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Background: Posterior cruroplasty repair of a large paraesophageal hiatus hernia has a higher than desirable rate of recurrence attributable to the inexorable cyclic negative intrathoracic pressure of respiration and positive intraabdominal pressure produced by straining, physical exertion, and coughing. To reduce the risk of recurrence after repair of a large hiatus hernia and intrathoracic stomach, we have used posterior cruroplasty reinforced with an onlay polypropylene mesh prosthesis. This paper reviews the feasibility of this technique. Study Design: We did a retrospective review of 44 patients with large hiatus hernia and intrathoracic stomach who had posterior cruroplasty and onlay of polypropylene mesh prosthesis applied to the crura and adjacent diaphragm to repair the hiatal defect. Results: Preoperative symptoms (mean duration, 26 months) included pain (33 patients), vomiting (21), dysphagia (19) and anemia (8). The typical patient (28 men and 16 women, mean age, 60) had two-thirds or more of the stomach above the diaphragm. Organoaxial gastric volvulus and herniated large or small bowel were present in 10 and 9 patients, respectively. A gastrostomy was performed for temporary drainage in 38 patients in addition to the hernia repair; 11 patients underwent a concomitant Nissen fundoplication. Postoperative complications included pleural effusion (four patients), atrial dysrhythmia (three patients), and superficial wound infection (two patients). Mean followup for 43 patients was 52 months. There have been no clinical recurrences. Conclusions: Mesh prosthesis reinforced hiatus hernia repair is effective, appears to have a low clinical recurrence rate, and should be an option in the treatment of a large hiatus hernia with intrathoracic stomach.

The routine versus selective use of intraoperative cholangiography has been the subject of debate for some time. Most authors currently advocate routine intraoperative cholangiography with laparoscopic cholecystectomy. The authors report their experience with the selective and routine utilization of intraoperative cholangiography at two institutions. At institution A, 155 laparoscopic cholecystectomies were attempted, and 21 cholangiograms were performed (based on preoperative criteria of ultrasound, liver function tests, and history of jaundice, or intraoperative anatomical uncertainty). At institution B, 164 laparoscopic cholecystectomies were attempted and 127 cholangiograms were performed (a routine intraoperative cholangiography policy). At institution A, there were no common bile duct injuries but there was one retained stone. At institution B, there was one common bile duct injury and no retained stones. The patient with the retained stone from institution A had a preoperative indication (total bilirubin = 4.4 mg/dl) for a cholangiogram, but it was not performed due to technical difficulties. This patient later required endoscopic sphincterotomy with stone extraction. One patient at institution B had a choledochotomy which was detected by intraoperative cholangiography (IOC). This was managed with a T-tube. The selective use of cholangiograms in laparoscopic cholecystectomy will not yield a higher incidence of common bile duct injuries or retained stones compared to routine use. Further, a cholangiogram may not necessarily prevent choledochotomy but can prevent extension of common bile duct injury. Thus, it should always be performed when there is anatomic uncertainty.

Twenty patients with metastatic prostatic cancer were treated on an ambulatorybasis with continuous 5 fluorouracil (5-FU) infusion 250–300 mg/M 2 per day through a chronic indwelling central venous catheter. All patients had symptomatic, progressive disease despite previous standard therapies. Partial remission was seen in 2 of 20 patients (10%), stable disease in 9 of 20 (45%), and progressive disease in 9 of 20 (45%); mean duration of benefit in responding and stable disease patients was six months. Improvement in pain and ECOG performance status were seen in most of the patients in the responding and stable disease categories. Forty percent of the patients experienced no significant drug toxicity; treatment interruption was necessary for stomatitis in 6 patients (30%), hand/foot syndrome in 3 patients (15%), and diarrhea in 1 patient (5%). No significant myelosuppression or other significant organ toxicities were encountered, Continuous systemic venous infusion of 5-FU may provide significant palliative effect for some patients with symptomatic, refractory carcinoma of the prostate.

Forty patients with chronic cholecystitis or cholelithiasis were prospectively randomized for therapy with either ciprofloxacin or fleroxacin to study the penetration of these two agents into gallbladder tissue, plasma, and bile. Patients received a 3-day course of ciprofloxacin (500 mg twice a day) or fleroxacin (400 mg once daily) and were subdivided into four groups reflecting intraoperative sample collection at 4, 7, 14, and 25 to 26 h following the last quinolone dose. Mean concentrations in plasma for ciprofloxacin and fleroxacin at 4 and 25 to 26 h postdose were 2.5 and 10 micrograms/ml and 0.3 and 1.8 micrograms/ml, respectively. The concentrations of ciprofloxacin and fleroxacin in bile and gallbladder wall tissue at 25 to 26 h postdose were 4.5 and 8.6 micrograms/ml and 1.2 and 4.4 micrograms/ml, respectively. Both agents demonstrate rapid tissue penetration with persistence at levels appropriate for treatment of biliary pathogens.

This is a review article covering the development of monoclonal antibodies attached to a radioactive isotope which are used in scanning for metastatic adenocarcinoma of the colon. The most recent and complete study described 223 patients, of which 169 were evaluated. All patients required an operation. At operation, biopsies were taken of the resected tumor. Some false negative areas, such as dilated varicosities and inflammatory areas, were encountered. The latter can be seen as a chronic inflammatory process such as a leaking anastomosis with a diverticulum or old traumas in the pelvis. This technique allows a physician to follow patients, especially those who have had an abdominal perineal or exoneration of their pelvic organs, for possible recurrence in this area. There is also some discussion about possible future uses in the treatment of the metastatic disease.

Gastric bypass and vertical banded gastroplasty are the two procedures used most frequently in the treatment of morbid obesity. In a pilot study, we used a porcine model in which laparoscopic gastric stapling and Roux-en-Y gastrojejunostomy were accomplished.

Introduction. Hepatic artery infusion (HAI) chemotherapy has long been studied, but its appropriate use remains controversial; there has been no available animal model. Methods. The Yucatan minipig was chosen because it has liver anatomy and biochemistry similar to human. An HAI catheter was placed via the gastroduodenal artery; liver biopsy was performed, and adequate perfusion was confirmed via fluorescein injection. The animals were maintained on various doses, 0.3, 0.6, 3.0 mg/kg/day, of FUDR or saline continuously for 4–10 weeks. Liver biopsies were performed laparoscopically at 4-week intervals. Tissue was examined by light (LM) and transmission electron microscopy (TEM) and also phenotyped for levels of P450 isoforms 2C9 and 3A4. Serum liver function tests were done every 2 weeks. Results. Eight pigs had HAI with saline or FUDR. Serum liver function tests remained normal throughout the infusion for all doses. LM revealed no change during infusion, with each pig used as its own control. TEM showed increasingly edematous and dilated endoplasmic reticulum with FUDR but not saline. This phenomenon was more pronounced at higher doses and when infusion had progressed in time, but reverted to baseline when infusion was stopped. The P450 3A4 isozyme was up regulated with increasing doses of FUDR, but was down regulated when a toxic dose (10× the maximum human dose) was used. The P450 2C9 isozyme remained relatively constant at the lower doses of FUDR but showed a 2-fold increase at the toxic dose. Conclusion. The Yucatan minipig can be used as a model for HAI chemotherapy to study the effects of various chemotherapeutic agents on liver morphology and biochemistry. Our data with FUDR have shown changes in electron microscopy and liver biochemistry occur earlier than changes seen in tests used clinically. Because these changes can affect the metabolism of other drugs before clinical liver malfunction is apparent, unsuspected systemic toxicity may accompany HAI. Other antitumor agents may produce significantly different results and should be evaluated in this model before widespread application in man.

Serosal bipolar electrodes and strain gauge force transducers were placed on the right and left colon in subhuman primates to record spike discharges and circular muscular contractions. The effect of glucagon on colonic motor and electrical activity were studied before and after meals. Serum concentration of gastric inhibitory polypeptide was measured simultaneously 15 minutes before and 45 minutes after eating. Serum levels of gastric inhibitory polypeptide increased in response to eating; pre- and postcibal concentrations were not altered by glucagon. The gastrocolic response of the colon to eating was demonstrated. Glucagon inhibited the intrinsic activity of the entire colon before meals and partly inhibited the right colon after meals. Postcibal left colon activity was not inhibited by glucagon. This indicates that a distinct mechanism accounts for the left colonic postcibal increase in contractile and electrical spike activity. A neural or humoral mechanism is implicated but is not specifically identified.

At Wood Veterans Administration Center, 268 patients who had a polypectomy have been followed up to 20 years with semiannual proctosigmoidoscopic and barium enema examinations. For the present review of benign polyp disease, patients having coexisting carcinoma, chronic inflammatory disease, and those lost to followup have been excluded; 154 patients followed for a mean of 7 years comprise the study group. Thirty per cent of patients developed recurrent polyps. The risk of recurrence during the first year was 16 times that expected in a population of similar age and sex, but thereafter diminished steadily. After 48 months risk of polyp recurrence was little higher than the incidence expected in a normal population. Neither patient age, presenting symptoms nor the site or size of the initial polyp(s) were of any prognostic value regarding recurrence. Patients presenting with a villous adenoma or with more than 3 polyps had a significantly increased risk of recurrence may persist indefinitely. The overall incidence of colonic carcinoma may have been increased, but the location of subsequent cancer was not related to the site of a previously excised polyp.

Data obtained from a survey of the membership of the Society for Surgery of the Alimentary Tract and the American Society of Colon and Rectal Surgeons indicated that concomitant administration of oral neomycin-erythromycin base and systemic cephalothin, together with mechanical colon cleansing, was the most popular method of colon preparation. We designed a prospective double blind clinical trial to compare administration of intravenous cephalothin, oral neomycin-erythromycin base, and the combination of both the intravenous and oral antibiotics. Intake of patients to the intravenous cephalothin group was stopped because the data indicated that this method of prophylaxis resulted in significantly higher numbers of septic complications. The incidence of wound infection was 30 per cent and the overall incidence of septic complications was 39 per cent in patients receiving only intravenous cephalothin combined with mechanical colon cleansing. The incidence of wound infection and the overall incidence of septic complications was only 6 per cent in the comparison group, and the differences are highly significant.

Ninety-one patients with metastatic colorectal cancer were treated with continuous ambulatory 5-fluorouracil (5FU) infusion 250-300 mg/m2/day through a chronic indwelling central venous catheter. Twenty-six of the 91 patients (29%) had received previous bolus 5FU. Fifty-eight of the 91 patients (64%) had two or more sites of disease, and 74 of 91 patients (81%) had liver metastases. Results were complete remission in 5 of 91 (6%), partial remission in 25 of 91 (27%), stable disease in 33 of 91 (36%), and progressive disease in 28 of 91 (31%), for an overall response rate of 30 of 91 (33%); median duration of response was 7 months. Twenty-six of 65 previously untreated patients (40%) experienced objective response. Median survival from initiation of treatment for all patients was 11 months. Forty-one percent of patients experienced no significant toxicity and were able to continue therapy without treatment interruption. Toxicities necessitating treatment interruption included stomatitis in 35 patients (39%), hand-foot syndrome in 33 patients (36%), and diarrhea in 10 patients (11%). No significant myelosuppression or serious catheter-related complications were encountered. We conclude that continuous systemic venous infusion of 5FU produces a higher response rate than traditional bolus 5FU schedules, with apparent enhancement of survival and easily managed toxicity.

The effectiveness of short-term, low-dose, preoperative oral administration of neomycin and erythromycin base combined with vigorous purgation in reducing the incidence of wound infections and other septic complications of elective colon and rectal operations has been studied in a prospective, randomized, double-blind, clinical trial. One hundred and sixteen patients completed the study; all received mechanical preparation; 56 received neomycin-erythromycin base while 60 received an identical appearing placebo. The two patient groups were comparable in age distribution, clinical diagnoses, associated systemic diseases, types of operation performed and similar clinical features. The overall rate of directly related septic complications was 43 per cent in the placebo group and 9% in the group receiving neomycin and erythromycin base. The wound infection rates were 35% in placebo and 9% in antibiotic treated patients. Oral administration of neomycin and erythromycin base together with vigorous mechanical cleansing reduces the risk of septic complications after elective colo-rectal operations.

Serosal bipolar electrodes to record spike discharges and strain gauge force transducers to record circular muscle contractions were placed in pairs on the terminal ileum, cecum, right colon at the ileocecal valve, ascending colon, and proximal transverse colon of sixteen primates. After an overnight fast, electromotor responses to continued fasting or to ingestion of a meal (randomized order) were recorded in awake animals. Feeding led to increased spike discharges and increased frequency of muscle contractions at all sites. The onset of these responses usually was within 6 minutes after feeding; the responses increased progressively during 30 to 45 minutes and then remained more or less at a constant plateau of increased activity. Atropine completely blocked the postcibal responses of ileum and proximal colon for up to 30 minutes. Transit time data of labeled meals excluded direct stimulation by a food bolus as the mechanism of the observed postcibal colonic response. The pattern of response was consistent with humoral mediation.

The approach to treatment of regionally recurrent or inoperable cancers has had its impetus from the dynamic and forwardthinking studies of Oscar Creech and his associates. 1-7 The most striking results have been obtained with melanomas of the extremities. 6,8,9 Other areas have also been explored by the perfusion technique, and although the results are not as spectacular as extremity perfusion, significant palliation has been obtained. Areas of interest available to regional perfusion, include the brain, head and neck, breast, lung, liver, abdomen, and pelvis. Many excellent recent reports have reviewed the approaches and methods of treatment of these various areas. 1,3-5,10-12 The results, in terms of palliation, in most of these areas have been gratifying, as reported. It is our purpose here to describe our approach to the regional perfusion of the pelvis. Applicable tumors, indications for perfusion and techniques of perfusion, choice of agent used, complications, and results

A comparison has been made of the changes in body weight, stool bulk, and fecal fat and nitrogen excretion after both selective and truncal vagal denervation in the same animal in an effort to study differences between these two procedures. The following results were obtained. 1. 1. After pyloroplasty alone or pyloroplasty accompanied by vagotomy, either truncal, selective, or “reverse selective,” that is, sectioning only the hepatic and celiac trunks, body weight decreased. This weight was not regained totally in any animal over a two to seven month period of observation but neither were there any further significant losses despite further surgery. 2. 2. Stool bulk increased after truncal vagotomy and did not differ significantly after selective division. 3. 3. Fecal fat excretion (a) increased after pyloroplasty alone; (b) increased after pyloroplasty accompanied by selective vagotomy; (c) increased after pyloroplasty accompanied by truncal vagotomy. 4. 4. Fecal nitrogen excretion (a) did not increase after pyloroplasty alone; (b) did not increase after pyloroplasty accompanied by selective vagotomy; (c) increased after pyloroplasty accompanied by truncal vagotomy. 5. 5. The presence of greater stool bulk after truncal vagotomy did not coincide with a decrease in body weight in the animals in which it occurred. The excretion of fecal fat is greater after selective vagotomy than after truncal vagotomy when both are performed in the same animal, but nitrogen excretion is greater after truncal division. From this data, we have concluded that selective vagotomy has no great advantages over truncal division, and the extra time and care necessary to perform selective denervation are not warranted.

Zollinger-Ellison syndrome is caused by a neuroendocrine tumor of the pancreas that secretes gastrin, causing massive gastric acid secretion. Treatment of the acid hypersecretion may be accomplished with pharmacologic acid inhibition. The goal of surgical treatment should be removal of all gross tumor in those without distant metastases. Cure rates approximate 30% and 20-year survival exceeds 70% even without cure.

• A predictable and progressive experimental intestinal obstruction, simulating a malignancy but without neoplastic change, has been produced by application of a silicone rubber ring around the bowel of 20 rats, seven dogs, and five monkeys. Serosal reaction produced fibrous tissue that resulted in an "apple core" obstruction. An easily assembled extraluminal balloon device of silicone rubber can be used to produce acute and progressive experimental obstruction, especially of the large bowel. ( Arch Surg 116:194-196, 1981)

The duration of postoperative ileus and changes in contractile frequency of circular muscle were recorded in the colon of monkeys before and after primary resection for distal large bowel obstruction. Obstruction was induced gradually by an implanted device. Resection and primary anastomosis resulted in reduced contractile frequency (postoperative ileus) lasting less than 48 h, significantly shorter than the period of ileus after a control laparotomy.

A case report is made of a 91 year old veteran who presented with a small bowel obstruction at the ileocecal valve secondary to an adenoacanthoma at the base of the appendix. The tumor was removed with the right colon and the patient has done well to the present (one year follow-up). A short review of the theory of the origin of the squamous component is presented. There is a brief discussion of the clinical material that suggests these tumors have a response similar to an adenocarcinoma of the colon and should be treated as such.

Bipolar electrodes were placed in the ascending and descending colon of 13 patients during laparotomy. The magnitude of their operations varied from exploratory laparotomy to total gastrectomy. The magnitude and length of the operations performed did not correlate positively with the duration of postoperative ileus. Signals were recorded for up to 4 hours daily for up to 8 days after operation during periods of rest and, in some patients, after administration of epidural or parenteral morphine sulfate. Power spectrum analyses of electrical control activity (ECA) showed dominant frequencies in both lower (2-9 cpm) and higher (9-14 cpm) ranges. During postoperative recovery, the mean ECA frequencies in right and left colon were relatively constant, but a variety of dominant ECA frequency relationships were observed. The modal pattern in the right colon was a shift in the dominant frequency from the higher to the lower range as recovery progressed, while the modal pattern in the left colon was persistent dominance of ECA in the higher frequency range. Electrical response activity (ERA) initially was comprised of only random, disorganized single bursts but became progressively more complex through the initial 3 postoperative days with the appearance of more organized bursts and clusters, some of which propagated very slowly (about 5 cm/min) both orad and aborad. ERA recovery culminated, typically on the third or fourth postoperative day, with the return of long bursts of continuous ERA, some of which propagated at a higher velocity (about 80 cm/min) and exclusively in the aborad direction and which were accompanied by passage of flatus or by defecation.

Previous experiments demonstrated that feeding is followed by increased electrical spike discharges and contractions of colon smooth muscle. This gastrocolic response has a definite lag period before onset, and is not due to distention of the colon by food. In these experiments, the possible association between altered serum concentration of certain gastrointestinal hormones and the gastrocolic response was investigated in eight stump-tailed monkeys. The animals had extraluminal miniature strain gauge force transducers and bipolar silver electrodes applied in pairs to the serosal surface of the cecum, ascending colon, and transverse colon to record contractions of circular muscle and electrical spike discharge potentials. The serum concentrations of gastrin, cholecystokinin, and gastric inhibitory polypeptide were measured by radioimmunoassay, and the contractile responses of the bowel were recorded, before and after presentation to fasted animals in random order of a dry meal, a wet saline meal, a wet magnesium sulfate meal, or a continued fast. The dry meal was associated with an increase in frequency of electrical spike discharges and contractions of circular colon muscle, as well as an increase in the serum concentration of gastric inhibitory polypeptide, both events occurring 15–60 min after beginning the meal. Other meals had no effect on colon motility or serum gastric inhibitory polypeptide concentration. Serum gastrin and cholecystokinin concentrations were unchanged by all experimental manipulations. This evidence supports our hypothesis that the gastrocolic response has an hormonal basis.

• The idea that the longitudinal muscle of the muscularis externa of the colon is confined to the colonic teniae in the monkey and human is a common conceptual error. Forty-six colon specimens taken from human and nonhuman primates were reviewed histologically and the distribution and structure of the longitudinal muscle were evaluated. We found that the longitudinal muscle forms a complete coat around the colon although it is considerably thicker in the region of the teniae coli. In addition to its anatomic importance, this observation has implications for the physiology of colon muscle and for certain current hypotheses concerning the etiology of diverticulitis. (Arch Surg116:61-63, 1981)

Three patients with “islet cell-carcinoid” tumors of the duodenum are reviewed. In each of these cases the presence of lymph node metastasis eventually prompted total gastrectomy as the course of treatment. The patient in case I is now clinically free of tumor five years after operation. In case II the patient's death occurred two years after surgery, and although tumor was found at operation, it was not related to his death. In case III the patient is alive and well five years after his surgical procedures.

DURING the past 25 years, the incidence of Salmonella infections, as reported by the Communicable Disease Center in Atlanta, 1 has shown a 20-fold increase. During the same period of time, there has been a steady decline in the incidence of typhoid fever until fewer than 500 cases were reported in 1964. In 1951, there were only 1,500 cases of salmonellosis reported in the United States. By 1965, this had risen to 20,000 cases with an estimated one in ten cases being reported. 2 Accompanying this marked increase in the incidence of salmonellosis is the sharp rise in numbers of serotypes. There were 400 serotypes reported in 1960. 3 Today, there are over 1,200 different subspecies, all of which have either been reported to be pathogenic or found in a carrier state for man. 2 The problem of good public health control has become increasingly difficult since a large reservoir

1. 1. Eight puppies had total gastrectomy and three are living and well fifteen months after operation. 2. 2. Total gastrectomy is feasible in puppies and compatible with adequate if not normal growth. 3. 3. Hypochromic anemia does occur and is associated with a general debility in the animals but responds to parenteral iron therapy. 4. 4. Pernicious anemia has not developed in any of the animals. 5. 5. In all animals with total gastrectomy osteomalacia has developed with resulting pathologic fractures from the animals which recovered spontaneously.

• A five-year surgical wound surveillance program included the following features: (1) observations were made by a trained nurse-surveyor; (2) all surgical services, without exception, were surveyed; (3) the nurse-surveyor reported directly to the Chief, Surgical Service; (4) all infected wounds and all suspected of harboring an infection were observed daily by the nurse-surveyor; (5) all wounds were inspected on the third and seventh postoperative days, at hospital discharge, and at a follow-up clinic visit; and (6) cultures were obtained from all infected wounds. Data concerning infections for all surgical services were published each month at the mortality-morbidity conference. The number of wounds closed primarily and the number of infected wounds were recorded, together with calculations of wound infection rates by operation class, for each surgical service and for the whole hospital. During the study, the rate of wound infections progressively declined. The overall incidence decreased from 3.5% before the study began to less than 1% at its conclusion. ( Arch Surg 1983;118:303-307)

A study of 50 patients was undertaken to determine the effects of an isotonic 5 percent crystalline amino acid solution on nitrogen balance. Patients were divided randomly into two groups: 24 receiving amino acids and 25 receiving dextrose in water. (One patient in the treatment group dropped out after one day of intravenous therapy.) Administration of amino acids postoperatively maintained nitrogen balance, as compared with controls. No untoward metabolic changes or other complications occurred. Amino acid peripherally administered is an alternate source of calories and nitrogen. It is of value in treating short-term under-nutrition.

Fifteen children with islet-cell tumor (s) of the pancreas and ulcer diathesis (Zollinger-Ellison syndrome) were collected in a tumor registry established to study pathophysiology and natural history of this syndrome. Eight children had less than total gastrectomy and six of these died. Five died from complications of recurrent ulcerations. All seven children with total gastrectomy remain alive and well. Metastatic or multiple tumors or both were present in all seven at the time of total gastrectomy. Follow-up bioassay or gastrin radioimmunoassay studies were performed in six of the seven patients. Serum gastrin levels remained elevated for periods of 5 and 11 years in two patients. Presumably gastrin-producing tumor remains in those patients. One patient with increased gastrin six years after total gastric resection now has low levels after eight years. Two other patients have progressively lower levels each year following total gastrectomy.

PATIENTS harboring nonbeta islet cell pancreatic tumors (Zollinger-Ellison syndrome [Z-E]) which elaborate a gastrin or "gastrin-like" substance are not easily differentiated from the more common peptic ulcer patients. Many of these patients with hypergastrinism are first treated medically or with surgical procedures for ordinary peptic ulcer disease. As a result, many succumb from the complications of gastric hypersecretion before a diagnosis of a gastrin-producing tumor can be confirmed. 1 Gregory et al 2 was the first to extract a "gastrin-like" material from a tumor obtained in a case of Z-E syndrome. Further studies on the nature of the gastric secretagogues extracted from two Z-E tumors indicate it to be the same as one or possibly both of the gastrin peptides isolated from human antral mucosa. 3 The reports of Sircus 4 and Bank et al 5 of a gastric secretagogue, "presumably gastrin," in the circulation of Z-E patients have naturally