Pancreatic disease is a relatively common problem in the setting of cirrhosis or liver transplantation. The role of pancreatic surgery in this high-risk population must be carefully considered due to unique complications related to physiological changes associated with these operations. The management strategies for pancreatic malignancies have advanced significantly in recent decades, although the role of these treatment options in the setting of cirrhosis or liver transplantation remains limited based upon the limited experience gained over this time frame. Furthermore, although advances in chemotherapy options for these malignancies have increased survival for the general population, the safety of these treatments in cirrhotic or liver transplant patients has yet to be evaluated. Cystic lesions of the pancreas pose additional challenges in this population due to the uncertain fate of many of these lesions. Newer management strategies aimed at limiting surgical intervention for cystic lesions can be applied to better identify those patients with the highest risk for progression to invasive malignancies. Finally, chronic pancreatitis principles in the cirrhotic or liver transplant population are oftentimes nonoperative, given significant surgical risks unique to the cirrhotic population. In contrast, those patients with prior liver transplantation may be approached with a more standard treatment algorithm using a multidisciplinary operative and nonoperative approach. Advances in endoscopic therapies for palliation of these patients hold significant promise toward care of these chronic pancreatitis patients. This chapter focuses on synthesizing existing evidence and experience gained in the management and surgical decision-making for cirrhotic and liver transplantation patients.
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