ABSTRACT BACKGROUND: The unresectable pancreatic head tumors develop obstructive jaundice and cholestasis during follow-up. Cholestasis is associated with complications and treatment options are endoscopic stenting (ES) and biliary bypass surgery (BBS). AIMS: The aim of the current study was to compare the safety and efficacy of biliary bypass surgery (BBS) and endoscopic stenting (ES) for cholestasis in advanced pancreas cancer. METHODS: This is a retrospective cohort of patients with cholestasis and unresectable or metastatic pancreas cancer, treated with BBS or ES. Short and long-term outcomes were evaluated. We considered the need for hospital readmission due to biliary complications as treatment failure. RESULTS: A total of 93 patients (BBS=43; ES=50) were included in the study. BBS was associated with a higher demand for postoperative intensive care (37 vs.10%; p=0.002, p<0.050), longer intensive care unit stay (1.44 standard deviation±2.47 vs. 0.66±2.24 days; p=0.004, p<0.050), and longer length of hospital stay (7.95±2.99 vs. 4.29±5.50 days; p<0.001, p<0.050). BBS had a higher risk for procedure-related complications (23 vs. 8%; p=0.049, p<0.050). There was no difference in overall survival between BBS and ES (p=0.089, p>0.050). ES was independently associated with a higher risk for treatment failure than BBS on multivariate analysis (hazard ratio 3.97; p=0.009, p<0.050). CONCLUSIONS: BBS is associated with longer efficacy than ES for treating cholestasis in advanced pancreatic cancer. However, the BBS is associated with prolonged intensive care unit and hospital stays and higher demand for intensive care. BACKGROUND followup. followup follow up. up follow-up (ES BBS. . AIMS (BBS cancer METHODS longterm long term evaluated RESULTS 9 BBS=43 BBS43 43 (BBS=43 ES=50 ES50 50 37 (3 vs.10% vs10 vs 10 p0002 p 0 002 p=0.002 p<0.050, p0050 p<0.050 , 050 p<0.050) 1.44 144 1 44 (1.4 deviation247 deviation 2 47 deviation±2.4 066224 66 24 0.66±2.2 days p0004 004 p=0.004 7.95±2.99 795299 7 95 99 (7.95±2.9 429550 4 29 5 4.29±5.5 p0001 001 p<0.001 p<0.050. procedurerelated procedure related 23 (2 8% 8 p0049 049 p=0.049 p=0.089, p0089 089 (p=0.089 p>0.050. p>0.050 p>0.050) hazard 3.97 397 3 97 p0009 009 p=0.009 CONCLUSIONS However BBS=4 BBS4 (BBS=4 ES=5 ES5 ( vs.10 vs1 p000 00 p=0.00 p005 p<0.05 05 1.4 14 (1. deviation24 deviation±2. 06622 6 0.66±2. 7.95±2.9 79529 (7.95±2. 42955 4.29±5. p<0.00 p004 04 p=0.04 p=0.089 p008 08 (p=0.08 p>0.05 3.9 39 BBS= (BBS= ES= vs.1 p00 p=0.0 p<0.0 1. (1 deviation2 deviation±2 0662 0.66±2 7.95±2. 7952 (7.95±2 4295 4.29±5 p=0.08 (p=0.0 p>0.0 3. p0 p=0. p<0. deviation± 066 0.66± 7.95±2 795 (7.95± 429 4.29± (p=0. p>0. p=0 p<0 06 0.66 7.95± 79 (7.95 42 4.29 (p=0 p>0 p= p< 0.6 7.95 (7.9 4.2 (p= p> 0. 7.9 (7. 4. (p 7. (7

RESUMO RACIONAL: Os tumores irressecáveis da cabeça do pâncreas desenvolvem icterícia por obstrução e colestase durante o acompanhamento. A colestase está associada a complicações e as opções de tratamento são colocação de prótese endoscópica (PE) e a cirurgia biliodigestiva (CB). OBJETIVOS: O objetivo do presente estudo é comparar a segurança e eficácia da cirurgia biliodigestiva (CB) com a prótese endoscópica (PE) para colestase em câncer de pâncreas avançado. MÉTODOS: Este é um estudo coorte retrospectivo de pacientes com colestase e câncer de pâncreas irressecável ou metastático, tratados com CB ou PE. Os resultados de curto e longo prazo foram avaliados. Consideramos a necessidade de readmissão hospitalar por complicações biliares falha no tratamento. RESULTADOS: Foram incluídos 93 pacientes (CB=43; PE=50). A CB foi associada a maior demanda por cuidados intensivos pós-operatórios (37 vs. 10%; p=0,002, p<0.05), maior tempo de permanência na UTI (1,44±2,47 vs. 0,66±2,24 dias; p=0,004, p<0.05) e maior tempo de internação hospitalar (7,95±2,99 vs. 4,29±5,5 dias. A CB apresentou maior risco de complicações relacionadas ao procedimento (23 vs. 8%; p=0,049, p<0.05). Não houve diferença na sobrevida global entre CB e PE (p=0,089). A PE foi independentemente associada a um maior risco de falha do tratamento do que a CCB na análise multivariada (HR=3,97; p=0,009). CONCLUSÕES: A CB está associada a uma eficácia mais prolongada do que a PE no tratamento da colestase no câncer pancreático avançado. Entretanto, a CB está associada a internações prolongadas em UTI e hospitalares e maior demanda por cuidados intensivos. RACIONAL acompanhamento (PE CB. . OBJETIVOS (CB avançado MÉTODOS metastático avaliados RESULTADOS 9 CB=43 CB43 43 (CB=43 PE=50. PE50 PE=50 50 PE=50) pósoperatórios pós operatórios 37 (3 vs 10% 10 p0002 p 0 002 p=0,002 p<0.05, p005 p<0.05 , 05 1,44±2,47 144247 1 44 2 47 (1,44±2,4 066224 66 24 0,66±2,2 dias p0004 004 p=0,004 7,95±2,99 795299 7 95 99 (7,95±2,9 42955 4 29 5 4,29±5, 23 (2 8% 8 p0049 049 p=0,049 p<0.05. p=0,089. p0089 p=0,089 089 (p=0,089) HR=3,97 HR397 HR 3 97 (HR=3,97 p=0,009. p0009 p=0,009 009 p=0,009) CONCLUSÕES Entretanto CB=4 CB4 (CB=4 PE5 PE=5 ( p000 00 p=0,00 p00 p<0.0 1,44±2,4 14424 (1,44±2, 06622 6 0,66±2, 7,95±2,9 79529 (7,95±2, 4295 4,29±5 p004 04 p=0,04 p008 p=0,08 08 (p=0,089 HR=3,9 HR39 (HR=3,9 CB= (CB= PE= p=0,0 p0 p<0. 1,44±2, 1442 (1,44±2 0662 0,66±2 7,95±2, 7952 (7,95±2 429 4,29± (p=0,08 HR=3, HR3 (HR=3, p=0, p<0 1,44±2 144 (1,44± 066 0,66± 7,95±2 795 (7,95± 42 4,29 (p=0,0 HR=3 (HR=3 p=0 p< 1,44± 14 (1,44 06 0,66 7,95± 79 (7,95 4,2 (p=0, HR= (HR= p= 1,44 (1,4 0,6 7,95 (7,9 4, (p=0 (HR 1,4 (1, 0, 7,9 (7, (p= 1, (1 7, (7 (p

ABSTRACT Schistosomiasis is an infectious disease caused by parasitic flatworms of the genus Schistosoma. The species Schistosoma mansoni is associated with hepatosplenic disease. Schistosomiasis involving the gallbladder alone is highly unusual, with a few cases reported. Herein, we present the case of a woman from a region with endemic schistosomiasis who presented with a painless solid lesion and wall thickening of the gallbladder. She underwent an uneventful laparoscopic cholecystectomy. Microscopic examination of the surgical specimen revealed Schistosoma mansoni eggs associated with granulomatous reaction, leading to the diagnosis of schistosomiasis of the gallbladder, prompting subsequent treatment with praziquantel and follow-up. This case illustrates the importance of suspicion for this diagnosis in endemic areas, as it can be misdiagnosed with malignancy if not examined microscopically. Complications and treatment strategies are poorly characterized for the few cases of schistosomiasis; reporting this case can serve as a helpful reminder of a rare presentation of this disease. unusual reported Herein cholecystectomy reaction followup. followup follow up. up follow-up areas microscopically

RESUMO RACIONAL: A pancreatectomia distal minimamente invasiva (PDMI) está associada a menos perda sanguínea e recuperação funcional mais rápida, no entanto, os benefícios da pancreatectomia distal robótica (PDR) são desconhecidos quando comparada a pancreatectomia distal laparoscópica (PDL). OBJETIVOS: Comparar PDR versus PDL no tratamento cirúrgico de lesões benignas, neoplasias pancreáticas malignas, pré-malignas e limítrofes. MÉTODOS: Estudo retrospectivo comparando PDL com PDR. Os desfechos primários avaliados foram morbidade e custos hospitalares. Os desfechos secundários foram fístula pancreática (FP), complicações infecciosas, readmissão, tempo cirúrgico e tempo de internação hospitalar (TIH). RESULTADOS: Trinta pacientes submetidos a PDL e 29 submetidos a PDR foram incluídos no estudo. Não houve diferença em relação às características pré-operatórias. Não houve diferença em relação às complicações gerais (PDL – 72,4% versus PRD – 80%, p=0,49). Os custos foram superiores para PDR (PDR=US$ 6688 versus PDL=US$ 6149, p=0,02), principalmente devido aos custos mais elevados de materiais cirúrgicos (PDR=US$ 2364 versus PDL=1421, p=0,00005). Vinte e um pacientes submetidos a PDR e 24 submetidos a PDL desenvolveram fístula pancreática (PF), no entanto, apenas 4 submetidos PDR e 7 a PDL apresentaram complicações infecciosas associadas a FP. O tempo cirúrgico (PDR=224 min. versus PDL=213 min., p=0,36) e a conversão para cirurgia aberta (1 PDR e 2 PDL) não tiveram diferença estatística. CONCLUSÕES: A morbidade pós operatória da pancreatectomia distal robótica é comparável à pancreatectomia distal laparoscópica. Entretando, os custos da pancreatectomia distal robótica são mais elevados. RACIONAL PDMI (PDMI rápida entanto (PDR PDL. . (PDL) OBJETIVOS benignas malignas prémalignas pré limítrofes MÉTODOS hospitalares FP, FP , (FP) readmissão TIH. TIH (TIH) RESULTADOS estudo préoperatórias. préoperatórias operatórias. operatórias pré-operatórias 724 72 72,4 80 80% p=0,49. p049 p p=0,49 0 49 p=0,49) PDR=US$ PDRUS US (PDR=US 668 PDLUS PDL=US 6149 p=0,02, p002 p=0,02 02 p=0,02) 236 PDL1421 1421 PDL=1421 p=0,00005. p000005 p=0,00005 00005 p=0,00005) PF, PF (PF) PDR=224 PDR224 224 (PDR=22 min PDL213 213 PDL=21 p=0,36 p036 36 1 ( estatística CONCLUSÕES Entretando (FP (TIH 72, 8 p04 p=0,4 PDR=US 66 614 p00 p=0,0 23 PDL142 142 PDL=142 p00000 p=0,0000 0000 (PF PDR=22 PDR22 22 (PDR=2 PDL21 21 PDL=2 p=0,3 p03 3 p0 p=0, 6 61 PDL14 14 PDL=14 p0000 p=0,000 000 PDR=2 PDR2 (PDR= PDL2 PDL= p=0 PDL1 PDL=1 p000 p=0,00 00 PDR= p=

ABSTRACT BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown. AIMS: To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias. METHODS: This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS). RESULTS: Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP – 72,4% versus LDP – 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP). CONCLUSIONS: The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher. BACKGROUND MIDP (MIDP recovery However (LDP unknown AIMS lesions premalignant pre neoplasias METHODS PF, PF , (PF) readmission (OT LOS. LOS . (LOS) RESULTS characteristics 724 72 72,4 80 80% p=0,49. p049 p p=0,49 0 49 p=0,49) RDP=US$ RDPUS US (RDP=US 6688 6 688 6,68 LDPUS LDP=US 6149 149 6,149 p=0,02, p002 p=0,02 02 p=0,02) 2364 364 2,36 LDP1421 1 421 LDP=1,421 p=0,00005. p000005 p=0,00005 00005 p=0,00005) Twentyone Twenty one RDP=224 RDP224 224 (RDP=22 min LDP213 213 LDP=21 p=0.36 p036 36 similar ( LDP. LDP) CONCLUSIONS (PF (LOS 72, 8 p04 p=0,4 RDP=US 668 68 6,6 614 14 6,14 p00 p=0,0 236 2,3 LDP142 42 LDP=1,42 p00000 p=0,0000 0000 RDP=22 RDP22 22 (RDP=2 LDP21 21 LDP=2 p=0.3 p03 3 p0 p=0, 66 6, 61 6,1 23 2, LDP14 LDP=1,4 p0000 p=0,000 000 RDP=2 RDP2 (RDP= LDP2 LDP= p=0. p=0 LDP1 LDP=1, p000 p=0,00 00 RDP= p= LDP=1

RESUMO RACIONAL: A neoplasia sólida pseudopapilífera do pâncreas é um tumor pancreático incomum, mais frequente em mulheres jovens. A polipose adenomatosa familiar, por sua vez, é uma condição genética associada a câncer colorretal e que também aumenta o risco de desenvolvimento de outros tumores. OBJETIVOS: Discutir a associação entre polipose adenomatosa familiar e neoplasia sólida pseudopapilífera, que é bastante rara. MÉTODOS: Reportamos dois casos de pacientes com polipose adenomatosa familiar, um homem e uma mulher, que desenvolveram neoplasia sólida pseudopapilífera do pâncreas e foram submetidos a ressecção laparoscópica com preservação esplênica. RESULTADOS: As vias de sinalização da ß-catenina e Wnt tem um papel importante na tumorigênese da neoplasia sólida pseudopapilífera, e sua ativação constitutiva devido a inativação do gene adenomatous polyposis coli na polipose adenomatosa familiar pode explicar a relação entre polipose adenomatosa familiar e neoplasia sólida pseudopapilífera. CONCLUSÕES: A ressecção do cólon deve ser priorizada, com preferência pela abordagem minimamente invasiva para minimizar o risco de desenvolvimento de tumor desmoide. A ressecção pancreática geralmente não requer linfadenectomia extensa para neoplasia sólida pseudopapilífera, portanto, a preservação esplênica é factível. RACIONAL incomum jovens vez tumores OBJETIVOS rara MÉTODOS mulher RESULTADOS ßcatenina ß catenina CONCLUSÕES priorizada desmoide portanto factível

ABSTRACT BACKGROUND: Solid pseudopapillary neoplasm of the pancreas is an uncommon pancreatic tumor, which is more frequent in young adult women. Familial adenomatous polyposis is a genetic condition associated with colorectal cancer that also increases the risk of developing other tumors as well. AIM: The aim of this study was to discuss the association of familial adenomatous polyposis with solid pseudopapillary neoplasm of the pancreas, which is very rare. METHODS: We report two cases of patients with familial adenomatous polyposis who developed solid pseudopapillary neoplasm of the pancreas of the pancreas and were submitted to laparoscopic pancreatic resections with splenic preservation (one male and one female). RESULTS: ß-catenin and Wnt signaling pathways have been found to play an important role in the tumorigenesis of solid pseudopapillary neoplasm of the pancreas, and their constitutive activation due to adenomatous polyposis coli gene inactivation in familial adenomatous polyposis may explain the relationship between familial adenomatous polyposis and solid pseudopapillary neoplasm of the pancreas. CONCLUSION: Colonic resection must be prioritized, and a minimally invasive approach is preferred to minimize the risk of developing desmoid tumor. Pancreatic resection usually does not require extensive lymphadenectomy for solid pseudopapillary neoplasm of the pancreas, and splenic preservation is feasible. BACKGROUND tumor women well AIM rare METHODS female. female . female) RESULTS ßcatenin ß catenin CONCLUSION prioritized feasible

RESUMO Racional: Tumores sólidos pseudopapilíferos do pâncreas são em geral massas circunscritas, com componentes sólidos e císticos, mais frequentemente encontrados em mulheres jovens. Na maioria dos casos, são neoplasias benignas e portanto, a abordagem minimamente invasiva pode ser considerada vantajosa. Objetivo: Avaliar os resultados das pancreatectomias laparoscópicas em pacientes com esses tumores. Métodos: Foram avaliados pacientes submetidos à pancreatectomias minimamente invasivas em um única instituição. Foram analisadas variáveis demográficas, clinicopatológicas, complicações pós-operatórias e sobrevida. Resultados: Todos os pacientes eram mulheres e a idade mediana foi de 39 (18-54) anos. Duas pacientes com tumores na cabeça do pâncreas foram submetidas à duodenopancreatectomia e outra à enucleação. Duas pacientes com tumores no colo do pâncreas realizaram pancreatectomia central. Outras cinco com neoplasias no corpo e cauda foram submetidas à pancreatectomia distal, uma delas com preservação do baço. Nenhuma necessitou de conversão para laparotomia. Houve duas fístulas pancreáticas clinicamente relevantes (20%). O tempo mediano de internação foi de cinco (2 a 8) dias e duas pacientes foram reinternadas (20%). Todas as margens de ressecção foram negativas e após seguimento mediano de 38 (14-71) semanas, todas estavam livres de doença. Conclusão: As ressecções pancreáticas minimamente invasivas de tumores sólidos pseudopapilíferos são factíveis para tumores em diferentes localizações no pâncreas, com morbidade aceitável obedecendo-se os princípios oncológicos para o tratamento dessas neoplasias.

ABSTRACT Background: Solid pseudopapillary pancreatic neoplasia is usually a large well-circumscribed pancreatic mass, with cystic and solid areas more frequently found in young women. It is a benign pancreatic neoplasia in most cases, therefore minimally invasive surgery could be an interesting approach. Aim: Evaluate the results of minimally invasive surgery for this neoplasia. Methods: Patients with this tumor who underwent minimally invasive pancreatectomies between 2009 and 2015 in a single institution, were analyzed regarding demographic, clinical-pathological futures, post-operative morbidity and disease-free survival. Results: All were women, and their median age was 39 (18-54) years. Two patients with tumor in the head of the pancreas underwent laparoscopic pancreaticoduodenectomy, and another one underwent laparoscopic enucleation. Two patients with tumor in the neck underwent central pancreatectomy. Distal pancreatectomies were performed in the other five, one with splenic preservation. None required blood transfusion or conversion to open surgery. Two (20%) developed clinical relevant pancreatic fistulas, requiring readmission. Median length of postoperative hospital stay was five days (2-8). All resection margins were negative. Patients were followed for a median of 38 months (14-71), and there was no recurrence. Conclusions: Minimally invasive surgery for solid pseudopapillary pancreatic neoplasia is feasible for tumors in different locations in the pancreas. It was associated with acceptable morbidity and respected the oncologic principles for treatment.

OBJECTIVE: To evaluate the prognostic significance of microvessel density and p53 expression in pancreatic cancer. METHODS: Between 2008 and 2012, 49 patients with pancreatic adenocarcinoma underwent resection with curative intention. The resected specimens were immunohistochemically stained with anti-p53 and anti-CD34 antibodies. Microvessel density was assessed by counting vessels within ten areas of each tumoral section a highpower microscope. RESULTS: The microvessel density ranged from 21.2 to 54.2 vessels/mm2. Positive nuclear staining for p53 was found in 20 patients (40.6%). The overall median survival rate after resection was 24.1 months and there were no differences in survival rates related to microvessel density or p53 positivity. Microvessel density was associated with tumor diameter greater than 3.0 cm and with R0 resection failure. CONCLUSIONS: Microvessel density was associated with R1 resection and with larger tumors. p53 expression was not correlated with intratumoral microvessel density in pancreatic adenocarcinoma.