Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65-87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 +/- 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients > or =75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.

Survival after distal splenorenal shunt in appreciably better in nonalcoholic patients than in alcoholics. This increase in survival does not appear to be dependent upon the state of biochemical liver function or the severity of changes in liver histology since these latter were similar for both groups. We suggest that the poorer survival of alcoholics may be related to continuing alcohol toxicity, and that a possible reason for the failure to demonstrate this difference in survival after portacaval shunts may be due to the harmful effects of total portal diversion on the liver.

Twelve patients with malignant obstruction of the biliary tree were treated by dilating the lesion percutaneously and inserting an internal large-bore teflon prosthesis in place bridging the the stricture. All 12 patients had unresectable neoplasms. The procedure was devised because existing modes of palliation using surgical techniques are associated with significant mortality or mobidity. There are also many problems with nonsurgical catheter drainage. Decompression was achieved in all 12 patients as shown radiographically by passage of contrast into the duodenum. Disappearance of pruitus was achieved in seven of seven patients, and in 10 of 12 disappearance of jaundice (bilirubin, before prosthesis, 18.4 +/- 4.5 mg/dl [mean +/- 1 SD], bilirubin 1 month after prosthesis, 1.8 +/- 0.6 mg/dl [mean +/- 1 SD], P less than 0.001) with improvement of general clinical status was achieved. Percutaneous placement of a permanent biliary tract prosthesis is safe and effective for the palliative decompression of malignant biliary tract obstruction.

The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.