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A retrospective review of patients treated for carcinoma of the common bile duct has demonstrated improvement in diagnostic capabilities, leading to earlier management by resectional therapy. The ability to resect these tumors is directly translatable to improved long-term survival. Efforts to obtain proof of malignancy prior to resection are often frustrated by the inability to obtain adequate representative tissue for frozen section. Choledochoscopic biopsies and incisional biopsies have given the highest yield of positive diagnoses. In experienced hands, a program of fewer preoperative tests with emphasis on early operation, diagnosis, and definitive treatment may be more cost-effective in the management of patients with common bile duct cancer.

Jaundice is rarely encountered in polycystic disease of the liver. In the present case, pressure from tense cysts at the hilus of the liver caused a marked narrowing of the common hepatic duct and slowing of bile flow with the formation of stasis stones. Decompression of the cysts and removal of debris in the intrahepatic ducts resulted in a rapid decrease of the serum bilirubin level.

Surgeons who are completing their training should be enabled to assume final patient responsibility for 1 year in an environment where they can easily obtain advice and guidance. A cooperative adjustment in the number of surgical specialists should be made as long as inadequately qualified physicians are appropriately retrained. Separate training programs should be considered to emphasize experience with frequently performed low-risk procedures. Equitable entrance requirements should be established for all graduates of various preparatory health care schools not endorsed by the CCME who might be qualified for admission to approved surgical training programs and subsequent Specialty Board examinations. We should be prepared to assist in the making of difficult recommendations regarding priorities in the expenditure of health care dollars as funds become increasingly restricted. A surgeon's performance should be monitored in his hospital and as long as he meets locally approved standards of practice, all other quality control measures should be optional. The development of surgical investigators should be encouraged by providing financial and job stability during the prolonged period required for research and surgical training. Much of what I have said regarding medical education, practice and research is related to the role of the government. What will be the rules and regulations of the government under which our schools must operate and our surgical practice and research be conducted in the future? How much money will the government offer to support education and research, and what funds will be available for patient care? Obviously, the profession has taken on a big, aggressive, domineering partner in all of these fields since many of us graduated from medical school. Our governmental partner is fairly new to the problems of medicine, but since many of today's problems are also new to us, we must learn to work effectively with the government and all of its agencies as we attempt to meet the challenges of the future.

This study reports four new cases of Caroli's disease complicated by the development of cholangiocarcinoma. Caroli's disease appears to be a premalignant condition, but early diagnosis of malignancy in the cyst wall is difficult because signs of ductal stenosis develop slowly and treatment is often based on erroneous diagnosis of recurrent cholangitis. When carcinoma is present, operative intervention makes no difference in survival. In patients with Caroli's disease, adequate intraductal and hepatic biopsies should be obtained at the first operation. These patients should be followed carefully, and malignant growth should be suspected when cholangitis occurs despite patent anastomoses. Earlier diagnosis will obviate repeated operations in patients with malignant Caroli's disease.

Using Senn's treatise as the benchmark from which to measure the advances of pancreatic surgery during the last century, it may be said that acceptable, if not totally successful, progress has been achieved in a number of areas. Injuries to the head of the pancreas, particularly those combined with duodenal trauma, continue to pose difficult operative and management problems. Persistent pancreatic and intestinal fistulas and infection substantially increase morbidity and prolong the hospital stay of some patients with injuries of the body and tail of the gland. Means to control or eliminate the effects of extravasated activated pancreatic juice are needed. Severe hemorrhagic gangrenous pancreatitis, with its excessive morbidity and mortality, offers numerous opportunities for improvement in management. The role of peritoneal lavage and of early resection have not been completely settled and require further carefully controlled evaluation. Why in one case of acute pancreatitis does the mild edematous variety develop and in the next the devastating gangrenous type? Although the majority of patients with chronic pancreatitis can be successfully treated, surgery often falls short of complete rehabilitation. Careful selection of patients and procedures as well as collaboration with colleagues in the psychologic and rehabilitative fields are essential to achieve optimal results. What are the important events within the pancreas that lead to the pathologic changes of chronic pancreatitis? Cancer of the pancreas remains one of the most discouraging problems of pancreatic surgery, and unfortunately, major surgical therapeutic break-throughs do not appear at hand. Earlier diagnosis or technical improvements may add a few percentage points to the survival rate, but our greatest hope for improvement may lie in adjunctive therapies that will help to control the basic biologic aggressiveness of this tumor. What accounts for the biologic aggressiveness of this tumor and how might this characteristic be modified? Of the endocrine tumors the best surgical results by far have been achieved with insulinomas. Diagnosis, localization, and excision are usually successful although occult and multiple tumors still pose a problem. Malignancy is rare (10 percent) in insulinomas, common in vipomas (35 percent), and frequent (66 percent) in gastrinomas and glucagonomas. Although the incidence of malignancy in the latter three tumors diminishes the efficacy of surgical excision, prolonged palliation and occasional cures are achieved. Operation is once again assuming an important role in the management of gastrinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

We reviewed our experience from 1955 to 1979 with benign postoperative biliary strictures to determine which factors were associated with a favorable outcome. Patients operated on from 1970 to 1979 were significantly more likely (p less than 0.01) to achieve a good result (86 percent) than were patients undergoing surgery between 1955 and 1969 (68 percent). An inverse correlation (r = -0.96, p less than 0.05) was present between the number of previous repairs and the percentage of good results. Patients referred without a previous repair were most likely to achieve a good result (86 percent). Roux-Y jejunal reconstructions were associated with the best results (p less than 0.01). In recent years Silastic transhepatic stents were used in 20 patients with hilar strictures; 18 (90 percent) achieved good results. Patients stented for the shortest period (less than 1 month) were less likely to achieve a good outcome than those stented for longer periods (p less than 0.025). Patients with difficult hilar strictures who were stented for more than 9 months were more likely to have a good result if a changeable Silastic transhepatic stent was employed (p less than 0.01). This analysis suggests that early referral, Roux-Y jejunal reconstruction, judicious use of Silastic transhepatic stents, and prolonged stenting of hilar strictures will improve the outlook in patients with postoperative biliary strictures.U

Sixty-one cases of pyogenic liver abscess seen at the UCLA Hospital and the Wadsworth Veterans Administration Hospital are reviewed. Hepatic abscess should be suspected in those patients with continued sepsis who, in addition, have an increase in size and tenderness of the liver. Since the introduction of antibiotic therapy, as well as of newer diagnostic technics, there has been an increased awareness of this clinical situation. Recently there have also been changes in the etiologic, bacteriologic, and operative approach to this lesion. Previously, liver abscess has been due primarily to portal infection from intraperitoneal disease. In this series 60 per cent of the cases were due to either intraperitoneal disease or generalized septicemia. Biliary obstructive disease in older patients has also begun to increase. The predominant organisms cultured were streptococcus and staphylococcus. Gram-negative organisms, which previously accounted for the majority of abscesses, were found in only twelve cases. In the past, drainage through an “extraperitoneal” approach has been emphasized. With vigorous antibiotic therapy, however, the transabdominal approach may be employed with minimal danger. Solitary pyogenic abscess is best treated by open surgical drainage as soon as it is diagnosed. When there are multiple small abscesses in the liver, effective surgical drainage seldom can be accomplished and one must depend upon intensive chemotherapy, which at times can provide an effective recovery. An understanding of these concepts will allow early and more vigorous therapy to be instituted.

A technic for drainage of hepatic lymph into the jejunum is described. This procedure has been applied to dogs with obstruction of the common bile duct and to five infants with congenital biliary atresia. Serum bilirubin values may be lowered for more than four months without hypoproteinemia after this operation. Reducing elevated serum bilirubin values to almost normal levels does not appear to prevent the progression of biliary cirrhosis.

T HE increased apphcation of total gastrectomy in the treatment of maIignant neopIasm of the stomach has been associated with concern about gastrointestina1 function after this procedure. The progress of most patients who have survived for proIonged periods after tota remova of the stomach has been satisfactory. 2** However, certain probIems have been encountered in the management of others. Three principal disturbances are encountered after tota gastrectomy, (I) regurgitation of intestina1 contents, (2) nutritiona disturbances and (3) anemia. Interest in correction of these has stimuIated the empIoyment of various types of gastric reservoirs foIIowing tota gastrectomy.3 The present paper is a report of our experiences when a segment of jejunum has been interposed between the esophagus and the duodenum after tota gastrectomy. A preIiminary report on the first seven patients was published in 1952.

Obturator hernia can be a lethal disease because of its frequent occurrence in the elderly debilitated patient, plus the relatively high frequency of strangulated bowel. Although an accurate preoperative diagnosis is not always possible, the signs and symptoms of intestinal obstruction will usually dictate early operation. The abdominal or retropubic approach allows the best exposure with easy reduction of the sac and resection of nonviable intestine if needed. Because most defects are small, simple pursestring closure of the sac is adequate. When a large defect is present, the use of a patch of peritoneum, fascia, or prosthetic cloth may be necessary.

1. 1. A review of our clinical material indicates that immediate, primary, end-to-end repair of injuries to the common bile duct has a minimal chance of success. We believe that other methods of repair deserve consideration in such cases. 2. 2. The clinical results of most authors, as well as our own results, indicate that any one reconstructive procedure, regardless of type, has only a 50 to 60 per cent chance of success. 3. 3. Histological changes which seemed to recreate the process of stricture formation at the suture line of an end-to-end anastomosis occurred in experimental animals at the end of a year. 4. 4. Because of the small size of the common duct in the dog, the procedure of two-layer anastomosis of duct to intestine is attended with considerable operative mortality. Although the anastomosis was wide open in nearly all these dogs, each had developed signs of recurrent cholangitis, probably due to reflux of intestinal contents into the biliary system.

The possible relationship between peptic ulcer disease and the anatomic rearrangement after Roux-en-Y choledochojejunostomy was studied in a series of ninety-seven patients who had undergone this procedure for the treatment of benign extrahepatic biliary obstruction. Peptic ulcer was documented in ten of thirty-nine patients in whom significant complications had developed in the postoperative period. Eight of these had at least one bleeding episode, four had two, and one had three bleeding episodes. Two patients died from the bleeding episodes. Nine of these patients had duodenal ulcers, and one had a gastric ulcer. Four required surgical intervention for complications of the ulcer: three for bleeding and one for perforation. Other complications in this series included fifteen cases of cholangitis, four of infection, and ten of abdominal pain of unknown origin. For comparative purposes, a series of thirty-nine patients who had undergone choledochoduodenostomy at the UCLA and Wadsworth VA Hospitals were reviewed. Of these, twelve had significant postoperative complications: five cases of fistula, three of cholangitis, three of stricture, and one of peptic ulcer. It has been speculated that the cause of peptic ulcer after choledochojejunostomy is secondary to the divergence of alkaline bile secretions from the duodenum. Others have judged that a secondary gastric hypersecretory phenomenon is primarily responsible. In view of our findings, it is believed that a complete preoperative evaluation of peptic ulcer potential is warranted, and postoperative protection of patients with a proclivity to ulcer disease is essential. In high risk patients, vagotomy and pyloroplasty should be considered.

A review of 250 patients with cancer of the stomach showed that only 4.8 per cent were alive on follow-up of at least two years. Five out of thirty-eight patients who had total gastrectomy, five out of fifty-nine who had subtotal gastrectomy, and two out of ten who had esophagogastrectomy survived to the close of the study. Although these findings tend to support the value of total gastrectomy for cancer of the stomach, other recent reports do not agree. Since even the best results from operation for cancer of the stomach are unsatisfactory, new forms of treatment are needed.