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Background. The papillary cystic and solid tumor of the pancreas is rare. It occurs predominantly in young women, and most present a benign behavior. The pathogenesis of this tumor has attracted a number of investigations but remains unclear. Methods. We present three patients with this tumor and a review of 289 others from the world's literature, a total of 292 cases. On the basis of the analyses of the clinical and pathologic features from the reported cases, the pathogenesis of this unusual tumor has been further explored. Results. Ninety percent of the patients were female, with a mean age of 23.9 years. The tumors were usually quite large with a mean diameter of 10.3 cm. Ninety-two percent of these tumors were totally or partially cystic. Rupture of the capsule resulted in hemoperitoneum in eight cases, five of which were without any identifiable cause. Forty-three tumors (14.7%) have been recognized as malignant. The overall prognosis has been excellent and an aggressive approach to resection is indicated. Conclusions. The results of immunohistochemical staining and electromicroscopy were rather diverse, but most, including the current cases, support the hypothesis that the tumor originates from pleuripotential embryonic stem cells. Thus the term pancreatic embryonic tumors seems preferable to papillary cystic and solid tumor of the pancreas to delineate the origin of the tumor and to reflect some of its biologic characteristics.

The contribution of free fatty acid oxidation to the elevation in energy expenditure after trauma has not been well characterized. Six control subjects and six traumatized patients were fasted for 48 hours and given a primed continuous infusion of (1-14C)palmitate to measure plasma palmitate and total free fatty acid kinetics. Traumatized patients had greater urinary nitrogen losses (20.8 vs. 9.3 g N per day) and a significantly greater ratio of measured to predicted resting energy expenditure (+36% vs. -6%) compared with controls. Individual and total plasma free fatty acid concentrations were similar for the two groups. The turnover and oxidation of plasma palmitate and total free fatty acids were not changed by multiple trauma. These results demonstrated that plasma free fatty acids and palmitate do not contribute to increased energy expenditure following trauma.

The treatment of pulmonary metastases from soft tissue sarcomas with chemotherapy has an overall response rate of less than 30%, and the majority of these responses are short lived. It is postulated that increased drug delivery to the pulmonary metastases may improve the outcome of these patients. An isolated perfusion system would have the ability of delivering increased levels of drug to target tissue without the systemic toxic effect of the drug. The purpose of this study was to establish the pharmacokinetics of doxorubicin delivery, lung toxicity, and the ideal dose for clinical application in an in vivo isolated perfusion model. Our results suggest that normothermic isolated perfusion of the lung with doxorubicin using a dose level up to 6 micrograms/ml in the perfusate can be accomplished without histologic lung injury, systemic toxicity, or adverse clinical outcome. Perfusate concentration of greater than 7 micrograms/ml caused significant histologic injury and adverse clinical outcome without systemic toxicity. The technique may be utilized in selective settings to improve treatment in mesenchymal tumors metastatic to the lung.

Student oral and written surgical clerkship performances may be related to the clerkship structure and the time of year the students rotate through the clerkship. The influence of calendar block, hospital site (university hospital, affiliated private tertiary-care hospital, and rural preceptor experience), and the mix of general surgical versus subspeciality rotations on oral and written student surgery clerkship scores was analyzed. Multivariate analysis of variance revealed significant differences in score for calendar block (p = 0.02) only; this difference resided in the written examination. The various combinations of rotations were not different from one another in terms of measured outcome.

The current treatment of pancreatic cancer with resection and/or radiation is considered unsatisfactory because of a high incidence of failure and a moderate incidence of complications. A sizable number of these patients present with localized or regional disease. Regional high-dose chemotherapy, such as with isolated perfusion, may offer an alternative therapy with low treatment-related morbidity and mortality and better end results in this group of patients. In an effort to develop such a treatment modality, we evaluated the pharmacokinetics and toxicity of mitomycin C (MMC) during isolated perfusion of pancreas in a canine model. From this study, it appears that a dose of 0.25 mg MMC/kg body weight is most suitable for isolated perfusion of pancreas at 39 degrees C, maintaining flow rate and pressure within physiologic range. Isolated perfusion with a dose of 0.25 mg/kg body weight has very mild short- and long-term toxicities and markedly increases drug delivery to the pancreas, duodenum, and peripancreatic lymph nodes, making it the most suitable dose for possible clinical application.

Mesothelioma of the peritoneum is a rare malignant neoplasm easily mistaken by both surgeon and pathologist for one of the more common neoplasms of the abdomen. Review of our records from metropolitan-area hospitals for the past 15 years identified seven patients with primary peritoneal mesotheliomas. Their diagnosis, management, and survival is analyzed. We report a case of an extended survivor (7 years) and one of a long-term survivor (15 years), as well as what we believe to be the only case in the literature presenting with a coexistent malignant neoplasm. Prevention of this commonly fatal neoplasm is linked to avoiding occupational exposure to asbestos; long-term survival for a few patients may be achieved with correct identification of the neoplasm and aggressive management. This report includes a review of the literature.

This monograph is well written and easy to read and provides a comprehensive overview of gastric carcinoma beginning with epidemiology and ending with a description of current chemotherapeutic efforts to reduce the mortality associated with this dread disease. The major portion of the book is a description of the authors' experience and the methods of diagnosis and management they employ for carcinoma of the stomach. The classification of gastric carcinoma and the descriptions of precancerous conditions and lesions are accompanied by some color plates of excellent quality and are presented in a particularly lucid manner. The authors' methods and procedures for the management of gastric cancer are, in general, consistent with those of other students of the disease. The authors have had considerable experience with gastric carcinoma; for example, they treated a total of 189 patients with adenocarcinoma of the gastroesophageal junction from July 1, 1982, to October 1, 1987. The extent

Isolated perfusion of organs or anatomic sites with chemotherapeutic agents offers a pharmacokinetic advantage of increasing drug bioavailability to target tissues which may result in a greater magnitude of biologic effect (pharmacologic or toxic) without systemic toxicity. Using a previously developed animal model, isolated perfusion (IP) of the canine pancreas-duodenum with incremental doses of mitomycin C (MMC) had shown a dose of 0.25 mg/kg body weight to be the maximum tolerable dose. The current study was designed to compare the pharmacologic advantage of drug delivery by IP by directly measuring tissue drug levels of radiolabeled MMC and comparing them with tissue levels attained by selective intraarterial (IA) and intravenous (IV) routes using identical doses of drug (n = 4 each). IP of pancreas-duodenum was performed for 45 min with a perfusate-to-systemic drug leak rate of less than 5%. IP was accomplished by using extracorporeal pump oxygenator at 39 degrees C and flow initiated at 110-120 ml/min, with a mean pressure of 90 mm Hg. Vascular inflow and outflow was isolated to the cannulated superior pancreaticoduodenal artery and vein. In the IA group drug was infused over 45 min through same artery as IP. IV group underwent identical dosing through the jugular vein. Direct measurement of drug in harvested pancreas and duodenum for each individual was done by tissue solubilization and scintillation assay. A 6-fold greater tissue level of drug in IP over IA and a 15-fold increase in IP over IV methods of delivery were found (P less than 0.01).

The pancreas was generally ignored in antiquity, both as an organ and as a seat of disease. The first description of the pancreas is attributed to Herophilus. It was in the 17th century that the main duct of the organ was described and its significance demonstrated. At that time, Brunner thought that the pancreas was not essential to digestion, and he failed to associate the pancreas with diabetes. Claude Bernard discovered the function of the pancreas in digestion. In 1922, Banting and Best obtained isletin and demonstrated the capacity of the substance to cause a dog to recover from diabetic coma. In 1889, Reginald Fitz firmly established pancreatitis as a disease entity. In 1927, the first case of hyperinsulinism due to a tumor of the islet cells was reported. Twenty-eight years later, Zollinger and Ellison described two patients with unusually severe peptic ulcer disease, both of whom had noninsulin-secreting tumors of the pancreatic islets. Subsequently, gastrin was isolated as the hormone responsible for this syndrome. In March 1940, Dr. O. Whipple performed the first recorded one-stage pancreaticoduodenectomy. Much progress has been made since then and today transplantation of isolated islets and portions of whole pancreas is a reality.

Major complications of operations that remove or transplant a portion of the pancreas appear related to the arterial blood supply. Hemorrhage is a result of inadequate control of the appropriate principal arteries, and ischemia and its consequences occur when the arterial blood supply to portions of preserved pancreas has been inadvertently interrupted. This radiographic study of the principal arteries of the pancreas demonstrates that these vessels may be visualized and their origin determined in the vast majority of cases. The application of data gained from preoperative arteriography can potentially decrease the incidence of major complications associated with removal or transplantation of portions of the pancreas.

SUMMARY During a 21-year period ending with 1962, a total of 221 operations for the attempted cure of metastatic tumors in the lung were performed on 205 Mayo Clinic patients. Of the 205 primary tumors, 164 (80 per cent) were carcinomas and 41 (20 per cent) were sarcomas. The over-all survival rate of 185 traced patients was 77.3 per cent, 38.6 per cent, and 30.3 per cent for 1, 3, and 5 years, respectively.

In fifty cases of pancreatic pseudocyst the diagnosis was established by autopsy in five cases and operation in forty-five cases. Alcoholism was identified as the most common etiologic factor. The best physical or laboratory evidence of pseudocyst was displacement of the stomach or duodenum in 86 per cent of forty-four patients examined by barium studies. External drainage with a catheter, the most common method of surgical management, was associated with low morbidity. Delay in operation appeared responsible for a number of complications, some of which were fatal. Eight of the fifty patients died, with hemorrhage being the primary cause of death in seven.

A solitary inflammatory polyp of the stomach characterized by an eosinophilic infiltrate, fibrosis, and granuloma formation is a rare entity. The clinical and histologic findings of this lesion are distinctly different from those of diffuse eosinophilic gastroenteritis. It is not related to eosinophilic granuloma of the lung or bone. Although the polyp may cause epigastric pain or gastrointestinal hemorrhage, it is often an incidental finding. Simple excision is adequate treatment.

Necropsy examinations were performed on 100 dogs to study the biliary system, blood supply, and topographic anatomy of the liver. The major ligamentous attachments of the relatively mobile organ are the left triangular and hepatoduodenal ligaments. Considerable fixation is provided by the hepatic veins and the intimate attachment of the liver to the inferior vena cava. The six lobes of the liver are arranged in three natural divisions. The portal vein, its branches, and their distribution are consistent as are major hepatic veins. The hepatic artery branches and major bile ducts have patterns which may be readily related to the divisional boundaries. The branches of the hepatic artery vary in number from one to five. Three branches were present in 64 of 100 specimens. A single gallbladder and cystic duct were found in each of 100 specimens. The common bile duct is formed from three (64%) or four (36%) major collecting or divisional ducts. When four divisional ducts are present, the right and left divisions of the liver are each drained by a single duct with two ducts draining the central division. The cystic duct may join either the right or left central divisional duct to form the common bile duct.

Cryonecrosis of normal bone is followed by repair of the defect by regeneration of bone from the periosteum and endosteum 2 . Similar results have been observed after freezing of malignant cells invading bone 4 . Since regeneration of bone and cartilage are similar, the possibility of regeneration of cartilage after destruction of a local area by freezing is suggested. Reconstructive problems make excision of some tracheal tumors hazardous or unacceptable. If freezing does not permanently impair the architecture of the trachea, it may offer a method of controlling or eradicating neoplasms which invade or arise from the trachea. Mongrel dogs each underwent an operation to allow the application of a cryoprobe to the external surface of the trachea. Sixty per cent of the circumference of three tracheal rings was frozen by repeated applications of the cryoprobe, each for a period of 5 min, to the anterior and lateral surfaces of the trachea. After freezing, two animals were sacrificed at each of several intervals varying from 5 min to 6 weeks. Necropsy examinations were performed on all animals. The mucosal response of trachea to freezing included gross evidence of ulceration within 6 hrs, histological evidence of beginning reepithelialization at 72 hrs, and complete healing after 2 weeks. Changes in connective tissue and vascular elements were apparent for 2 to 3 weeks after freezing. Cryonecrosis and subsequent repair of the tracheal cartilage lagged behind the sequential changes described for the mucosa and connective tissue. Although subtle changes in the staining characteristics of cartilage occurred within 6 hrs, absence of chondrocytes in the area of maximum freezing was not seen until 24 hrs. Fragmentation of cartilage did not occur until 72 hrs and was not maximal until 5 days. Healing of cartilage was first apparent after 2 weeks, and chondrocytes reappeared between 2 and 4 weeks after freezing. The most striking observation was the remarkable return of frozen cartilage to a near normal form and appearance. The progressive return from destruction of all layers to an essentially normal tracheal architecture suggested that the cryoprobe may be of value in the management of some tracheal tumors.

ConclusionThe inhibition of the gastric secretory response of canine Heidenhain pouches to meat that follows acidification of the duodenum persists after removal of the pancreas.

The purpose of the distal splenorenal shunt is to provide decompression of gastroesophageal varices while avoiding insult to the diseased liver. However, the technical difficulty of the operation has prevented widespread application of the procedure. It is important, therefore, that the technical problems an hazards of the operation continue to undergo analysis. This report has described successful establishment of a Warren shunt in three patients with abnormalities of the left renal vein. Previous left nephrectomy or an anomaly of the left renal vein does not preclude the use of the distal splenorenal shunt in the treatment of variceal hemorrhage.

Primary perineal hernia is rare and may be mistaken for other diseases of the perineum and adjacent organs. It most often presents as a mass at the inferior margin of the gluteus maximus muscle. Reduction into the pelvis identifies the defect in the levator ani or coccygeus muscles. Discomfort with sitting is a common complaint. Most authors have preferred to repair primary perineal hernias through an abdominal incision.

A patient in whom a large radiation-induced rectovaginal fistula was successfully repaired by a pull-through operation is described. Normal bowel and vaginal function were restored. If repair of a rectovaginal fistula is indicated, and the fistula is large and located in the proximal vagina, the abdominal endorectal operation should be considered.

In male patients injuries to the ureter occur most frequently during surgical procedures performed on the abdominal aorta. A patient has been described in which ureteral obstruction resulted when the ureter was compressed between a common iliac artery and one limb of an aortofemoral bypass prosthesis. Although unusual, this complication may occur when an arterial prosthesis is positioned anterior to the ureter.

Intravenous infusions of either dopamine, vasopressin, or simultaneous dopamine and vasopressin were administered to normal adult mongrel dogs, and the effect on systemic and portal hemodynamics monitored. Dopamine increased superior mesenteric artery blood flow and portal venous pressure. Because of this portal hypertensive effect, dopamine should not be given to patients with cirrhosis and portal hypertension. Dopamine administered with vasopressin failed to protect against a reduction in cardiac output, and completely reversed the portal hypotensive effect of vasopressin. Isoproterenol remains the drug of choice for offsetting the adverse hemodynamic effects of vasopressin administration.

Nine patients with cirrhosis and portal hypertension were given intraoperative vasopressin (40 U/hr) in a continuous peripheral infusion during establishment of a distal splenorenal shunt. In all patients a significant and sustained reduction in portal venous pressure was achieved. As a result, blood loss during dissection and the time required for operation were minimized. The expected vasopressin-induced reduction in cardiac output was limited to a transient decrease at 5 minutes. There were no significant cardiac arrhythmias. These results suggest that vasopressin given through a peripheral vein during shunt operations is safe and facilitates dissection by providing significant and sustained reductions in portal venous pressure.

• 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 biliary excretion of 3H-digoxin in rats prepared for bile sampling with minimal interruption of the enterohepatic circulation was compared with that in rats with complete interruption after intraduodenal or intravenous administration. Following dosage by either route, significantly more radioactivity was recovered from animals with nearly intact enterohepatic circulation. The method described allows direct measurement of this cycle in unanesthetized animals without the consequences of bile depletion.

Because biliary intestinal fistulas have no specific ~yrnptoms or physical signs, they are often overlooked mtil related complications occur. These complications it~clude gallstone iteus, obstruction of the common bile duct, cholangitis, hemorrhage from the fistula, :,nd obstruction of the small intestine or colon as a ~csult of extrinsic inflammation. The management of i~atients with biliary intestinal fistulas is therefore ~sually complex and often controversial. Whether or ,aot the fistula should be repaired during operations for gallstone ileus and what procedure to perform in cases in which a fistula is the result of peptic ulcer :~re examples of the problems in management. This p~per is a review and discussion of the etiology, associated complications, and management of twentytwo patients with biliary intestinal fistulas. Clinical Material

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.

The amount of Arfonad and the time necessary to achieve a desired degree of hypotension are variable. The initial response of portal vein pressure in dogs is no change or a rise in pressure. A reduction in portal venous pressure occurs only when hypotension is achieved and is associated with a marked reduction in total hepatic blood flow. Flow through the hepatic artery is consistently reduced and is slow to recover after Arfonad is discontinued.

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

• Of 42 critically ill patients with toxic megacolon, 31 required emergency surgery, and 11 were treated without operation. Of the 11 patients treated by medical measures alone, there were two deaths (18%): one early, secondary to undiagnosed colonic perforation, and one late death from recurrent ulcerative colitis. Nine of ten survivors (90%) experienced continued morbidity, and five (50%) required subsequent elective surgery. Thirty-one patients required emergency operation for failure of medical treatment (19), colonic perforation (ten), and uncontrolled hemorrhage (two). Early and late morbidity was 74% (two-thirds occurring after subtotal colectomy and ileostomy). Surgical mortality was 19% (8% over the last ten years). (Arch Surg112:518-522, 1977)