OBJECTIVEThe optimal perioperative blood glucose range to improve surgical site infection (SSI) in surgical intensive care unit (ICU) patients remains unclear. We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy (IT). RESEARCH DESIGN AND METHODSPatients were randomly assigned to receive perioperative intensive IT, with a target blood glucose range of 4.4-6.1 mmol/L, or intermediate IT, with a target blood glucose range of 7.7-10.0 mmol/L in the surgical ICU. We defined the primary end point as the incidence of SSI. RESULTSStudy participants were randomly assigned to glucose control with one of two target ranges: for 225 patients in the intermediate IT group or for 222 patients in the intensive IT group, respectively. No patients in either group became hypoglycemic (<4.4 mmol/L) during their stay in the surgical ICU. In our series, the rate of SSI after hepato-biliary-pancreatic surgery was 6.7%. Patients in the intensive IT group, compared with the intermediate IT group, had fewer postoperative SSIs (9.8% vs. 4.1%, P = 0.028) and a lower incidence of postoperative pancreatic fistula after pancreatic resection (P = 0.040). The length of hospitalization required for patients in the intensive IT group was significantly shorter than that in the intermediate IT group (P = 0.017). CONCLUSIONSWe found that intensive IT decreased the incidence of SSI among patients who underwent hepato-biliary-pancreatic surgery: a blood glucose target of 4.4 to 6.1 mmol/L resulted in lower rate of SSI than did a target of 7.7-10.0 mmol/L.Hyperglycemia is common in acutely ill patients, including those treated in intensive care units (ICUs) (1). Until 2001, neglecting hyperglycemia was standard ICU care because a very impressive large randomized trial involving patients admitted to a surgical ICU showed that intensive insulin therapy (IT), targeting a blood glucose concentration of 4.4-6.1 mmol/L, significantly reduced in-hospital mortality (2). However, trials examining the effects of tight glycemic control (TGC) have had conflicting results (1,(3)(4)(5)(6). Systematic reviews and meta-analyses have also led to differing conclusions (7,8). The main reason these clinical trials and meta-analyses had negative results for TGC was the high incidence of hypoglycemia (10-17%) induced by intensive IT (7,8). A slide set summarizing this article is available online.

Carcinosarcoma of the hepatobiliary tract is highly aggressive and has a poor prognosis even after curative resection. The purpose of this study was to collate and analyze published data to clarify the surgical outcome of carcinosarcoma of the hepatobiliary tract and the relationships between potential prognostic factors and survival after surgery. We surveyed worldwide literature from 1970 to 2012 and obtained clinicopathological data for 131 patients who had undergone surgical resection for carcinosarcoma of the hepatobiliary tract, including one patient from our clinic. The relationships between potential prognostic factors and survival rates were examined using the Kaplan-Meier method and the log-rank test. The overall 1-, 3-, and 5-year survival rates for patients with carcinosarcoma of the hepatobiliary tract after surgery were 44.0, 29.3, and 27.0 %, respectively. In univariate analyses, age and gender were not significant prognostic factors; however, advanced stage according to the classification of the Union for International Cancer Control in resected specimens was significantly associated with a shorter survival time after surgery. Although carcinosarcoma of the hepatobiliary tract remains a rare disease worldwide, its poor prognosis, even after curative resection, demands further epidemiological and pathological study that could lead to the development of new management strategies.

Completion pancreatectomy is a safe and effective option in select patients with local pancreatic cancer recurrence in the remnant pancreas after initial pancreatectomy. It is essential to select patients who have a good performance status and can tolerate major surgery and the resultant apancreatic state.

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A 55-year-old man suffering from melena was admitted to our hospital. A blood test showed severe anemia. Contrast-enhanced computed tomography (CT) revealed a huge lesion in the duodenum and dilatation of the common bile duct. Upper gastrointestinal endoscopy also identified hemorrhaging from the tumor in the duodenum. Due to the low density of the tumor mass, we performed emergency pylorus-preserving pancreaticoduodenectomy. Histology revealed an area of well-differentiated liposarcoma as well as an area of highgrade spindle cells and pleomorphic sarcoma without obvious differentiation. The final pathological diagnosis was dedifferentiated liposarcoma. This is the first case report of primary liposarcoma of the duodenum.