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All carotid arteriograms performed between January 1, 1986 and December 31, 1991 were reviewed for instances of midcervical carotid stenosis. Sixteen cases were identified. A stenosis related to the hypoglossal nerve was specifically identified in three operative reports in the retrospective review. Pathologic examinations of the specimens confirmed the presence of atherosclerotic plaque or fibrous dysplasia. In another case, relief of intermittent neurologic symptoms (TIAs) was obtained by division of the stylohyoid ligament. Prospective observation of five cases confirmed a stenosis immediately distal to a transverse neurofascial band formed by the hypoglossal nerve, which arose with the vagus nerve in three patients, and a large cervical contribution to the ansa hypoglossi in two. Presumably the lesion was caused by the turbulent flow in the internal carotid artery distal to the band. Isolated stenosis of the midcervical internal carotid artery unrelated to bifurcation disease may be the result of turbulence induced by tethering neural or myofascial bands.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.

Millions of people continue to smoke. Recent studies confirm the pioneering epidemiologic data that indicated that, despite the well-established effects on the lung, most of the hundreds of thousands of premature deaths annually result from extrapulmonary toxicity, particularly accelerated cardiac and vascular disease. As with lung cancer, abstention significantly reduces the risk, even after myocardial infarction or surgery for complications of vascular disease. Erythrocytosis, thrombocytosis, and leukocytosis, by increasing blood viscosity, aggravate ischemia. The neutrophils of smokers release excessive amounts of oxidants which damage tissue and antiproteases. Increased alveolar permeability enhances allergy. Lymphocytic suppressor cells increase, which leads to immunocompetence, increased infection, and cancer. Smokers lose weight and die at an earlier age, even after cancer chemotherapy and peptic ulcer surgery. Smoking prevents inhibition of gastric night acid secretion by histamine-blocking agents. Menopause occurs earlier and children are damaged in utero and after birth by passive smoking. Recent evidence indicates that nicotine releases endorphins, which account for the addiction. Surgeons need to do more to combat this menace. Many victims need professional assistance to stop the habit.

Segmental pulmonary resection was employed in 61 patients with cancer whose ages ranged from 44 to 82 years (average 62 years). There were 39 patients in the curative group with disease staged T1N0M0, 9 patients in the limited group with residual thoracic disease, 8 patients in the palliative group with severe chronic obstructive pulmonary disease, and 5 patients in the metastatic group. Two patients died within 30 days after operation. Significant palliation was obtained in the limited and metastatic groups. Most patients in the palliative group died from emphysema within 1 to 2 years after resection. Early survival rates (64 percent after an average of 16 months) in the curative group were not as good as had been anticipated because small peripheral, asymptomatic, and predominantly scar adenocarcinoma spread systemically more than similar bronchogenic cancer. Furthermore, about half the deaths were related to the many other diseases of smoking. However, the local recurrence rate of 5 percent was low. Segmentectomy was well tolerated, even in patients with compromised pulmonary function.

This review has emphasized the need to manage carcinoma of the lung with a systematic approach. Diagnostic and staging procedures should be performed to prevent unnecessary thoracotomy. In patients with limited pulmonary reserve, segmentectomy or wedge resection is an acceptable procedure. A staging mediastinal node dissection should be included in every resection for lung cancer. Those patients with positive mediastinal nodes found in this manner should receive postoperative mediastinal irradiation.

Two hundred patients undergoing vagotomy for duodenal ulceration over a period of forty-three months were randomly given Heineke-Mikulicz or Finney pyloroplasty. One died of a myocardial infarction twenty-four fhours after operation, six-teen died within seven years from conditions unrelated to surgery, nine were lost to follow-up study, and 174 were followed up an average of 5.2 years. These patients were evaluated for signs and symptoms of recurrent ulceration or complications of their operation. A majority underwent postoperative secretoay and gastric emptying studies. The proved rate of ulcer recurrence was higher in patients with Heineke-Mikulicz pyloroplasty (4 per cent versus 2 per cent); however, over-all recurrence (proved, probable, and possible) was 13 per cent in each category. The dumping syndrome, seen in 14.4 per cent with Heineke-Mikulicz and 10.7 per cent with Finney pyloroplasty, was the most common complication...

Profundaplasty has been performed on 112 limbs (88 primary and 24 secondary) in eighty-five men. Seventy-six limbs had incapacitating claudication, twenty-three rest pain, and thirteen either gangrene or ischemic ulceration. In thirty-six limbs treated by profundaplasty alone there were no deaths but five subsequently had amputation for ischemic pain. In the seventy-six limbs treated by profundaplasty plus other operative augmentation there were three operative deaths and one late death; three required further operative surgery and in four amputation was necessary. Oblique arteriographic films of the femoral area are essential for evaluation of the profunda femoris artery. Both radionuclide and Doppler pressure studies confirmed physical and arteriographic findings. The latter would appear superior because of ease of availability and cost. After profundaplasty alone and aortofemoral bypass there was a moderate increase in calf blood flow, but in only those with a patent superficial femoral artery did blood flow and pressure studies return to within normal limits. Profundaplasty is an important addition to the armamentarium of the vascular surgeon in dealing with arteriosclerotic insufficiency of the lower extremities.

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.

A consecutive series of 276 men had 317 inguinal hernias repaired by the preperitoneal approach. Of these, 162 (59 per cent) had 194 (61 per cent) "complete" repairs using Marlex prostheses. Fifty-five of 152 indirect hernias (36 per cent) were patched similarly. Seventeen of twenty-two mixed bilateral defects (77 per cent) had a prosthetic patch. Thrity-three of forty-eight repairs (68 per cent) for recurrent hernia in forty-five men also employed Marlex. Two patients died postoperatively. Four of 194 repairs using Marlex failed. These preliminary results indicate that the advantages of preperitoneal exposure can be complemented by an initially satisfactory technic of repair using a prosthesis instead of the classic relaxing incision, which is difficult to use with this posterior approach.

Review of our experience with twenty-two bile duct injuries and the literature leads us to the following conclusions: (1) Most biliary strictures follow surgery and can be avoided by adequate exposure, accurate dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. (2) Injuries diagnosed at the time of surgery should be repaired by end-to-end anastomosis over a T tube if length is adequate or by Roux-en-Y choledochojejunostomy if length is inadequate. (3) The diagnosis of biliary injury should be suspected when jaundice, biliary fistula, or cholangitis occur in the postoperative period. (4) IVC, PTC, ERCP, or fistulography should be used when possible to delineate the site of injury or stricture and assist in planning the operative repair. (5) Surgery should be performed as soon as the diagnosis is made and the patient is in satisfactory condition for operation. (6) Early reoperation may be necessary to establish drainage and prepare for a later definitive procedure. In some cases, definitive repair can be performed this time. (7) Most late strictures should be repaired with a choledochojejunostomy to a defunctionalized limb of jejunum when resection and primary end-to-end repair cannot be accomplished.

One hundred years ago, Edoardo Bassini, a professor of surgery in northern Italy, pioneered the modern approach to inguinal repair. Today, the most common operation performed for hernia is one of the many modifications of the procedure he introduced. Since he reported his series from 1887 to 1894 in the Italian and German literature, and other surgeons soon claimed priority, most surgeons today are unfamiliar with the details and importance of Bassini's contribution. Therefore, his illustrious career is outlined and his papers regarding herniorrhaphy, along with previous biographies, are discussed. Pernicious and benign modifications of his operation are described, and the present status of his procedure is discussed in light of its revival as the Shouldice operation and amid the continuing criticism of its many modifications.

From 1966 to 1977, 396 men aged 25 to 89 years (mean 58) underwent 505 repairs for recurrent inguinal herniation (including bilateral defects and recurrences). Since by 1972 it was realized that the approach precluded an effective relaxing incision, when this was indicated (66 per cent) a Marlex prosthesis was used. Seventy-four patients underwent 83 repairs with this material; 26 (35 per cent) had had previous repairs for recurrence, 29 (40 per cent) underwent contralateral herniorrhpahy, whereas another 12 (16 percent) underwent bilateral repair. Fifty-five (2 of 3) protrusions were direct. None of the patients died. Although overall 110 (22 per cent) of the operations failed, only 6 of 83 hernias (7 per cent) in which Marlex was used recurred, with a mean follow-up study of 4 years. It is important to use a large enough piece of plastic and remove attenuated fascia from around the defect. No infection or extrusion occurred. Preperitoneal placement of Marlex is recommended for difficult, repeatedly recurrent inguinal hernias.

One hundred and eighty-seven men, aged twenty to eighty years with an average of forty-eight years, underwent surgery for perforated duodenal ulcer. Seventeen received an immediate definitive procedure; none died. Nine (5 per cent) of the remaining 170 who had omentopexy died one to fifteen days postoperatively. They were older and waited longer. One hundred and twenty-one patients (76 per cent) were adequately followed. Thirty-nine (32 per cent) had "acute" perforation and eighty-two had "chronic" perforation. Twenty-four (30 per cent) of the latter underwent definitive operation within three months without mortality. Overall, 25 per cent of the ninety-nine patients followed after omentopexy required reoperation within twelve months. However, only three (8 per cent) of the thirty-nine with "acute" perforation required operation as compared with twenty-one (37 per cent) of the fifty-eight with "chronic" perforation. The main reason for early operation in the "chronic" group was obstruction; 21 per cent failed to empty their stomach immediately or soon after omentopexy and half as many either had pain or bled severely within twelve months and also required reoperation. The "acute" and "chronic" groups continued to differ in their need for further operation. Overall, 57 per cent of the ninety-seven patients required a definitive operation one to twenty-four years later. However, only ten of the thirty-nine patients (26 per cent) in the "acute" group required definitive operation as compared with forty-five of the fifty-eight patients (77 per cent) in the "chronic" group. Outlet obstruction of the stomach was the main indication for definitive surgery in twenty-six of the fifty-five (47 per cent) reoperations. This high incidence of gastric obstruction after omentopexy was not peculiar to our institution since, over the past six years, eighteen patients having omentopexy elsewhere had to be operated on for this complication. We recommend that patients with "chronic" perforation should not undergo omentopexy but rather immediate vagotomy and a drainage procedure.

During the past six years, thirty-seven patients underwent interposition graft shunting for thirty-three instances of bleeding from varices and five instances of intractable ascites, either electively (twenty-seven instances) or as an emergency (eleven instances). Autogenous jugular vein was used in twenty-five instances, homologous vena cava in nine, and Dacron in four. Portacaval and mesocaval anastomoses were done in equal numbers (nineteen). Using Childs' method of clinical evaluation, thirty-three patients were Class C and four Class B. There were five (13.2 per cent) early deaths with one (3.5 per cent) in the elective and four (36 per cent) in the emergency group. Twelve grafts were open at autopsy, fifteen at splenoportography, and seven assumed patent because patients were asymptomatic. Two Dacron grafts and two homografts thrombosed. There were ten late deaths, only one related to graft failure. Apparently, the operation controls ascites, with autogenous jugular vein being the ideal material. Interposition grafting is a simple, safe procedure that can be used for portal decompression in patients with bleeding varices.

We conclude that (1) the activated clotting time (ACT) is an accurate method of monitoring anti-coagulation during peripheral vascular surgery and can easily be performed by a technician in the operating room or at the bedside; (2) an initial heparinizing dose of 120 to 130 units/kg is adequate in 95 per cent of the patients; (3) the ACT should be maintained at greater than twice the control values (180 to 200 seconds), which required supplementation within 2 hours in 21 per cent; (4) the response to heparin is twofold: an initial sensitivity or resistance followed by an independent and variable rate of consumption; (5) the patient's heparin dose-response curve should be used to calculate the amount of supplemental heparin needed to maintain the ACT at a safe level; (6) protamine should be given if the ACT at the conclusion of the operation is greater than 150 seconds (50 per cent of our patients); and (7) a final ACT 15 to 30 minutes postoperatively should be obtained to ensure adequate reversal or to detect heparin rebound or depletion of clotting factors.

The characteristic pulmonary hypertensive effect of the heparin and protamine interaction has been studied in the isolated pig lung preparation using sequential autologous blood perfusate and dextran perfusate. A significant (p less than 0.001) increase in pulmonary artery pressure at constant flow was seen in 10 of 14 dextran and 12 of 15 blood perfusions. The average increase for dextran was 112 percent and for blood, 109 percent. Antihistamines did not inhibit the response. However, this was abolished in all 11 animals treated with aspirin. In 11 intact swine, thromboxane B2 blood levels increased significantly (p less than 0.01) from 0.46 +/- 0.38 ng/dl to 2.97 +/- 1.5 ng/dl. Thus, pulmonary hypertension associated with protamine reversal of heparinization is associated with prostaglandin release from the lung, and this does not require mediation of platelets or leukocytes.

Eleven men with disabling reactive hypoglycemia, in a range of 12 to 50 mg per 100 ml, were treated an average of seven years after gastric surgery with a 10 cm reversed jejunal segment. The reversal was placed at the gastric outlet in six patients and just below the ligament of Treitz in five. The former technic produced a somewhat better correction of hypoglycemia than did the latter. A good result was obtained in all eleven and none has had recurrence of seizures or fainting. Whereas the average minimal blood sugar before reversal was 34 mg per 100 ml, after reversal it was increased to 64 mg per 100 ml. The most severe hypoglycemia was noted in a patient after vagotomy and pyloroplasty. We recommend that all patients with dumping syndrome undergo glucose tolerance tests and plasma insulin determinations to ascertain whether they have reactive hypoglycemia. It is our conclusion that introduction of a reversed jejunal segment can control refractory reactive hypoglycemia resulting from previous gastric surgery.

Seven hundred ninety-three vagotomies with either pyloroplasty (645 patients) or antrectomy (148 patients) were reviewed between 1970 and 1981. Mortality was lowest with elective pyloroplasty (0.4 percent) followed by elective antrectomy (0.7 percent), and emergency pyloroplasty (5.1 percent). The risk of death was significantly higher (p less than 0.05) for the older half of the population (older than 55 years of age). Major morbidity was lowest after elective pyloroplasty (6.3 percent) when compared with elective antrectomy (10.6 percent), and greatest after emergency pyloroplasty (18.1 percent). Proved ulcer recurrence was most frequently seen after pyloroplasty (4.5 percent) and least frequently seen after antrectomy of age) had a significantly decreased risk of ulcer recurrence (p less than 0.001). Disabling sequelae occurred in 3.6 percent of those who underwent pyloroplasty, in 5.6 percent of those who underwent antrectomy with Billroth I reconstruction, and in 8.5 percent of those who underwent antrectomy with Billroth II reconstruction. Significantly more patients who underwent antrectomy with Billroth II reconstruction required reoperation (p less than 0.01) than did those who underwent either pyloroplasty or antrectomy with Billroth I reconstruction. Although antrectomy has become a popular operation, vagotomy combined with pyloroplasty is still the procedure of choice in patients over the age of 55 years. In those requiring emergency operations for duodenal ulcer, and in those in whom antrectomy is technically difficult because of a badly scarred duodenum. Billroth II reconstruction should be avoided after vagotomy and antrectomy.

Our experience from 1960 to 1976 with total infrarenal aortic thrombosis (Leriche syndrome) was reviewed. Sixteen heavy smokers (14 men and 2 women) with an average age of fifty-four years underwent thrombectomy with aortoiliac (12 patients) or aortofemoral (4) Dacron bypasses. The last ten patients were hydrated for 12 hours preoperatively with 3,000 ml of Ringer's solution containing supplemental potassium. Mannitol (25 g), furosemide (20 mg), and heparin (120 u/kg) were given intraoperatively. Thrombectomy was accomplished by transection of the aorta, with proximal manual control of the aorta after the renal arteries were occluded. With this technic there were no deaths or renal complications, whereas previously, three of the six patients developed renal complications and one died. Ninety-two per cent of the grafts have remained open. We recommend that the direct transabdominal approach be continued rather than the extraanatomic bypass (axillobilateral-femoral), since further propagation of the aortic thrombosis may then lead to infarction of the kidneys or other viscera.

This study has demonstrated an imbalance between the blood proteolytic and antiproteolytic system in acute pancreatitis. Serum elastase activity is markedly increased and elastase inhibitory capacity is decreased in this disease as compared with those in chronic pancreatitis and the control values. We have found that a return to normal values represents better evidence of resolution than amylase determinations. These results offer the clinician a biochemical guideline for the medical management of acute pancreatitis.