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

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.

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.

• 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)

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

In a series of 50 patients with cancer of the pancreas who wee undergoing resection of the pancreatic head and the duodenum, the average survival was 16.2 months. If the resected margin was free of tumor the average survival was 20.3 months. In 103 less favourable cases treated by biliary bypass, with or without gastroenterostomy, the average survival was only 6.2 months. Although these series are not comparable, pancreaticoduodenal resection for cancer of the pancreas and periampullary area has been utilized in cases without distant metastases in an effort to extend the period of palliation and to achieve occasional long-term survival. Currently available diagnostic techniques may permit earlier diagnosis and improved results. A positive tissue diagnosis is not essential before proceeding with resection, but this aspect of the operation should be fully discussed with the patient. An unfavorable condition of the residual pancreas for anastomosis, or a positive frozen section examination of the pancreas at the line of transection may indicate total pancreatectomy, but complete resection is not used routinely. The incidence of jejunal ulceration, a serious late postoperative complication, may be reduced by utilizing a 60-70% gastric resection or antrectomy and vagotomy.

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.

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.

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

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.

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.

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

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.

SummaryThe sera of rabbits which were homografted with skin are shown to be toxic to lymph node cells of the skin donor rabbit. Cytotoxicity was demonstrated upon incubation in vitro for 2 hours at 37°C. Sera of grafted rabbits became toxic after graft breakdown had commenced (11 days), and reached a peak after the rejection (20-30 days). The sera were in all instances more toxic to lymph node cells of the skin donor than to cells of other rabbits.The authors wish to acknowledge the technical assistance of C. C. Chamberlain and J. D. McClelland.

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.

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

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.

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

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 . . .

SummaryCirculating white blood cells and the upper centrifugal layer of bone marrow cells taken from normal adult chickens caused a high percentage of deaths when injected into embryonic chicks. Considerably lower percentage of deaths was produced by injection of red blood cells, lower centrifugal layer of bone marrow cells, or embryonic blood.

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 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.

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

We have previously reported our efforts to minimize postgastrectomy symptoms in two patients with benign disease who underwent resection of the head of the pancreas and the duodenum. In these cases the pylorus and first portion of the duodenum were preserved during pancreaticoduodenectomy. Our experience has now been extended to encompass 18 patients, eight of whom were available for comprehensive evaluation an average of six months postoperation. These studies have attempted to differentiate malabsorption of pancreatic insufficiency from possible gastrointestinal dysfunction of the new alimentary connection. Pancreatic insufficiency was evaluated by a 72-hour stool collection and radioactive trioctanoate (RATO) test. Gastrointestinal absorption was evaluated by D-xylose excretion and the Schilling test, as well as serum vitamin. A, vitamin B-12, carotene, folate, iron, and total iron binding capacity. Gastrointestinal secretion and motility were assessed by using pyloric fluoroscopy, gastric barium emptying, the Hunt test, and gastric acid analysis. Finally, a questionnaire regarding clinical symptoms of postgastrectomy syndromes and malabsorption was answered. Although every patient exhibited marked pancreatic insufficiency by laboratory tests, 88% described normal formed bowel movements, and weight loss was claimed by only 25%. Other test findings were generally normal. While the follow-up period has been limited to three years, the current data demonstrate that gastrointestinal function subsequent to preservation of the pylorus has not thus far predisposed to postgastrectomy syndromes or marginal ulcers. All of the patients required intensive pancreatic enzyme replacement.

Sclerosing cholangitis is a nonspecific pathological condition characterized by gross and microscopic changes of a chronic inflammatory nature; these involve the wall of the biliary ductal system and, occasionally, the surrounding tissue. Primary sclerosing cholangitis is one form of this disease (Fig. 10.1), but the lack of characteristic pathological changes and of distinguishing clinical features has made it difficult to identify primary sclerosing cholangitis as a clinical entity, to evaluate various forms of treatment, and to establish a definite prognosis of the disease.

Current reviews of the treatment of cancer of the pancreas, most of which evaluate cases treated in the past one or two decades, continue to present discouraging results. The advantages and disadvantages of performing a resection must be carefully evaluated for each patient. The dilemma of resection should be discussed with the patient before operation and when capable he or she should influence the decisions the surgeon anticipates facing during the operation. Pancreatoduodenectomy is the treatment of choice for carefully selected cases of carcinoma of the head of the pancreas and other periampullary carcinomas. Total pancreatectomy has not, at this point, been shown to provide sufficient advantages to warrant routine adoption as the treatment of choice when resection is to be performed.

During total pancreaticoduodenectomy for chronic pancreatitis, four patients received an intraportal pancreatic mixed-cell autograft prepared by collagenase digestion. The technique of this autotransplantation procedure was successfully developed using a normal canine pancreas, but has proved difficult to apply in the human chronic pancreatitis model. Our four patients became insulin-dependent, with proof of intrahepatic insulin production in only one patient. Three factors have contributed to the lack of graft success: 1) the preoperative endocrine status, 2) systemic hypotension and portal hypertension secondary to graft infusion, and 3) difficulty applying the successful technique in a normal dog pancreas to an extensively scarred human pancreas. The preoperative insulin response during a glucose tolerance test was blunted or delayed in the three patients tested. An immediate decrease in blood pressure and rise in portal pressure occurred in every patient and prevented infusion of the entire graft (30-50%) in three patients. Unfortunately, the patient with the most compromised insulin status was the only patient able to receive the entire graft. Our experience would indicate that further refinements in technique are necessary to prevent the vascular reaction and allow infusion of the entire graft. Furthermore, normal islet cell function is necessary before a successful graft can be expected.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to l-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primary carcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

THE FIRST successful arterial repair for renovascular hypertension in man was reported inThe Journalby Freeman and associates in 1954. 1 Subsequently, arterial repair (or replacement) has become a widely accepted therapy for this condition. Since many candidates for such an operation are young, it is desirable to know how long the repaired or reconstructed renal artery can provide for adequate blood flow to the kidney. Unfortunately, this kind of information is scarce. The following report demonstrates that a repaired artery can provide adequate flow of blood to the kidney for as long as 20 years. Report of a Case A 23-year-old woman came to the emergency room of UCLA Hospital on Oct 4, 1955, for treatment of a bee sting. Her blood pressure was 200/130 mm Hg. A subsequent examination showed stenosis of the right renal artery. Ureteric catheterization studies showed diminished urine flow and decreased phenolsulfonphthalein (PSP)

• We report a retrospective study of 107 cases of carcinoma of the sigmoid colon and upper rectum treated for primary cure at the University of California at Los Angeles Hospital between 1955 and 1970. Excluded from this analysis were patients treated by abdominoperineal resection, local excision, fulguration, or abdominoperineal pull-through procedures. Ninety-one patients were treated by local segmental resection and 16 by left hemicolectomy. Both groups were similar in regard to patient age and general health, lesion size, location, and pathological Dukes' classification. Five-year survival was 70.3% after local segmental resection and 56.3% after left hemicolectomy. Hospital mortality was 1% after the former and 6.2% after the latter. Rate of recurrence after local segmental resection was 41% of that seen after left hemicolectomy, while complications were one-third as great. The present results after local segmental resection are comparable to the results reported in the literature when hemicolectomy was the procedure used. The data presented suggest that local segmental resection is an effective cancer operation for carcinoma of the sigmoid and upper rectum, and is fraught with a lesser morbidity and mortality than a radical left hemicolectomy. ( Arch Surg 112:920-923, 1977)

Traditional management of patients with primary sclerosing cholangitis (PSC) has included steroids and/or choledochotomy plus prolonged T-tube drainage. The authors have not been convinced, however, that either of these therapies significantly influence the course of the disease. Therefore, a more aggressive surgical approach was adopted that included performance of a choledochoenteric anastomosis in all patients with PSC who had either (1) a major area of extrahepatic blockage, or (2) primary involvement of the extrahepatic bile ducts. Using this approach, 17 of 22 patients (77%) managed surgically at the UCLA Medical Center from 1974 through 1980 have undergone a choledochoenteric anastomosis. Of these 17 patients, 13 (77%) have had an excellent or good result following surgery. Four patients whose disease was confined to the common bile duct have all had excellent results (mean follow-up 49.3 months since surgery). In addition, 18 of the entire group of 22 patients (82%) are still alive, a mean of 52.2 months after operation and 64.7 months following establishment of the diagnosis. These results in 22 patients encourage the authors to continue to pursue an aggressive surgical approach for patients with primary sclerosing cholangitis.

An analysis was made of thirty-six patients with pancreaticoduodenal tumors treated by pancreaticoduodenal resection. The operative mortality has been lowered in the last four years to 5.9 per cent. Nearly 17 per cent of the patients have been long-term survivors, that is, for more than four years and in one instance for more than twelve years. The continued use of pancreaticoduodenal resection in the treatment of such tumors is justified. A rare case of carcinoma of the head of the pancreas was encountered in a three year old child who is still living four years after pancreaticoduodenal resection. Concurrent mixed parotid tumors have been found in two patients with carcinoma of the pancreas. The long-term survival in this series is believed to have been affected by: Early tumor detection and radical resection . Recognition of the importance of vague abdominal symptoms and of diabetes as early indications of pancreaticoduodenal tumor is helpful in tumor detection. The site of origin of the tumor . The greatest relative number of long-term survivors have had tumors of the bile duct. Patients with lesions of the ampulla of Vater have been second. Those with primary carcinoma of the head of the pancreas have rarely become long-term survivors. Resection of the portal vein when it was involved with a tumor was performed in three patients with repair of the vein by end to end anastomosis in one by Teflon patch grafts in two others. Although this maneuver permits resection of an otherwise inoperable tumor, it has not been seen to increase survival time. The location of the tumor in the pancreas . Tumors in the uncinate process of the gland have posed difficult problems in resection and the survival rate has been poor. Inanition . Severe persistent nutritional disturbances generally indicate recurrence of the tumor. However, in rare cases of patients who adjust poorly to the altered physiology after pancreaticoduodenal resection, death may occur from inanition without evidence of tumor recurrence.

Blunt trauma to the abdomen may produce a wide range of intra-abdominal injuries. Subcapsular hematoma of the liver, disruption of the common bile duct, and subcapsular disruption of the pancreatic duct are three injuries discussed; all are rare, isolated injuries frequently accompanied by minimal initial abdominal signs and symptoms. Each injury, however, has serious potential late complications. The diagnosis and treatment of these conditions are discussed with a view toward preventing or minimizing the late complications.

Fourteen patients in whom the diagnosis of coronary insufficiency had been confirmed by electrocardiograms obtained with the patients at rest or with exercise have been studied by coronary angiography. Eight of these who had the classic "effort angina" with depression of the S-T segment induced by two-step exercise or treadmill exercise were found to have single or multiple coronary occlusions conforming to the description of Blumgart, Schlesinger and Davis. One patient showed elongated narrow segments without occlusions. Another showed multiple local narrowed segments in the same vessel without occlusions. Three patients showed localized narrow segments strategically located so as to compromise the circulation to a large area of myocardium. These patients had predominantly nocturnal angina. Two had electrocardiographic changes during periods of pain, but not with standard exercise. These cases are believed to correspond to Prinzmetal's variant form of angina. In one case of adult coarctation, angina on effort was associated with depression in the S-T segment. The presence of adequate coronary arteries seen angiographically suggested that this form of coronary insufficiency is due to a discrepancy between the available myocardial blood supply and the greatly increased work of the heart during exercise. The findings indicate that myocardial ischemia may be brought about as a consequence of several different distributions of coronary atheroma. A rational surgical approach to the problem of coronary heart disease will depend on the recognition of these several types.

Coronary artery injections of radio-opaque material into the vessels of autopsy hearts first disclosed that angina pectoris in most cases is due to extensive narrowing and occlusion of the...

Excerpt Dr. James V. Maloney, Jr.: Except for carcinoma of the skin, carcinoma of the lung has become the most common cancer among adult males. Despite its common nature, there are a number of disc...

The surface of the muscles below the deep fascia is an easy, useful site for thyroid autografts with an unmodified thin tissue slice method. A 100% success has been demonstrated in experimental animals. Autotransplantation of thyroid tissue by this method may be used clinically in the treatment of lingual thyroid excision [4]. Allografts can be implanted in the same site until rejection occurs, usually within 2 weeks. One clinical case was performed as well as experiments in animals. The selective ability of thyroid tissue to pick up tracer doses of radioactive I131 and I125 was used as a biological method of determining the viability of the graft.

Seven new cases and follow-up data on two previously reported cases of congenital cystic dilatation of the common duct are presented. All known five year survivors are also reviewed as well as all those known to have had complications after choledochocystoduodenostomy, loop choledochocystojejunostomy, or Roux-en-Y choledochocystojejunostomy. The long-term morbidity of choledochocystoduodenostomy is about 65 per cent. A Roux-en-Y choledochocystojejunostomy with concomitant cholecystectomy is recommended.