HIV infection has been a major global health problem for almost three decades. With the introduction of highly active anti-retroviral therapy in 1996, and the advent of effective prophylaxis and management of opportunistic infections, AIDS mortality has decreased markedly. In developed countries, this once fatal infection is now being treated as a chronic condition. As a result, rate of morbidity and mortality from other medical conditions leading to end-stage liver, kidney and heart disease is steadily increasing in individuals with HIV. Presence of HIV infection used to be viewed as a contraindication to transplantation for multiple reasons:,concerns for exacerbation of an already immunocompromised state by administration of additional immunosuppressants; the use of a limited supply of donor organs with unknown long-term outcomes; and, the risk of viral transmission to the surgical and medical staff. This Review examines open questions on kidney transplantation in patients infected with HIV-1 and clinical strategies that have resulted in good outcomes. It also describes the clinical concerns associated with the treatment of renal transplant recipients with HIV.

Background Interactions between antiretrovirals (ARVs) and transplant immunosuppressant agents (IS) among HIV-infected transplant recipients may lead to lack of efficacy or toxicity. In transplant recipients not infected with HIV, cyclosporine (CsA) and tacrolimus (TAC) trough levels (C0) or those drawn two hours after dosing (C2) correlate with drug exposure (AUC/dose) and outcomes. Due to ARV-IS interactions in HIV-infected individuals, and the high rate of rejection in these subjects, we investigated the correlations between IS concentrations and exposure to determine the best method to monitor immunosuppressant levels. Methods We prospectively studied 50 HIV-infected transplant recipients undergoing kidney or liver transplantation evaluating the pharmacokinetics of the IS over time after transplantation (weeks 2 to 4, 12, 28, 52, and 104). IS levels were measured with LC/MS/MS and AUC calculated using WinNonLin 9.0. Correlation analyses were run on SAS 9.2 Results CsA concentration at C4 correlated better with AUC than C0 or C2, and TAC concentration correlated better at C0 or C2. Conclusions We suggest that C0 is acceptable for TAC monitoring, but poor predictability will occur at C0 with CsA. The low correlation of C0 with CsA AUC could be responsible for the higher rejection rates on CsA that has been reported in these subjects.

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The first laparoscopic cholecystectomy was performed in the mid-1980s. Since then, laparoscopic surgery has continued to gain prominence in numerous fields, and has, in some fields, replaced open surgery as the preferred operative technique. The role of laparoscopy in staging cancer is controversial, with regards to gallbladder carcinoma, pancreatic carcinoma, hepatocellular carcinoma and liver metastasis from colorectal carcinoma, laparoscopy in conjunction with intraoperative ultrasound has prevented nontherapeutic operations, and facilitated therapeutic operations. Laparoscopic cholecystectomy is the preferred option in the management of gallbladder disease. Meta-analyses comparing laparoscopic to open distal pancreatectomy show that laparoscopic pancreatectomy is safe and efficacious in the management of benign and malignant disease, and have better patient outcomes. A pancreaticoduodenectomy is a more complex operation and the laparoscopic technique is not feasible for this operation at this time. Robotic assisted pancreaticoduodenectomy has been tried with limited success at this time, but with continuing advancement in this field, this operation would eventually be feasible. Liver resection remains to be the best management for hepatocellular carcinoma, cholangiocarcinoma and colorectal liver metastases. Systematic reviews and meta-analyses have shown that laparoscopic liver resections result in patients with equal or less blood loss and shorter hospital stays, as compared to open surgery. With improving equipment and technique, and the incorporation of robotic surgery, minimally invasive liver resection operative times will improve and be more efficacious. With the incorporation of robotic surgery into hepatobiliary surgery, donor hepatectomies have also been completed with success. The management of benign and malignant disease with minimally invasive hepatobiliary and pancreatic surgery is safe and efficacious.

Historically, HIV-positive individuals have not been considered to be candidates for liver transplantation due to the need for further immunosuppresion of these patients post-transplant, as well as other factors such as pharmacokinetic interactions between the necessary antiretroviral and immunosuppressant drugs. However, HIV-positive individuals with end-stage liver disease are now eligible for liver transplantation in British Columbia. The purpose of this study was to summarize the outcomes of HIV-positive individuals referred for liver transplanation in British Columbia.

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At the inception of pancreatic surgery by Dr Whipple in 1930s, the mortality and morbidity risk was more than 20%. With further understanding of disease processes and improve ments in pancreas resection techniques, the mortality risk has decreased to less than 5%. Age and chronic illnesses are no longer a contraindication to surgical treatment. Life expectancy and quality of life at a later age have improved, making older patients more likely to receive pancreatic surgery, thereby also putting emphasis on operative patient selection to minimize complica tions. This review summarizes the benign and malignant illnesses that are treated with pancreas operations, and innovations and improvements in pancreatic surgery and perioperative care, and describes the careful selection process for patients who would benefit from an operation. These indications are not reserved only to Whipple operation, but to pancreatectomies as well.