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Haemorrhage via the pancreatic duct, a rare cause of upper gastrointestinal bleeding (GIB), often poses a diagnostic dilemma. We analysed our experience with 10 patients (8 men, 2 women; mean age 44 years, range 34 – 62) treated during a 12 year period. All had a history of alcohol abuse and presented with major upper GIB requiring a median of 8 units (range 2 – 40) blood, transfusion. Nine had upper abdominal pain at the time of admission and nine had a history of pancreatitis. Upper gastroduodenal endoscopy (median 4; range 1 – 9), was diagnostic in only one. Side-viewing endoscopy showed bleeding from the pancreatic duct in 7 of 8 patients. Visceral aneurysms were demonstrated in 7 of 9 patients in whom coeliac angiography was carried out: (splenic artery 4, gastroduodenal artery 2, and pancreaticoduodenal artery 1). Two of 4 selective embolisations were successful. Six patients underwent distal pancreatectomy, 1 had gastroduodenal artery ligation and 1 died of coagulopathy following a total pancreatectomy. Pancreatic duct haemorrhage should be considered in patients with unexplained recurrent upper GIB, alcohol abuse and epigastric pain, particularly in those with established chronic pancreatitis. Selective angiography is essential for diagnosis and management. For bleeding sites in the head of the pancreas, embolisation should be attempted to avoid major resection. Distal pancreatectomy is preferred for splenic artery lesions.

Minimal access surgery via the operating laparoscope has been performed by our gynaecological colleagues for many years. General surgeons have been slow to develop expertise in the techniques of laparoscopic surgery. The new small television cameras and the excellent colour television reproduction, together with purpose designed instrumentation, have made safe laparoscopic surgery a reality rather than a dream. The first laparoscopic cholecystectomy was performed in France by Phillippe Mouriat of Lyons in 1987. Francois Dubois of Paris, one of the leading pioneers in the field, performed his first laparoscopic cholecystectomy in May 1988. Several other groups commenced later that year. Eddie Reddick of Nashville, Tennessee and Jacques Perissat of Bordeaux, France, performed their first laparoscopic cholecystectomies in September and November of 1988 respectively1-4. These pioneers, as well as others, have developed considerable expertise. By early 1990, Dubois reported 350 cases, Reddick 200 cases, and Perissat 193 patients1. Furthermore, many people have received training in laparoscopic cholecystectomy at major institutions. Laparoscopic cholecystectomy appears to have established itself as an important new technique. Standard open operative cholecystectomy is the "gold standard" for the management of symptomatic gallstones in the gallbladder. It is a little over 100 years since the first successful cholecystectomy was performed by Carl Langenbauch. Operative cholecystectomy has withstood the recent threats of oral drug dissolution therapy and extracorporeal shock wave lithotripsy. Does the advent of laparoscopic cholecystectomy mark a new milestone in management? Alternatively, could this be a dangerous innovation which will lead to morbidity, including common bile duct damage, and life threatening intra-operative haemorrhage requiring rapid laparotomy for control? I believe that laparoscopic cholecystectomy will become a major milestone in general surgery if correctly introduced by adequately trained biliary surgeons with laparoscopic expertise. It is not surprising that the procedure

Survival following major juxtahepatic venous injury is rare in blunt liver trauma despite the use of intracaval shunting. Prolonged liver arterial inflow control, total hepatic venous isolation and lobectomy without shunting was used in a patient to repair a combined vena caval and hepatic venous injury after blunt liver injury. An extended period of normothermic hepatic ischemia was tolerated. Early recognition of retrohepatic venous injury and temporary liver packing to control bleeding and correct hypovolemia are essential before caval occlusion. Hepatic vascular isolation without shunting is an effective simple alternative technique allowing major venous repair in complex liver trauma.

During a 10 year study period 234 patients were admitted on 371 occasions with a total of 566 acute variceal bleeding episodes. Of these, 173 patients had 343 variceal bleeds which required balloon tamponade to achieve initial control of bleeding during 229 admissions and were then referred for emergency injection sclerotherapy. Sixty-eight percent of these patients had alcoholic cirrhosis and 42% were poor risk Grade C patients. Injection sclerotherapy was performed initially using the rigid Negus oesophagoscope under general anaesthesia and later using the fibreoptic endoscope under light sedation. Definitive control of variceal bleeding was achieved with sclerotherapy during 197 hospital admissions (92%). Of the 17 failures of emergency sclerotherapy, 4 patients died from uncontrolled bleeding and 13 patients underwent major surgical intervention. Definitive control of variceal bleeding was achieved with a single injection treatment in 138 hospital admissions (70%). Complications were mostly of a minor nature and occurred at a rate of 6% per injection treatment. The overall hospital admission mortality was 36%. The majority of patients died due to liver failure. The mortality in patients who required 4 injection treatments to control variceal bleeding was 71%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients whose variceal bleeding continues or recurs after initial conservative management. Patients whose variceal bleeding is not controlled by 2 injection treatments require more major emergency surgery.