Estado inmuno-nutricional y cáncer de páncreas

El cáncer de páncreas es una entidad clínica poco frecuente, pero reviste una gran trascendencia por su elevada letalidad (supervivencia global a 5 años del 5%), alta tasa de irresecabilidad (80%) y notable complejidad quirúrgica (cifra de complicaciones graves del 30%). Como en otros tumores, la carcinogénesis acontece debida a mutaciones genéticas, que derivan en alteraciones cito-histológicas y, finalmente, en la adquisición capacidad invasora y metastásica. Los fenómenos inflamatorios favorecen el inicio, desarrollo y progresión de las neoplasias merced a una compleja patogenia en la que están implicados, fundamentalmente, los macrófagos y las citokinas proinflamatorias (IL-1, IL-6, TNFα).Además, la existencia de un estado de inflamación sistémica crónica se ha relacionado con el hipercatabolismo, el deterioro general y la caquexia terminal del paciente oncológico. Este estado proinflamatorio tiene un reflejo en la analítica sanguínea: elevación de reactantes de fase aguda (como la proteína C reactiva), hipoalbuminemia, neutrofilia, trombocitosis, linfopenia. En base a esto, se han definido scores y puntuaciones para cuantificar y graduar la alteración del estado inmuno-nutricional (Neutrophil Lymphocyte Ratio, Platelet Lymphocyte Ratio, Glasgow Prognostic Score, Prognostic Nutritional Index). Se ha demostrado que los valores obtenidos en los citados scores se correlacionan con los resultados de supervivencia oncológica en los pacientes con cáncer en general y con tumores pancreáticos en particular. También se ha estudiado su capacidad para predecir complicaciones postoperatorias e, incluso, para sospechar la degeneración maligna de algunas lesiones preneoplásicas del páncreas.Pancreatic cancer, though rare, is a clinical entity of exceeding interest due to its high mortality (5-year survival of 5%), unresectability (80%) and surgical complexity (implying a rate of complications up to 30%). As it occurs in other tumours, genetic mutations are the initial event of carcinogenesis, followed by histological aberrations. Finally, the malignant cell obtains invasive and metastatic ability. Inflammation has been related with development and progression of neoplasms, based on different pathogenic routes in which macrophages and proinflammatory cytokines (IL-1, IL-6, TNFα) play a major role. Moreover, chronic and systemic inflammatory condition is associated with induction of hypercatabolism, general impairment and terminal cachexia that appear in oncologic patients. This condition generates remarkable abnormalities in blood analysis:increased acute-phase reactants (such as reactive C protein), hypoalbuminemia, elevated neutrophils and platelets, lymphopenia. Consequently, different indexes and scores have been defined in order to quantify and graduate inflammatory and nutritional condition (Neutrophil Lymphocyte Ratio, Platelet Lymphocyte Ratio, Glasgow Prognostic Score, Prognostic Nutritional Index). Several studies have observed that these scores correlate with survival among oncologic patients, in cluding those with pancreatic cancer. Besides, association between prediction of postoperative morbidity and inflammatory scores has also been studied, as well as suspicion of malignant evolution of some preneoplastic pancreatic lesions

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain

Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95 % CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95 % CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95 % CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2 % of the sites used nutritional support (< 50 % used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4 % tried to use early oral feeding, but 88.2 % of the surveyed teams used some nutritional support; 26.5 % of respondents used TPN in 100 % of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6 % used TPN always, and EN in 19.3 % of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4 % of the units used early oral feeding, and 32.3 % used EN; 22.6 % used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country

Resultados de una encuesta sobre el soporte nutricional perioperatorio en la cirugía pancreática y biliar en España

Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (&lt; 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country.Introducción: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. Métodos: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. Resultados: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95 %: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95 %: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95 %: 7,6-13,3; rango, 2-33). Solo el 41,2 % de los grupos utilizaban soporte nutricional antes de la cirugía (< 50 % habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4 % habían intentado administrar una dieta oral precoz, pero el 88,2 % de los grupos usaron algún tipo de soporte nutricional y el 26,5 % usaron NP en el 100 % de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6 % utilizaron NP siempre y NE en el 19,3 % de los casos. Conclusiones: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4 % de las unidades usan nutrición oral precoz y el 32,3 % emplean la NE tras este tipo de cirugía. El 22,6 % de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación

Valoración de los factores pronóstico en el resultado del tratamiento del hepatocarcinoma mediante trasplante o resección

Objetivo. Determinar qué pacientes se beneficiarían de una resección parcial y cuales de un THO. Material y métodos. Desde junio 1986 a diciembre 2001: 93 resecciones (grupo A) y 71 THO (grupo B) por CHC.Resultados. La incidencia de recidiva es del 62,1 % en el grupo A y del 19 % en el grupo B (p=0,0001). La supervivencia media y actuarial a 5 años es 34,6 meses y 34 % en el grupo A y 95,2 meses y 50 % en el grupo B (p=0,047), con una SLE media y a 5 años de 33,7 meses y 18 % en el grupo A y de 90 meses y 49 % en el grupo B (p=0,0006). Los factores pronóstico en el grupo A son: edad 10 ng/ml, transfusión perioperatoria, tamaño > 3 cm, grado de diferenciación MD o PD, invasión vascular y margen libre 200 ng/ml, incidental, > 3 nódulos, tamaño > 5 cm, bilateral, MD o PD, presencia de invasión vascular, presencia de satelitosis, estadio pTNM IV e incumplimiento de los criterios de Mazzaferro. No se alcanzan diferencias significativas a favor del THO en pacientes con edad > 55 años, etiología mixta alcohólica y vírica, tamaño > 5 cm, tumores bilaterales, MD o PD, invasión vascular, satelitosis o estadio IV. Conclusiones. El THO ofrece mayores posibilidades de curación que la resección hepática parcial salvo en los pacientes con tumor bilateral, tamaño > 5 cm, > 3 nódulos, MD o PD, invasión vascular, satelitosis o estadio IV. No hemos demostrado ningún beneficio de la quimioembolización previa al THO. Hemos encontrado una relación entre el nivel preoperatorio de AFP > 200 ng/ml y la presencia de invasión vascular e incidencia de recidiva tumoral

Intraductal papillary neoplasia of the bile duct with malignancy: a differentiated entity of cholangiocarcinoma with a better prognosis. A review of three new cases

Introduction: Intraductal papillary neoplasms of the bile duct have been recognized as a differentiated entity to other biliary tumors since 2001. They are characterized by intraductal growth, with or without mucus production, and have malignant potential, although they have a better prognosis than other types of cholangiocarcinoma. Case reports: From January 2010 to August 2015, we included three patients with a confirmed diagnosis of bile duct intraductal papillary neoplasia with malignancy that were treated at our center. Two cases were male and one female with a mean age of 67.3 years. All three patients presented malignancy at the time of diagnosis. One patient was asymptomatic and the diagnosis was reported in the hepatectomy specimen after a liver transplant due to autoimmune hepatitis. The other two patients presented with cholestasis and acute cholangitis and the diagnosis was made based on imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) and endoscopic retrograde cholangiopancreatography (ERCP) with brushing and a biopsy. The treatment in both cases was surgical with a left hepatectomy, and resection of the left bile duct and segment I. They did not receive adjuvant treatment. None of the cases had recurrence of the disease. Discussion: Malignant intraductal papillary neoplasias of the biliary tract represent a different entity of cholangiocarcinoma with a better prognosis. Its diagnosis is based on imaging tests and histology by ERCP. The treatment is surgical, achieving a high rate of success with a low relapse rate

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Background & Aims: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. Methods: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. Results: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14–24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). Conclusions: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. Impact and implications: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.Methods An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.Results A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p &lt; 0.001). In all, 64% of the patients with benign IPMN had a Shin score &lt; 3 and 57% of those with a diagnosis of malignancy had a score &gt;= 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.Conclusion Patients with a Shin score &lt;= 1 should undergo surveillance, while patients with a score = 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines