in the distal biliary system, usually the common bile duct that drains into the duodenum. Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require hepatectomy, or removal of part of the liver, with or without pancreaticoduodenectomy. Chronic pancreatitis Treatment of chronic pancreatitis typically includes pain control and management of exocrine insufficiency. Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis. Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis. Trauma Damage to the pancreas and duodenum from blunt abdominal trauma is uncommon. In rare cases when this pattern of trauma has been reported, it has been seen as a result of a lap belt in motor vehicle accidents. Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum. Due to the rarity of this procedure in the setting of trauma, there is not robust evidence regarding post-operative outcomes. Contraindications Absolute contraindications for the procedure are metastatic disease in the abdominal cavity or nearby organs. These are found most often on the peritoneum, in the liver, and in the omentum. In order to determine if there are metastases, surgeons will inspect the abdomen at the beginning of the procedure after gaining access. Alternatively, they may perform a separate procedure called a diagnostic laparoscopy which involves insertion of a small camera through a small incision to look inside the abdomen. This may spare the patient the large abdominal incision that would occur if they were to undergo the initial part of a pancreaticoduodenectomy that was cancelled due to metastatic disease. Further contraindications include encasement of major vessels (such as celiac artery, inferior vena cava, or superior mesenteric artery) as mentioned above. Surgical considerations Pylorus-sparing pancreaticoduodenectomy Clinical trials have failed to demonstrate significant survival benefits of total pancreatectomy, mostly because patients who submit to this operation tend to develop a particularly severe form of diabetes mellitus called brittle diabetes. Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the spleen) is removed to prevent further spread of infection and possible morbidity. In recent years the pylorus-preserving pancreaticoduodenectomy (also known