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The main objective of this study was to analyse the results of the surgical treatment of ampullary neuroendocrine tumours (NET) based on transduodenal ampullectomy and pancreatoduodenectomy, in a reference centre in hepatobiliopancreatic pathology.Retrospective, observational study, including all patients operated on for pancreatic and/or duodenal NET in a reference unit of hepatobiliopancreatic pathology and prospectively registered between January 1Of 181 patients operated on for pancreatic and/or duodenal NET, only 9 were located in the ampulla of Vater, which represents 4.9% of all pancreatic and/or duodenal NET. Pancreatoduodenectomy (PD) was performed in 6 patients, while 3 patients underwent transduodenal ampullectomy (TDA). Longer surgical time and more postoperative complications were observed in the PD group. There were no differences in hospital stay. Overall and disease-free survival at 5 years in the PD group compared to ATD was 83.3% vs. 100% and 50% vs. 100%, respectively.Ampullary NET without locoregional involvement or risk factors, can be treated by conservative surgeries such as transduodenal ampullectomy.

Introduction Chronic pain in chronic pancreatitis is difficult to manage. The objective of our study is to assess the control of pain that is refractory to medical treatment in patients with an inflammatory mass in the head of the pancreas, as well as to compare the two surgical techniques. Methods A retrospective study included patients treated surgically between 1989 and 2011 who had been refractory to medical treatment with inflammation of the head of the pancreas. An analysis of the short and long-term results was done to compare patients who had undergone pancreaticoduodenectomy (PD) and/or resection of the head of the pancreas with duodenal preservation (RHPDP). Results 22 PD and 12 RHPDP were performed. Postoperative complications were observed in 14% of patients, the most frequent being delayed gastric emptying (14.7%) and pancreatic fistula (11.7%). No statistically significant differences were found in terms of surgical technique. Pain control was satisfactory in 85% of patients, 43% presented de novo diabetes mellitus, and 88% returned to their work activities. Fourteen patients died during follow-up, 7 due to malignancies, and some were related to tobacco use and alcohol consumption. The overall 5 and 10 year survival rates were 88% and 75% respectively. Conclusion Cephalic resection in patients with intractable pain in chronic pancreatitis is an effective therapy that provides good long-term results in terms of pain control, with no significant differences between the two surgical techniques. Patients with chronic pancreatitis have a high mortality rate associated with de novo malignancies.

Resumen Introduccion El dolor cronico en la pancreatitis cronica es de dificil manejo. El objetivo de nuestro trabajo es la valoracion del control del dolor refractario al tratamiento medico en pacientes afectos de masa inflamatoria en la cabeza pancreatica, asi como comparar dos tecnicas quirurgicas realizadas. Metodos Estudio retrospectivo sobre pacientes intervenidos entre 1989 y 2011 refractarios al tratamiento medico con predominio inflamatorio en la cabeza pancreatica. Se realizo un estudio comparativo a corto y a largo plazo entre los pacientes intervenidos mediante duodenopancreatectomia cefalica (DPC) y/o pancreatectomia cefalica con preservacion duodenal (PCPD). Resultados Se realizaron 22 DPC y 12 PCPD. En el 44% de los casos se presentaron complicaciones posquirurgicas, siendo las mas frecuentes el vaciamiento gastrico retardado (14,7%) y la fistula pancreatica (11,7%). No se evidenciaron diferencias estadisticamente significativas segun la tecnica quirurgica. Se consiguio el control del dolor de forma satisfactoria en el 85% de los pacientes, hubo un 43% de diabetes mellitus de novo, y la reincorporacion a la actividad laboral fue del 88%. Catorce pacientes fallecieron durante el seguimiento; de ellos, 7 a causa de neoplasias, algunas de ellas relacionadas con el consumo de tabaco y alcohol. La supervivencia global a 5 y 10 anos fue del 88 y del 75%, respectivamente. Conclusion La reseccion cefalica en pacientes con dolor intratable en la pancreatitis cronica es una terapeutica eficaz, con buenos resultados a largo plazo en terminos de control del dolor y sin diferencias significativas entre ambas tecnicas quirurgicas. Los pacientes con pancreatitis cronica presentan una elevada mortalidad asociada a neoplasias de novo.

Resumen Introduccion El adenocarcinoma de duodeno es una neoplasia poco frecuente, sobre la que existen pocas experiencias publicadas de los resultados tras su reseccion. El objetivo es analizar los resultados obtenidos en nuestro centro tras la reseccion curativa del adenocarcinoma duodenal (AD). Metodos Estudio retrospectivo de los pacientes intervenidos con reseccion curativa por AD entre 1990 y 2017 en nuestro hospital. Resultados Se intervino a 27 pacientes. En 23 casos (85%) se realizo duodenopancreatectomia cefalica (DPC) y en 4 casos (15%) con localizacion en la 3.a-4.a porcion duodenal se realizo duodenectomia (DD) segmentaria. La morbilidad postoperatoria global fue del 67% (18 pacientes). La mortalidad postoperatoria global fue 7% (2 pacientes), sin embargo, la mortalidad postoperatoria relacionada con la cirugia fue de 4% (un paciente). El estudio anatomopatologico evidencio reseccion con margenes libres en todos los casos intervenidos. La mediana de adenopatias resecadas fue 18 (0 a 38), siendo 1 (0 a 8) las adenopatias afectadas. Tras una mediana de seguimiento de 23 (9-69,7) meses, la supervivencia actuarial fue de 62,2 (25,2 a 99,1) meses y la supervivencia actuarial libre de enfermedad fue de 49 (0 a 133) meses. Conclusiones La reseccion quirurgica del AD comporta una elevada morbilidad postoperatoria, sin embargo, consigue una supervivencia prolongada. Dependiendo de la localizacion y en ausencia de infiltracion pancreatica, la DD segmentaria con margenes libres es una alternativa a la DPC.

Introduction:Pancreatic cancer is the seventh leading cause of cancer-related death worldwide, and surgical resection with radical intent remains the only potentially curative treatment option today. However, borderline resectable pancreatic ductal adenocarcinomas (BR-PDAC) stand in the gray area between the resectable and unresectable disease since they are technically resectable but have a high probability of incomplete exeresis. Neoadjuvant treatment (NAT) plays an important role in ensuring resection success.Different survival prognostic factors for BR-PDAC have been well described, but evidence on the predictive factors associated with resection after NAT is scarce. This study aims to study if CA 19-9 plasmatic levels and the tumor anatomical relationship with neighboring vascular structures are prognostic factors for resection and survival (both Overall Survival and Progression-Free Survival) in patients with type A BR-PDAC. Methods:This will be a retrospective cohort study using data from type A BR-PDAC patients who received NAT in the Bellvitge University Hospital. The observation period is from January 2010 until December 2019; patients must have a minimum 12-month follow-up. Patients will be classified according to the MD Anderson Cancer Center criteria for BR-PDAC. Discussion:Patients with BR-PDAC have a high risk for a margin-positive resection. Serum Carbohydrate Antigen 19-9 plasmatic levels and vascular involvement stand out as disease-related prognostic factors.This study will provide valuable information on the prognostic factors associated with resection. We will exclude locally advanced tumors and expect this approach to provide more realistic resection rates without selecting those patients that undergo surgical exploration. However, focusing on an anatomical definition may limit the results' generalizability.

La educación social en el ámbito residencial de protección a la infancia se vio afectada por el confinamiento domiciliario. Y posteriormente, se siguió trabajando en un escenario de incertidumbre por la situación de excepcionalidad, los cambios laborales, la supresión de permisos y visitas familiares de los niños y niñas, o la falta de información clara. Los objetivos del estudio han sido explorar el significado del confinamiento para los y las profesionales de la educación social, identificar las principales dificultades percibidas, y visibilizar los elementos de afrontamiento. En esta investigación cualitativa mediante encuesta abierta online participaron 69 profesionales (71% mujeres, 29% hombres). Los resultados señalan la oportunidad, pero también la incertidumbre que ha supuesto el confinamiento, destacando el miedo al contagio y la sobrecarga laboral. Las competencias personales y el soporte emocional del equipo han sido claves para el afrontamiento del confinamiento. Finalmente se discuten las implicaciones para el desarrollo profesional de los y las profesionales de la educación social.

Several techniques have been proposed for liver transplantation with inadequate hepatic artery (HA) anastomosis. We aimed to analyze outcomes of arterial reconstruction with the splenic artery (SA). This was a prospective study of our experience with recipients who underwent arterial anastomosis on the SA compared with patients who underwent standard HA. We included 54 patients in the SA group and 1405 in the HA group. Patients in SA group were more frequently retransplantation (31% vs. 8%; P = 0.001), required more transfusion (11 ± 12 vs. 6 ± 9.9 PRC; P = 0.001), had longer surgeries (424 ± 95 vs. 394 ± 102 min; P = 0.03), and longer hospital stays (28 ± 29 vs. 20 ± 18 days; P = 0.002). There were no differences in vascular and biliary complications (15% and 7%; P = 0.18; and 32% and 23%; P = 0.32), primary dysfunction (11% and 9%; P = 0.74), reoperation (12% and 10%; P = 0.61), postoperative mortality (13% and 7%; P = 0.12) and 5 years survival (66% vs. 63%; P = 0.71). Following primary transplantation, there were no differences. The outcomes of arterial reconstruction using the recipients' SA in adult liver transplantation are comparable to those for standard HA reconstruction after a first transplant.

Background Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. Methods This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. Results A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. Conclusion The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).

"Hemosuccus pancreaticus" (HP), "wirsungorrhagia" or "pseudohemobilia" is a rare cause of upper gastrointestinal bleeding consisting of blood loss along the duct of Wirsung with exteriorization through the ampulla of Vater. Due to its rarity, the literature on HP is limited to retrospective studies, case reports, and case series.

Background There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy. Methods Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy. Results We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35). Conclusions Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist's discretion.A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %;The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist’s discretion.A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %;The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.

Introduction The need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear. Aims The aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL). Methods This is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up. Results Fifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8 min, p = 0.0341). Conclusions Fluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.

Resumen Introduccion Se ha definido un grupo de resecabilidad borderline resectable (APBR) en el adenocarcinoma de pancreas. El objetivo del estudio es evaluar los resultados en el tratamiento quirurgico tras neoadyuvancia del APBR. Metodo Entre 2010 y 2014 incluimos pacientes afectos de APBR en un protocolo de neoadyuvancia y cirugia, estadificados mediante tomografia computarizada multidetector (TCMD). El tratamiento con quimioterapia se baso en gemcitabina y oxaliplatino (GEMOX). Posteriormente, se realizo TCMD para descartar progresion, y se administro 5-FU en infusion y radioterapia concomitante. Se practico TCMD y reseccion en ausencia de progresion. Se realizo un estudio estadistico descriptivo, dividiendo la serie en grupo reseccion (grupo GR) y grupo progresion (grupo PROG). El seguimiento finalizo en febrero de 2016. Resultados Indicamos tratamiento neoadyuvante a 22 pacientes, 11 de ellos fueron finalmente intervenidos. Se realizaron 9 duodenopancreatectomias cefalicas, una duodenopancreatectomia total y una pancreatectomia corporocaudal. De los 11 pacientes, 7 requirieron algun tipo de reseccion vascular; 5 resecciones venosas, uno arterial y otro ambas. No hubo mortalidad postoperatoria, 7 (63%) tuvieron alguna complicacion y 4 fueron reintervenidos. La estancia hospitalaria postoperatoria mediana fue 17 dias (7-75). El estudio patologico evidencio margenes microscopicos libres (R0) en el 63% de los pacientes y ausencia de afectacion adenopatica en 10 pacientes (ypN0). Al cierre del estudio, todos los pacientes habian fallecido, con una supervivencia actuarial mediana de 13 meses (9,6-16,3). La supervivencia actuarial mediana del grupo GR fue superior al grupo PROG (25 vs. 9 meses; p Conclusion El tratamiento neoadyuvante del APBR permite seleccionar un grupo de pacientes en el que la reseccion consigue una supervivencia superior al grupo en el que se observa progresion. La reseccion pancreatica posneoadyuvancia requiere resecciones vasculares en la mayoria de los casos.

The availability of new imaging techniques has conditioned an increase in the incidental diagnosis of small nonfunctioning pancreatic neuroendocrine tumors (PNET-NF). The best treatment is controversial, some authors advise a conservative approach in selected cases. Our aim is to analyze the evolution of incidental, small size PNET-NF, treated with clinical follow-up without surgery.We performed a retrospective analysis of a prospective database of patients diagnosed incidentally with PNET-NF since November 2007 to September 2015. We include those with PNET-NF ≤2cm and asymptomatic. The diagnosis was performed using imaging tests indicating endoscopic ultrasound-guided fine-needle aspiration in case of doubts in the diagnosis. The follow-up was performed at our center, registering clinical and/or radiological changes.We included 24 patients with a median age of 70 years, and a similar distribution in terms of sex. The diagnosis was made through computed tomography multidetector or magnetic resonance imaging and octreotide scan. The tumors were located mainly in the head and neck (46%), with a mean size of 11,5±3,55mm at diagnosis (5-19mm). In 2 cases endoscopic ultrasound fine needle aspiration was used (8%), confirming the diagnosis of low-grade PNET with Ki675%. The median follow-up was 39 months (7-100). In 19 patients (79%) they remained the same size, 21% (5) increased its size with a mean of 2,6±2mm (1-6). No cases had progression of disease.In selected patients, non-surgical management of PNET-NF is an option to consider, when they are asymptomatic and ≤2cm. Larger studies with more patients and more time of follow-up are needed to validate this non-operative approach.

Resumen Objetivo La disponibilidad de nuevas tecnicas de imagen ha condicionado un incremento en el diagnostico incidental de pequenos tumores neuroendocrinos pancreaticos no funcionantes (TNP-NF). El mejor tratamiento de estos tumores es controvertido: algunos autores aconsejan una actitud conservadora en casos seleccionados. Nuestro objetivo es analizar la evolucion de TNP-NF incidentales de pequeno tamano, tratados con seguimiento clinico sin cirugia. Metodos Se realizo un analisis retrospectivo de una base de datos prospectiva de pacientes diagnosticados incidentalmente de TNP-NF desde noviembre de 2007 hasta septiembre de 2015. Incluimos aquellos con TNP-NF ≤ 2 cm y asintomaticos. El diagnostico se realizo mediante pruebas de imagen, indicando ecoendoscopia-puncion en caso de dudas diagnosticas. El seguimiento se hizo en nuestro centro, con registro de cambios clinicos y radiologicos. Resultados Incluimos a 24 pacientes con una mediana de edad de 70 anos y distribucion similar en cuanto al sexo. El diagnostico se realizo mediante tomografia computarizada multidetector, resonancia nuclear magnetica y gammagrafia con octreotide. Los tumores se localizaban principalmente en cabeza y cuello (46%), con un tamano medio de 11,5 ± 3,55 mm al diagnostico (5-19 mm). En 2 casos se asocio ecoendoscopia-puncion (8%), confirmando el diagnostico de TNP de bajo grado con Ki67 Conclusion En pacientes seleccionados, el manejo no quirurgico de TNP-NF, asintomaticos y ≤2 cm es una opcion a tener en cuenta. Son necesarios estudios con mayor numero de pacientes y un seguimiento mayor para validar esta opcion conservadora.

Resumen Introduccion El tratamiento de los tumores neuroendocrinos pancreaticos no funcionantes (TNEPNF) es la reseccion en caso de enfermedad localizada o metastasis hepaticas resecables. Existe controversia en metastasis hepaticas irresecables. Metodos Analizamos los datos perioperatorios y de supervivencia de 63 pacientes resecados por TNEPNF entre 1993 y 2012, dividiendolos en 3 escenarios: A, reseccion pancreatica (44 pacientes); B, reseccion pancreatica y hepatica por metastasis hepaticas sincronicas (12 pacientes), y C, reseccion pancreatica en presencia de metastasis hepaticas irresecables (6 pacientes). Se estudiaron factores pronosticos de supervivencia y recidiva. Resultados Las cirugias mas frecuentes fueron, pancreatectomia corporocaudal (51%) y duodenopancreatectomia cefalica (38%). El 44% de los pacientes requirieron una cirugia asociada, resecando sincronicamente pancreas e higado en 9. Dos pacientes recibieron un trasplante hepatico durante el seguimiento. Segun la clasificacion de la OMS, se distribuyeron en G1: 10 (16%), G2: 45 (71%) y G3: 8 (13%). La morbimortalidad postoperatoria fue del 49 y del 1,6%, respectivamente. Al cierre del estudio, 43 (68%) seguian vivos, con una supervivencia actuarial media de 9,6 anos. La clasificacion de la OMS y la recidiva fueron factores de riesgo de mortalidad en el estudio multivariante. La supervivencia actuarial mediana por escenarios fue de 131 meses (A), 102 meses (B) y 75 meses (C), sin diferencias estadisticamente significativas. Conclusiones El tratamiento del TNEPNF sin enfermedad a distancia es la reseccion. Las metastasis hepaticas resecables en los tumores bien diferenciados deben resecarse. La reseccion del tumor pancreatico con metastasis hepaticas sincronicas irresecables debe considerarse en TNEPNF bien diferenciados. El grado de clasificacion de la OMS y la recidiva son factores de riesgo de mortalidad a largo plazo.

Introduction Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA). Material and methods The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital. Results A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 63% (17 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0–38) were retrieved and evaluated, with a median of 1 involved node (range, 0–8). Median follow up was 23 (9–69.7) months. Actuarial overall survival was 62.2 (25.2–99.1) months. Actuarial disease-free survival was 49 (0–133) months. Conclusions The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy.

Resumen Introduccion La duodenopancreatectomia cefalica (DPC) es el tratamiento de eleccion de los tumores del area periampular. Esta intervencion presenta una elevada morbilidad postoperatoria, y suele estar contraindicada en los pacientes con hepatopatia cronica (CH). Analizar los resultados de la DPC en pacientes cirroticos, y compararlos con los de pacientes no cirroticos. Metodos Entre abril de 1994 y noviembre de 2014 registramos de forma prospectiva a todos los pacientes a los que se les realizo una DPC por cancer del area periampular en el Hospital Universitari de Bellvitge. Se recogieron de forma prospectiva variables preoperatorias, intraoperatorias y del postoperatorio inmediato. Se definio grupo de estudio a los pacientes tratados mediante DPC y afectos de cirrosis hepatica (grupo CH), y grupo control a pacientes intervenidos sin cirrosis hepatica (grupo NCH); se realizo un estudio caso/control (1/2). Resultados Registramos a 15 pacientes del grupo CH, todos ellos con una buena funcion hepatica (Child A), y a 30 del grupo NCH. La causa de la hepatopatia fue VHC (60%) y enolismo (40%). En los 3 instantes estudiados, los pacientes del grupo CH presentaron una cifra de plaquetas en sangre inferior y una ratio de protrombina superior, respecto al grupo NCH. La morbilidad postoperatoria fue del 60%, con una estancia media de 25 ± 19 dias; sin diferencias significativas en la incidencia de complicaciones entre el grupo CH y NCH (73 vs. 53%; p = 0,1). La presencia de ascitis durante el postoperatorio fue superior en el grupo CH respecto al NCH (28 vs. 0%; p Conclusiones La DPC es una intervencion segura entre los pacientes hepatopatas con buena funcion hepatica preoperatoria, a pesar de comportar una elevada morbilidad.

Background and Aims When ERCP fails, EUS-guided interventional techniques may be an alternative. The aim of this study was to evaluate the general outcomes and safety of EUS-guided methylene blue cholangiopancreatography in patients with failed ERCP in benign biliopancreatic diseases. Methods Patients with benign biliopancreatic diseases and failed ERCP were included. EUS-guided cholangiopancreatography plus injection of methylene blue was performed, and then ERCP using coloring agent flow as an indicator of papilla orifice was performed. Procedures were prospectively collected in this observational, single-center study. Technical success, clinical success, and adverse events were analyzed retrospectively. Results Eleven patients were included (10 choledocholithiasis, 1 pancreatic stricture). The main reason for failed ERCP was an unidentifiable papilla. EUS-guided ductal access with cholangiopancreatography and papilla orifice identification was obtained in all cases. Technical success and clinical success rates of 91% were achieved, with successful biliopancreatic drainage in 10 patients. Adverse events included 1 peripancreatic abscess attributed to a precut, which was successfully treated. No adverse events were related to the first EUS-guided stage. Conclusion EUS-guided cholangiopancreatography with methylene blue injection seems to be a feasible and helpful technique for treatment in patients with benign biliopancreatic diseases with previous failed ERCP because of an undetectable papilla.

Resumen La escasez de organos para trasplante ha hecho aumentar progresivamente la aceptacion de donantes con criterios marginales, como la edad. Metodos Se ha realizado un analisis comparativo de la evolucion postrasplante dependiendo de la edad de los donantes (grupo I : edad inferior a 70 anos [n = 474] vs. grupo II : edad superior a 70 anos [n = 105]), a lo largo de un periodo de 10 anos. Resultados No habia diferencias significativas entre ambos grupos en dias de UCI, sexo, peso y requerimientos de farmacos vasoactivos. El grupo I presento parada cardiaca de forma mas frecuente (GI: 14 vs. GII: 3%; p = 0,005). No hubo diferencias en la disfuncion primaria (GI: 6 vs. GII: 7,7%; p = 0,71), estancia en UCI (GI: 2,7 ± 2 vs. GII: 3,3 ± 3,8 dias; p = 0,46) y hospitalaria (GI: 13,5 ± 10 vs. GII: 15,5 ± 11; p = 0,1), ni mortalidad hospitalaria (GI: 5,3 vs. GII: 5,8%; p = 0,66). Tras una mediana de seguimiento de 42 meses, tampoco se encontraron diferencias en la incidencia de complicaciones biliares (GI: 17 vs. GII: 20%; p = 0,40) ni vasculares (GI: 11 vs. GII: 9%; p = 0,69). La supervivencia actuarial a 5 anos fue similar entre ambos grupos de estudio (GI: 70 vs. GII: 76%; p = 0,54). Conclusiones En nuestra experiencia, la utilizacion de injertos de donantes mayores de 70 anos, si se evitan factores de riesgo adicionales (tiempo de isquemia, esteatosis, hipernatremia), no empeora los resultados del trasplante hepatico a corto ni a largo plazo.

Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. Methods We performed a comparative analysis of the post-transplant evolution depending on donor age (group I : less than 70 years old (n=474) vs group II: 70 or more years old [n=105]) over a 10 year period (2002–2011). Results Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs GII: 7.7%; P=.71), ICU stay (GI: 2.7±2 vs GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs GII: 20%, P=.4) or vascular complications (GI: 11 vs GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs GII: 76%, P=.54). Conclusions In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischaemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.

Endoscopic management of walled-off pancreatic necrosis (WOPN) is an area of great interest with many still unanswered questions, including the role of mechanical necrosectomy versus irrigation. The aim of this study was to evaluate a new method of endoscopic transmural necrosectomy. Patients with WOPN after necrotizing pancreatitis, who underwent endoscopic transmural necrosectomy using a lumen-apposing metal stent with vigorous irrigation sessions, were prospectively recruited between September 2011 and August 2014. Initial endoscopic session was performed by EUS-guided drainage and lavage sessions by flushing saline through the stent. Technical and clinical success rates, number of repeat interventions, and adverse events were analyzed. Twelve patients with 13 WOPN collections (median size 12.4 ± 2.94 cm) underwent endoscopic treatment. Clinical success was achieved in 100 % of cases after a median of three sessions per patient (range 2–8). The median length of hospitalization was 15.9 days. Median procedure time of the access session was 31 ± 10.16 min. No adverse events (AE) were described during the procedures or 24 h after. There were four AE (two infections and two bleedings) between sessions, but only two were severe (16.6 %). There was no need for surgery, and no mortalities occurred. Mean time to stent retrieval was 9 ± 3.4 weeks. Mean follow-up was 13 months with only one recurrence at 12 months after stent removal. This new variant of irrigation endoscopic transmural necrosectomy without mechanical debridement helps to simplify the technique, is feasible, and has excellent outcomes in WOPN treatment.

Venous outflow is critical to the success of liver transplantation (LT). In domino liver transplantation (DLT), the venous cuffs should be shared between the donor and the recipient, and the length can be compromised. The aim of this study was to describe and compare the technical options for outflow reconstruction used at our institution. This was a retrospective analysis of 39 consecutive DLT recipients between January 1997 and May 2013. Twenty-seven men and 12 women (mean age, 61.8 ± 4.3 years) underwent LT and consented to receive a liver from a donor with familial amyloid polyneuropathy (FAP). The main indications were hepatocellular carcinoma and hepatitis C virus cirrhosis. All recipients underwent transplantation by a piggyback technique. Liver procurement in the FAP donors was performed with the classic technique in 22 patients and with the piggyback technique in the last 17. In these latter cases, for vascular outflow reconstruction, a cadaveric venous graft was interposed between the hepatic vein (HV) stump of the FAP liver and the recipient HV in 11 cases (28%). Since 2011, we have employed arterial grafts to be interposed between the vessels stumps: a tailored arterial graft in 5 patients and an aortic graft in 1 case. There was no postoperative mortality. Arterial and portal complications presented in 2 (5.1) and 4 patients (10.3), respectively. Postoperative outflow complications (post-LT subacute Budd-Chiari syndrome) occurred in 4 patients, and all of them had received a venous interposed graft for reconstruction. The incidence of outflow complications tended to be higher among patients with venous grafts than those with arterial graft interposition. Overall patient survival at 1, 3, 5, and 10 years was 97%, 79%, respectively. Arterial grafts constitute a feasible and safe option for vascular outflow reconstruction in DLT because they are associated with a relatively low incidence of complications. The recently proposed Bellvitge arterial graft technique should be added to the current range of available surgical modalities. Liver Transpl 21:1051-1055, 2015. © 2015 AASLD.

Introduction Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centers in Spain have published their results of surgery for acute pancreatitis. Objective To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. Materials and methods We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyze the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed. Results A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery ( Conclusions Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

Resumen Introduccion La cirugia es el tratamiento aceptado en la pancreatitis aguda infectada, aunque la mortalidad sigue siendo elevada. Como alternativa, el manejo en etapas se ha propuesto como alternativa para mejorar los resultados. El drenaje percutaneo inicial permitiria demorar la cirugia, y mejorar los resultados postoperatorios. Pocos centros a nivel nacional han publicado sus resultados tras la cirugia por pancreatitis aguda. Objetivo Revisar los resultados obtenidos tras el tratamiento quirurgico de pancreatitis aguda durante un periodo de 12 anos, con especial interes en la mortalidad postoperatoria. Material y metodos Hemos recogido la experiencia en el tratamiento quirurgico de la pancreatitis aguda grave (PAG) en el Hospital Universitari de Bellvitge desde 1999 hasta 2011. Para analizar los resultados, consideramos 2 periodos de estudio, anterior y posterior a 2005. Realizamos un estudio descriptivo y un analisis de factores de riesgo de mortalidad postoperatoria. Resultados Se ha intervenido a 143 pacientes por PAG, realizandose necrosectomia o desbridamiento de necrosis pancreatica o peripancreatica, o laparotomia exploradora en caso de hallar isquemia intestinal masiva. La mortalidad postoperatoria ha sido del 25%. Los factores de riesgo fueron la edad avanzada (superior a 65 anos), la presencia de fallo organico, la esterilidad de la muestra intraoperatoria obtenida y la cirugia precoz ( Conclusiones La infeccion pancreatica puede aparecer en cualquier momento de la evolucion de la enfermedad, incluso en fases tempranas. La cirugia en PAG comporta una elevada mortalidad, y la demora de la misma es un factor a tener en cuenta para mejorar los resultados.

Introduction A borderline resectable group (APBR) has recently been defined in adenocarcinoma of the pancreas. The objective of the study is to evaluate the results in the surgical treatment after neoadjuvancy of the APBR. Method Between 2010 and 2014, we included patients with APBR in a neoadjuvant and surgery protocol, staged by multidetector computed tomography (MDCT). Treatment with chemotherapy was based on gemcitabine and oxaliplatin. Subsequently, MDCT was performed to rule out progression, and 5-FU infusion and concomitant radiotherapy were given. MDCT and resection were performed in absence of progression. A descriptive statistical study was performed, dividing the series into: surgery group (GR group) and progression group (PROG group). Results We indicated neoadjuvant treatment to 22 patients, 11 of them were operated, 9 pancreatoduodenectomies, and 2 distal pancreatectomies. Of the 11 patients, 7 required some type of vascular resection; 5 venous resections, one arterial and one both. No postoperative mortality was recorded, 7 (63%) had any complications, and 4 were reoperated. The median postoperative stay was 17 (7–75) days. The pathological study showed complete response (ypT0) in 27%, and free microscopic margins (R0) in 63%. At study clossure, all patients had died, with a median actuarial survival of 13 months (9.6–16.3). The median actuarial survival of the GR group was higher than the PROG group (25 vs 9 months; P Conclusion The neoadjuvant treatment of APBR allows us to select a group of patients in whom resection achieves a longer survival to the group in which progression is observed. Post-adjuvant pancreatic resection requires vascular resection in most cases.

Introduccion: La eficacia de las protesis de aposicion luminal (PAL) en el drenaje transmural guiado por USE (DT-USE) de colecciones pancreaticas (CP) es conocido, pero se han descrito obstrucciones completas y parciales de su luz intra-stent. La colocacion de una protesis plastica doble pigtail (PDP) coaxial puede ser beneficioso evitando el taponamiento y prevencion de otros eventos adversos e incidencias. Objetivo: Comparar la eficacia y seguridad de la utilizacion de PAL con y sin PDP en el DT-USE de CP. Material y Metodo: Estudio consecutivo, comparativo en un centro terciario. Periodo 05/2011 – 06/2016. Inclusion prospectiva: de CP (pseudoquistes (PSQ), necrosis pancreaticas encapsuladas (NPE)) con indicacion de drenaje, y colocacion de PAL o PAL+PDP aleatoria, no controlada. Exclusion: otro tipo de colecciones y protesis. Parametros principales evaluados: exito tecnico, exito clinico, eventos adversos, incidencias tecnicas y evolucion clinica. Analisis estadistico retrospectivo. Resultados: De 83 drenajes guiados por USE de CP, inclusion de 36. Grupo PAL: 20 procedimientos (17 casos), media 51,4anos ± 14,4; ASAII-III 100%; PSQ 50% y NPE 50%; tamano medio 10,3 cm ± 2,9; infectadas 45%. Acceso: 19G+cistotomo(n = 15), NAVIX™(n = 3) y HotAXIOS™(n = 2). Necrosectomia 30%. Grupo PAL+PDP: 16 procedimientos (15 casos), media 62,2anos ± 11,9; ASA II-III 81,3%/IV-V 18,7%; PSQ 37,5% y NPE 62,5%; tamano medio 9,7 cm ± 4,7; infectadas 81,3%. Acceso: 19G+cistotomo(n = 5), HotAXIOS™(n = 11). Necrosectomia 43,8%. Duracion procedimiento: media (SD) PAL 38,2(12,4) minutos vs. PAL+PDP 46,3(6,2) minutos. Exito tecnico 100% en ambos grupos. Exito clinico en PAL/PAL+PDP del 90% y 87,5%. Incidencias tecnicas: 1 en cada grupo (total 2); recidiva 2 en cada grupo (total 4). Eventos adversos mayor en PAL respecto PAL/PDP (30 vs. 0%), p = 0,024 (test exacto de Fisher). Mortalidad en grupo PAL+PDP: n = 2, (ASA IV-V), no relacionada con el procedimiento. Conclusiones: El uso de PAL con PDP coaxial en el DT-USE de CP va asociado a menos eventos adversos comparado con el uso de PAL sin PDP. *Test exacto de Fisher p-valor = 0.024.

Early detection of pancreatic and periampullary neoplasms is critical to improve their clinical outcome. The present authors previously demonstrated that DNA hypermethylation of adenomatous polyposis coli (APC), histamine receptor H2 (HRH2), cadherin 13 (CDH13), secreted protein acidic and cysteine rich (SPARC) and engrailed-1 (EN-1) promoters is frequently detected in pancreatic tumor cells. The aim of the present study was to assess their prevalence in pancreatic juice of carcinomas of the pancreas and periampullary area. A total of 135 pancreatic juices obtained from 85 pancreatic cancer (PC), 26 ampullary carcinoma (AC), 10 intraductal papillary mucinous neoplasm (IPMN) and 14 chronic pancreatitis (CP) patients were analyzed. The methylation status of the APC, HRH2, CDH13, SPARC and EN-1 promoters was analyzed using methylation specific-melting curve analysis (MS-MCA). Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations were also tested with allele-specific quantitative polymerase chain reaction amplification. Out of the 5 promoters analyzed, APC (71%) and HRH2 (65%) were the most frequently methylated in PC juice. APC methylation was also detected at a high frequency in AC (76%) and IPMN (80%), but only occasionally observed in CP (7%). APC methylation had a high sensitivity (71-80%) for all types of cancer analyzed. The panel (where a sample scored as positive when ≥2 markers were methylated) did not outperform APC as a single marker. Finally, KRAS detection in pancreatic juice offered a lower sensitivity (50%) and specificity (71%) for detection of any cancer. APC hypermethylation in pancreatic juice, as assessed by MS-MCA, is a frequent event of potential clinical usefulness in the diagnosis of pancreatic and periampullary neoplasms.

Introduction The treatment of patients with non-functioning pancreatic neuroendocrine tumours (NFPNET) is resection in locally pancreatic disease, or with resectable liver metastases. There is controversy about unresectable liver disease. Methods We analysed the perioperative data and survival outcome of 63 patients who underwent resection of NFPNET between 1993 and 2012. They were divided into 3 scenarios: A, pancreatic resection (44 patients); B, pancreatic and liver resection in synchronous resectable liver metastases (12 patients); and C, pancreatic resection in synchronous unresectable liver metastases (6 patients). The prognostic factors for survival and recurrence were studied. Results Distal pancreatectomy (51%) and pancreaticoduodenectomy (38%) were more frequently performed. Associated surgery was required in 44% of patients, including synchronous liver resections in 9 patients. Two patients received a liver transplant during follow-up. According to the WHO classification they were distributed into G1: 10 (16%), G2: 45 (71%), and G3: 8 (13%). The median hospital stay was 11 days. Postoperative morbidity and mortality were 49% and 1.6%, respectively. At the closure of the study, 43 (68%) patients were still alive, with a mean actuarial survival of 9.6 years. The WHO classification and tumour recurrence were risk factors of mortality in the multivariate analysis. The median actuarial survival by scenarios was 131 months (A), 102 months (B), and 75 months (C) without statistically significant differences. Conclusions Surgical resection is the treatment for NFPNET without distant disease. Resectable liver metastases in well-differentiated tumours must be resected. The resection of the pancreatic tumour with unresectable synchronous liver metastasis must be considered in well-differentiated NFPNET. The WHO classification grade and recurrence are risk factors of long-term mortality.

Resumen Objetivo Analizar las indicaciones y resultados de nuestro centro en la reseccion de metastasis en el pancreas. Pacientes y metodos Analisis de la base de datos prospectiva desde 1990 hasta 2010. Se analizan los detalles clinicopatologicos, perioperatorios y los resultados de seguimiento. Resultados De 710 resecciones pancreaticas realizadas, en 7 casos (0,99%) fueron por metastasis en el pancreas. La edad media de los pacientes fue de 53,3 anos (20-77 anos), 5 hombres y 2 mujeres. Cinco pacientes estaban (70%) asintomaticos. El origen de las metastasis fue: colon (n = 3), rinon (n = 2), yeyuno (n = 1) y testiculo (n = 1). Se localizaron en 4 casos en la cabeza, 2 en la cola y uno en el cuerpo. En 4 pacientes (57%) las metastasis fueron metacronicas y el intervalo libre de enfermedad fue de 29 meses (17-48). Hubo 3 casos (43%) de metastasis sincronicas. Se realizo cirugia radical en todos los casos incluyendo la del tumor primario en los casos sincronicos. En las metastasis sincronicas el tiempo medio libre de recidiva fue de 14 meses y la supervivencia de 21,6 meses, inferior al de los pacientes con metastasis metacronicas que fue de 27,8 meses y la supervivencia de 32 meses. El intervalo libre de recidiva y supervivencia global fue de 21,85 y 27,5 meses, respectivamente. Conclusion La reseccion de las metastasis en pancreas puede prolongar la supervivencia en pacientes seleccionados.

BACKGROUND Concomitant quantification of multiple mutant KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog) alleles may provide information in addition to that provided by standard mutation-detection procedures. We assessed the feasibility of a nanofluidic digital PCR array platform to detect and quantify KRAS mutations simultaneously in clinically relevant samples. METHODS We assessed 2 groups of patients (colorectal and pancreatic disease): Group 1 consisted of 27 patients with colorectal carcinomas, 14 patients with adenomas, and 5 control individuals; group 2 consisted of 42 patients with pancreatic carcinoma, 4 with adenocarcinomas of the ampulla, and 6 with chronic pancreatitis). Digital PCR was performed with the Digital Array Chip (Fluidigm). RESULTS Nanofluidic digital PCR detected mutant alleles at 0.05% to 0.1%, depending on the variant analyzed. For the colorectal disease group, conventional PCR detected 9 (64%) of 14 adenomas that were positive for KRAS mutants, whereas digital PCR increased this number to 11 (79%) of 14. Sixteen (59%) of 27 carcinomas showed KRAS mutation with conventional PCR. Two additional cases were detected with digital PCR. In 5 cases (3 adenomas, 2 carcinomas), the total number of mutant alleles changed. For the pancreatic disease group, digital PCR increased the number of positive cases from 26 to 34 (81%) and identified ≥2 mutant alleles in 25 cases, compared with conventional PCR, which identified multiple KRAS mutant alleles in only 12 cases. A good correlation was observed between results obtained with tumor biopsies and those obtained with pancreatic juice. CONCLUSIONS Digital PCR provides a robust, quantitative measure of the proportion of KRAS mutant alleles in routinely obtained samples. It also allows a better classification of tumors, with potential clinical relevance.

Resumen Introduccion El tratamiento de la coledocolitiasis asociada a colelitiasis es controvertido. Los costes hospitalarios podrian ser un factor decisivo para elegir entre las distintas opciones terapeuticas. Objetivos Comparar la eficacia y los costes de 2 alternativas en el tratamiento de la coledocolitiasis: 1) Un-tiempo: colecistectomia y exploracion de la via biliar por laparoscopia y 2) Dos-tiempos: colangiopancreatografia retrograda endoscopica y colecistectomia laparoscopica secuencial. Material y metodos Estudio observacional, retrospectivo de 49 pacientes con coledocolitiasis y vesicula in situ, tratados de forma consecutiva y simultanea durante 2 anos, mediante una de las 2 estrategias. Se compararon las complicaciones postoperatorias, estancia, numero de procedimientos por paciente, conversion a laparotomia, eficacia en la extraccion de calculos y costes hospitalarios. Resultados No hubo diferencias en cuanto a caracteristicas clinicas y morbilidad de los pacientes. La estancia postoperatoria media para el grupo Un-tiempo fue menor que para el grupo Dos-tiempos. Tres pacientes del grupo Dos-tiempos requirieron conversion a laparotomia. La mediana de costes por paciente fue menor para la estrategia en Un-tiempo, representando un ahorro global de 37.173 € durante el periodo estudiado. Conclusiones Entre las 2 opciones terapeuticas, no se han encontrado diferencias significativas en cuanto a la eficacia, ni la morbimortalidad postoperatorias, pero si desde el punto de vista de la estancia y los costes hospitalarios. El manejo de los pacientes con coledocolitiasis en un solo tiempo represento un ahorro de 3 dias de estancia y 1.008 € por paciente.

Pancreaticoduodenectomy (PD) is usually contraindicated in chronic liver disease. The objective of the present study was to analyze PD results in cirrhotic patients, and compare them with non-cirrhotic ones.Between 1994 and 2014 we prospectively collected all patients with a PD for periampullar neoplasms in Hospital Universitari de Bellvitge. We registered preoperative, intraoperative and postoperative variables. We defined patients undergoing PD with liver cirrhosis as the study group (CH group), and those without liver cirrhosis as the control group (NCH group). A case/control study was performed (1/2).We registered 15 patients in the CH group, all with good liver function (Child A), and included 30 patients in NCH group. The causes of hepatopathy were HCV (60%) and alcoholism (40%). For the 3 moments studied, the CH group had a lower blood platelet count and a higher prothrombin ratio, compared with NCH group. Postoperative morbidity was 60% and mean postoperative stay was 25±19 days, with no differences in terms of complications between CH group and NCG group (73% vs. 53%, P=.1). Presence of ascites was higher in the CH group compared with NCH group (28 vs. 0%, P.001). There were no differences in terms of hemorrhage or pancreatic fístula. Four patients of the CH group and 2 patients of the NCH group were reoperated on (26.7 vs. 6.7%, P=.1). There was no postoperative mortality.PD is a safe procedure in cirrhotic patients with good liver function although it presents high morbidity.

Resumen Objetivo Definir factores pronostico de supervivencia a largo plazo tras la duodenopancreatectomia cefalica por adenocarcinoma pancreatico. Introduccion La cirugia es el tratamiento aceptado en el adenocarcinoma de pancreas cefalico, sin embargo la supervivencia a largo plazo sigue siendo baja. Material y metodos Hemos recogido la experiencia en el tratamiento del adenocarcinoma de cabeza de pancreas (ADCP) en el Hospital Universitari de Bellvitge mediante duodenopancreatectomia cefalica (DPC) desde 1991 hasta 2007. Resultados Se realizaron 204 DPC por ADCP. El estudio histologico evidencio que el tumor resecado tenia un tamano superior a 3 cm. en 70, con permeacion linfatica en un 73%, invasion perineural en 89% y afectacion linfatica en 71%. En 120 pacientes se resecaron mas de 15 adenopatias. Tras la cirugia, se administro tratamiento adyuvante a 113 pacientes (60%). Se contabilizaron 148 fallecimientos (73%), estando vivos al cierre del mismo 55 (27%). La supervivencia actual media fue de 2,54 anos (IC95% 2,02–3,07) y la supervivencia actuarial a 5 anos de 13,55% (IC95% 7,69–19,41). El estudio de factores de riesgo de mortalidad revelo que el sexo femenino (p=0,005), la ausencia de transfusion perioperatoria (p=0,003), la reseccion de mas de 15 adenopatias en la intervencion (p=0,004) y la administracion de tratamiento adyuvante (p=0,004) comportaron mejor pronostico a largo plazo. El estudio multivariante demostro que transfusion y sexo fueron las variables de interes. Conclusiones La cirugia del adenocarcinoma de cabeza de pancreas debe incluir una linfadenectomia suficiente y debe realizarse con baja morbilidad y sin necesidad de transfusion perioperatoria.

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.

Introduction Surgery is the accepted treatment in adenocarcinoma of the head of the pancreas (ADHP); 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 (CDP) due to pancreatic adenocarcinoma. Material and methods We have collected data on the treatment of adenocarcinoma of the head of the pancreas by means of a cephalic duodenopancreatectomy performed at the Hospital Universitari de Bellvitge (Barcelona) from 1991 to 2007. Results A total of 204 CDP due to ADHP were performed. The histology showed that the resected tumour was larger than 3cm 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 = .003), the resection of more than 15 lymph nodes during the operation ( P = .004), and the administration of adjuvant treatment ( P = .004) had a better long-term prognosis. The multivariate analysis showed that transfusion and gender were the most significant variables. Conclusions Surgery of head of the pancreas adenocarcinoma must include an adequate lymphadenectomy, and must be performed with a low morbidity and without the need of a peri-operative transfusion.

Introduccion: Habitualmente se ha utilizado fluoroscopia durante la practica de drenajes transmurales guiados por USE, aunque con la mejoria y conocimiento de la tecnica junto a la innovacion de los utensilios, recientemente se han descrito experiencias sin la ayuda de fluoroscopia. Objetivo: Evaluar el exito tecnico y terapeutico del drenaje transmural con y sin utilizacion de fluoroscopia (FL vs. NFL). Material y Metodo: Revision descriptiva, comparativa y retrospectiva en el que se evaluaron los pacientes con colecciones abdominales tratados con drenaje transmural guiado por USE, con y sin utilizacion de FL. Periodo de Enero 2013- Julio 2014. Tecnica de drenaje: acceso con aguja 19 Gauges; creacion de ostomia (guia 0,035-inch; cistotomo; +/-balon dilatador), colocacion de protesis (metalica +/- 1 pigtail coaxial vs. plasticas pigtail). Parametros evaluados: duracion del procedimiento, exito tecnico/clinico y complicaciones. El uso de la fluoroscopia, fue no estandarizado, en funcion de su disponibilidad. Resultados: Durante el periodo de estudio se evaluaron 17 pacientes (13 H/4 M; 53,5 ± 21,5 anos). Tipo de colecciones: pseudoquiste (n = 6); necrosis encapsuladas (n = 11); post-cirugia (n = 1). Tamano medio: 10 ± 7 cm. Infeccion (n = 7). Localizacion: cabeza (n = 1), cuerpo (n = 13), cola (n = 4). No drenaje previo por otras tecnicas. Abordaje: transgastrico (n = 18) y transduodenal (n = 1). Protesis utilizadas: 11 en grupo FL (9 metalicas, 2 plasticas); 12 grupo NFL (8 metalicas, 4 plasticas). Exito tecnico igual entre FL vs. NFL (100%). Exito clinico 89 vs. 100% (FL vs. NFL). Duracion procedimiento: 40 vs. 42,5 min (FL vs. NFL). No incidencias mayores durante los procedimientos en ambos grupos. Complicaciones > 7 dias: 3 HDA, 1 obstruccion stent (FL) vs. 1 migracion, 1 obstruccion stent (NFL). Conclusiones: La realizacion de drenajes transmurales guiados por USE sin la ayuda de FL es factible, sin comportar mas fallos tecnicos durante los pasos del procedimiento y de una forma segura, segun nuestra experiencia.

Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centres in Spain have published their results of surgery for acute pancreatitis.To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality.We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyse the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performedA total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures.Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.