A long-term evaluation of the modified mesh-plug hernioplasty in over 2,000 patients.

BACKGROUND: A modified technique for mesh-plug hernioplasty is a long-term, safe and efficacious treatment for primary unilateral inguinal herniorrhaphy. METHODS: Prospective analysis of 2,038 patients who underwent primary unilateral hernioplasty from 1997 to 2005 at a private university medical center. A modified technique using a mesh-plug was performed under local anesthesia with intravenous sedation. The modified technique consisted of placing the mesh plug into the preperitoneal space and suture fixation of the plug using the inner petals. The main outcome measures were Surgical morbidity, postoperative recovery, hernia recurrence, and chronic pain. RESULTS: There were 1,265 indirect and 773 direct hernias. Mean operative time was 28 min; mean recovery room time, 47 min. A total of 1,936 (95%) returned to normal activities within 3 days. Only 367 patients (18%) required prescription pain medication. Nine patients (0.4%) have been treated for chronic pain. No mesh infections or mesh migration have occurred. Three recurrences (0.15%) have been detected with a 99% follow-up over 2-10 years (mean 72 months). CONCLUSION: The modified mesh-plug hernioplasty is a safe and efficacious treatment option for the primary unilateral inguinal hernia patient.

Synchronous, metachronous, and multiple hepatic resections of liver tumors originating from primary gastric tumors.

BACKGROUND: The role of hepatic resection for noncolorectal gastrointestinal malignancies involving the liver is not well defined. To address this issue we studied our experience with resection of liver tumors arising from primary gastric malignancies. METHODS: A retrospective study of 195 patients who underwent a total of 207 liver resections identified 12 patients with primary gastric cancer who underwent 16 resections for liver involvement. There were 10 adenocarcinomas and two leiomyosarcomas. We examined the type of hepatic surgery, the status of residual disease, and the primary histologic findings. Morbidity, mortality, and actual survival rates were recorded. RESULTS: Thirty-day operative mortality was 8.3% (1 of 12). Hospital mortality was 25% (3 of 12). Operative morbidity occurred in three of nine survivors (33%). Synchronous en bloc resection (n = 3) of stomach and liver for adenocarcinoma produced two long-term survivors (no evidence of disease for 10 and 13 years). Mean survival after synchronous discontinuous resection (n = 4) was 8 months (range, 2 to 17 months). Metachronous resection for adenocarcinoma (n = 3) produced one long-term survivor (74 months), and one patient with recurrent leiomyosarcoma underwent a total of five liver resections and survived 64 months. CONCLUSIONS: For adenocarcinoma, en bloc resection of contiguous liver involvement produced long-term survivors. Synchronous resection of discontinuous metastases did not. Metachronous resection of isolated disease and multiple resections of recurrent isolated disease may have value in carefully selected patients.

Survival after repeat hepatic resection for recurrent colorectal hepatic metastases.

BACKGROUND: This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. METHODS: The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population. RESULTS: The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13). CONCLUSIONS: In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.

Pheochromocytoma: operative strategy.

We studied 28 patients who had undergone 30 operations for pheochromocytoma since 1964. The tumor types included bilateral, extra-adrenal, malignant, recurrent, and multiple endocrine neoplasia, with 20 tumors confined to the adrenal gland. The preoperative studies used to localize the tumor included ultrasonography, intravenous urography, angiography, and computed tomography. Patients underwent exploratory operations via flank, subcostal, bilateral subcostal, midline, or thoracoabdominal approaches. In one case, that of a recurrence after bilateral adrenalectomy, surgical exploration discovered a tumor that had not been localized during the preoperative workup. Two patients underwent splenectomy because of injury incurred during operative exploration. Our experience suggests that preoperative localization is highly reliable, and therefore the benefits of extensive surgical exploration may be outweighed by its risks. We believe that with the exception of tumors that occur in association with childhood or pregnancy, multiple endocrine neoplastic syndromes, or recurrent disease, a direct approach to the tumor, possibly via the flank, is justified. Our results suggest that exploration of the contralateral adrenal or periaortic area is not so important as to be worth jeopardizing the spleen or other organs by a complex or extensive dissection.

A 15-year review of esophagectomy for carcinoma of the esophagus and cardia.

OBJECTIVE: To evaluate the effect of surgical approach and adjuvant therapy on patients with carcinoma of the esophagus and/or cardia. DESIGN: Retrospective analysis of 157 consecutive patients who underwent esophagectomy. SETTING: A private university medical center and its affiliated community hospital. PATIENTS: One hundred twenty men and 37 women (mean age, 61.7 years) with carcinoma of the esophagus and/or cardia that was surgically treated between 1978 and 1993. INTERVENTIONS: Three approaches were used for resection: Transhiatal esophagectomy (THE) (n = 67), transthoracic esophagectomy (TTE) (n = 71), and abdominal-only esophagectomy (AOE) (n = 19). Sixty-five patients received adjuvant radiotherapy and chemotherapy. MAIN OUTCOME MEASURES: Surgical mortality, morbidity, and survival and the effect of adjuvant therapy. RESULTS: The overall surgical mortality rate was 7.6%: 12.7% with the TTE, 4.5% with the THE, and 0% with the AOE approach. A significantly increased incidence of adult respiratory distress syndrome (P < .001) and empyema (P < .001) was seen with the TTE approach. The average intraoperative blood loss (P = .08) and the median intensive care unit stay (P = .26) and hospital stay (P = .40) were decreased with the THE and AOE approaches when compared with the TTE approach without significance. The overall median survival time was 17 months, with a 5-year survival rate of 21%. There was no significant difference in survival by pathologic stage between approaches. The addition of adjuvant therapy did not affect the overall median survival time or the 5-year survival rate. Node-positive patients did benefit from adjuvant radiotherapy and chemotherapy, with increased median survival times from 7 to 15 months and a 5-year survival rate from 0% to 15% (P = .01). CONCLUSIONS: The THE and AOE approaches have fewer early complications than does TTE. Both THE and TTE have equal long-term survival rates. Adjuvant therapy provides increased survival to node-positive patients with carcinoma of the esophagus and/or cardia.

Transhiatal stapled esophagojejunostomy without a pursestring suture in patients with previous gastric resection.

Previous gastric resection complicates alimentary tract reconstruction after esophagectomy. Colonic interposition is the standard conduit in this circumstance, but has substantial mortality and morbidity, especially important when treatment goals are to provide effective alimentation and minimize hospital stay. This report details the technique of a transabdominal, intrathoracic, stapled esophagojejunostomy created without a pursestring suture, which was used to reconstruct the esophagus in 3 patients who had previously undergone partial gastrectomy. This technique avoids both colon interposition and thoracotomy, thereby minimizing the associated complications.

Abdominal emergencies.

Acute surgical conditions of the abdomen are heralded by pain, and can occur in patients hospitalized for unrelated reasons. A thorough history and physical examination, aided by certain laboratory and radiographic studies, are essential in making a correct diagnosis.

Recurrent intracranial epithelioid hemangioendothelioma associated with multicentric disease of liver and heart: case report.

Epithelioid hemangioendothelioma is an unusual vascular neoplasm with prominent cytoplasmic vacuolization representing primitive lumen formation. A case is presented of this unique vascular neoplasm in a woman with a seizure disorder who had cardiac, hepatic, and recurrent nervous system lesions. To our knowledge, this is the third known case of intracranial epithelioid hemangioendothelioma. Emphasis is placed on the indolent course of this rare neoplasm, with a recommendation for aggressive surgical treatment and diligent follow-up.

Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases.

Complications of laparoscopic cholecystectomy were evaluated by a survey of surgical department chairpersons at 4,292 US hospitals. The 77,604 cases were reported by 1,750 respondents. Laparotomy was required for treatment of a complication in 1.2% of patients. The mean rate of bile duct injury (exclusive of cystic duct) was 0.6% and was significantly lower at institutions that had performed more than 100 cases. Bile duct injuries were recognized postoperatively in half of the cases and most frequently required anastomotic repair. Intraoperative cholangiography was practiced selectively by 52% of the respondents and routinely by 31%. Bowel and vascular injuries, which occurred in 0.14% and 0.25% of cases, respectively, were the most lethal complications. Postoperative bile leak was recognized in 0.3% of patients, most commonly originating from the cystic duct. Eighteen of 33 postoperative deaths resulted from operative injury. These data demonstrate that laparoscopic cholecystectomy is associated with low rates of morbidity and mortality but a significant rate of bile duct injury.

Invasive therapy of metastatic colorectal cancer to the liver.

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

Integration of surgery in multimodality therapy for esophageal cancer.

BACKGROUND: While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival. PATIENTS AND METHODS: Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months. RESULTS: Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months). CONCLUSION: The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.

A prospective study of the mesh-plug hernioplasty.

A prospective study of patients with symptomatic inguinal hernias was undertaken to determine the safety and efficacy of the mesh-plug hernioplasty. Between May 1, 1997 and March 1, 1999 a total of 309 mesh-plug hernioplasties were performed on 283 patients. There were 43 recurrent and 26 bilateral hernioplasties. There were 273 men and 10 women ranging in age from 15 to 94 years (mean 47 years). There were 199 indirect, 104 direct, and six femoral hernias. Mean operative time for primary hernioplasty was 26 minutes (range 20-34) and 35 minutes (range 31-40) for recurrent hernioplasty. All procedures were performed as outpatient surgery with mean recovery room time being 45 minutes (range 25-27) for primary hernioplasty. Two hundred sixty-six patients (94%) returned to normal activities within 3 days. All manual laborers (124 patients) returned to work without restriction on postoperative day 14. Only 43 patients (15%) required prescription pain medication. At one year postoperatively 283 patients (100% follow-up) have been examined and no recurrence has been detected. At 2 years postoperatively 135 patients (100% follow-up) have been examined and no recurrence has been detected. The mesh-plug hernioplasty uses a minimum of medical resources, is associated with a small amount of postoperative pain, and has an early return to normal activities and manual labor without a documented early recurrence in this study.

Surgical palliation for ductal adenocarcinoma of the pancreas.

The short and long term outcomes of operative palliation for unresected ductal adenocarcinoma were evaluated in a critical review of 319 patients from 1972-1990. A total of 154 of 243 operated patients had palliative procedures, including biliary drainage in 86 per cent and combined biliary drainage and gastrojejunostomy in 53 per cent. Overall mortality rate was 13 per cent; one-half of the patients had some complication during their remaining lifetime. Biliary enteric anastomoses provided clinical relief of jaundice in 78 per cent of patients at hospital discharge; jaundice recurred in 16.7 per cent. The overall outcomes of choledochojejunostomy, cholecystojejunostomy, and choledochoduodenostomy were similar and superior to biliary intubation. Choledochojejunostomy was associated with a trend toward longer survival. Gastrojejunostomy did not affect overall results. However, upper gastrointestinal hemorrhage was more frequent when gastrojejunostomy was added to biliary bypass. Late duodenal obstruction developed in 6 per cent of patients initially treated by biliary drainage alone. Mean survival was 8.1 months; one-year survival was 18.2 per cent. Operative palliation for ductal cancer of the pancreas has important morbidity and mortality. Biliary enteric anastomoses provide lifelong relief of jaundice for most patients. Selective, rather than routine, gastrojejunostomy is recommended.

Intraoperative radiation therapy in biliary tract cancer.

From 1983 to 1986, nine patients with advanced cancers of the proximal biliary tract were treated with intraoperative electron beam radiation therapy (IORT) following surgical resection or intubation. Five patients also received external beam radiation and four received chemotherapy. Early complications were minimal. Late complications included cholangitis, gastroduodenal ulceration, gastric outlet obstruction and portal vein thrombosis. Symptomatic recurrent or residual disease developed in eight patients with a median disease-free survival of 6 months. Seven patients failed locally; four recurred outside of the intraoperatively radiated field. The longest survivor is free of disease at 40 months; one patient is alive with disease at 30 months. Mean and median survivals were 16.8 months and 13 months respectively with 56 per cent 1-year survival. This was not different from a mean survival of 11 months and 46 per cent 1-year survival observed in 13 concurrent patients treated by external beam +/- 192Ir. Survival of six patients not treated by radiation was only 4.6 months (P = 0.3). Two thirds of patients had good or fair palliation. IORT has theoretical advantages for the treatment of locally advanced biliary cancer; preliminary results suggest useful palliation and potential long-term survival. Complications require ongoing evaluation and superiority to conventional treatment modalities has not been demonstrated.

Hepatic resection for metastatic colorectal cancer.

One-hundred thirty-one primary hepatic resection for colorectal secondary tumors were performed at Rush-Presbyterian-St. Luke's Medical Center between 1975 and 1993. Perioperative mortality occurred in five patients (3.8%). Twenty-three patients had minor morbidities (18%); major morbidity occurred only in the five patients who died. Curative resections were performed in 107 patients. Overall actuarial survival at 2, 3, and 5 years was 62, 42, and 25 per cent, respectively. Patients with extrahepatic disease (5-year survival, 0% vs 27%; P = 0.049) and positive resection margins (0% vs 30%; P < 0.001) had significantly poorer survival. Among the curative resections, patients who had metachronous hepatic resections did significantly better than those who underwent synchronous colon and hepatic resections (35% vs 13%; P = 0.002). This survival benefit persisted when comparison was restricted to patients with synchronous metastases. Age, sex, race, number of lesions, site of colon primary resection, blood transfusion, disease-free interval, and extent of resection had no effect on survival. All patients who are acceptable surgical risks with potentially resectable metastatic colorectal cancer confined to the liver should undergo exploration. Assessment of resectability should include intraoperative ultrasound in all patients to maximize the probability of tumor clearance.

An open, minimally invasive approach to the lumbar spine.

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

Major abdominal operations in acquired immunodeficiency syndrome.

Twenty-one major abdominal operations performed on 20 patients with Acquired Immunodeficiency Syndrome (AIDS) were reviewed. Fourteen operations were for therapeutic indications, eight were emergent. The array of pathology encountered included opportunistic infection with Mycobacterium avium intracellulare, Cytomegalovirus, Cryptosporidium, abdominal tuberculosis, lymphoma, Kaposi's sarcoma, AIDS-related immune thrombocytopenia, perforated appendicitis and colonic pseudo-obstruction. Hospital mortality was 20 per cent. Major morbidity occurred in 15 per cent of patients and was more common following emergency operations. Preoperative demographic, hematologic, or nutritional parameters examined or the presence of single-organ system dysfunction did not predict outcome. Fifty-three per cent of hospital survivors are alive with a nine-month median postoperative follow-up. It is concluded that major abdominal procedures in patients with AIDS should not be withheld due to fear of excessive morbidity or mortality. General surgeons are involved in the evaluation and treatment of increasing numbers of patients with HIV infection. Appropriate management requires recognition of a wide range of surgical pathology and attention to details of safe intraoperative conduct.

Intraoperative ultrasound in the management of liver neoplasms.

The purpose of this study was to determine the impact of intraoperative ultrasound (IOUS) on the management of patients with neoplasms of the liver. Fifty-nine patients with liver neoplasms (primary, 6; metastatic, 53) and without pre- or intraoperative evidence of extrahepatic disease underwent laparotomy for possible liver resection. Preoperative imaging studies included external ultrasound (n = 12), magnetic resonance imaging (n = 11), and/or computed tomography (n = 57). Intraoperative evaluation on all patients included inspection, bimanual palpation, and ultrasonography. External ultrasound, magnetic resonance imaging, and computed tomography identified all intraoperatively confirmed liver neoplasms in 33, 45, and 67 per cent of cases, respectively. Unsuspected neoplasms were identified in 12 patients (20%) by inspection/palpation and in 19 patients (32%) by IOUS. In eight patients (14%), the occult neoplasms were identified only IOUS, and in one patient the neoplasms were identified only by inspection/palpation. Occult neoplasms identified by IOUS were characterized by small size (less than 2 cm). Findings from the intraoperative evaluation, such as unsuspected neoplasms and vascular proximity or invasion, altered the preoperative plan in 20 (34%) patients. Inspection, and particularly palpation, identifies a number of preoperatively unsuspected liver neoplasms. Intraoperative ultrasound, however, is the most sensitive method for detection of liver neoplasms and influences the operative management in a substantial number of patients.

Do angiogenesis and growth factor expression predict prognosis of esophageal cancer?

A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor alpha. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls (P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression (P < or = 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.

Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas.

A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.