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To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

This study attempts to characterize any changes occurring in the human gastric control electrical rhythm (CER), following a variety of gastric surgical procedures. Pairs of electrodes were implanted in selected specific sites on the stomachs of 57 patients undergoing either antrectomy and vagotomy, proximal gastric vagotomy (PGV), vagotomy and drainage, gastric resection without vagotomy, or fundoplication. Five patients undergoing nongastric operations served as controls. After operation recordings were obtained with differential preamplifiers, an oscilloscope, and a dual-channel tape recorder. An electrical signal compatible with a CER was found almost always in the distal body or antrum, regardless of whether vagotomy was performed. In contrast, a CER was found only occasionally in the fundus, and was never found following PGV. Although there was a difference in the frequency of occurrence of fundic CER in patients with and without vagotomy, it was not statistically significant (p = 0.0668). Patients with prolonged postoperative convalescence because of gastric atony were compared with patients with normal postoperative courses regarding the presence or absence of CER in the gastric antrum or fundus. A statistically significant relationship between abnormal gastric motility and absence of CER was not established.

There were 425 consecutive patients treated for Hodgkin's disease at this Medical Center from 1943 to 1983. Of these, 255 patients underwent a staging laparotomy and had complete preoperative clinical records. Overall, 35% had a change in stage (24% were upstaged, 11% downstaged). Twenty-nine per cent of clinical stage I patients were upstaged; 31% of stage II patients were upstaged, while less than 1% were downstaged; and four per cent of stage III patients were upstaged while 44% were downstaged. The diagnostic laparotomy yielded involvement in the spleen in 71% of patients with abdominal involvement, in the periaortic lymph nodes in 41%, in the liver in 11%, and the bone marrow in seven per cent. Only 12% of the 135 patients with negative laparotomies subsequently relapsed in the abdomen after a mean follow-up of 4.8 years. A multifactorial analysis was performed to identify dominant factors predicting the risk for abdominal disease. The factors best predicting abdominal involvement in stage I and II patients were: antecedent symptoms (greater than or equal to 2, 1, 0; p less than 0.00001), histological type [nodular sclerosing (NS) less than lymphocyte-predominant (LP) less than mixed cellularity (MC) less than lymphocyte-depleted (LD); p = 0.0009], and sex (females less than males, p = 0.01). The clinical stage (I vs. II), the site of lymphoma presentation, and the age and race of the patient did not have significant predictive value for the risk of abdominal disease after the other factors were accounted for. A mathematical model was derived for identifying dominant prognostic factors for predicting the risk of abdominal disease in an individual patient setting. The lowest risk patients were asymptomatic females with NS histology (6%) or LP histology (8%), while the highest risk patients were men with multiple symptoms and either MC histology (85%) or LD histology (93%). This information can be useful in making clinical decisions in Hodgkin's lymphoma patients, especially those at an increased risk for surgery.

A multifactorial analysis was used to identify the dominant prognostic variables affecting survival from a computerized data base of 339 melanoma patients treated at this institution during the past 17 years. Five of the 13 parameters examined simultaneously were found to independently influence five year survival rates: 1) pathological stage (I vs II, p = 0.0014), 2) lesion ulceration (present vs absent, p = 0.006), 3) surgical treatment (wide excision vs wide excision plus lymphadenectomy, p = 0.024), 4) melanoma thickness (p = 0.032), and 5) location (upper extremity vs lower extremity vs trunk vs head and neck, p = 0.038). Additional factors considered that had either indirect or no influence on survival rates were clinical stage of disease, age, sex, level of invasion, pigmentation, lymphocyte infiltration, growth pattern, and regression. Most of these latter variables derived their prognostic value from correlation with melanoma thickness, except sex which correlated with location (extremity lesions were more frequent on females, trunk lesions on males). This statistical analysis enabled us to derive a mathematical equation for predicting an individual patient's probability of five year survival. Three categories of risk were delineated by measuring tumor thickness (Breslow microstaging) in Stage I patients: 1) thin melanomas (<0.76 mm) were associated with localized disease and a 100% cure rate: 2) intermediate thickness melanomas (0.76-4.00 mm) had an increasing risk (up to 80%) of harboring regional and/or distant metastases and 3) thick melanomas (>/=4.00 mm) had a 80% risk of occult distant metastases at the time of initial presentation. The level of invasion (Clark's microstaging) correlated with survival, but was less predictive than measuring tumor thickness. Within each of Clark's Level II, III and IV groups, there were gradations of thickness with statistically different survival rates. Both microstaging methods (Breslow and Clark) were less predictive factors in patients with lymph node or distant metastases. Clinical trials evaluating alternative surgical treatments or adjunctive therapy modalities for melanoma patients should incorporate these parameters into their assessment, especially in Stage I (localized) disease where tumor thickness and the anatomical site of the primary melanoma are dominant prognostic factors.

The cases of 380 patients with pancreatitis were analyzed retrospectively. There were 237 men (62%) and 143 women (38%). Etiologic factors included: alcoholism, 62%; biliary lithiasis, 16.6%; idiopathic, 12%; miscellaneous, 7%; and trauma, 2.4%. Acute pancreatitis occurred in 279 patients (73%); 189 (67%) were treated nonoperatively, 90 (33%) underwent operation; electively in 43 and urgently in 47. Postoperatively, one patient (2.3%) died in the elective group and 14 (30%) in the emergency group. Chronic pancreatitis occurred in 101 patients. Their pertinent findings were: alcoholism in 78%, biliary lithiasis in 8%, absence of abdominal pain in 15%, diabetes in 40%, and jaundice in 20%. Fifty patients were treated without operation; 43 were alcoholics, 17 of them died in the follow-up period. Fifty-one patients, 36 of them alcoholics, underwent a variety of operations, with three deaths (6%); 21 were improved after operation. It was concluded that 30% of patients with acute pancreatitis require operation, mainly to correct biliary lithiasis. Emergency operations dictated by relentless deterioration or uncertain diagnosis had a high operative mortality (30%), particularly in patients with necrotizing or hemorrhagic pancreatitis. Operative treatment for chronic pancreatitis was most effective when directed toward specific goals, including pseudocysts, obstructed pancreatic or common bile ducts. Operations done without specific anatomical objectives were often therapeutic failures.

The experience with 108 cases of hepatic injuries was reviewed retrospectively and a classification based on the severity of the hepatic injury was used to group these patients accordingly. Using this criteria, the factors determining the observed morbidity and mortality were analyzed. Hepatic injuries amenable to relatively simple surgical treatment were found in 72 patients (67%). Nine deaths occurring in this group were attributed to the commonly encountered associated injuries inside and outside the abdomen. Moderately severe imjuries requiring suturing of the hepatic parenchyma and ligation of injured vessels and bile ducts were seen in 15 patients (14%). Two of these patients died. Severe hepatic injuries resulting in major blood loss requiring partial hepatectomy were seen in 21 patients (19%). Seven of the eight deaths (7.4%) attributable to the hepatic injury occurred in this group. As noted, ten other patients died from causes other than the hepatic injury for an overall mortality of 16.7%. A pre-established patient management program based on the classification of hepatic injuries is proposed as a method for improving the management of patients with hepatic injuries.