days, with 14.6% of readmissions. The Clavien-DeOliveira Classification was applied to evaluate the severity of postoperative complications. The overall morbidity was 47.6%. The most common complications were general, followed by infection of surgical wound and cardiopulmonary events. Taking into account that a surgical drain was used in 32% of patients, the prevalence of pancreatic fistula was 8.5%, and were classified in the most severity grades (III, IV, and V). The postoperative mortality was 4.9%. The associated surgery was a risk factor of mortality. Conclusions The Fast-track programme after pancreatoduodenectomy in high volume centres is a safe and effective method, that can improve the morbidty and mortality results.

The surgical treatment of benign tumors of the neck of the pancreas usually consists of enucleation or formal pancreatectomy. Central pancreatectomy has been put forward because it has fewer major complications and can preserve endocrine and exocrine function. Between January 1999 and march 2003, three patients with benign tumors of the neck of the pancreas underwent central pancreatectomy. all patients underwent computed tomography scans, intraoperative ultrasound and frozen-section analysis. pathologic examination showed two mucinous cystadenomas and one serous cystadenoma. after a mean follow-up of 34 months, none of the patients has shown major complications or local recurrence, or has developed diabetes. In conclusion, central pancreatectomy is a useful technique for selected benign or low-grade malignant pancreatic tumors of the neck of the pancreas.