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

Introduction

Involvement of surgical resection margins is a fundamental prognostic factor in pancreatic oncological surgery. However, there is a lack of standardized histopathology definition. The aims of this study are to investigate the real rate of R1 resections when surgical specimens are evaluated according to a standardized protocol and to study its survival implications.

Patients y methods

One hundred consecutive surgically resected patients with pancreatic ductal adenocarcinoma were included in the study. They were further divided in 2 groups: pre-protocol, evaluated before the introduction of the standardized protocol and post-protocol, analyzed with the standardized protocol.

Results

R0 resection rate in the pre-protocol group was 78%, falling to 47% after the introduction of the standardized protocol (p = 0,003). The posterior retroperitoneal margin was the most frequently involved margin. In cases with tumors located at the pancreatic head and analyzed according to the standardized protocol R1 involvement negatively affected survival. Median survival in the R0 group was 22 months versus 16 in those with the margin involved (HR: 2.044; IC 95% 1,00-4,16; P=.043).

Conclusions

Standardized evaluation of the retroperitoneal margins in pancreatic cancer increases the rate of R1 patients. In cases with pancreatic cancer located at the pancreatic head involvement of posterior retroperitoneal margin significantly decreases survival.     

Morbimortalidad de la resección pancreática

Aim

Assess the postoperative morbidity rates in pancreatic resection.

Material and method

Prospective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy.

Results

Overall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality.

Discussion

Pancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years.     

Consecuencias de la fractura de pene: complicaciones y resultados funcionales a largo plazo

IntroductionPenile fracture (PF) is a urological emergency with low incidence, and evidence of its long-term outcomes is scarce. This study focuses on postoperative complications and long-term functional outcomes in patients with PF and surgical repair at our center.Materials and methodClinical records of patients undergoing urgent surgery for PF at a third level hospital between 2006 and 2020 were retrospectively reviewed. Functional outcomes were assessed with voluntary telephone interviews from June 2020 to February 2021. Lower urinary tract symptoms were screened by IPSS questionnaire, sexual function by EHS and IIEF-5, and morphological alterations by direct questions to patients.ResultsA total of 41 patients underwent surgery for PF. Eleven of them also had urethral injury (higher incidence if there was bilateral corpora cavernosa injury, 19.4 vs. 80%, P < .05). Only one patient presented a Clavien-Dindo type 3a complication due to wound dehiscence, 4 (13%) type 2 and 9 (29%) type 1. Twenty-four patients underwent long-term follow-up, of whom 20 (83.3%) presented normal sexual function. Twelve patients (50%) had a palpable nodule at the fracture site, 8 (33.3%) had new onset penile curvature and one patient with previous urethral injury presented urethral stricture.ConclusionIn cases of penile fracture, there is a higher incidence of urethral injury if both corpora cavernosa are affected. Long-term functional sequelae after surgical repair of a PF are rare.     

Nueva técnica de proctectomía trasanal con escisión total del mesorrecto totalmente robótica en el tratamiento del cáncer de recto

Anterior resection with total mesorectal excision is the standard method of rectal cancer resection. However, this procedure remains technically difficult in mid and low rectal cancer. A robotic transanal proctectomy with total mesorectal excision and laparoscopic assistance is reported in a 57 year old male with BMI 32 kg/m2 and rectal adenocarcinoma T2N1M0 at 5 cm from the dentate line.     

Cephalic pancreaticoduodenectomy with mesentericoportal venous reconstruction. Technical features

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.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

Calidad de vida y resultados a largo plazo de las reintervenciones efectuadas por laparoscopia tras cirugía del hiato esofágico

Introduction

Laparoscopic surgery has had a significant impact on gastro-oesophageal reflux disease (GORD), para-oesophageal hiatal hernia (POHH) and achalasia. There have been a percentage of poor results due to reappearance, persistence or appearance of new symptoms. Reinterventions of the hiatus are more complicated and are not always accompanied by a satisfactory clinical response.

Objective

To evaluate the long-term results of a series of 20 patients reintervened by laparoscopy and their quality of life.

Material and methods

A total of 20 patients operated on between February 1998 and December 2008 after previous surgery for the hiatus. The mean age of the patients was 56 (19-77) years. A total of 18 patients had been operated on due to GORD or POHH and 2 due to achalasia. They were followed up until December 2008 and a quality of life GIQLI test was performed.

Results

Of the 20 patients, 13 were operated on by laparoscopy and 7 by laparotomy. The mean pre-operative time was 74 (1-24) months. The reintervention was for GORD and HH in 12 (63%); dysphagia in 4 (21%) and POHH (3). Conversion was 10% and the operating time was 180 (105-300) min. The procedures were: pillar closure and re-Nissen (10), re-Nissen (2), Toupet (2), Collis (1), mesh removal (1), re-myotomy (2), and pexy (1). There was 16% morbidity and no mortality. After a follow up of 68 (1-116) months, 14 patients were symptom-free. The GIQLI score was 106 (97-124), which was less than standard (125).

Conclusions

Reintervention of hiatus is reliable and effective over the long-term, but quality of life scores were lower than normal.     

Aprendizaje de la cirugía del cáncer de recto por laparoscopia sin aumento de la morbimortalidad

Introduction

The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis.

Objective

Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins.

Results

Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins.

Conclusions

It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.     

Morbilidad y mortalidad de la ileostomía derivativa temporal en la cirugía por cáncer de recto

Introduction

A temporary diverting ileostomy is frequently used to reduce the consequences of a distal anastomotic leakage after total mesorectal excision in rectal cancer surgery. This surgical technique is associated with high morbidity and a not negligible mortality. The aim of this study is to evaluate the morbidity and mortality rate associated with an ileostomy and its posterior closure.

Material and methods

Between 2001 and 2012, 96 patients with temporary diverting ileostomy were retrospectively analyzed. Morbidity and mortality were analyzed before and after the stoma closure. The studied variables included age, sex, comorbidities, time to bowel continuity restoration and adjuvant chemotherapy.

Results

In 5 patients the stoma was permanent and another 5 died. The morbidity and mortality rates associated with the stoma while it was present were 21 and 1% respectively. We performed a stoma closure in 86 patients, 57% of whom had previously received adjuvant therapy. There was no postoperative mortality after closure and the morbidity rate was 24%. The average time between initial surgery and restoration of intestinal continuity was 152.2 days. This interval was significantly higher in patients who had received adjuvant therapy. No statistically significant difference was found between the variables analyzed and complications.

Conclusions

Diverting ileostomy is associated with low mortality and high morbidity rates before and after closure. Adjuvant chemotherapy significantly delays bowel continuity restoration, although in this study did not influence in the rate of complications.     

Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.     

What are the main errors made by surgeons in the management of pancreatic cancer?

The present review identifies two major conceptual errors. Therapeutic nihilism, which should be discounted in view of the results currently achieved by surgery, and noncentralization, since better results have been demonstrated, both in terms of morbidity and mortality and in survival, in high-volume centers than in low volume centers. The present review also identifies errors in management, the most important of which are: undervaluing the medical record, which is of great utility and continues to be the pillar on which the entire diagnostic process is based; the systematic use of preoperative biliary drainage, which used to be considered mandatory but should be used highly selectively in patients with severe jaundice or biliary tract infections, and viewing preoperative imaging tests as unreliable, when current radiological techniques, particularly helical computed tomography (CT), are highly reliable in establishing tumor resectability and consequently they should be used in all treatment planning. Moreover, because radiological tests are highly reliable, laparoscopic staging has lost diagnostic value; obtaining a preoperative histological diagnosis, which is not mandatory except when neoadjuvant therapy is planned or when tumors requiring nonsurgical treatment are suspected; undervaluing the use of surgical palliation, since this technique provides better long-term results than nonsurgical palliation, and consequently still plays a role in patients with good general health status and prolonged life expectancy; systematically performing gastrojejunostomy with bilio-enteric bypass, as this procedure should only be performed in tumors of the uncus or when there is imminent biliary or gastroduodenal obstruction; the use of supraradical surgical techniques such as regional, total or extensive pancreatectomy, since these techniques do not prolong survival after resection. Furthermore, the use of vascular resections would only be justified if resection with disease-free margins could be performed; undervaluing close postoperative monitoring within specialized units since this is the key to reducing morbidity and mortality rates in this type of surgery; and lastly when an intraoperative pancreatic incidentaloma is present, performing diagnostic maneuvers such as biopsy or pancreatic mobilization, since these procedures hamper subsequent radiological interpretation and possible surgical intervention.     

Técnicas oncoplásticas para el manejo de tumores centrales de mama

Central tumors of the breast are in a difficult location for breast conservation that in many occasions had resulted in mastectomy. At the present time, the use of oncoplastic techniques have increased conservative management in this group of women, with an adequate oncological resection and good aesthetic results being achieved. This article describes oncoplastic procedures for the removal of breast central tumors with special interest in conservation and reconstruction of the areola-nipple complex.     

Two exceptional cases of pancreatic tumor

Pancreatic cancer carries a poor prognosis. The only potentially curative treatment is surgical resection. However, this procedure can only be performed in a few cases due to presentation of the tumor in advanced stages. We present 2 exceptional cases of pancreatic cancer presentation. Case 1: A 59-year-old man presented with recurrent melena despite endoscopic sclerosis of a duodenal ulcer. A computed tomography (CT) scan revealed a 7-cm mass in the head of the pancreas infiltrating the second portion of the duodenum. Duodenal biopsy showed a poorly differentiated carcinoma. Palliative pancreatoduodenectomy was performed. Case 2: A 49-year-old man presented with sporadic pain in the right hypochondrium and a familial history of pancreatic cancer in first and second degree relatives. CT and magnetic resonance imaging revealed a 1-cm cystic lesion in the head of the pancreas. Cytology showed mucoid material and atypia. Given a probable diagnosis of mucinous cystoadenoma, pancreatoduodenectomy was performed.     

Surgical treatment of pancreatic adenocarcinoma using cephalic duodenopancreatectomy (Part 2). Long term follow up after 204 cases

Introduction

Surgery is the accepted treatment in adenocarcinoma of the head of the pancreas; 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 due to pancreatic adenocarcinoma.

Material and methods

We have collected data on the treatment of adenocarcinoma of the head of the pancreas (ADHP) by means of a cephalic duodenopancreatectomy (CDP) performed n the Bellvitge University Hospital (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 3 cms 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=0.003), the resection of more than 15 lymph nodes during the operation (P=0.004), and the administration of adjuvant treatment (p=0.004) 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 lymphadectomy, and must be performed with a low morbidity and without the need of a peri-operative transfusion.     

Neoplasias de recto poco frecuentes. Revisión de conjunto

Most rectal neoplasms are adenocarcinomas, but there is a small percentage of tumors which are of other histological cell lines such as neuroendocrine tumors, sarcomas, lymphomas and squamous cell carcinomas, which have special characteristics and different treatments. We have reviewed these rare tumors of the rectum from a clinical and surgical point of view.