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The acoustical behavior of air-saturated aerogel powders in the audible frequency range is not well understood. It is not clear, for example, which physical processes control the acoustic absorption and/or attenuation in a very light, loose granular mix in which the grain diameter is on the order of a micron. The originality of this work is the use of a Biot-type poro-elastic model to fit accurately the measured absorption coefficients of two aerogel powders with particle diameters in the range 1-40 μm. It is shown that these materials behave like a viscoelastic layer and their absorption coefficient depends strongly on the root mean square sound pressure in the incident wave. Furthermore, it was found that the loss factor controlling the energy dissipation due to the vibration of the elastic frame is a key model parameter. The value of this parameter decreased progressively with the frequency and sound pressure. In contrast, other fitted parameters in the Biot-type poro-elastic model, e.g., the stiffness of the elastic frame and pore size, were found to be relatively independent of the frequency and amplitude of the incident wave. It is shown that these materials absorb acoustic waves very efficiently around the frequencies of the frame resonance.

Background: This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications., Methods: The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy., Results: The mean age of the study patients was 69 years (range, 15-80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2-97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet)., Conclusion: Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors' hands, Toupet had the worst results and modified Dor was most protective for heartburn.

Background: This case-control study evaluated and compared the outcomes of laparoscopically assisted (LTE) and open transhiatal esophagectomy (OTE)., Methods: In this study, 17 patients who underwent LTE during this period August 1999 through June 2003 were compared with 14 matched control patients who underwent OTE during this period December 1989 through September 2001. The groups had stage I esophageal cancer or lesser disease at the preoperative evaluation. Patients with prior upper abdominal or thoracic surgery were excluded., Results: There was no significant difference between the groups with respect to age, body mass index, American Society of Anesthesiology (ASA) classification, or operating time. The estimated blood loss was 331 (+/- 220) ml for LTE and 542 (+/- 212) ml for OTE (p = 0.01). The hospital stay was 9.1 (+/- 3.2) days for LTE and 11.6 (+/- 2.9) days for OTE (p = 0.04). Comparing only the last six LTE with the OTE, the operating time was 311 (+/- 31) min for LTE and 388 (+/- 14) min for OTE (p = 0.02)., Conclusions: The findings showed shorter operative time, less blood loss, and a shorter hospital stay with LTE than with OTE.

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

Indications for sentinel lymph node mapping (SLNM) for patients with ductal carcinoma in situ (DCIS) of the breast are controversial. We reviewed our institutional experience with SLNM for DCIS to determine the node positive rate and clarify indications for nodal staging in patients with DCIS. Since 1998 we have used SLNM to stage breast cancer patients using both blue dye and radiocolloid. In DCIS patients, SLNM has been reserved for patients considered at high risk for harboring coexistent invasive carcinoma or treated by mastectomy. All sentinel nodes were evaluated with serial sectioning, hematoxylin and eosin staining, and immunohistochemical evaluation for cytokeratins. We identified 44 patients with 46 cases of DCIS (two patients with bilateral disease). SLNM identified at least one sentinel node in all cases. In all cases, the sentinel node(s) were negative for axillary metastasis. We calculated the binomial probability of observing 0 of 46 cases as negative when the expected incidence according to published reports in the surgical literature was 13 per cent and found a P value of <0.01. Based on this case-series observation, we conclude SLNM should not be routinely performed for patients with DCIS. We now use SLNM only for DCIS patients treated by mastectomy.

We performed this study to evaluate two patient groups with primary hyperparathyroidism depending on whether their abnormal gland(s) could be preoperatively imaged with sestamibi. Patients with primary hyperparathyroidism evaluated by preoperative sestamibi examination from January 1999 to June 2000 were divided into two groups depending on the ability of sestamibi to localize their disease. Records were reviewed to determine pre- and postoperative biochemical data, weight of the excised glands, and total operating room time. When the sestamibi imaging was positive a minimally invasive parathyroidectomy was performed; however, when sestamibi scanning was negative patients underwent a formal bilateral neck exploration. All 40 patients in the sestamibi-positive group and 17 of 18 patients in the sestamibi-negative group were cured of their primary hyperparathyroidism as a result of surgery. Sestamibi scanning with a minimally invasive parathyroidectomy shortens operating room time and is most effective when adenomas are large. The results of this study suggest that strategies to preoperatively increase the activity of adenomas may improve the sensitivity of sestamibi scan localization of parathyroid adenomas.

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

The purpose of this study was to evaluate the impact of adjuvant chemotherapy on survival after surgery for T3N0 colon cancer. All patients with node-negative (N0) colon cancer with tumor invasion beyond the muscularis propria (T3) treated with colectomy between 1982 and 1995 at a single institution were included. Patients were divided into two groups depending on postcolectomy treatment with or without adjuvant chemotherapy. Groups were evaluated to determine perioperative and pathologic variables that could potentially influence outcome and surveillance data to determine disease-free and overall survival. In 253 patients with T3N0 colon cancer 226 remained under observation and 27 were treated with adjuvant chemotherapy. The groups were similar (P = not significant) when compared for tumor location, size, differentiation, number of nodes harvested, and transfusion requirements. Four of the 27 patients who received chemotherapy developed a recurrence (14.8%), whereas 22 of the 226 observation patients developed a recurrence (9.7%). Disease-free survival for the chemotherapy group at 5 years was 84 per cent and for the observation group 87 per cent. Statistical analysis (Mantel-Cox) showed no significant difference between the groups on the basis of survival (P = 0.3743). We conclude that resection alone is a highly effective treatment for T3N0 colon cancer leaving limited opportunity for adjuvant chemotherapy to significantly impact survival. Adjuvant chemotherapy for T3N0 colon cancer patients should be limited to patients enrolled in clinical trials designed to identify subgroups of T3N0 colon cancer patients at a survival disadvantage or less toxic adjuvant chemotherapies.

Background: Cholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure., Methods: Between 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA < 4 who were living < 2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions., Results: Since 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained approximately 60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed > 1 day (range, 2-20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided., Conclusion: Successful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

Image-guided core needle breast biopsy (IGCNBB) is an incisional biopsy technique that has been associated with tumor cell displacement. Theoretically tumor cell displacement may affect local recurrence rates in patients treated with breast-conserving therapy (BCT). We performed a study to determine if the biopsy method impacted local control rates following BCT. Patients with nonpalpable breast cancer (invasive and intraductal) diagnosed at our institution and treated with BCT between July 1993 and July 1996 were selected to provide a follow-up period in which the majority of local recurrences should be detected. Patients were divided into two groups based on their method of diagnosis. Group I patients were diagnosed by IGCNBB and group II patients were diagnosed by wire localized excisional breast biopsy (WLEBB). Factors potentially affecting local recurrence rates were retrospectively reviewed. Two hundred eleven patients were treated with BCT, 132 were diagnosed by IGCNBB and 79 by WLEBB. The two patient groups were similar when compared for prognostic factors and treatment. All patients' BCT included histologically negative margins. There were 4 (3.0%) local recurrences in Group I at a median follow-up of 44.4 months and 2 (2.5%) local recurrences in group II at a median follow-up of 50.1 months. This difference was not significant. Breast cancer patients diagnosed by IGCNBB can be treated by BCT with acceptable local control rates. Additional surveillance of our institutional experience and others' is mandatory to validate IGCNBB as the preferred biopsy method for nonpalpable mammographic abnormalities.

Background and Purpose: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned., Methods: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed., Results: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy., Conclusion: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.

Background: Radial scar is a breast lesion with mammographic and histologic features similar to carcinoma. We reviewed the characteristics of patients with radial scars to better understand these lesions and to determine the incidence of associated carcinoma., Methods: Records for all patients undergoing diagnostic wire localized excisional breast biopsy from January 1993 to September 1999 were reviewed to identify those with histologic or mammographic evidence of radial scar. Clinical records, mammograms, and pathologic slides of these patients were reviewed., Results: We identified 45 cases of radial scar: 10 patients had mammographic and histologic evidence of radial scar (group I), 29 only mammographic evidence (group II), and 6 only histologic evidence (group III). Breast cancer risk was similar in the three patient groups. Carcinoma was identified in 18 patients with mammographic radial scars., Conclusion: Mammographically detected radial scars were associated with carcinoma in 18 of 39 (46%) cases. Histologically identified radial scars are not associated with malignancy and should not be confused with mammographically identified lesions.

Background: An understanding of the patterns of failure after potentially curative treatment of breast cancer patients can lead to the development of improved methods of patient management., Methods: We compared two groups of patients in whom breast cancer recurred after potentially curative treatment. Patients were assigned to their groups based on the status of their lymph nodes at the time of presentation., Results: In all, 294 recurrences were analyzed to demonstrate that the patterns of failure for the two groups were identical. In the node-positive group, recurrence occurred sooner and their primary tumors were larger., Conclusion: The nearly identical patterns of treatment failure in lymph node negative and positive breast cancer patients suggests that metastasis in node negative patients occurs by a similar mechanism. The shorter time to recurrence and larger primary tumor may only reflect a lead time bias, in that node-positive patients have a greater tumor burden in their lymph nodes that facilitates identification by pathologists.

Background: Several recent studies have investigated the influence of family history on the progression of DCIS patients treated by tylectomy and radiation therapy. Since three treatment strategies have been used for DCIS at our institution, we evaluated the influence of family history and young age on outcome by treatment method., Methods: Between 1/1/82 and 12/31/92, 128 patients were treated for DCIS by mastectomy (n = 50, 39%), tylectomy alone (n = 43, 34%), and tylectomy with radiation therapy (n = 35, 27%). Median follow-up is 8.7 years. Thirty-nine patients had a positive family history of breast cancer; 26 in a mother, sister, or daughter (first-degree relative); and 26 in a grandmother, aunt, or cousin (second-degree relative). Thirteen patients had a positive family history in both first- and second-degree relatives., Results: Six women developed a recurrence in the treated breast; all of these were initially treated with tylectomy alone. There were no recurrences in the mastectomy group or the tylectomy patients treated with postoperative radiation therapy. Patients with a positive family history had a 10.3% local recurrence rate (LRR), vs. a 2.3% LRR in patients with a negative family history (p = 0.05). Four of 44 patients (9.1%) 50 years of age or younger recurred, compared to two of 84 patients (2.4%) over the age of 50 (p = 0.10). Fifteen patients had both a positive family history and were 50 years of age or younger. Among these women, the recurrence rate was 20%. Women in this group treated by lesionectomy alone had a LRR of 38% (3 of 8)., Conclusion: The most important determinant of outcome was the selection of treatment modality, with all of the recurrences occurring in the tylectomy alone group. In addition to treatment method, a positive family history significantly influenced LRR in patients treated by tylectomy, especially in women 50 years of age or younger. These results suggest that DCIS patients, particularly premenopausal women with a positive family history, benefit from treatment of the entire breast, and raise concerns about treating patients with a possible genetic susceptibility to breast cancer with tylectomy alone.

Background: We hypothesized that wide-field brachytherapy (BRT) after margin negative excision would result in complication rates, local recurrence rates, and cosmesis scores equivalent to external beam radiotherapy (ERT)., Methods: Patients with T(is,1,2) tumors less than or equal to 4 cm, 0 to 3 positive axillary nodes, and negative inked surgical margins were entered prospectively into BRT phase I/II trial. Patients who met the eligibility criteria for BRT but were treated with ERT during the same time period were retrospectively identified as controls. A blinded panel of healthcare professionals graded cosmetic outcome., Results: Fifty patients with 51 breast cancers received BRT from January 1992 to October 1993. We identified 94 patients eligible for BRT but concurrently treated with ERT. At a median follow-up of 75 months, the two groups were similar for grade III treatment toxicities, local/regional recurrence rates, and cosmesis scores., Conclusions: For selected breast cancer patients undergoing breast-conserving therapy, BRT is an attractive alternative to ERT.

Evaluation and management of patients with nipple discharge (ND) aims to identify carcinoma when present, and in benign cases, stop the discharge when bothersome. We reviewed our recent experience with ND to develop a simple and effective algorithm to manage these patients. Records of all patients with ND evaluated from December 1996 through June 1999 were reviewed. Patients were liberally offered duct excision for a clinical suspicion of malignancy (persistent clear or bloody fluid) or to stop bothersome discharge. Patients with breast imaging abnormalities (mammography or ultrasound) related to their ND underwent biopsy and were considered separately. Of 104 patients with ND, 11 underwent biopsy as a result of mammographic findings; three of these cases proved malignant. The remaining 93 patients were evaluated with 55 tests that did not demonstrate malignancy, including ductography, discharge fluid cytology, serum prolactin and thyroid-stimulating hormone levels, and image-guided breast or nipple biopsy. Thirty-nine patients underwent duct excision with only a single patient demonstrating malignancy. Clinical follow-up has not identified malignancy in any patient managed nonoperatively. When diagnostic breast imaging is negative, malignancy related to ND is uncommon. Patients with ND should have diagnostic breast imaging and, if it is negative, should be offered duct excision. There is little role for ductography, cytology, or laboratory studies in evaluating these patients.

We reviewed our institutional experience with primary hyperaldosteronism to compare clinical outcomes after laparoscopic versus open adrenalectomy. All patients surgically treated for primary hyperaldosteronism from 1988 through 1999 are included in this study. Patients were assigned to either the LA (laparoscopic) or OA (open) group depending on the initial surgical approach selected for treatment. Records were reviewed to determine demographics, operative results, and complications. Twenty-four patients were surgically treated for primary hyperaldosteronism. There were no significant differences between groups with respect to age, weight, number of preoperative antihypertensive medications, or preoperative potassium level. The results of adrenalectomy with respect to number of postoperative antihypertensive medications or serum potassium level were also similar. Operative times were not significantly different (191 +/- 53 minutes for OA and 205 +/- 88 minutes for LA) between groups, but four LA patients were converted to OA. Estimated blood loss was 401 +/- 513 cm3 for OA and 127 +/- 131 cm3 for LA (P = 0.07). Hospital length of stay was 6.7 +/- 3.7 days for OA and 3.3 +/- 2.7 days for LA (P = 0.02). Complications were nine for OA and three for LA (P = 0.001 by Pearson's Chi square). LA is similar to OA in the treatment of primary hyperaldosteronism. The significantly fewer complications and shorter length of hospital stay associated with LA makes the laparoscopic approach the preferred method for treating primary hyperaldosteronism.

Minimally invasive parathyroidectomy offers patients a less morbid surgical approach to treat primary hyperparathyroidism. Biochemically diagnosed hyperparathyroid patients undergo a preoperative sestamibi scan to localize abnormal parathyroid tissue. If the scan is positive, a focused unilateral neck exploration is performed through a 2-3 cm incision with the aid of a gamma detector to identify the radioactive, abnormal parathyroid gland(s).In the Ochsner Clinic's initial experience with minimally invasive parathyroidectomy, 34 patients were evaluated with 20 positive scans, 4 suggestive scans, and 10 negative scans. Of the 24 patients with scans demonstrating abnormal parathyroid activity, 23 were successfully managed with the minimally invasive technique. The mean total surgical time was 72.9 minutes, and the mean weight of the excised parathyroid glands was 1445.4 mg. All 10 patients with negative scans had a traditional bilateral neck exploration lasting a mean time of 146.5 minutes; the mean weight of the excised parathyroid glands was 388.6 mg. Hypercalcemia was cured in all 24 patients in the positive group and 9 of 10 patients in the negative scan group.Ochsner's initial experience with minimally invasive parathyroidectomy demonstrates that about 70% of patients can expect to be candidates for this technique, which is associated with excellent cure rates and shorter operative times.

In the last decade, laparoscopy has been the most innovative surgical movement in general surgery. Minimally invasive surgery performed through a few small incisions, laparoscopy is the standard of care for the treatment of gallbladder disease and the gold standard for the treatment of reflux disease. The indications for a laparoscopic approach to abdominal disease continue to increase, and many diseases may be treated with laparoscopic techniques. At Ochsner, laparoscopic techniques have demonstrated better cosmetic results, shorter recovery times, and an earlier return to normal activity compared with open surgery.

Objective: To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer., Methods: A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases., Results: The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group., Conclusions: Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.

The initial reports of sentinel lymph node mapping for breast cancer currently appearing in the surgical literature are demonstrating the practicality and accuracy of the technique to evaluate patients for axillary nodal disease. We reviewed our initial 100 patient experience with sentinel node mapping to evaluate our ability to employ this technique in breast cancer patients. We combined a peritumoral injection of a radioactive substance and blue dye. Each sentinel node was evaluated with frozen section analysis, hematoxylin and eosin staining, and, if still negative, five re-cuts were taken from deeper levels of the node and evaluated for immunohistochemical evidence of cytokeratin staining. Sentinel node(s) were identified in all but two patients with 51% demonstrating metastasis. We have demonstrated the ability to accurately perform sentinel node mapping in the evaluation of our breast cancer patients. This exciting advance should become a standard part of breast cancer surgery.

Image-guided core-needle breast biopsy (IGCNBB) is widely used to evaluate patients with abnormal mammograms; however, information is limited regarding the reliability of a benign diagnosis. The goal of this study was to demonstrate that a benign diagnosis obtained by IGCNBB is accurate and amenable to mammographic surveillance. Records of all patients evaluated by IGCNBB from July 1993 through July 1996 were reviewed. Biopsies were classified as malignant, atypical, or benign. All benign cases were followed by surveillance mammography beginning 6 months after IGCNBB. Of the 1110 patients evaluated by IGCNBB during the study period, 855 revealed benign pathology. A total of 728 of the 855 patients (85%) complied with the recommendation for surveillance mammography. A total of 196 IGCNBBs were classified as malignant; 59 cases were classified as atypical. The atypical cases were excluded from the statistical analysis. Only two patients have demonstrated carcinoma after a benign IGCNBB during the 2-year minimum follow-up period. The sensitivity and specificity of a benign result were 100.0 and 98.9 per cent, respectively. A benign diagnosis obtained by IGCNBB is accurate and therefore amenable to mammographic surveillance. The results of this study support IGCNBB as the preferred method of evaluating women with abnormal mammograms.

Background: Male breast carcinoma is rare; therefore, the effect of family history on the course of the disease has not been well described. Germ-line mutations in breast carcinoma susceptibility genes, particularly BRCA2, are associated with an increased risk of male breast carcinoma. The authors sought to correlate significant family history with clinical phenotype in males with breast carcinoma., Methods: One hundred forty-two men with breast carcinoma were treated at Memorial Sloan-Kettering Cancer Center or the Ochsner Clinic from 1973 to 1994. The authors reviewed the effect imparted by a family history of breast carcinoma on the duration of symptoms, the age at diagnosis, and the survival of men with this disease., Results: Fifteen percent of male breast carcinoma patients had a first-degree relative with the disease. Fifty-eight years was the mean age at diagnosis for those with a family history, compared with 61 years for those without (P = not significant [NS]). The mean duration of symptoms was 23 months for those with a family history, compared with 22 months for those without. Three of 22 patients (13.6%) with a family history, compared with 11 of 90 patients (12%) without a family history, had Stage III disease (P = NS) at presentation. The overall 5-year and 10-year survival rates were 86% and 64%. Survival was not affected by family history. Lymph node positivity reduced 5-year and 10-year survival rates to 73% and 50% (P = 0.0004)., Conclusions: For men with breast carcinoma, the presence of a family history did not affect the age at presentation, the duration of symptoms, the stage of disease at presentation, or the overall survival. In multivariate analysis, the most powerful predictor of outcome for these men was the status of the axillary lymph nodes., (Copyright 1999 American Cancer Society.)

In the past, various two- and three-dimensional Cartesian, poroelastic finite element formulations have been proposed and demonstrated. Here an axisymmetric formulation of a poroelastic finite element is presented. The intention of this work was to develop a finite element formulation that could easily and efficiently model axisymmetric sound propagation in circular structures having arbitrary, axially dependent radii, and that are lined or filled with elastic porous sound absorbing materials such as foams. The formulation starts from the Biot equations for an elastic porous material expressed explicitly in axisymmetric form. By following a standard finite element development, a u-U formulation results. Procedures for coupling the axisymmetric elements to an adjacent acoustical domain are described, as are the boundary conditions appropriate for unfaced foams. Calculations described here show that the present formulation yields predictions as accurate as a Cartesian, three-dimensional model in much reduced time. Predictions made using the present model are also compared with measurements of sound transmission through cylindrical foam plugs, and the predicted results are shown to agree well with the measurements. Good agreement was also found in the case of sound transmission through a conical foam plug.

Background: We reviewed our image-guided core needle breast biopsy (IGCNBB) experience with patients diagnosed with invasive carcinoma (IC) to determine the accuracy of a core biopsy diagnosis of invasion and our ability to perform a single definitive cancer operation., Methods: All IGCNBBs between July 1993 and July 1997 were reviewed to identify patients diagnosed with IC. Data included initial surgical treatment, surgical pathology, and subsequent surgical treatment., Results: Of the 1,676 biopsies, invasive carcinoma was diagnosed in 208 with follow-up in 204 cases. Invasive carcinoma diagnosis was confirmed in 202 of 204 cases (99%). One hundred ninety-two patients had surgical treatment. Of these 192 patients, 173 (90%) could have achieved definitive surgical treatment with a single operation., Conclusions: An IGCNBB diagnosis of IC is accurate and allows for definitive breast cancer therapy. The potential impact on patient management is that a single operation can usually accomplish what traditionally has required at least two surgical procedures.

Currently, relatively safe, reliable resection techniques are available for most patients with esophageal carcinoma who present with nonmetastatic disease. For optimal results, the surgeon must be familiar with both transhiatal and transthoracic approaches and must individualize the approach depending on the tumor size and location and the patient's functional status. Whereas post-resection survival rates are good for patients with early-stage disease (Stage I or IIa), most patients present with locally advanced, Stage III disease. Although some progress has been made in the past decade in regard to early diagnosis among patients with Barrett's metaplasia undergoing endoscopic surveillance and additional progress has been made in adapting multimodality treatment programs successfully to patients with locally advanced disease, the overall cure rate for patients with esophageal carcinoma remains low.

Purpose: Extrahepatic metastasis represents a frequent pattern of disease progression when fluorodeoxyuridine (FUDR) is given by the intraarterial route for the treatment of unresectable colorectal liver metastases. Systemic fluorouracil (5-FU) plus leucovorin was added to intrahepatic FUDR to prolong the duration of disease control., Methods: Only patients with colorectal cancer who had evidence of unresectable metastases confined to the liver were eligible. Laparotomy was performed to establish arterial perfusion of the liver. Cycles of intrahepatic FUDR followed by a 1-week rest period then intravenous chemotherapy with 5-FU plus leucovorin were administered until maximal regression of hepatic metastases. Maintenance chemotherapy with 5-FU plus leucovorin was then given until disease progression., Results: Fifty-seven patients entered this trial; four patients (7%) were ineligible and 13 (23%) did not receive any chemotherapy on study because of findings at laparotomy. The 40 eligible patients who began chemotherapy are included in the statistical analyses. Twenty-five patients (62% of those who received chemotherapy) experienced regression of liver metastases. The median time to tumor progression was 9 months, but only 3% remained progression-free at 24 months. The median survival duration was 18 months. Toxicity was tolerable with no cases of biliary sclerosis. One treatment-related fatality due to sepsis was observed., Conclusion: Although short-term treatment results appear to be somewhat better than we have previously observed with intrahepatic FUDR alone, the sequential regimen did not have an impact on long-term, progression-free survival in patients with unresectable liver metastases. We are now investigating this regimen as surgical adjuvant therapy in selected patients following hepatic metastasectomy where this aggressive approach might have a greater therapeutic effect in the minimal residual disease setting.

Objective: The goal was to evaluate one institution's experience with image-guided core-needle breast biopsy (IGCNBB) and compare the pathologic results with wire-localized excisional breast biopsy (WLEBB) for patients with positive cores and the mammographic surveillance results for patients with negative cores., Summary Background Data: IGCNBB is becoming a popular, minimally invasive alternative to WLEBB in the evaluation of patients with nonpalpable abnormalities., Methods: This study includes all patients with nonpalpable breast imaging abnormalities evaluated by IGCNBB from July 1993 to February 1997. Patients with positive cores (atypical hyperplasia, carcinoma in situ, or invasive carcinoma) were evaluated by WLEBB. Patients with negative cores (benign histology) were followed with a standard mammographic protocol. IGCNBB results were compared with WLEBB results to determine the sensitivity and specificity for each IGCNBB pathologic diagnosis., Results: Of 1440 IGCNBBs performed during the study period, 1106 were classified as benign, and during surveillance follow-up only a single patient was demonstrated to have a carcinoma in the index part of the breast evaluated by IGCNBB (97.3% sensitivity, 99.7% specificity). IGCNBB demonstrated atypical hyperplasia in 72 patients, 5 of whom refused WLEBB. The remaining 67 patients were evaluated by WLEBB: nonmalignant findings were found in 31, carcinoma in situ was found in 25, and invasive carcinoma was found in 11 (100% sensitivity, 88.8% specificity). IGCNBB demonstrated carcinoma in situ in 84 patients; WLEBB confirmed carcinoma in situ in 54 and invasive carcinoma in 30 (65.4% sensitivity, 97.7% specificity). IGCNBB demonstrated invasive carcinoma in 178 patients. Three were lost to follow-up. On WLEBB, 173 of the remaining 175 had invasive carcinoma; the other 2 patients had carcinoma in situ (80.8% sensitivity, 99.8% specificity)., Conclusions: An IGCNBB that demonstrates atypical hyperplasia or carcinoma in situ requires WLEBB to define the extent of breast pathology. Mammographic surveillance for a patient with a benign IGCNBB is supported by nearly 100% specificity. An IGCNBB diagnosis of invasive carcinoma is also associated with nearly 100% specificity; therefore, these patients can have definitive surgical therapy, including axillary dissection or mastectomy, without waiting for the pathologic results of a WLEBB. Based on the authors' findings, IGCNBB can safely replace WLEBB in evaluating patients with nonpalpable breast abnormalities.

Patients with clinical features of intestinal obstruction without a history of prior laparotomy or physical evidence of a hernia can be a diagnostic challenge. We attempted to evaluate our preoperative diagnostic accuracy, to assess the effectiveness of our diagnostic tools, and to determine the incidence of various causes of intestinal obstruction in this select group. Medical records of all patients admitted to our institution and taken to surgery with a diagnosis of intestinal obstruction from 1975 through 1995 were reviewed. Patients with a history of prior laparotomy, evidence of hernia, or emergent indications for surgery on admission were excluded. The most common cause of intestinal obstruction in this select group of patients was malignancy. The ability to detect malignancy preoperatively is significantly better than the ability to detect benign causes of obstruction (Pearson Chi square = 4.09 with a P value of 0.04). Preoperative detection of malignancy in these patients is critical for optimal treatment planning and counseling for patients and their families.

Background: Stereotactic core needle breast biopsy (SCNBB) is a minimally invasive technique used to sample nonpalpable mammographic abnormalities. The optimal management of atypical ductal hyperplasia (ADH) diagnosed by SCNBB is unknown. We hypothesized that ADH diagnosed by SCNBB should be evaluated by excisional breast biopsy (EBB) because of the risk of identifying carcinoma in association with ADH that would be missed if a diagnostic sampling technique alone was utilized., Methods: To test this hypothesis, a prospective diagnostic protocol was created which called for SCNBB instead of EBB for patients with mammographic abnormalities considered suspicious for malignancy. If ADH was noted on histologic evaluation of the cores, patients were advised to undergo an EBB., Results: A review of the initial 900 patients evaluated by SCNBB yielded 39 patients (4.3%) with ADH detected by SCNBB. Thirty-six of these 39 patients agreed to proceed with EBB: 19 patients demonstrated benign findings including atypical ductal hyperplasia, 13 patients demonstrated noninvasive ductal carcinoma, and 4 patients had evidence of invasive carcinoma., Conclusions: A 47% rate of detecting noninvasive or invasive breast carcinoma supports the hypothesis that ADH detected by a sampling technique, such as SCNBB, should be managed by EBB.

Objective: To examine trends for use of transhiatal esophagectomy (THE) and to relate outcome variables to changes in use, controlling for preoperative risk., Background: High operative morbidity and mortality rates are reported with conventional transthoracic esophagectomy (TTE). Transhiatal esophagectomy has been proposed as an alternative but is controversial., Methods: In this retrospective study divided into early and late time periods, outcome variables were subjected to univariate and multivariate analyses., Results: Use of THE increased significantly in the late period (p < 0.0001). Patients who had THE had significantly higher American Society of Anesthesiologists (ASA) risk scores (p < 0.001). By the late period, 92% of patients with ASA III/IV scores were resected by THE. Postoperative morbidity decreased significantly and operative mortality decreased from 15% to 0% (p < 0.01) between the early and late time periods. By multivariate analysis, ASA > or = III and TTE were associated with adverse surgical outcome. Pathologic stage determined disease-free survival, which was 37% at 3 years for all survivors., Conclusions: Increased use of THE results in better operative outcome and does not adversely affect disease-free survival.

Pelvic recurrence from colorectal cancer produces significant morbidity. Radiation can help palliate the pain produced by this recurrence. Frequently patients with recurrent colorectal cancer will progress to a constant unrelenting pain and obstructive uropathy with sacral and bladder involvement. These patients can be candidates for an aggressive surgical resection with the hope of significant palliation and prolonged survival. From October 1988 to December 1991, six patients had total pelvic exenteration at our institution. Of these six patients, two had en bloc sacral resection at levels S1-S2 and one at S2-S3. Two patients had residual disease at the time of primary surgery, and in the other four patients, recurrence occurred 7 to 48 months after primary resection. One patient died with disease at 7 months, and five patients are alive at 9, 25, 25, 37, and 37 months since the pelvic resection; four have no evidence of disease. The present Karnofsky performance status is 80% or greater in all patients. There were no operative deaths. Of the five living patients, the survival from diagnosis of the primary lesion is 25 to 97 months. Total pelvic exenteration and abdomino-sacral exenteration can produce significant palliation and prolong survival in a selected group of patients with pelvic recurrence from colorectal cancer.

Breast conservation therapy is an accepted treatment option for early stage breast carcinoma, but is rarely considered appropriate for locally advanced nonmetastatic lesions. Mastectomy specimens of 46/50 patients treated at the Ochsner Clinic and the Mallinckrodt Institute of Radiology with neoadjuvant chemotherapy prior to mastectomy +/- irradiation were evaluated by a single pathologist to assess tumor response to chemotherapy. Forty percent of this group would potentially have been eligible for breast conservation therapy, using a residual tumor size of < or = 4 cm with negative surgical margins as the criteria. Patients most likely to qualify for breast conservation therapy were those with T3N0-1 lesions (67%). Least likely were patients with skin involvement at diagnosis 4/33 (12%). Tumors with an extensive intraductal component at biopsy often had residual islands of intraductal carcinoma occupying the original tumor volume, even when the invasive component was absent or much reduced. A prospective trial will be required to determine whether or not acceptable local control rates can be obtained after breast conservation therapy for that subset of patients with a favorable response to induction chemotherapy.

From January 1981 to December 1990, 55 consecutive patients underwent esophageal resection by either the transhiatal (THE, 26 patients) or transthoracic (TTE, 29 patients) approach. Patient age, tumor size, and tumor stage were similar in the two groups. THE patients had a significantly worse mean preoperative American Society of Anesthesiologists (ASA) risk class assigned by the anesthesiologist. Patients who underwent THE had a significantly lower operative mortality and rate of cardiopulmonary complications, significantly shorter intensive care unit and hospital length of stay, and a significantly better postoperative survival when operative deaths are included in the analysis. Operative deaths in the TTE group were concentrated among patients > 65 years of age (4 of 9 died), in an ASA risk class > or = III (3 of 7 died) or with moderate or severe cardiac or pulmonary impairment preoperatively (4 of 6 died).

Fine needle aspiration (FNA) biopsy in conjunction with ultrasonic definition of nonpalpable masses in the neck region is being used more frequently. Currently available preoperative localization tests have failed, in many instances, to delineate adequately the location of missed adenomas of the parathyroid gland. We describe herein the use of ultrasonically guided FNA of parathyroid tissue with immunoperoxidase confirmation for precise localization of the diseased gland. Three patients with persistent hypercalcemia after exploration of the neck were referred to Ochsner Clinic, New Orleans. In two of these patients, a parathyroid adenoma had been removed, while in one patient no adenoma was found. All patients had elevated calcium (range 10.9 to 11.6 milligrams per deciliter), low phosphorous and elevated parathyroid levels. Preoperative ultrasonography to localize the suspected parathyroid glands was performed, with FNA and immunohistochemical confirmation. Smears confirmed adequate cellular material. Alcohol fixed, Papanicolaou stained and air dried, Wright's and Giemsa stained smears were evaluated for the presence of parathyroid cells by conventional cytologic examination. The Papanicolaou-stained slides were then decolorized in 1 percent hydrochloric acid in 70 percent ethanol. After decolorization, the smears were stained for parathyroid hormone (PTH) in an avidin-biotin complex (ABC) system, using a commercially available ABC kit (Vector Laboratories Inc.). The primary antibody is a polyclonal antiserum generated in rabbits against a synthetic human PTH. Negative controls were obtained from normal thyroid glands. In all three patients, the diseased gland was localized by ultrasound with cytologic and immunohistochemical confirmation, one on the right side and two on the left side. At surgical excision, the adenomas weighed 0.8 and 0.75 gram and the carcinoma, 0.75 gram. In two, intraoperative identification of the diseased gland was aided by ultrasound directed methylene blue injection into the adenoma. During a follow-up evaluation of eight to 24 months, serum calcium had remained normal in two patients, and one patient had become hypocalcemic and required calcium supplements. The preoperative localization allowed a direct surgical approach to the side in question in all patients. Ultrasonically guided FNA in an immunoperoxidase system can be a valuable preoperative localization technique for patients with recurrent hyperparathyroidism, thus avoiding extensive exploration of the neck with the subsequent complications.

Breast preservation has been shown to be a good alternative to mastectomy in selected patients with breast cancer. The purpose of this study was to evaluate the characteristics of cancer developing in the opposite breast to determine if breast preservation should be attempted in that breast as well. From 1979 to 1988, 172 women underwent tylectomy, axillary dissection and irradiation for carcinoma of the breast. All had follow-up mammogram. Mean age was 55 years. Mean follow-up time was 50 months. Thirteen patients (7.6%) developed cancer in the opposite breast. Three cancers were carcinoma in situ, nine were stage I, and one was stage IIa. Nine of 13 patients had breast preservation therapy, and four had mastectomies. Ten patients are alive with no evidence of disease, two are alive with disease and one died with disease. Breast preservation for bilateral breast cancer is a safe alternative if patients can be followed closely.

Mammographic changes after lumpectomy, axillary dissection and irradiation are common and unpredictable. To study the significance of these changes at the first follow-up mammogram, we retrospectively reviewed reports of 172 women treated in this manner between 1979 and 1988. The mean follow-up time was 50 months. Eight patients had recurrences in the same breast, while 13 patients had carcinoma develop in the opposite breast. The mean time of follow-up mammograms was 11 months (range of one to 48 months). Twenty-six patients had a normal mammogram, while 146 patients had some changes within the irradiated breast. Thirty-one patients had suspicious findings--a mass, speculation or new microcalcifications. None of these 31 patients had carcinoma confirmed by biopsy or follow-up examination. Of eight patients with recurrence in the same breast, six had a biopsy because of findings on physical examination, while two had changes from previous mammograms. The mean time to recurrence was 50 months (range of 24 to 81 months). We conclude that mammographic changes in the irradiated breast are common after lumpectomy and irradiation for carcinoma of the breast. A baseline mammogram should be done six months after irradiation is completed. Changes that occur at this time should be considered secondary to surgical treatment and irradiation and are not an indication for immediate biopsy. These findings should be reconfirmed by a mammogram performed one year after irradiation to prove that these changes are stable. Physical examination and yearly mammography of both breasts are imperative in the follow-up evaluation of patients treated in this manner.

Aneurysms of the celiac artery are unusual lesions and account for only 4% of all splanchnic aneurysms. In recent years, the incidence has been noted to rise because of the increased use of sonography, computerized tomography, and arteriography. Although patients are often asymptomatic at the time of diagnosis, the risk of rupture is high; therefore, surgical resection should be undertaken in acceptable candidates. We report the case of a large celiac artery aneurysm treated with distal pancreatectomy and celiac artery aneurysmectomy.

A carotid body tumor is a paraganglioma of the carotid bifurcation. Histologic appearance does not correlate with the malignant potential of the lesion, and thus a reliable prognostic marker for these tumors is lacking. To determine whether flow cytometric analysis of paraffin block specimens by DNA index and synthetic phase fraction (SPF) would be of prognostic value, a retrospective chart review of 14 patients with carotid body tumors was performed. Three of 14 tumors were aneuploid and were the only tumors with SPF greater than 15%. One of 3 patients (33%) with an aneuploid tumor (SPF = 22%) developed a local recurrence; no patient with a diploid tumor developed a recurrence. Two of 3 (67%) patients with aneuploid tumors (SPF = 18%) but only 1 of 11 (9%) with a diploid tumor were symptomatic preoperatively (P = 0.03). DNA index and SPF may help select a subgroup of patients with more aggressive tumors who are at increased risk for recurrence and therefore require closer follow-up.

This study was conducted to analyze the effect of different doses of cyclophosphamide (CY) on the lymphocyte populations in the rat. Monoclonal antibodies against rat determinants were used: W3/13 (T lymphocytes), W3/25 (T helper), OX-8 (non-helper), and OX-33 (B lymphocytes). Blood samples were collected on days 0, 3, 7, and 14 from four groups of F-344 Fisher rats (n = 4): three that received 25, 50, or 75 mg/kg of CY and a control group. The duration and severity of lymphocyte depletion were dose-related and were evident for both helper and non-helper cells (p less than 0.02). The helper-to-non-helper ratio increased for the group that received 25 mg/kg when compared with control and other groups, but was only significantly changed when compared with the 75 mg/kg group (p = 0.004). This effect was transitory and was only seen on day 3. The control and the 25 mg/kg groups gained weight; the other two groups lost weight (p less than 0.05). Lower doses of CY were associated with a transitory immunostimulatory effect and no morbidity when compared with higher doses.

Although fine needle aspiration (FNA) of thyroid masses has been performed since the 1950s, only recently has it become a common method of diagnosing thyroid malignancy. To assess the trends in thyroid surgery during the last 38 years at this institution, a retrospective study of the total number of cases during 2-year periods of each decade were reviewed, yielding 509 cases. Results showed that the total number of cases and the type of surgical procedure remained stable until recent years when FNA was more commonly used. For the 1987-1988 period, the total number of cases decreased (from an average of 112 per period in 1950-1981 to 60 in 1987-1988), but the percentage of cases with carcinoma was markedly increased (from 6.3% in 1950-51 to 46.7% in 1987-88). The percentage of total thyroidectomies performed increased due to a preoperative pathological diagnosis afforded by FNA. A decrease in surgical complications was also seen (from an average of 4.5% per period in 1950-1981 to 1.6% in 1987-1988). FNA has been shown to reduce the number of patients requiring surgery, increase the percentage of carcinoma in operative cases, increase the number of total thyroidectomies, and increase the percentage of preoperative pathologic diagnoses.

Neutropenic enterocolitis is a symptom complex of fever, abdominal pain, distention, nausea, vomiting, diarrhea, and bloody stools occurring in a patient with a low neutrophil count and is most often seen in patients with acute leukemia after a course of chemotherapy. In most cases, neutropenic enterocolitis is a self-limited condition, but complications of transmural intestinal necrosis and bowel perforation may occur in a small number of patients. Surgical management should be reserved for those patients with bowel wall necrosis or perforation; however, early identification of these patients is difficult. We report our experience with the use of diagnostic peritoneal lavage in three patients with the symptoms and signs of neutropenic enterocolitis. In each case, Gram's stain of lavage fluid revealed no evidence of polymicrobial contamination of the peritoneal cavity. All three patients were managed medically, with resolution of their abdominal symptoms. Peritoneal lavage is helpful in excluding bowel perforation and avoiding unnecessary surgical intervention in patients with neutropenic enterocolitis.

Thymomas are the most common anterior mediastinal masses. Malignant potential and prognosis are unrelated to histologic appearance. Deoxyribonucleic acid (DNA) flow cytometry is of prognostic significance in a variety of tumors. We reviewed the records of 35 patients who on pathologic examination had a thymoma or thymic carcinoma. Flow cytometric studies, including DNA indices (ploidy) and S phase fraction, were done on paraffin block specimens from 31 patients. We believe this is the first report of DNA flow cytometric studies in thymic pathology. Mean survival was 63.5 +/- 13.3 months for patients with benign thymomas, 10.5 +/- 4.6 months for patients with malignant thymomas, and 19.3 +/- 4.1 months for patients with thymic carcinomas. Patients with benign thymomas lived significantly longer than those with malignant thymomas (P = .001) and thymic carcinomas (P = .03). DNA flow cytometry demonstrated four aneuploid tumors (two benign thymomas and two malignant thymomas). All thymic carcinomas were diploid. There was no statistically significant difference among the groups. The mean S phase fraction was 15.22% for benign thymomas, 11.15% for malignant thymomas, and 14.31% for thymic carcinomas. No statistically significant difference was found among the groups. We conclude that flow cytometry is not a useful guide to malignant potential or prognosis in thymomas and thymic carcinomas.

While hepatic resection of metastatic colorectal carcinoma is accepted as effective in selected patients, resection of metastases to other solid organs has not gained wide acceptance. We retrospectively reviewed the records of 49 patients who had resection of isolated pulmonary (18 patients) and hepatic (31 patients) metastases from the large bowel, comparing disease-free survival and overall survival. Tumor parameters analyzed included Dukes' stage, deoxyribonucleic acid (DNA) flow cytometry, and number of metastases. Dukes' B and diploid tumors had longer disease-free survival and overall survival than did Dukes' C and aneuploid tumors, though the difference was not significant. Patients with a single lung metastasis had a significantly longer disease-free survival (P = .02) than did patients with multiple metastases. Mean and median survival were longer in patients with lung metastases. Five-year actuarial survival was 19% for patients with liver metastases and 47% for patients with lung metastases. Resection of isolated pulmonary metastases from the large intestine results in survival comparable to or better than resection of hepatic metastases. An aggressive surgical approach is warranted in patients with isolated resectable pulmonary metastases of colorectal carcinoma.

Forty-four consecutive stricture repairs by one surgeon with long-term follow-up study are reported. Sutured anastomoses were performed in 39 patients. Essentials of the sutured repair include minimal dissection of the proximal duct, a one-layer anastomosis, mucosa-to-mucosa apposition, and a preference for hepaticojejunostomy with a T-tube stent. Eighty-six per cent of the patients treated by this technique achieved satisfactory results. This technique is the procedure of choice for repair of biliary stricture.

In dogs with appendicitis-peritonitis, intraperitoneal povidone-iodine caused death more rapidly than the instillation of saline solution. The bacterial content of canine peritoneal fluid increased with time. Although fewer bacteria were found in fluid from povidone-iodine-treated dogs, the differences were not statistically significant. Qualitative chemical analysis of peritoneal fluid revealed iodide, but not free iodine, 15 to 30 minutes after instillation of povidone-iodine. Iodine was present in the peritoneum at 2 hours but not at 3 or 6 hours. The antibacterial effect of povidone-iodine was demonstrated in mice challenged intraperitoneally with lethal doses of Escherichia coli. Povidone-iodine diminished mortality when injected immediately (p less than 0.005) but not when given 1 to 3 hours later. Immediate injection of povidone-iodine into mice lowered the number of E. coli by 3 logs. Injection of povidone-iodine 3 hours after bacterial challenge lowered the number of E. coli by only 1/3 log. This lesser bactericidal effect in mice is attributed to greater dispersal and sequestration of bacteria throughout the peritoneal cavity with time and with inactivation of povidone-iodine by reduction to iodide in vivo. In dogs with appendicitis-peritonitis, the more rapid death after treatment with povidone-iodine was not associated with differences in peritoneal microflora but with peritoneal absorption of excessive amounts of iodide.

Thirty-five consecutive cases of adenocarcinoma of the ampulla of Vater seen over the past 36 years were reviewed. The introduction of new diagnostic techniques over the course of this study improved the accuracy of preoperative diagnosis but did not lead to earlier diagnosis. The surgical resectability rate was 88%, and 53% of postoperative survivors were free of disease at 5 years. Of the 14 patients with metastases to regional lymph nodes, 27% survived disease-free for 5 years. Surgical mortality was 25% for the entire series but has been reduced to 6.6% over the past decade. Surgical mortality was primarily due to leakage of the pancreaticojejunostomy; the risk of pancreaticojejunostomy leak correlated inversely with the degree of chronic pancreatitis in the pancreatic remnant. In 35% of resected cases, a benign adenomatous component was contained within the cancer of the ampulla of Vater. Cure rates are good for this lesion. The most important factor in maximizing cure rate is careful attention to the technical details of pancreaticojejunostomy in order to minimize surgical mortality. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater.