Search

Background. Although numerous important contributions have originated from basic science research performed by surgeons, it seems that such dedicated work is becoming increasingly difficult to accomplish. What are the reasons for this change and what improvements can be made? This study aims to characterize the basic research training and careers of senior academic surgeons to assess and devise strategies for sustaining productive and quality surgical research. Methods. A 25-item survey was sent to 850 senior-level members of academic societies, including the Association of Academic Surgeons, Society of University Surgeons, and American Surgical Association. It addressed each surgeon's clinical and research training and career, as well as opinions concerning surgical research. Results. Three hundred seventy-seven (44%) surveys were received. Mean age was 64 years, and 73% were full professors. Seventy-two percent of respondents performed basic science research during training, and for 71% of this group, research was a significant reason for choosing a clinical specialty. Ninety-one percent performed research in the same specialty area during and after training. Of those who performed research during training, a full 99% continued to perform research on completion of training. However, 38% stopped performing basic research by age 39. Seventeen and twenty-three percent stopped basic research between 40 and 49 and between 50 and 59 years of age, respectively. The most common factors causing them to stop were increased clinical load (40%) and increased administrative duties (38%). For respondents who had stopped research prior to age 40, 73% cited increased clinical load as the primary reason. Eighty-five percent felt a dedicated research period should be included in surgery training. Conclusions. Most respondents had participated in basic research during training, and continued similar research after training. However, an overwhelming clinical practice at the junior faculty level seemed to hinder research. We conclude: (1) the majority consensus is that research training is integral to the development of academic surgeons; (2) such research training opportunities appear adequate; however, (3) faculty performing research, particularly at the junior level, need to be better protected from other academic duties, such as clinical practice and administration. The challenge to the leadership of academic surgery will be to enhance such research productivity in the context of increasing academic demands.

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.

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 an effort to determine the role of interventional radiologic and endoscopic techniques in the management of benign biliary strictures, a retrospective analysis was carried out on 194 consecutive patients with bile duct strictures treated at UCLA between 1955 and 1990. Patients were classified as group 1 (1955 through 1979; n = 138) or group 2 (1980 through 1989; n = 56). Follow-up was for a minimum of 24 months and was in excess of 3 years in 179 patients (92%). Although the incidence of recurrent strictures was similar in the two groups (21% and 23%), the reoperation rate was significantly lower (P less than .02) in group 2 (6%) than in group 1 (21%). Percutaneous transhepatic biliary dilatation, used in 20 patients in group 2, was successful in 13 (93%) of 14 patients with anastomotic strictures and three (50%) of six patients with primary strictures (P less than .05). We conclude that surgical reconstruction remains the standard therapy for patients with primary bile duct strictures. Percutaneous transhepatic biliary dilatation has limited usefulness for these patients, but may be more appropriate for those with anastomotic strictures.

• Recent studies have advocated the nonoperative treatment of elderly patients with bile duct cancer using biliary endoprostheses. In addition to a 30-day mortality rate of 9%, disadvantages with this approach include lack of a definitive diagnosis and the inability to assess resectability. For comparison, we reviewed 42 consecutive cases of bile duct cancer managed surgically at UCLA (from 1954 to 1988) among patients age 70 years or older. Histologic confirmation of bile duct cancer was obtained for 40 surgical patients (95%) in the series. The 30-day mortality rate was 10%. There was a trend to more aggressive surgical management during the study, with a concomitant doubling in survival rates (from 21% among patients treated between 1954 and 1978 to 53% among patients treated between 1979 and 1988 at 1 year after surgery.) We conclude that elderly patients should not be denied surgical evaluation of malignant neoplasms of the bile duct simply on the basis of age. (Arch Surg. 1991;126:1186-1191)

• Improvement in survival rates for solid tumors, the cancers of greatest concern to the surgeon, has lagged far behind the dramatic advances that have been made in the treatment of leukemias, lymphomas, and certain childhood tumors. The application of new technical procedures and an aggressive approach to certain metastatic lesions offer chances for improving operative results, but the greatest contribution to curing cancer that can be made by surgeons at this time is the complete removal of the small localized primary tumor. By more active participation in "early detection programs" surgeons can increase their opportunities to treat cancer at this stage. The American College of Surgeons, in consultation with the National Cancer Institute, has conducted a detailed survey that analyzes the lack of surgical participation in clinical trials with a view toward developing a more active surgical interest in evaluating new methods of treatment for the solid tumors. One of the current efforts to improve the outcome of these recalcitrant cancers involves increasing the number of trained surgical scientists in the field of cancer. (Arch Surg. 1990;125:158-162)

The method of surgeon payment influences several important aspects of surgical care. The preoperative processes of laboratory tests and radiographic procedures were performed more frequently and less selectively by salaried surgeons without any corresponding improvement in outcome. Socioeconomic factors and difference in severity of disease accounted for most of the variations in outcome, but in appendicitis there was a trend for fee-for-service surgeons to undertake earlier operation resulting in fewer secondary complications. Although the patient-physician relationship was least developed by salaried surgeons, this was not reflected in any less knowledge of the procedure by the patient or dissatisfaction with surgical care. Operative workloads were highest for surgeons receiving salary plus percentage in fee-for-service group practice.

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.

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.

Reports, early in this century, on the treatment of portal hypertension by surgical diversion of the portal blood flow about the liver were largely ignored because of the anticipated high mortality. Whipple, Blakemore and Lord in the early 1940's described a technique of performing a splenorenal or portacaval shunt with an epithelial lined vitallium tube. Blalock, whom I assisted, was one of the first outside of the Whipple Group to successfully perform such an operation. Although he used the vitallium tube technique in his first cases he soon became convinced that the results were better with a direct suture anastomosis. Venous shunts, which seemed such a logical way to treat portal hypertension, were widely and quickly adopted. Little attention was paid to the problem of portal encephalopathy which had been described in experimental animals years before by Pavlov. As some of the follow up studies on these shunted patients began to appear it was evident that this was a common and at times a severe problem. Some of the earliest doubts about the shunt operation were expressed by surgeons in Japan. The most successful methods developed to date for the treatment of portal hypertension provided a shunt for blood from the esophageal variceal region while at the same time preserving portal blood flow through the liver. Two of these methods have been (1) the distal or selective splenorenal shunt proposed by Warren & Zeppa and (2) the coronary caval shunt first described by Inokuchi. These methods, although somewhat more difficult technically than end to side portacaval shunts, reduce portal hypertension and preserve blood flow through the liver thereby lowering significantly the incidence of encephalopathy. The vascular stapling instrument developed by Professor Inokuchi in the 1950's has allowed him to perform this and other types of difficult vascular surgery with excellent results.

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

Although pyloric preservation can be performed during pancreaticoduodenectomy without increased morbidity or mortality or decreased survival, the long-term benefit of this technique remains unproven. In this study, the functional status of patients recovered from pyloric-preserving pancreaticoduodenectomy was evaluated by comparing 6 long-term survivors of the standard Whipple procedure (1–7 years postoperative; mean, 4.7 yr) to a similar group of 6 patients recovered from pylorus preservation pancreaticoduodenectomy (1–7 years postoperative; mean, 3.0 yr). All patients completed a questionnaire evaluating postgastrectomy symptoms. Fasting blood specimens were obtained for hematologic and biochemical analysis. Ten of the 12 patients then underwent endoscopy; perianastomotic and midgastric biopsies were graded for inflammation. Gastric emptying of both liquid and solid phases was measured with an isotopically-labeled meal. Gastric emptying data were compared between groups and also to a group of 7 normal controls studied previously using the same methodology. Analysis of questionnaire results and mean laboratory values revealed no significant differences between the 2 surgical groups. Serum carotene levels were low in most patients. Several patients demonstrated abnormal indices of iron homeostasis. No significant abnormalities were noted on endoscopic examinations and biopsy results did not differ between the 2 surgical groups. Liquid gastric emptying was significantly prolonged in patients following standard pancreaticoduodenectomy (t1/2=98.3±26.2 min) as compared to pylorus preservation patients (t1/2=37.5±10.9 min) or normal controls (t1/2=33.1±2.8 min). We conclude that, in the long-term, pylorus preservation appears to be at least functionally equivalent to the standard pancreaticoduodenectomy. As such, we believe that pyloric preservation, obviating vagotomy and gastric resection, deserves consideration during pancreaticoduodenectomy.

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.

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.

Summary Stenosis of the sphincter of Oddi without demonstrable common duct stones or debris is a rare cause of recurrent episodic upper abdominal pain with limited specific physical findings. Objective evidence (for example, cholangiographic demonstration of common duct dilatation with delayed emptying into the duodenum and elevations of serum bilirubin or alkaline phosphatase levels) should be detectable. The morphine-Prostigmin test is unreliable and should not be depended upon alone. Markedly positive tests may be considered as additional supportive evidence of stenosis. Of the special preoperative diagnostic tests available, ERCP seems to hold the most promise. Manometric and cholangiographic studies made at operation may also be helpful in properly identifying patients who may be helped by sphincteroplasty. Sphincteroplasty is a procedure with potentially serious risk that should be used with utmost discrimination and care.

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.

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.

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

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.

A series of 63 patients with primary bile duct carcinomas seen at the UCLA Hospital since 1955 have been analyzed and divided into four groups, depending upon the site of the tumor in the extrahepatic ductal system. More than half of the tumors occurred in the upper one-third, while the other half was about equally divided between those occurring in the middle and lower thirds of the extrahepatic duct system. Three wide-spread intraluminal papillary tumors have been placed in a special category. The difficulties of establishing a correct diagnosis at the time of operation are again demonstrated in this series. The most commonly used palliative procedure has been the insertion of a tube into the duct that passes above and below the tumor through the site of obstruction. The tumors are generally small, well-localized, and frequently slow-growing. Tumors in the lower one-third of the duct may be treated by radical en bloc resection (pancreaticoduodenectomy) and offer the best prognosis, both for long-term palliation and cure. More than half of the tumors in this series were located at or near the confluence of the hepatic ducts, and resection of the tumor was attempted in only six of 34 cases. It is possible that, were procedures available that would permit a more extensive en bloc resection of tumors in the middle and upper thirds of the duct system, the period of palliation might be extended and more “cures” obtained. Detailed anatomical studies of the hepatic ducts, arteries, and portal veins at the hilus support the concept of combining extended hepatic resection with tumor excision and including segments of the hepatic blood supply in selected patients with tumors in the upper one-third of the duct. Operative procedures for resection of the right and left lobes have been proposed. One such operation has been performed; in a second patient, hepatic lobectomy and tumor excision were performed without interruption of the blood supply to the remaining lobe.

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.

Allogeneic liver grafts obtained from cadaveric donors were transplanted in 29 dogs, 3 pigs, and 1 human. Extracorporeal perfusion was used while the donor liver was excised, and asanguinous hypothermic perfusion through the hepatic artery and portal vein was continued until the venous effluent was clear. In contrast to the relatively long survival following canine hepatic allografting from anesthetized donors, the average survival following cadaveric canine orthotopic and heterotopic grafting was less than 1 1 2 days. Hepatocellular injury due to prolonged hypoxia is believed to have caused the “out-flow block” syndrome, venous congestion and death in almost all dogs. The anaerobic bacterial flora of the canine liver is believed to make it particularly susceptible to short periods of hypoxia. In contrast, the porcine and human liver appear to tolerate hypoxia for periods of over 3 hours without developing congestion. The experience with heterotopic liver grafting in a patient is presented with survival of 12 days.

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.

OF the numerous surgical procedures1 2 3 4 5 6 7 so far designed to increase blood flow to the myocardium in patients with angina pectoris, none have won wide acceptance since conclusive evidence of their therapeutic benefit has been lacking. It seemed to us that the most effective means of increasing myocardial blood flow would be to remove the obstructing atheromatous plugs from the coronary arteries themselves. Experience with peripheral arterial endarterectomy suggested the possibility of a direct surgical approach by this method to occluded coronary arteries. The feasibility of such an operation was supported by both pathologic and experimental observations of one of us . . .

The clinical, radiologic and pathologic features of 37 patients diagnosed as having primary sclerosing cholangitis (PSC) were reviewed. Sixty-two per cent were men, and 35% had ulcerative colitis. The patients demonstrated considerable variability in their natural history and pathology. It appeared that they could be divided into four fairly distant groups (1) sclerosing cholangitis affecting primarily the distal common bile duct; (2) sclerosing cholangitis occurring soon after an attack of acute necrotizing cholangitis; (3) chronic diffuse sclerosing cholangitis; and (4) chronic diffuse sclerosing cholangitis associated with inflammatory bowel disease. It is suggested that the patients in these groups may have different etiologies, may respond to different treatment regimes, and may have different prognoses.

Operative endoscopy of the biliary system has been employed with ever increasing frequency at the UCLA Hospital during the last three years. In addition to its established value with respect to disclosing unsuspected stones in the bile ducts, choledochoscopy has been of great value in terms of more accurate diagnosis and staging of periampullary and bile duct neoplasms. It has been observed that many biliary tract carcinomas are multicentric in origin and that cholangiography is not adequate to identify small intrahepatic ductal lesions. More than one cell type of bile duct carcinoma may be present in the same patient. Choledochoscopy should be used in addition to the conventional criteria for resectability in all patients with ductal or periampullary carcinoma. Use of this technic will spare some patients needless radical procedures and should improve long-term cure rates by identifying those patients with truly localized disease for curative resections.

Sclerosing diseases of the biliary system encompass a spectrum ranging from primary sclerosing cholangitis (usually of the extrahepatic biliary tree) to primary biliary cirrhosis of the intrahepatic bile canaliculi. In a study of 35 patients with primary intra- and extrahepatic biliary sclerosis, age of onset, sex distribution, symptomatology, associated diseases, radiographic abnormalities and chemical profile were considered. The difficulty of differentiating sclerosing cholangitis and biliary cirrhosis from other causes of obstructive jaundice preoperatively was stressed, in addition to points of differential clinical and laboratory findings. The etiology of these entities as well as the possibility that they represent variant clinical manifestations of the same disease process were also considered. Mechanical and pharmacological treatment alternatives that were attempted included drainage procedures, the easiest and most widely used of which was the T-tube. However, this could prove to be a source of infection and should therefore be removed early, inasmuch as cholangitis represents a major cause of morbidity. Steroids have been used with varying effectiveness; subjective improvement was generally attained, although objective improvement has been difficult to document. When choleuretics and cholestyramine were administered, we noted significant palliation. Antibiotics were reserved for treatment of cholangitis. Until the underlying etiology of this rare malignant sclerosing process is found, only symptomatic treatment can be offered.

Sclerosing cholangitis is a nonspecific condition characterized by gross and microscopic pathologic changes of a chronic inflammatory nature involving the wall of the biliary ductal system and occasionally surrounding tissue. Primary sclerosing cholangitis (PSC) is one form of this process. Of unknown etiology, PSC generally has an unfavorable prognosis, and therefore it is important to differentiate this condition from other causes of bile duct sclerosis. Each of the various conditions producing clinical and pathologic evidence of sclerosing cholangitis demonstrates certain specific characteristics that usually enable its identification. (Table I.) In its differing forms, PSC may mimic the findings of any of the other four causes of sclerosis. We believe, however, that it would be a mistake to attempt identification of cases of PSC by a set of rigid criteria that may or may not be valid. Positive identification of this disease process must await more precise diagnostic procedures—perhaps a specific immunologic test similar to the serum antimitochondrial antibody test that Sherlock [11] has reported to be positive in 88 per cent of cases of primary biliary cirrhosis and consistently negative in surgically obstructive jaundice and cholestasis associated with the sclerosing cholangitis of ulcerative colitis. Notwithstanding our discussion of certain important specific diagnostic criteria that help to identify the various causes of sclerosing cholangitis (Table II, see pages 318–319), we must still admit that in certain patients the true cause of the biliary pathology will be established only with the passage of time. This is particularly true when PSC is suspected, and at times it is also true in cases of suspected bile duct carcinoma when positive histologic confirmation cannot be obtained. The ultimate unfavorable outcome prevalent in both of these diseases makes such an uncertain diagnosis a particularly trying position for the patient as well as his surgeon.