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In the majority of patients, strictures of the common bile duct result from an injury to the duct. The earlier the injury is repaired or the more quickly the diagnosis of stricture is made and repaired, with antibiotics to prevent infection, the better are the results of the repair. Five types of repair have been utilized: (1) choledochoduodenostomy, (2) duct-to-duct repair, (3) choledochojejunostomy, (4) plastic revision of the stricture, or (5) dilatation of a previous stricture when multiple, previous operative procedures or the difficulty of operative exposure proves too great for adequate repair. Our overall results after repair of biliary stricture are good or excellent in 84 per cent of patients. We have had the best results in patients in whom choledochoduodenostomy was performed.

The present study correlates the indications for operation in 215 patients with duodenal ulcer disease with the results of operative management. The majority of patients had conservative surgery utilizing truncal vagotomy and pyloroplasty or gastrojejunostomy. None of the 194 patients operated on electively died and four patients died after emergency operations, for an overall operative mortality in the entire series of 1.8 per cent. The incidence of recurrent ulcer symptoms in all patients was 10 per cent. We could demonstrate only a modest correlation between indications for operation and long-term results of conservative surgical management; the indication for surgery, whether that of chronic (intractability, stenosis) or more acute (hemorrhage, perforation) ulcer disease is only moderately reliable as a predictor of long-term results. In this series of patients, those with obstructing duodenal ulcers (pyloric stenosis) had the best long-term results after conservative surgical management.

The results of 157 operations performed for portal hypertension and esophageal varices on 148 patients at the Cleveland Clinic in the 10 year period between 1970 and 1980 are reported. One hundred four shunt procedures and 53 ligation procedures were performed. The overall operative mortality rate of 13 percent did not differ significantly from the 11 percent rate reported from this institution in 1971. A comparatively higher rate of recurrent variceal hemorrhage and a lower rate of encephalopathy reflected our increased use of selective shunts and ligation procedures. There was no improvement in overall long-term survival, which was approximately 50 percent. The two most important factors in predicting the results of all operations for esophageal varices continue to be assessment of preoperative liver function and the timing of the operation. The best results were obtained in patients with good liver function who had an elective operation. Our data suggest that the portacaval shunt is associated with a higher incidence of late mortality, largely as a result of liver failure; therefore, our preference now is to perform a distal selective splenorenal shunt procedure whenever possible. If a selective shunt procedure cannot be performed, we advocate either a mesocaval shunt or a ligation procedure, depending on patient risk and the suitability of veins for a shunt procedure.

Fifteen patients, all of whom underwent surgery at this institution from 1955 to 1981, were included in this study. Bile duct cysts were classified into Types I to V to include cysts of the intra- and extra-hepatic bile ducts. The association of this entity with other congenital abnormalities is discussed. Carcinoma of the biliary tree occurred in two cases. The treatment of this condition is surgical. Excision is preferred whenever technically possible; otherwise a bypass procedure is performed. The technique of excision described by Lilly [32,34] is preferred because it is safer, decreasing the risk of injury to the hepatic artery and portal vein. Controversy continues regarding the procedure of choice.

Examples of the use of endoscopic pancreatography in the preoperative evaluation and postoperative follow-up study of patients with pancreatic disease are presented and discussed. Six cases selected from a total experience of forty-eight patients have been summarized. The direct role of pancreatography in the management of these cases is cited. There is a small but definite risk to the procedure. With increased use of endoscopic pancreatography, it is hoped that earlier diagnoses of a variety of pancreatic diseases will be obtained which will permit more accurate medical and surgical therapy.

A series of forty-eight patients in whom choledochoduodenostomy was performed to relieve malignant obstruction of the common bile duct is reported. A side to side choledochoduodenostomy was performed in forty-six patients, and an end to side in only two in whom it was technically preferable. The operation uniformly cleared the jaundice rapidly, and although the immediate morbidity was high, only 15 per cent of the complications were related to the biliary-duodenal anastomosis. There were no late instances of ascending cholangitis in forty-three survivors of the operation whose progress was followed until they died of the primary disease. The various alternatives to side to side choledochoduodenostomy all appear to be inferior to this operation, for various reasons, and the theoretic objections to its use are refuted by our results. It is our belief that side to side choledochoduodenostomy is the palliative procedure of choice to relieve unresectable malignant obstruction of the distal part of the common bile duct, when the gallbladder is surgically absent or otherwise unsuitable for use. The fashioning of a Roux-Y anastomosis between the common bile duct and the jejunum is needlessly complicated, and should be reserved only for those patients in whom the duodenum cannot be adequately mobilized.

Summary o 1. Since radical mastectomy with removal of the pectoral muscles is no longer the standard technic used in the treatment of all patients with breast cancer, biopsy must be performed in such a way that simple operations will not enter the site of the biopsy which is potentially contaminated with cancer cells. 2. Not only the technic of biopsy but also the timing of the definitive operation is important. After excisional biopsy, for example, it may be better to wait until the wound has healed before performing definitive surgery. 3. One of the advantages of not performing definitive operation at the same time as biopsy is that the biopsy can be performed in the operating room on an outpatient basis. This avoids the delay that often attends admission to the hospital for definitive surgery. 4. A second advantage of delay is that the patient is not unnecessarily frightened if she is told that no definitive or mutilating operation will be performed at the time of biopsy. After the nature of the tumor is known, she will have an opportunity to discuss with the surgeon which treatment will be given. 5. Since the treatment of cancer of the breast is now so varied, it is essential to know as much as possible about the nature of the lesion before making a final decision as to its treatment, and evaluation of multiple permanent sections is often important in this decision.