Evolución y ventajas en la utilización de los abordajes mínimamente invasivos en la patología pancreática

La cirurgia mínimament invasiva; percutània, endoscòpica, laparoscòpica i robòtica aplicada a la patologia pancreàtica, té els seus orígens a finals del segle XX, principis del XXI. Inicialment d’una manera desconfiada, incrèdula i prudent es va anar introduint paulatinament en centres de referencia en cirurgia mínimament invasiva i especial dedicació a la cirurgia pancreàtica. En menys de 20 anys són desenes de centres en tot el món que no només realitzen totes les cirurgies pancreàtiques en la seva gran majoria mitjançant abordatges laparosòpic o robòtic, sinó que hi ha intervencions com la pancreatectomia distal o les enucleacions que són a dia d’avui, i en centres de referencia en cirurgia pancreàtica, el gold standard. La mateixa evolució ha desenvolupat la cirurgia relacionada amb la patologia pancreàtica benigna; la pancreatitis aguda greu. Es actualment una evidencia mèdica, que els pacients amb aquesta malaltia presenten millores en morbimortalitat després de ser intervinguts de manera mínimament invasiva. Tots els projectes d’aquesta tesi van néixer de la necessitat d’avaluar i millorar els nostres propis resultats tant en l’ús dels abordatges mínimament invasius en la pancreatitis aguda greu com en la realització de la duodenopancreatectomia cefàlica laparoscòpica. Actualment ambdós sectors de la cirurgia pancreàtica són en molts països realitzats de forma habitual mitjançant abordatges mínimament invasius, demostrant la seva viabilitat, factibilitat i millora, sempre i quan siguin realitzats en mans expertes i en centres especialitzats en cirurgia pancreàtica.La cirugía mínimamente invasiva; percutánea, endoscópica, laparoscópica y robótica aplicada a la patología pancreática, tiene sus orígenes a finales del siglo XX, principios del XXI. De una forma inicialmente más desconfiada, incrédula y prudente se fue introduciendo paulatinamente en centros referentes en cirugía mínimamente invasiva y especial dedicación a la cirugía pancreática. En menos de 20 años son decenas de centros en todo el mundo que no solo desarrollan todas las cirugías pancreáticas en su gran mayoría por abordaje laparoscópico o robótico, sino que hay intervenciones como la pancreatectomía distal, o las enucleaciones que son hoy día en centros referentes el gold standard. La misma evolución le ha sucedido a la cirugía que rodea a la patología benigna pancreática; la pancreatitis aguda grave. Es ya una evidencia médica, que los pacientes con esta patología presentan mejoras en morbimortalidad tras ser intervenidos de forma mínimamente invasiva. Todos los proyectos en esta tesis surgieron de la necesidad de evaluar y mejorar nuestros propios resultados tanto en el uso de los abordajes mínimamente invasivos en la pancreatitis aguda grave como en la realización de la duodenopancreatectomía cefálica laparoscópica. Actualmente ambos ámbitos de la cirugía pancreática son en muchos países reproducidos regularmente de forma mínimamente invasiva, demostrando su viabilidad, factibilidad y mejora, siempre en manos expertas y en centros especializados en cirugía pancreática.Minimally invasive surgery; percutaneous, endoscopic, laparoscopic and robotic applied to pancreatic pathology, has its origins in the late twentieth century, early twenty-first. In an initially more distrustful, incredulous and prudent way, it was gradually introduced in reference centers in minimally invasive surgery with special pancreatic surgery dedication. In less than 20 years there are dozens of centers around the world that not only develop all pancreatic surgeries mostly by laparoscopic or robotic approach, but currently there are also interventions such as distal pancreatectomy, or enucleations that become the gold standard procedure at referring centers. The same evolution has happened to the surgery that surrounds the benign pancreatic pathology; the severe acute pancreatitis. It is already a medical evidence that patients with this pathology present improvements in morbidity and mortality after being operated into a minimally invasive procedures. Every project in this thesis arose from the need to evaluate and improve our own results both, in the use of minimally invasive approaches in severe acute pancreatitis and in the performance of laparoscopic pancreatoduodenectomy. Currently, in many countries, both areas of pancreatic surgery are regularly reproduced in a minimally invasive approach, demonstrating their viability, feasibility and improvement, always in expert hands and in centers specialized in pancreatic surgery

Evolución y ventajas en la utilización de los abordajes mínimamente invasivos en la patología pancreática /

Departament responsable de la tesi: Departament de Cirurgia.Premi Extraordinari de Doctorat concedit pels programes de doctorat de la UAB per curs acadèmic 2019-2020La cirurgia mínimament invasiva; percutània, endoscòpica, laparoscòpica i robòtica aplicada a la patologia pancreàtica, té els seus orígens a finals del segle XX, principis del XXI. Inicialment d'una manera desconfiada, incrèdula i prudent es va anar introduint paulatinament en centres de referencia en cirurgia mínimament invasiva i especial dedicació a la cirurgia pancreàtica. En menys de 20 anys són desenes de centres en tot el món que no només realitzen totes les cirurgies pancreàtiques en la seva gran majoria mitjançant abordatges laparosòpic o robòtic, sinó que hi ha intervencions com la pancreatectomia distal o les enucleacions que són a dia d'avui, i en centres de referencia en cirurgia pancreàtica, el gold standard. La mateixa evolució ha desenvolupat la cirurgia relacionada amb la patologia pancreàtica benigna; la pancreatitis aguda greu. Es actualment una evidencia mèdica, que els pacients amb aquesta malaltia presenten millores en morbimortalitat després de ser intervinguts de manera mínimament invasiva. Tots els projectes d'aquesta tesi van néixer de la necessitat d'avaluar i millorar els nostres propis resultats tant en l'ús dels abordatges mínimament invasius en la pancreatitis aguda greu com en la realització de la duodenopancreatectomia cefàlica laparoscòpica. Actualment ambdós sectors de la cirurgia pancreàtica són en molts països realitzats de forma habitual mitjançant abordatges mínimament invasius, demostrant la seva viabilitat, factibilitat i millora, sempre i quan siguin realitzats en mans expertes i en centres especialitzats en cirurgia pancreàtica.La cirugía mínimamente invasiva; percutánea, endoscópica, laparoscópica y robótica aplicada a la patología pancreática, tiene sus orígenes a finales del siglo XX, principios del XXI. De una forma inicialmente más desconfiada, incrédula y prudente se fue introduciendo paulatinamente en centros referentes en cirugía mínimamente invasiva y especial dedicación a la cirugía pancreática. En menos de 20 años son decenas de centros en todo el mundo que no solo desarrollan todas las cirugías pancreáticas en su gran mayoría por abordaje laparoscópico o robótico, sino que hay intervenciones como la pancreatectomía distal, o las enucleaciones que son hoy día en centros referentes el gold standard. La misma evolución le ha sucedido a la cirugía que rodea a la patología benigna pancreática; la pancreatitis aguda grave. Es ya una evidencia médica, que los pacientes con esta patología presentan mejoras en morbimortalidad tras ser intervenidos de forma mínimamente invasiva. Todos los proyectos en esta tesis surgieron de la necesidad de evaluar y mejorar nuestros propios resultados tanto en el uso de los abordajes mínimamente invasivos en la pancreatitis aguda grave como en la realización de la duodenopancreatectomía cefálica laparoscópica. Actualmente ambos ámbitos de la cirugía pancreática son en muchos países reproducidos regularmente de forma mínimamente invasiva, demostrando su viabilidad, factibilidad y mejora, siempre en manos expertas y en centros especializados en cirugía pancreática.Minimally invasive surgery; percutaneous, endoscopic, laparoscopic and robotic applied to pancreatic pathology, has its origins in the late twentieth century, early twenty-first. In an initially more distrustful, incredulous and prudent way, it was gradually introduced in reference centers in minimally invasive surgery with special pancreatic surgery dedication. In less than 20 years there are dozens of centers around the world that not only develop all pancreatic surgeries mostly by laparoscopic or robotic approach, but currently there are also interventions such as distal pancreatectomy, or enucleations that become the gold standard procedure at referring centers. The same evolution has happened to the surgery that surrounds the benign pancreatic pathology; the severe acute pancreatitis. It is already a medical evidence that patients with this pathology present improvements in morbidity and mortality after being operated into a minimally invasive procedures. Every project in this thesis arose from the need to evaluate and improve our own results both, in the use of minimally invasive approaches in severe acute pancreatitis and in the performance of laparoscopic pancreatoduodenectomy. Currently, in many countries, both areas of pancreatic surgery are regularly reproduced in a minimally invasive approach, demonstrating their viability, feasibility and improvement, always in expert hands and in centers specialized in pancreatic surgery

Laparoscopic-adapted Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure that is becoming increasingly popular among surgeons. Postoperative pancreatic fistula (POPF) remains the most feared specific complication in reconstruction after PD. The Blumgart anastomosis (BA) has been established as one of the safest anastomosis for pancreas remnant reconstruction, with low rates of POPF and postoperative complications. The procedure for performing this anastomosis by laparoscopic approach has not been reported to date. METHODS: We describe our technique of LPD with laparoscopic-adapted BA (LapBA) and present the results obtained. A case-matched analysis with open cases of BA is also reported. RESULTS: Since February 2013 to February 2016, thirteen patients were operated of LapBA. An equivalent cohort of open PD patients was obtained by matching sex, ASA, pancreas consistency and main pancreatic duct diameter. Severe complications (grades III-IV) and length of stay were significantly lesser in LapBA group. No differences in POPF, readmission, reoperation rate and mortality were detected. CONCLUSIONS: The LapBA technique we propose can facilitate the pancreatic reconstruction after LPD. In this case-matched study, LPD shows superior results than open PD in terms of less severe postoperative complications and shorter length of stay. Randomized control trials are required to confirm these results

KRAS assessment following ESMO recommendations for colorectal liver metastases. Is it always worth it?

Background: Genetic evaluation is essential in assessing colorectal cancer (CRC) and colorectal liver metastasis (CRLM). The aim of this study was to determine the pragmatic value of KRAS on oncological outcomes after CRLM according to the ESMO recommendations and to query whether it is necessary to request KRAS testing in each situation. Methods: A retrospective cohort of 126 patients who underwent surgery for hepatic resection for CRLM between 2009 and 2020 were reviewed. The patients were divided into three categories: wild-type KRAS, mutated KRAS and impractical KRAS according to their oncological variables. The impractical (not tested) KRAS group included patients with metachronous tumours and negative lymph nodes harvested. Disease-free survival (DFS), overall survival (OS) and hepatic recurrence-free survival (HRFS) were calculated by the Kaplan-Meier method, and a multivariable analysis was conducted using the Cox proportional hazards regression model. Results: Of the 108 patients identified, 35 cases had KRAS wild-type, 50 cases had a KRAS mutation and the remaining 23 were classified as impractical KRAS. Significantly longer medians for OS, HRFS and DFS were found in the impractical KRAS group. In the multivariable analyses, the KRAS mutational gene was the only variable that was maintained through OS, HRFS and DFS. For HRFS (HR: 13.63; 95% confidence interval (CI): 1.35-100.62; p = 0.010 for KRAS), for DFS (HR: 10.06; 95% CI: 2.40-42.17; p = 0.002 for KRAS) and for OS (HR: 4.55%; 95% CI: 1.37-15.10; p = 0.013). Conclusion: Our study considers the possibility of unnecessary KRAS testing in patients with metachronous tumours and negative lymph nodes harvested. Combining the genetic mutational profile (i.e., KRAS in specific cases) with tumour characteristics helps patient selection and achieves the best prognosis after CRLM resection

Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis

To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure