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Biomedical subjects

Olivier R C Busch

Publications and source records attributed to Olivier R C Busch.

At least 19 recordsLinked to original sources
PubMed2006

Obstructive jaundice due to hepatobiliary cystadenoma or cystadenocarcinoma.

Hepatobiliary cystadenomas (HBC) and cystadenocarcinomas are rare cystic lesions. Most patients with these lesions are asymptomatic, but presentation with obstructive jaundice may occur. The first patient presented with intermittent colicky pain and recurrent obstructive jaundice. Imaging studies revealed a polypoid lesion in the left hepatic duct. The second patient had recurrent jaundice and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a cystic lesion at the confluence of the hepatic duct. In the third patient with intermittent jaundice and cholangitis, cholangioscopy revealed a papillomatous structure protruding into the left bile duct system. In the fourth patient with obstructive jaundice, CT-scan showed slight dilatation of the intrahepatic bile ducts and dilatation of the common bile duct of 3 cm. ERCP showed filling of a cystic lesion. All patients underwent partial liver resection, revealing HBC in the specimen. In the fifth patient presenting with obstructive jaundice, ultrasound examination showed a hyperechogenic cystic lesion centrally in the liver. The resection specimen revealed a hepatobiliary cystadenocarcinoma. HBC and cystadenocarcinoma may give rise to obstructive jaundice. Evaluation with cross-sectional imaging techniques is useful. ERCP is a useful tool to differentiate extraductal from intraductal obstruction.

Adult↗
PubMed2006

Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction.

The incidence of adenocarcinoma of the esophagus is rising rapidly in Western Europe and North America. It is an aggressive disease with early lymphatic and hematogenous dissemination. TNM cancer staging systems predict survival on the basis of the anatomic extent of the tumor. However, the adequacy of the current TNM staging system for adenocarcinoma of the esophagus or gastroesophageal junction (GEJ) is questioned repeatedly. Numerous prognostic factors have been described, but are not included in the TNM system. This review describes clinical parameters, aspects of operative technique, response to preoperative chemoradiotherapy therapy, complications and established pathologic determinants found in the resection specimen that have a prognostic impact. Furthermore, their potential application in the clinical setting in patients with adenocarcinoma of the esophagus or GEJ is discussed. Future directions to improve staging systems are given.

Adenocarcinoma↗
PubMed2006

Improved outcome of resection of hilar cholangiocarcinoma (Klatskin tumor).

BACKGROUND: Treatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors. METHODS: A total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988-1993; n=45), 2 (1993-1998; n=25), and 3 (1998-2003; n=29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival. RESULTS: The proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P<.05). Two-year survival increased significantly from 33%+/-7% and 39%+/-10% in periods 1 and 2 to 60%+/-11% in period 3 (P<.05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis. CONCLUSIONS: Mainly in the last 5-year period (1998-2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.

Adult↗
PubMed2006

Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection.

BACKGROUND: The aim of this study was to compare morbidity and mortality of patients who had epidural analgesia for at least 2 days after transthoracic esophagectomy for cancer with those who did not have epidural analgesia at all or who had it for less than 2 days. STUDY DESIGN: We analyzed 182 patients, 7 of whom were excluded. Patients were divided into two groups; 90 patients (51%) with epidural analgesia for at least 2 days (epidural group) and 85 patients (49%) who did not have epidural analgesia or had it for less than 2 days (no epidural group). To identify prognostic factors for pneumonia, univariate and multivariate logistic regression analyses were performed. RESULTS: There were no notable differences in clinicopathologic characteristics or intraoperative measurements. In favor of the epidural group, marked differences were found in pneumonia (28% versus 48%, p = 0.005), reintubation (17% versus 34%, p = 0.011), ICU-stay (median 2.8 versus 5.8 days, p = 0.001), hospital stay (median 17 versus 21 days, p = 0.015), and in-hospital mortality (0 versus 8 patients, p = 0.003). No epidural analgesia (odds ratio [OR] 2.48, 95% CI 1.30 to 4.71, p = 0.006) and atelectasis (OR 2.06, 95% CI 1.08 to 3.90, p = 0.028) were independent predictors for pneumonia. There were eight in-hospital deaths. CONCLUSIONS: No epidural analgesia for more than 2 days after a transthoracic esophageal cancer resection is associated with increased postoperative morbidity. To optimize postoperative recovery, it is of vital importance to ensure adequate epidural analgesia in these patients.

Analgesia, Epidural↗
PubMed2006

Nasogastric intubation after abdominal surgery: a meta-analysis of recent literature.

OBJECTIVE: To determine whether refraining from nasogastric intubation (NGI) in patients after abdominal surgery will result in the same therapeutic effectiveness as using NGI. Data Source We identified randomized trials from the Cochrane Central Register of Controlled Trials published between January 1990 and January 2005. STUDY SELECTION: Two of us independently selected trials based on randomization, abdominal surgery in patients, early vs late removal of the NGI, and reporting at least 1 of the following end points: hospital stay, gastrointestinal function, and postoperative complications. DATA EXTRACTION: Two of us independently performed trial quality assessment and data extraction. Trials were judged using a structured list that included factors relating to internal and external validity. Data were entered and analyzed by means of dedicated software from the Cochrane Collaboration. DATA SYNTHESIS: Seventeen randomized trials met the inclusion criteria. Meta-analysis showed that NGI does not offer any clinically relevant benefits for patients after abdominal surgery, such as recovery of gastrointestinal function or reduction of postoperative complications (relative risk, 1.18; 95% confidence interval, 0.98-1.42). Moreover, NGI showed some undesired effects, such as discomfort (in 60% of the NGI patients) and a later return to a liquid diet (weighted mean difference, 0.65 days; 95% confidence interval, 0.38-0.92 days) or a regular diet, whereas hospital stay was not shortened. CONCLUSIONS: Routine NGI seems to serve no beneficial purpose and may even be harmful in patients after modern abdominal surgery; also, it is uncomfortable. Therefore, NGI is recommended only as a therapeutic approach.

Digestive System Surgical Procedures↗
PubMed2006

Extracapsular lymph node involvement in node-positive patients with adenocarcinoma of the distal esophagus or gastroesophageal junction.

In adenocarcinoma of the esophagus or gastroesophageal junction, little attention has been paid to the biologic significance of extracapsular lymph node involvement (LNI). In the present study, a consecutive series of 251 patients with lymph node dissemination were reviewed. All patients underwent esophagectomy for adenocarcinoma and were prospectively followed. A total of 1562 positive lymph nodes were reexamined. Extracapsular LNI was identified in 456 lymph nodes (29%) in 166 patients (66%). Extracapsular LNI was confined to one lymph node in 63 patients (38%). The occurrence of extracapsular LNI increased significantly with the depth of invasion, presence of positive resectable truncal nodes, number of resected nodes, number of positive nodes, and lymph node ratio. The median potential follow-up period was 58 months (range, 12-143 months). In this period, 178 patients died of recurrent disease. The pattern of recurrence was comparable between patients with and without extracapsular LNI (P = 0.938). The median survival in patients with extracapsular LNI was 15 months (95% confidence interval, 12-18 months) compared with 41 months (95% confidence interval, 19-64 months) in those without extracapsular LNI (P < 0.001). Median survival of patients with 2 or more lymph nodes was 12 months (95% confidence interval, 8-15 months). Multivariate analysis demonstrated that T-stage, extracapsular LNI, and lymph node ratio were independent prognostic factors. The presence of extracapsular LNI identifies a subgroup with a significantly worse long-term survival. Together with the T-stage and the lymph node ratio, extracapsular LNI reflects a particularly aggressive biologic behavior and has significant prognostic potential.

Adenocarcinoma↗
PubMed2006

Management of spontaneous haemorrhage and rupture of hepatocellular adenomas. A single centre experience.

BACKGROUND: Hepatocellular adenomas (HCA) may present with spontaneous haemorrhage and rupture. The aim of this study was to assess management in 22 patients treated for haemorrhage and/or rupture of HCA. PATIENTS AND METHODS: Between May 1990 and July 2005, 22 female patients were diagnosed with acute haemorrhage and/or rupture of lesions highly suspicious of HCA. Preoperative imaging diagnostics and pathologic specimens were reviewed. RESULTS: Twelve haemodynamically stable and four unstable patients could be treated conservatively. One patient underwent acute partial liver resection, whereas four patients underwent laparotomy with initial packing of the liver. In one patient, selective embolisation of the left hepatic artery was performed. Fifteen patients eventually underwent resection after a mean time of 8 months after initial treatment. Six patients did not undergo resection and showed no complications or rebleeding after a mean follow-up of 24.6 months. Only in seven patients, histopathological examination showed HCA, and in one patient, HCA with focal nodular hyperplasia. CONCLUSION: HCA with haemorrhage and/or rupture does not necessarily require immediate liver resection. Conservative treatment is justified in stable patients. In case of an instable patient with or without hemoperitoneum, laparotomy with packing or selective embolisation can stop the bleeding.

Adenoma, Liver Cell↗
PubMed2005

Case report of a smuggler's dinner: carrots and asparagus, or bolitas?

BACKGROUND: Body packing is a distinct method of drug smuggling. Surgeons and intensive care specialists will be confronted with body packers when packets do not pass spontaneously and rupture, causing drug toxicity. CASE REPORT: We report of a 32-year-old Liberian male who presented with abdominal complaints and anxiety after having ingested 50 cocaine-containing packets of which 49 had passed the natural route in the previous days. X-ray of his abdomen showed a structure possibly compatible with a packet in or projected over the stomach. We decided to transfer the patient to the operation theatre for surgical removal via gastrotomy. However, no packet was found. During his first day in the intensive care unit he did not regain consciousness. Repeated urine analyses for cocaine were negative. After one day he deteriorated: he needed circulatory support because of hypotension, without signs of sepsis. Repeated surgery revealed no packet. In the end he turned out not to be suffering from cocaine intoxication. CONCLUSIONS: When confronted with a case of body packing in which packets do not pass spontaneously and produce bowel obstruction or in which badly wrapped packets rupture, causing drug toxicity, it is of utmost importance to establish the nature of the packet's content.

Adult↗
PubMed2005

Incidence and management of chyle leakage after esophagectomy.

BACKGROUND: Postoperative chyle leakage is a rare but well-recognized complication after esophageal surgery. The aim of this study was to identify its incidence and potentially predisposing factors and to assess the consequences and management. METHODS: A consecutive series of 536 patients who underwent esophagectomy for malignant disease of the esophagus or gastroesophageal junction was reviewed. RESULTS: There were 20 patients (3.7%) with chyle leakage. After transthoracic esophagectomy the risk for the development of chyle leakage was higher than after transhiatal resection (p = 0.006). Chyle leakage was associated with more positive nodes (p = 0.041). Patients with chyle leakage had significantly more pulmonary complications (p < 0.001) and longer intensive care unit (p = 0.015) and hospital stays (p = 0.001). No patient with chyle leakage died. Conservative management, consisting of no enteral feeding and total parenteral nutrition, was instituted in all patients, but was abandoned in 4 patients (20%) because of persistence of high chyle output through the chest tube. In contrast to patients who were successfully treated with conservative measures, patients who eventually needed a reoperation had a drain output of more than 2 L on the day conservative therapy was started and 1 and 2 days later. CONCLUSIONS: Chyle leakage is seen more often in patients who undergo transthoracic esophagectomy and in patients who have more positive nodes. Patients with chyle leakage have more pulmonary complications. Conservative therapy is often successful, but operative therapy should be seriously considered in patients with a persistently high daily output of more than 2 L after 2 days of optimal conservative therapy.

Adult↗
PubMed2005

Incidence and management of biliary leakage after hepaticojejunostomy.

This study analyzes the change in the management of biliary leakage after hepaticojejunostomy. Between 1993 and 2003 all patients (n = 1033) were studied with a hepaticojejunostomy as part of a pancreatoduodenectomy (n = 486), proximal bile duct resection (without liver resection) (n = 35), and biliodigestive bypass for malignant (n = 302) and benign (n = 210) disease. Biliary leakage was defined as the presence of bile-stained fluid (>50 mL) in the abdominal drain more than 24 hours after surgery, proven radiologically or at relaparotomy. The studied patients were divided into two equal periods to analyze the change in management. Overall, 24 of 1033 patients (2.3%) had biliary leakage. In multivariate analysis, a body mass index greater than 35 kg/m2 (P = .012), endoscopic biliary drainage (P = .044), and an anastomosis on the segmental bile ducts (P < .001) were independent predictors of leakage. Management in the first half of the study period (1993-1998) versus the second half (1999-2003) was maintenance of operatively placed drains (18% vs. 15%, respectively, P = 1.000), percutaneous transhepatic biliary drainage (18% vs. 69%, respectively, P = .012), surgical drainage (55% vs. 8%, respectively, P = .023), and re-hepaticojejunostomy (9% vs. 8%, respectively, P = 1.000). There was no mortality in the patients with biliary leakage. Leakage after a hepaticojejunostomy is a relatively rare complication without mortality and can safely be managed with percutaneous transhepatic biliary drainage.

Biliary Tract Diseases↗
PubMed2005

Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery?

OBJECTIVE: To analyze the management of delayed massive hemorrhage (DMH) after major pancreatic and biliary surgery. SUMMARY BACKGROUND DATA: Despite a decreased mortality rate for pancreatic and biliary surgery, DMH is still an important cause of postoperative mortality. The aim of the present study was to analyze the management of DMH after pancreatic and biliary surgery, and specifically to assess the role of embolization and surgical intervention. METHODS: The study group (SG) consisted of 1010 patients from 1994 to 2002 who underwent pancreatic or biliary surgery (cholecystectomy excluded). Patients from a previous study (1983-1993, n = 686) were used as a historical control group (HCG). RESULTS: The incidence of DMH (SG 2.3% vs. HCG 3.2%) declined somewhat but did not differ significantly between both periods. The number of patients with a septic complication (SG 74% vs. HCG 50%) and a sentinel bleed (SG 78% vs. HCG 100%) before the onset of DMH did not differ significantly. Embolization (SG 2 of 2 patients vs. HCG 0 of 2 patients) was not used frequently. Successful outcome after surgical intervention (SG 14 of 16 patients vs. HCG 8 of 14 patients) and the surgical procedures performed to obtain hemostasis were comparable and overall mortality (SG 22% vs. HCG 29%) was comparable. CONCLUSIONS: The incidence of DMH declined somewhat from 3.2% to 2.3% over the past years. Most patients present with septic complications and a sentinel bleed before onset of DMH. Despite general acceptance of embolization in our unit, it was used infrequently in patients with DMH. Aggressive surgical intervention was the treatment of choice in patients with DMH after pancreatic or biliary surgery.

Adult↗
PubMed2005

Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands.

OBJECTIVES: To evaluate the best available evidence on volume-outcome effect of pancreatic surgery by a systematic review of the existing data and to determine the impact of the ongoing plea for centralization in The Netherlands. SUMMARY BACKGROUND DATA: Centralization of pancreatic resection (PR) is still under debate. The reported impact of hospital volume on the mortality rate after PR varies. Since 1994, there has been a continuous plea for centralization of PR in The Netherlands, based on repetitive analysis of the volume-outcome effect. METHODS: A systematic search for studies comparing hospital mortality rates after PR between high- and low-volume hospitals was used. Studies were reviewed independently for design features, inclusion and exclusion criteria, cutoff values for high and low volume, and outcome. Primary outcome measure was hospital or 30-day mortality. Data were obtained from the Dutch nationwide registry on the outcome of PR from 1994 to 2004. Hospitals were divided into 4 volume categories based on the number of PRs performed per year. Interventions and their effect on mortality rates and centralization were analyzed. RESULTS: Twelve observational studies with a total of 19,688 patients were included. The studies were too heterogeneous to allow a meta-analysis; therefore, a qualitative analysis was performed. The relative risk of dying in a high-volume hospital compared with a low-volume hospital was between 0.07 and 0.76, and was inversely proportional to the volume cutoff values arbitrarily defined. In 5 evaluations within a decade, hospital mortality rates were between 13.8% and 16.5% in hospitals with less than 5 PRs per year, whereas hospital mortality rates were between 0% and 3.5% in hospitals with more than 24 PRs per year. Despite the repetitive plea for centralization, no effect was seen. During 2001, 2002, and 2003, 454 of 792 (57.3%) patients underwent surgery in hospitals with a volume of less than 10 PRs per year, compared with 280 of 428 (65.4%) patients between 1994 and 1996. CONCLUSIONS: The data on hospital volume and mortality after PR are too heterogeneous to perform a meta-analysis, but a systematic review shows convincing evidence of an inverse relation between hospital volume and mortality and enforces the plea for centralization. The 10-year lasting plea for centralization among the surgical community did not result in a reduction of the mortality rate after PR or change in the referral pattern in The Netherlands.

Chi-Square Distribution↗
PubMed2004

Pyogenic granuloma: an unrecognized cause of gastrointestinal bleeding.

Pyogenic granuloma is a lobular capillary hemangioma that mostly occurs on the skin, but it is also encountered on the mucosal surface of the oral cavity. Only a few cases in other parts of the digestive tract have been reported in Japanese patients. In this report, two Caucasian patients are described, who presented with gastrointestinal bleeding due to the presence of a pyogenic granuloma. One was located in the distal esophagus and could be treated with local excision and laser-photocoagulation therapy. The other one was located in the small intestine and was removed by surgical resection. Although extremely rare, pyogenic granuloma as a cause of gastrointestinal bleeding needs consideration. The lesion is benign, presumably reactive and can be adequately treated by excision or laser photocoagulation. Immunohistochemistry and/or polymerase chain reaction for herpesvirus 8 can reliably distinguish pyogenic granuloma from Kaposi's sarcoma, an important differential diagnosis.

Diagnosis, Differential↗
PubMed2004

Recurrent disease after microscopically radical (R0) resection of periampullary adenocarcinoma in patients without adjuvant therapy.

The survival rate after microscopically radical resection of pancreatic duct adenocarcinoma is still poor. Patients with ampulla of Vater and distal common bile duct adenocarcinoma indicate a much more favorable prognosis. Controversy exists as to whether adjuvant therapy could improve the outcome in these patients after resection. The aim of the present study was to analyze the pattern of recurrence in patients with periampullary adenocarcinoma after pancreatoduodenectomy. Between January 1992 and December 2002, all patients with an R0 resection were identified and used for this analysis. A total of 190 patients underwent a microscopically radical resection and received no adjuvant therapy. Of those, 72 patients were diagnosed with pancreatic duct adenocarcinoma, 86 patients were diagnosed with ampulla of Vater adenocarcinoma, and 31 patients were diagnosed with distal common bile duct adenocarcinoma. Recurrent disease was indicated in 81% of the patients with pancreatic duct adenocarcinoma, 50% of the patients with ampulla of Vater adenocarcinoma, and in 74% of the patients with bile duct adenocarcinoma. Multivariate analysis revealed that lymph node metastases were prognostic for recurrent disease in patients with pancreatic duct adenocarcinoma (P = 0.038). The depth of invasion (T4, P < 0.032) and lymph node metastases (P < 0.001) were prognostic in patients with ampulla of Vater adenocarcinoma. Poor tumor differentiation (P < 0.001) was prognostic in patients with distal bile duct adenocarcinoma. Selected patients with periampullary malignancies exhibited a high recurrence rate and should be encouraged to enroll in clinical trials for adjuvant treatment including local therapy (radiotherapy) according to the identified prognostic factors.

Ampulla of Vater↗
PubMed2003

Feasibility of early closure of loop ileostomies: a pilot study.

PURPOSE: A loop ileostomy is constructed to protect a distal anastomosis, and closure is usually performed not earlier than after two to three months. Earlier closure might reduce stoma-related morbidity, improve quality of life, and still effectively protect the distal anastomosis. This pilot study was designed to investigate the feasibility of early closure of loop ileostomies, i.e., during the same hospital admission as the initial operation. METHODS: Twenty-seven consecutive patients with a protective loop ileostomy were included. If patient's recovery was uneventful, water-soluble contrast enema examination was performed, preferably after seven to eight days. If no radiologic signs of leakage were detected, the ileostomy was closed during the same hospital admission. RESULTS: Twenty-seven patients (8 females; mean age, 60 years) were analyzed. Eighteen patients had early ileostomy closure on average 11 (range, 7-21) days after the initial procedure. In nine patients the procedure was postponed because of leakage of the anastomosis (n = 3), delayed recovery (n = 1), small bowel obstruction (n = 1), gastroparesis (n = 1), logistic reasons (n = 2), or irradical cancer resection followed by radiotherapy (n = 1). There was no mortality and four mild complications occurred after early closure: superficial wound infection (n = 2), intravenous-catheter sepsis (n = 1), small bowel obstruction (n = 1). CONCLUSION: Closure of a loop ileostomy early after the initial operation was feasible in 18 of 27 patients and was associated with low morbidity and no mortality.

Adult↗
PubMed2003

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life.

OBJECTIVE: To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy. SUMMARY BACKGROUND DATA: Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients. METHODS: Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70). RESULTS: Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months. CONCLUSIONS: Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

Aged↗