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• We retrospectively reviewed 76 cases of adenocarcinoma of the lower rectum treated by abdominoperineal resection between 1975 and 1985 to elucidate the relationship between pathologic stage and both the size and histologic grade of the tumor. Our results showed evidence of lymphatic invasion in 50% of the 36 patients with tumors 4.0 cm or less in diameter, 51% of the 68 patients with tumors of either a high or moderate degree of differentiation, and an alarming 53% of the 34 patients whose tumors satisfied both criteria simultaneously. Finally, a substantial proportion (25%) of patients who had only partial invasion of the muscular layer also had lymphatic metastases. These results differ significantly from what has been previously reported and lead us to conclude that the commonly used criteria of size and histologic grade are inadequate criteria and do not allow confident selection of patients with lesions suitable for local treatment. (Arch Surg1987;122:533-536)

• Arteriovenous fistulas of the mesentery are rare sequelae of abdominal injuries or operations. Symptoms, when present, are most often due to intestinal ischemia or portal hypertension. Cardiac failure is less common, and the case described in this report is, to our knowledge, the first in which the patient presented with duodenal obstruction—the superior mesenteric artery syndrome. A bruit is an expected finding and a thrill is pathognomonic of an arteriovenous fistula. With rare exception, operation is indicated to dismantle the fistula. ( Arch Surg 1986;121:1209)

Recent reports suggest that the distal splenorenal shunt does fulfill its physiological promises. The portal and the gastroesophagealsplenic areas are divided into separate "venous watersheds." As a result, varices are decompressed but portal hypertension is preserved. It should, therefore, have its greatest advantage for patients with the most severe impairment of hepatic reserve. In this evaluation, the procedure was considered the operation of choice for all shunt candidates who had a patent splenic vein. A series of 20 patients, 12 with Laennec cirrhosis, seven with postnecrotic cirrhosis, and one with Wilson disease, survived shunting and were discharged from the hospital. One patient died of hepatic coma eight weeks after operation. If lengthy follow-up studies confirm its capacity to prevent hemorrhage, the distal splenorenal shunt may be the safest elective shunt operation for patients with cirrhosis.

• The case records of ten patients with benign, three with endocrine, and 19 with malignant duodenal tumors were reviewed. Patients with benign tumors had episodes of bleeding that were recurrent in a number of cases. The endocrine tumors were all gastrinomas; patients had ulcer diathesis associated with the Zollinger-Ellison syndrome. All malignant tumors were symptomatic, with chronic gastrointestinal blood loss or duodenal obstruction. All benign tumors were demonstrated preoperatively, but only ten of 19 malignant tumors were confirmed preoperatively. The data suggest that duodenal tumors masquerade as more common diseases and as a result, their diagnosis and treatment are delayed inordinately. Awareness of this problem is encouraged, and a more aggressive diagnostic effort in selected patients, including fiberoptic endoscopy, is suggested. (Arch Surg111:377-380, 1976)

Gastric inhibitory polypeptide (GIP), immunoreactive insulin (IRI), and glucose levels in response to orally administered glucose were determined in ten patients with vagotomy and pyloroplasty (V&P) and in 21 normal subjects. The V&P patients had the expected early and exaggerated increase in mean serum glucose with a subsequent decline to a level below fasting. The early mean GIP response was similarly elevated and paralleled the glucose response. The early mean serum IRI of V&P patients was greater than that of normal subjects, but only at 30 minutes was the difference statistically significant (P

The facial nerve in 24 rats was exposed unilaterally and subjected to one of four procedures: (1) transection; (2) freezing with the cryoprobe; (3) tumor implantation without treatment; or (4) tumor implantation with subsequent freezing of tumor. Transection produced facial paralysis without return of function. Freezing of the nerve and freezing of tumor implanted on the nerve produced temporary paralysis with return of function in three weeks. Implantation of tumor and subsequent growth of untreated tumor did not impair function of the nerve. All tumors not treated by cryosurgery were widespread within one month. All tumors treated by cryosurgery were destroyed within 35 days.

Eighty patients were studied to determine the accuracy of echography of the abdominal aorta. When echograms were compared with findings at operation or autopsy the echographic diagnosis was correct in 79 (98.8%) of the 80 cases. Results of this study suggest that echography of the aorta is more accurate than physical examination. Echography may be used to identify, measure, and periodically evaluate small aneurysms of the aorta.

INITIALLY described by Devic and Bussy in 1912,1the association of osteomas or exostosis, soft-tissue tumors, and multiple polyposis of the colon was established as a predictable inherited syndrome by Gardner and his associates (1950-1953).2-4Subsequent reports and reviews, such as the analysis of 84 cases collected by Jones and Cornell in 1966,5have further defined the major features and natural history of this syndrome. It has been estimated that 50% of untreated patients who have multiple polyposis of the large intestine will develop adenocarcinoma of that organ by age 30.6In addition to polyps of the colon and rectum, a small number of patients with Gardner's syndrome have adenomatous polyps of the small intestine.7The premalignant nature of these lesions and, therefore, the need for their removal is suggested by the finding of adenocarcinoma of the small intestine in an occasional patient with Gardner's

Obstruction of the common and hepatic bile ducts by calculi has been a challenging surgical problem since Abbe performed the first successful choledocholithotomy in 1889. 1 In patients who have undergone cholecystectomy and choledocholithotomy, subsequent calculous obstruction of the bile ducts is the result of retained stones, that is, stones missed at the time of choledocholithotomy, or recurrent stones, that is, stones re-formed within the ductal system after choledocholithotomy. Recurrent stones may form secondary to a structural abnormality of the bile ducts, or they may occur without apparent cause. This study is primarily concerned with those patients who have idiopathic recurrent biliary stones. Material Forty-six patients underwent choledocholithotomy at the Mayo Clinic on at least two occasions during the 11-year period from Jan 1, 1950, through Dec 31, 1960. Since some of these patients had undergone choledocholithotomy prior to 1950, first or second choledocholithotomy as used in this paper will