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Cholangiocarcinoma (CCA) continues to be a difficult disease to both diagnose and treat. Optimal treatment includes resection to histologically negative margins. In recent years, advanced imaging, including magnetic resonance cholangiography and endoscopic ultrasound, has presumably improved the accuracy of determining resectability. From 2004 to 2009, a total of 61 patients with cholangiocarcinoma were evaluated for resection. The majority were men (37) and ages ranged from 29 to 87 years (mean, 67 years). Only 31 per cent were found to be obviously unresectable based on imaging alone. The remaining 69 per cent underwent exploration, at which time resection was found unfeasible in an additional 25 per cent (overall 56% unresectable). Although all resection specimens had grossly negative margins, 37 per cent were ultimately found to be microscopically positive. The overall 5-year actuarial survival for patients undergoing resection was 39.2 per cent with no survival difference between those with positive and negative margins. Despite advances in diagnostic imaging, more than half of patients with CCA presenting for surgical evaluation are ultimately found to be unresectable. However, the final determination can still only be made at the time of exploration. Even in the presence of microscopic residual disease, surgical intervention results in improved survival. An aggressive stance toward surgical intervention in patients with CCA remains justified.

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic débridement (DPD, n=13) or transgastric débridement using cyst-gastrostomy (CG, n=8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to débridement, a lower chance of needing multiple débridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.

The outcome of surgical intensive care unit (SICU) care after nonemergent orthotopic liver transplantation (OLTX) was evaluated in 168 consecutive patients over a 6-year period (1/90-12/95). Prospective data collected included age, first and last SICU day Simplified Acute Physiology Score and Quantitative Therapeutic Intervention System Score, SICU length of stay (LOS), and mortality. The patient population was 61 per cent male and 39 per cent female, with ages ranging from 20 to 75 years. A total of four patients died in the SICU, for a mortality of 2.4 per cent. Over the study period, SICU LOS decreased by 21 per cent, from 3.9 +/- 0.7 to 3.1 +/- 0.3 days (P < 0.05). Although no difference in admission severity of illness was observed over the study period, there was an increase in the intensity of intervention performed on admission to the SICU. Over the study period, there was no difference in severity of illness or intensity of intervention upon discharge to floor care. The decreased SICU LOS did not adversely affect patient mortality or severity of illness upon SICU discharge during the 6-year period. With intensified SICU intervention, nonemergent orthotopic liver transplantation patients can have a shorter SICU LOS without adverse effects on outcome.

Between February 1984 and July 1992, six adults with advanced pancreatic adenocarcinoma (n = 1), pancreatic neuroendocrine tumor (n = 2), and cholangiocarcinoma (n = 3) underwent radical foregut resections (n = 3) or radical pancreaticoduodenectomy (n = 3) combined with liver transplantation. The major postoperative complications included diarrhea (n = 4), pancreaticojejunostomy leak (n = 3), infection (n = 7), malnutrition (n = 3), refractory ascites (n = 2), and late hepatic artery thrombosis (n = 1). Tumor recurrence occurred in one patient. The actuarial survival for the group is 82 per cent at 1 year and 55 per cent at 2 years. The results demonstrate that radical pancreaticoduodenectomy/foregut resections combined with liver transplantation offer potential surgical cure of malignancies involving these organs. However, the procedure is formidable, with frequent complications.