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We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group I), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.

Objectives To characterize the career choices and developments made by leading senior surgeons in this country and to examine hypothetically whether application of a short tracking program would have hindered their career decisions. Design A survey pertaining to each surgeon's career, decisions, and opinions concerning surgical training. Setting and Participants Senior surgeons of regional and national surgical societies. Main Outcome Measure Survey responses. Results A total of 352 surveys (41.4%) were received. Respondents answered that the most common reasons for choosing a specialty were role models or mentors (56%), research (51%), and available patient population (23%). The 2 most common stages in a career at which the respondents became interested in a specialty, or an area of expertise, were at the junior residency level (when the specialty was chosen) and at the assistant professor level (when a more specific topic within the specialty was chosen). The most common stage at which the group believed they acquired their expertise was also at the assistant professor level. Seventy-one percent of respondents believed broad training was superior to a short tracking system, although none had participated in shortened surgical training. Conclusions Most leading senior surgeons in this country still believe that broad surgical training is superior and should be maintained. Because career specialties in this surveyed group were generally chosen in early residency, a hypothetical application of the short tracking system would have still allowed for these important decisions to be made. Also, it seems likely that specialty and career development would not have been hindered because "expertization" mostly occurred after training was completed. Regardless of training method, a role model or mentor seems most important in career choices and developments.

In the US, the remarkable decline in the incidence of gastric cancer during the mid-portion of this century has leveled off during the last two decades as an equally remarkable and poorly understood increase in the percentage of the generally more unfavorable cardia cancers has become apparent. The importance of H. pylori infection is being actively investigated and treatment to reduce the infection may offer a means of decreasing the disease, particularly in areas of high incidence. The potential danger of inciting gastric cancer by the prolonged use of drugs that severely reduce or eliminate gastric acid has been mentioned, but the degree of risk must await the passage of years before it can be properly evaluated. "Early gastric cancer" or, probably more appropriately, "superficial gastric adenocarcinoma" continues to comprise a relatively small segment of gastric cancers in the US and most Western countries. Seventeen per cent of cases in the ACS series were classified as stage I, a much higher incidence than reported for early gastric cancer in most individual North American series. The ACS report suggests "special education of the surgeon in the requisites for adequate gastrectomy with node dissection, coupled with effective adjuvant therapy" as a means of improving results in the US. This is a significant consideration because, unfortunately, gastric surgery for ulcer or cancer no longer plays the important role it did in past decades in many US surgical training programs. As has been demonstrated in Japan and in certain larger US series, excellent surgical technique, particularly for cardia tumors, plays an important role in obtaining improved results. The value of radical lymph node dissection continues to be controversial in US cases, and a successful chemotherapeutic regimen has yet to be found. Subtotal gastric resection, as noted in the ACS report, continues to be the procedure of choice in the US for most gastric cancers, even for cardia cancers. Although there is no improvement in survival, quality of life is thought by some to be better after total gastrectomy for cardia cancers rather than proximal subtotal esophagogastrectomy. However, equally important for improved survival is the ACS recommendation of earlier referral for gastric surgery patients with precursor lesions, but the lack of improvement in the pathological stage of disease in the two ACS time periods suggests that little progress is being made in this country in this regard.

Over a 21 year period, 245 cases of cancer of the pancreas were operated upon and followed-up at UCLA Hospital. A further 34 cases of periampullary tumor were treated by partial or total pancreatectomy. Apparent clearance of tumors at the time of pancreaticoduodenectomy that was confirmed by subsequent histopathology resulted in a patient survival time of 20.3 months as compared with a figure of 12.9 months when the pathological examination revealed tumor in a resection margin, although the surgeon believed that excision had been complete at the time of operation. Frozen section examination of resection margins is therefore mandatory. The result of performing a pancreaticoduodenectomy in which tumor was seen to be left behind was a survival time of only 6.8 months, which is similar to the survival time of 6.2 months following a palliative biliary bypass. Pancreaticoduodenectomy in patients over the age of 70 resulted in an average survival of only 7.6 months. Of patients having a palliative biliary bypass alone, 13% required subsequent reoperation to bypass distressing duodenal obstruction. A duodenal bypass should therefore be a routine concomitant of a biliary bypass. Total pancreatectomy with duodenectomy for pancreatic cancer gave an increased average survival of 26 months, and it is likely that the frequency of performance of this operation will increase.

For many years, the classical Whipple procedure has been the standard operative treatment for resectable periampullary cancer. Recently, the pylorus preservation operation has also been applied to periampullary tumours. This newer procedure has potential advantages in terms of ease of performance and postoperative physiology, but has yet to be proved as an adequate cancer operation. We, therefore, undertook the present retrospective analysis to compare the outcome following the pylorus preservation operation (n = 13) with that of the classical Whipple resection (n = 13) in 26 patients with histologically proved adenocarcinoma of the head of the pancreas. The two groups of patients were comparable for age, sex, pre-operative laboratory data, and resected margins free from tumour. More patients undergoing the classical Whipple resection had Stage I disease (10 versus 4, P < 0.05). However, this difference would not be significant if the two patients in the pylorus preservation group with carcinomas in situ were considered to have stage I disease. Mean tumour diameter in the pylorus preservation patient group (3·2±0·6 cm) was smaller (P

Major hepatic resections were performed on 138 patients for a variety of conditions. There was one intraoperative death. Including this patient, there were 15 deaths within 30 days of the operation (operative mortality 10.9%). Important postoperative complications were intra-abdominal sepsis (17%), biliary leak (11%), hepatic failure (8%), and hemorrhage (6%). The results of 30 resections for the benign lesions, liver cell adenoma, focal nodular hyperplasia, hemangioma, and cystadenoma showed no operative mortality and low morbidity. Of 26 patients with hepatocellular carcinoma, seven died within a month of operation. The cumulative survival of the 26 at five years was 38%, and of the 19 who survived the procedure, 51%. Poor survival followed resections for cholangiocarcinoma and "mixed tumors." The five-year cumulative survival of 22 patients who had colorectal metastases excised was 31%. Apart from a patient with carcinoid, prolonged survival was rare after resection of other secondaries and after en bloc resections for tumors directly invading the liver. Hepatic resection was of value in the management of some patients with hepatic trauma, Caroli's disease, liver cysts, and intrahepatic stones.

Four patients with hepatic cell adenoma have been treated at the UCLA Hospital since 1965. The most recent was a 22-year-old woman who underwent subtotal resection of a giant hepatic cell adenoma after an unusual and confusing clinical presentation. The tumor may be the largest reported to date and may have excreted metabolically-active substances. Increased familiarity with the varying clinical and radiographic presentations of these rare tumors may facilitate earlier diagnosis and management.

Three patients with biopsy proven histiocytosis X who developed a clinical and pathological picture compatible with sclerosing cholangitis are reported. In one patient, operative biopsy of the common bile duct revealed histiocytosis X in the granulomatous/xanthomatous phase. At necropsy, however, only fibrosis of the biliary tree was seen, a picture consistent with sclerosing cholangitis. Fibrotic obstruction of the biliary tree led to death from liver failure in all three patients. The aetiology of primary sclerosing cholangitis is unknown and may be multifactorial. Perhaps involvement of the biliary tree by histiocytosis X is one cause.

Despite recent advances in perioperative support care, surgery for obstructive jaundice is still associated with significant morbidity and mortality. For this reason, preoperative percutaneous transhepatic drainage (PTD) has been recommended for these patients. This method of management, however, has only been supported by retrospective and nonrandomized studies. Therefore, a prospective, randomized study was performed to determine the effect of preoperative PTD on operative mortality, morbidity, hospital stay, and hospital cost. Thirty-day mortality was 8.1% among 37 patients undergoing preoperative PTD, compared to 5.3% for 38 patients who went to surgery without preoperative drainage. Overall morbidity was also slightly, but not significantly, higher in patients who underwent preoperative PTD, (57% versus 53%). However, total hospital stay was significantly longer (p less than 0.005) in the PTD group (31.4 days versus 23.1 days). The cost of this excess hospitalization and the PTD procedure at our university medical center was over +8000 per patient. The authors conclude that preoperative PTD does not reduce operative risk but does increase hospital cost and, therefore, should not be performed routinely.

Management of the Pancreas After Pancreaticoduodenectomy SHERRELL ASTON;WILLIAM LONGMIRE; Annals of Surgery

Records were reviewed for all patients who underwent primary treatment for adenocarcinoma of the stomach at two UCLA hospitals between 1956 and 1975. Division of the data into two, ten-year time periods reveals a pattern of unchanging presentation and pathologic characteristics which probably accounts for the unaltered response to operative therapy. The consistency of certain prognostic findings justifies a surgical approach in which extensive resections are only selectively employed.

Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a ten-year period. Ages ranged from 13 to 56 years, and follow-up was up to nine years. Among the 14 patients with bile duct injury, eight were found to have complete transection, and five suffered a tangential laceration or incomplete disruption with a portion of a duct wall remaining intact. Five of the eight patients who had complete transection underwent primary end-to-end repair with T-tube splinting, while three were treated with primary Roux-en-Y choledocojejunostomy. All patients with incomplete disruption underwent primary repair with or without T-tube splinting. Of the five patients with complete disruption who were treated with primary end-to-end anastomosis of the bile duct in conjunction with T-tube splinting, all required secondary biliary tract reconstruction of some type. No patient with complete transection that was treated with primary Roux-en-Y biliary enteric anastomosis required reoperation. Partial transections were successfully treated with primary repair. Portal vein injury was encountered in ten patients. Injury was successfully managed by primary closure, interposition of a vein, or splenicmesenteric vein bypass. Associated injuries to liver, pancreas, kidney and duodenum were common. In four patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.

Hemangiomas are the most common benign tumors occurring in the liver. However, the natural history of hepatic hemangiomas has not been well defined. Four patients (3 women, 1 man) with recurrent giant liver hemangiomas underwent either surgical or radiation therapy as initial treatment for the primary tumor. The average time until recurrence was 14 years, and each tumor weighed more than 600 g. Each of the female patients had been given chronic estrogen (Premarin) replacement therapy. Three of the four patients underwent surgical resection for intractable symptoms or progressive enlargement. It is believed that estrogen replacement therapy may play a role in the pathogenesis of these tumors. Furthermore, operative intervention should be considered in patients with recurrent giant liver hemangioma.

Dies ist das erste einer Reihe von Symposien, die in Anlehnung an die „Panels by Correspondence” anglo-amerikanischer Publikationen nun auch in Langenbeck's Archiv erscheinen sollen. Drei international anerkannte Experten auf dem Gebiet der Pankreaschirurgie wurden gebeten, zu 7 Fragen und 3 Problemfallen Stellung zu nehmen. Da eine direkte Diskussion in dieser Runde nicht moglich war, hat der Moderator versucht, die Ansichten zusammenzufassen bzw. Differenzen aufzuzeigen. Die Herausgeber von Langenbeck's Archiv danken den drei distinguierten Chirurgen fur ihre wertvolle Mitarbeit.

Ninety episodes of acute cholangitis in 66 patients have been analyzed. In 71% of the episodes, an operation was performed. Eight deaths occurred, for a patient mortality rate of 12%. Sixty-seven per cent of the operations were performed after at least 72 hours of antibiotic therapy, whereas only 17% had to be done as life-threatening emergencies within 24 hours of admission to the hospital. Although 86% of the operative deaths occurred in the group operated on more than 72 hours after admission, this was not statistically significant. However, death did correlate with failure to respond to antibiotic therapy (p less than 0.001) irrespective of time of operation. Biliary cancer and congenital lesions were etiologic for 31% of the operative cases in this series, but were responsible for 71% of the postoperative deaths (p less than 0.05). We conclude that acute cholangitis has a wide spectrum of severity and that most cases will respond to antibiotic therapy, affording the surgeon the luxury of operating in an elective fashion. Moreover, acute cholangitis complicated by failure to respond to antibiotic therapy is more likely to occur in biliary cancer and congenital lesions, and subsequently will have a poorer prognosis.

Resection of the auricular appendage for recurrent embolism was performed in three cases of rheumatic heart disease with persistent auricular fibrillation. Mural thrombi were demonstrated in each case. Cardiac function was not apparently influenced by the operative procedure. No evidence of further embolization has been noted over a followup period of five to 10 months.

Over a 3-year period 4911 patients of whom 1411 were referred for d iagnostic purposes were evaluated by a screening program. Physical exa mination of the breasts followed by mammography was done. Thermography was recently added. Routinely 2 views were taken of each breast. Cancers have been detected which were missed by palpation alone and some missed radiographically were found by palpation or thermography. 46 cases of breast cancer were detected in the screening group of 3470 patients (13.2 per 1000) and 89 in the 1411 referred cases (61.7 per 1000). Papanicolaou smears at the clinic had detected 148 cervical cancers (2.9 per 1000). Relative cost of detection of breast cancer by the screening procedures was much greater per patient than the cost of the Papanicolaou smear method for cervical cancer but in number of cancers were occult. 53% of the cervical cancers were it situ. The detected breast cancers were later found to be 73% free of axillary metastases and thus compare favorably with the 53% of in situ cervical cancers. In the mammography screening group 3.7% of patients were biopsied and 35.4% of the biopsies revealed cancer. In the group referred for diagnostic mammography 14.5% received a biopsy and 42.2% of biopsies showed cancer. Of the 1950 patients receiving thermography 17% were positive. Of those with breast cancer 43.3% were positive with thermography. By using physical examination and thermography as screening procedures the use of mammography could be reduced. A number of combined cervical and breast cancer screening clinics if established could detect many early cancers. Personnel could be trained there and educational foci developed. Also all screening methods could be evaluated.