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Introduction Total pancreatectomy (TP) is an uncommon operation, with indications that have not been clearly defined and non-standardized postoperative results. We present a national multicentric study on TP and a comparison with the existing literature. Methods A prospective observational study using data from the national registry of patients after pancreaticoduodenectomy and TP performed for any indication during the study period: January 1–December 31, 2015. Results 1016 patients were included from 73 hospitals, 112 of whom had undergone TP. The percentage of TP from the total number of cases was 11%. The mean age was 63.5 years, and 57.2% were males. The most frequently suspected radiological diagnosis was pancreatic cancer (58/112 cases). The most common TP technique was “mesentery artery first” (43/112 cases). Venous resections were performed in 23 patients (20.5%). The percentage of postoperative complications within 90 days was 50%, but major complications (>IIIA) were only 20.7%. The overall 90-day mortality was 8% (9 patients). The average stay was 20.7 days. The 3 most frequent definitive histological diagnoses were: adenocarcinoma of the pancreas, intraductal papillary mucinous neoplasm and chronic pancreatitis. The R0 rate was 67.8%. Conclusions This study shows that the morbidity and mortality results of TP in Spain are similar or superior to previous publications. More precise TP studies are necessary, focused on specific complications such as endocrine insufficiency.

Resumen Introduccion La pancreatectomia total (PT) es una intervencion infrecuente, con unas indicaciones no claramente definidas y unos resultados postoperatorios no estandarizados. Presentamos un estudio multicentrico nacional sobre PT y una comparacion con la literatura existente. Metodos Estudio prospectivo observacional realizado mediante el registro nacional de pacientes operados de duodenopancreatectomia cefalica y PT realizadas por cualquier indicacion durante el periodo comprendido entre el 1 enero y el 31 diciembre del 2015. Resultados Se incluyo a 1.016 pacientes, pertenecientes a 73 centros; de ellos, 112 correspondian a PT. El porcentaje de PT/numero total de casos es del 11%. La edad media fue 63,5 anos y eran varones un 57,2%. El diagnostico radiologico de sospecha mas frecuente fue cancer de pancreas (58/112 casos). La tecnica de la PT mas habitual fue «arteria mesenterica primero» (43/112 casos). Se efectuaron resecciones venosas en 23 pacientes (20,5%). El porcentaje de complicaciones postoperatorias a 90 dias fue 50%, pero las complicaciones mayores (> IIIA) solo el 20,7%. La mortalidad global a 90 dias fue del 8% (9 pacientes). La estancia media fue 20,7 dias. Los 3 diagnosticos histologicos definitivos mas frecuentes fueron: adenocarcinoma de pancreas, neoplasia mucinosa papilar intraductal y pancreatitis cronica. La tasa de R0 fue del 67,8%. Conclusiones Este estudio demuestra que los resultados de morbimortalidad de la PT en Espana son similares o superiores a los publicados previamente. Es necesario un estudio mas especifico sobre PT centrado en complicaciones especificas, como la insuficiencia endocrina.

Resumen La duodenopancreatectomia cefalica (DPC) combinada con reseccion venosa portomesenterica (RVPMS) amplia la tasa de resecabilidad de los tumors pancreaticos. Realizada en casos seleccionados y por equipos quirurgicos experimentados, presenta la misma morbimortalidad y supervivencia a largo plazo que la DPC sin reseccion vascular, siempre que se obtengan unos margenes quirurgicos libres de tumor. La trombosis completa de la vena porta o mesenterica superior, la invasion de la arteria mesenterica superior o del tronco celiaco y la afectacion ganglionar periaortica o a distancia contraindican este procedimiento. La reconstruccion venosa puede realizarse mediante sutura lateral, anastomosis termino-terminal o mediante interposicion de injerto. Creemos que la interposicion de vena yugular autologa es un procedimiento que facilita la reseccion y minimiza los fenomenos de estasis venosa. Presentamos un caso de adenocarcinoma de cabeza de pancreas intervenido en nuestro hospital que infiltraba la confluencia venosa portomesenterica. Se practico una DPC con RVP-MS y reconstruccion con vena yugular autologa. Comentamos los aspectos tecnicos mas relevantes.

Background A pleural drainage system must be capable of efficiently evacuating the air or fluids from the pleural cavity so that adequate lung reexpansion can take place. The air flow and negative pressure of the system will depend on the particular design of each model. This experimental study analyzes the specifications and performance of the pleural drainage systems currently on the market. Methods Thirteen models of pleural drainage systems connected to wall suction were examined. The models were classified into the following three groups: dry systems; wet systems; and single-chamber systems. We determined the ambient air flow and the negative pressure generated according to the suction level. The components of each model are also described. Results Under normal conditions, dry (except for the Sentinel Seal; Sherwood Medical; Tullamore, Ireland), wet, and single-chamber systems reach similar air flow rates (17 to 30, 24 to 27, and 22 to 28 L/min, respectively). With higher wall suction levels, wet systems increase the air flow (26 to 49 L/min) but the negative pressure becomes unstable because of the water loss phenomenon, dry systems increase the air flow (29 to 50 L/min) without modifying the regulator pressure, and single-chamber systems also raise the air flow (45 to 51 L/min) but increase the negative pressure. When there is an air leak, dry systems (except for the Sentinel Seal) lose less negative pressure than the other systems. Conclusions The functioning of these systems can be optimized only by applying a suitable wall suction level adjusted to each case. Although the three types of systems are capable of evacuating adequate air flow rates, the negative pressure and the capacity to maintain it in the presence of an air leak are different in each system. Being fitted with valves and not water compartments makes the dry systems the safest and the ideal for use when the patient has to be moved.

The aim of this study is to analyze the incidence, risk factors, management, and follow-up of patients with portal vein thrombosis (PVT) undergoing primary orthotopic liver transplantation (OLT). Four hundred fifteen OLTs were performed in 391 patients. In 62 patients, partial (group 1; n = 48) or complete (group 2; n = 14) PVT was found at the time of surgery. Portal flow was reestablished by venous thrombectomy. In this study, we compare 62 primary OLTs performed in patients with PVT at the time of OLT with a group of 329 primary OLTs performed in patients without PVT (group 3) and analyze the incidence of PVT, use of diagnostic methods, surgical management, and outcome. We found no significant differences among the 3 groups for length of surgery, cold and warm ischemic times, and postoperative stay in the intensive care unit. With the piggyback technique, groups 1 and 2 had greater blood losses and required more blood transfusions than group 3. The early reoperation rate was greater in group 2. The incidence of rethrombosis was 4.8% (group 1, 2%; group 2, 14.3%). Reexploration and thrombectomy (2 patients) and retransplantation (1 patient) had a 100% mortality rate. In particular, the mortality rate of patients with complete PVT with extension into the splanchnic veins is high (33%). Three-month and 4-year patient survival rates were statistically similar in the 3 groups. The presence of PVT at the time of OLT is not a contraindication for OLT. However, if PVT extends into the splanchnic veins, the outcome is guarded.

Resumen La protesis anillada de politetrafluoroetileno (PTFE) es el sustitutivo de la vena cava inferior mas empleado en la actualidad, aunque carecemos de estudios clinicos que la comparen con protesis no anilladas. No hay consenso respecto a la necesidad de anticoagular o de asociar una fistula arteriovenosa distal temporal que aumente el flujo venoso. Por el momento no podemos determinar cual es la mejor estrategia terapeutica. Presentamos 1 caso de sarcoma retroperitoneal intervenido en nuestro hospital que infiltraba la vena cava infrarrenal, el colon derecho y el ureter. Se practico una reseccion tumoral en bloque y se reconstruyo la vena cava con una protesis de PTFE no anillada asociada a anticoagulacion sistemica.

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.

A ringed polytetrafluoroethylene (PTFE) graft is currently the most widely used replacement for the inferior vena cava, although clinical studies comparing this technique with non-ringed prostheses are lacking. There is no consensus on the need to use an anticoagulant or associate a temporary distal arteriovenous fistula to increase venous flow. At present, the best therapeutic strategy cannot be determined. We present a case of retroperitoneal sarcoma infiltrating the infrarenal vena cava, right colon and ureter that was surgically treated in our hospital. En bloc resection was performed and the vena cava was reconstructed using a non-ringed PTFE graft associated with systemic anticoagulation.

A pleural drainage system must be capable of efficiently evacuating the air or fluids from the pleural cavity so that adequate lung reexpansion can take place. The air flow and negative pressure of the system will depend on the particular design of each model. This experimental study analyzes the specifications and performance of the pleural drainage systems currently on the market.Thirteen models of pleural drainage systems connected to wall suction were examined. The models were classified into the following three groups: dry systems; wet systems; and single-chamber systems. We determined the ambient air flow and the negative pressure generated according to the suction level. The components of each model are also described.Under normal conditions, dry (except for the Sentinel Seal; Sherwood Medical; Tullamore, Ireland), wet, and single-chamber systems reach similar air flow rates (17 to 30, 24 to 27, and 22 to 28 L/min, respectively). With higher wall suction levels, wet systems increase the air flow (26 to 49 L/min) but the negative pressure becomes unstable because of the water loss phenomenon, dry systems increase the air flow (29 to 50 L/min) without modifying the regulator pressure, and single-chamber systems also raise the air flow (45 to 51 L/min) but increase the negative pressure. When there is an air leak, dry systems (except for the Sentinel Seal) lose less negative pressure than the other systems.The functioning of these systems can be optimized only by applying a suitable wall suction level adjusted to each case. Although the three types of systems are capable of evacuating adequate air flow rates, the negative pressure and the capacity to maintain it in the presence of an air leak are different in each system. Being fitted with valves and not water compartments makes the dry systems the safest and the ideal for use when the patient has to be moved.

Resumen El hallazgo intraoperatorio de una ileitis de Crohnno complicada, durante el transcurso de una laparotomia por sospecha de apendicitis,plantea dos cuestiones. Por un lado, realizar o no una apendicectomia profilactica, por otro, resecar o no el ileon terminal enfermo. Pese a que la recomendacion de la Guia Clinica de la Asociacion Espanola de Cirujanos es la de practicar una reseccion ileocolica en estos casos, no hay suficientes estudios que demuestren cual es la mejor opcion terapeutica y la postura clasica conservadora puede seguir siendo valida. Presentamos un caso de Crohn intervenido de urgencia por sospecha de asa estrangulada por bridaytratado con reseccion ileocolica de urgencia.