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Feeding prairie dogs a diet rich in cholesterol induces gallstone formation that is preceded by a sustained decrease in gallbladder smooth muscle contractility. Sphincterotomy is known to prevent gallstone formation in cholesterol-fed prairie dogs. Experiments were designed to determine whether the effect of Sphincterotomy is a consequence of hepatic bile diversion, and whether bile diversion prevents the altered contractility. Following sham operation, surgical biliary enteric bypass, or sphincterotomy, prairie dogs were fed a high-cholesterol or a regular diet. Gallbladder muscle contractility and the presence of crystals and stones were determined. In sham-operated animals, the cholesterol diet induced a decrease in gallbladder muscle contractility and caused the formation of cholesterol gallstones. In animals with bile diversion and sphincterotomy, the effects of cholesterol feeding were reduced or prevented. Thus, these procedures may prevent stone formation by preventing a reduction in gallbladder contractility. Contractility was depressed in animals with bile diversion fed a regular diet, compared with animals with a sham operation fed a regular diet. The mechanism for this depression may differ from that induced by the cholesterol diet. Diversion, and perhaps sphincterotomy, impairs gallbladder filling. Thus, gallbladder muscle is not stretched and does not contract against a load. This could result in a “disuse atrophy.” If the results from our study apply to humans, sphincterotomy may reduce stone formation by preventing the effects of lithogenic bile on gallbladder muscle contractility and by enhancing the ability of the muscle to empty the lithogenic bile.

Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p less than 0.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p less than 0.001). A significantly higher incidence of portal (86 percent) and systemic (57 percent) endotoxemia, however, was found after external drainage. The persistence of endotoxemia after external drainage, when serum bilirubin levels returned to normal units, indicates that bile flow is important in controlling endotoxemia during preoperative biliary drainage. These results suggest that the systemic endotoxemia observed after relief of obstruction by external drainage may contribute to the increased mortality, as found in previous rat studies. This observation may contribute to an understanding of why patients with preoperative external drainage of biliary obstruction have a higher incidence of septic complications.

Pancreatography is a valuable diagnostic technic to identify structural changes in the pancreatic ductal system. Although specific diagnoses based on ductal changes are not always possible, patients with surgically normal glands and those showing changes of chronic pancreatitis were reliably identified in this series. Patients evaluated for postcholecystectomy pain usually had normal pancreatograms and grossly normal pancreatic glands at the time of surgical exploration. The overall consistency in interpretation of pancreatograms by experienced radiologists was approximately 80 per cent. Pancreatic cancer was poorly predicted due to either minimal changes in the ductal system or inability to distinguish gross changes from those seen with chronic pancreatitis.

The paranoia associated with attempts to drastically contain the cost of medical care poses a serious threat to further improvements in health care through research. It is assumed that a constant flow of knowledge from the bench to the bedside is not only critical to a high standard of health care, but that it is also cost-effective. In order to fully appreciate this point of view, we must recall that many of our therapies, including those that involve operative intervention, are empiric, and at best, palliative. For example, the most common cancer, lung cancer, is incurable. The second most common gastrointestinal cancer, pancreatic cancer, is not only incurable but difficult to palliate. Trauma, the most common cause of death up to the age of 45, is not only poorly understood, but barely studied. Finally, the complications of atherosclerosis which affect the cardiovascular system occur in epidemic proportions within our aging population. These are only a few of a long list of disabling diseases that deserve further study. I would like to focus my remarks on two questions: (1) Has or will the initiatives towards cost containment in medical care influence biomedical research in an adverse way? and (2) Would an increased investment in clinically directed research result in a lessening of the financial burden shared by society for its health? There is little published evidence that prospective payment of hospitalization by diagnosis-related groups (DRGs), health maintenance organizations (HMO& individual practice associations, preferred provider organizations, for-profit medical corporations, investor-owned hospitals, or other presumed

The effectiveness and complications of gastric banding were evaluated in 15 miniature pigs. A Gore-tex or Dacron graft was employed to encircle the stomach. The animals were divided into five groups, three pigs in each group. Group 1 had a 13 mm pouch stoma with a Gore-tex band, Group 2 had a 16 mm pouch stoma with a Gore-tex band, Group 3 had a 13 mm pouch stoma with a Dacron band, Group 4 had a 16 mm pouch stoma with a Dacron band, and Group 5 had a sham operation. The weight variation in the control group was significantly higher than that in the other groups at the ninth postoperative week (p less than 0.05). There was no significant difference among Groups 1, 2, 3, and 4. The gastric band had migrated distally in seven pigs. It was located in the body of the stomach in four animals and in the pylorus in three. These three pigs died from stenosis of the pylorus. The band had eroded and penetrated all stomach layers in three other animals. There was no difference in the incidence of postoperative complications between the Gore-tex and Dacron band groups. The use of this simple operation in the treatment of the morbidly obese patient should be applied with caution.

Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients. Stone fragmentation occurred in 91 percent of patients and duct clearance in 79 percent. Adjunctive procedures were used in 54 percent. Two ESWL treatments were required for fragmentation in 28 percent. Complications were mild and relatively infrequent. Hemobilia (8 percent), gross hematuria (6 percent), and biliary sepsis (4 percent) occurred less frequently than expected. There were no deaths during the 1 to 31 days of hospitalization (mean 9 days). We conclude that ESWL is a safe and effective adjunct to the treatment of difficult-to-remove bile duct stones under the conditions observed in this trial.

Intestinalization, a new method of pancreatic preservation in which vascularized pancreatic fragments are placed inside a jejunal pouch, has been tested for its effectiveness in the prevention of shock and death due to segmental pancreatitis. Intestinalization of the fragment resulted in the survival of eight of nine animals (89 percent) in which recovery was uneventful, whereas animals with pancreatitis in situ or in a mobilized fragment without intestinalization had a mortality rate of 100 percent within 2 days. We conclude that intestinalization ameliorates the outcome of hemorrhagic pancreatitis in the pancreatic fragment by effectively draining toxic products. The procedure may also be useful in pancreatic transplantation since no reintervention is necessary if graft failure or rejection occurs because the pancreas is accessible by endoscopy.

Surgical therapy of 37 patients with chronic pancreatitis is reviewed. Procedures included longitudinal pancreaticojejunostomy (10), DuVal (5), distal resection (4), pancreaticoduodenectomy (2), sphincteroplasty (7), pseudocyst drainage (6) and other miscellaneous procedures. Complication rates were 30 percent for lateral pancreaticojejunostomy, 28.5 percent for sphincteroplasty and 72.7 percent for resection procedures. The overall complication rate was 54.5 percent, and there were two deaths (5.4 percent). Follow-up is presented on 20 patients, of whom 16 are improved, 2 are unchanged and 2 are worse. Eight patients are dead and nine are lost to follow-up. Ductal anatomy is the most important consideration in the selection of a procedure. Lateral pancraticojejunostomy, when applicable, is the procedure of choice. Resection should be considered when pancreaticojejunostomy has failed or is not indicated with pancreaticoduodenectomy, the procedure of choice in the diffusely diseased gland. Sphincteroplasty should be reserved for use in stenosing papillitis or as an ancillary procedure. Splanchnicectomy can be used for temporary palliation.

Twenty-five patients underwent a variety of gastrointestinal operations in an attempt to gain relief from symptoms of recurrent ulcer and/or postgastrectomy syndromes excluding dumping. Only eleven obtained a satisfactory result. Conversion to a gastroduodenostomy provided the best relief for bilious vomiting.

The clinical characteristics of thirty-seven cases of carcinoma of the ampulla of Vater are presented. Thirty-one patients were explored. Two underwent biopsy only. A third had decompression of the biliary tree by a T tube. In three, biliary-enteric bypass was performed; three others underwent local definitive procedures. The remaining twenty-four patients were subjected to radical pancreaticoduodenectomy. Six patients who had undergone radical resection are alive and free of disease two and a half to seventeen years later. Two patients who had undergone a radical procedure died after two and five years without evidence of recurrence.