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Long-term administration of the somatostatin analogue, octreotide, is complicated by gallstone formation. Somatostatin is known to inhibit hepatic bile secretion and gallbladder emptying. However, the effect of octreotide on gallbladder bile composition remains unknown. Therefore, we tested the hypothesis that octretide would alter hepatic bile composition and cause gallbladder stasis, thereby increasing gallbladder bile solute concentrations. Fourteen control prairie dogs received daily saline injections, whereas 10 animals received 1 micrograms of octreotide subcutaneously three times per day for 5 days. Cholecystectomy and common bile duct cannulation were then performed. Octreotide increased hepatic bile concentrations of bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.05), and total protein (p less than 0.01). Rsa, an index of gallbladder stasis, was decreased (p less than 0.01) in the octreotide group. Gallbladder bile total calcium (p less than 0.05), bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.01), total protein (p less than 0.05), and total lipids (p less than 0.05) were increased in the octreotide group. Animals receiving octreotide also had decreased hepatic (p less than 0.05) and gallbladder (p less than 0.001) bile pH. No differences in cholesterol saturation index were observed. These data suggest that in the prairie dog, octreotide (1) alters hepatic bile composition, (2) causes gallbladder stasis, and (3) increases gallbladder bile calcium, bilirubin, protein, lipid, and hydrogen ion concentrations. We conclude that octreotide causes alterations in gallbladder bile composition that increase the likelihood of cholesterol and calcium bilirubinate precipitation.

Bile duct strictures are an uncommon but serious complication of primary operations on the gallbladder or biliary tree. Most strictures occur as a result of injury to the bile duct during cholecystectomy. In addition, strictures can occur at the site of previous biliary anastomoses for reconstruction of the biliary tree. Most patients with benign bile duct strictures present soon after their initial operation; however, in some cases, presentation is delayed for years. Cholangiography is essential for defining the anatomy of the biliary tree prior to management. In many cases, nonoperative biliary drainage is useful to treat sepsis and biliary fistulas. A number of alternatives exist for elective repair of bile duct strictures. Experience would suggest, however, that a choledochojejunostomy or hepaticojejunostomy performed through a Roux-en-Y limb of jejunum is the preferable management in most cases. Postoperative biliary stenting may be valuable in optimizing the results. Nonoperative management by percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in a number of small series. Long-term results are limited, however. Comparative data suggest that surgical repair for benign postoperative strictures is associated with fewer long-term problems and with similar overall morbidity and costs.

In the treatment of gallstones with extracorporeal shock-wave lithotripsy, the bile acid ursodiol is administered to dissolve the gallstone fragments. We designed our study to determine the value of administering this agent.At 10 centers, 600 symptomatic patients with three or fewer radiolucent gallstones 5 to 30 mm in diameter, as visualized by oral cholecystography, were randomly assigned to receive ursodiol or placebo for six months, starting one week before lithotripsy.The stones were fragmented in 97 percent of all patients, and the fragments were less than or equal to 5 mm in diameter in 46.8 percent. On the basis of an intention-to-treat analysis of all 600 patients, 21 percent receiving ursodiol and 9 percent receiving placebo (P less than 0.0001) had gallbladders that were free of stones after six months. Among those with completely radiolucent solitary stones less than 20 mm in diameter, 35 percent of the patients receiving ursodiol and 18 percent of those receiving placebo (P less than 0.001) were free of stones after six months. Biliary pain, usually mild, occurred in 73 percent of all patients but in only 13 percent of those who were free of stones after three and six months (P less than 0.01). There were few adverse events. Only diarrhea occurred with a significantly different frequency in the two groups: 32.6 percent were affected in the ursodiol group, as compared with 24.7 percent in the placebo group (P less than 0.04). Severe biliary pain occurred in 1.5 percent of all patients, acute cholecystitis in 1.0 percent, and acute pancreatitis in 1.5 percent; endoscopic sphincterotomy was performed in 0.5 percent, and cholecystectomy in 2.5 percent.Extracorporeal shock-wave lithotripsy with ursodiol was more effective than lithotripsy alone for the treatment of symptomatic gallstones, and equally safe. Treatment was more effective for solitary than multiple stones, radiolucent than slightly calcified stones, and smaller than larger stones.

Gallbladder stasis, increased gallbladder absorption, and elevated biliary levels of calcium, hydrogen ion, and bilirubin have been implicated as factors potentially critical to cholesterol crystal precipitation. Previous studies, however, have analyzed bile only when crystals or gallstones have already formed. Therefore, we tested the hypothesis that changes in bile composition are a late effect, occurring only after crystal formation. Adult male prairie dogs were fed a standard nonlithogenic control diet (n = 7) or a lithogenic 1.2% cholesterol diet for 5, 9, or 14 days to cause cholesterol saturation (n = 7), cholesterol monohydrate crystals (n = 7), or gallstones (n = 7). Gallbladder bile was examined microscopically for crystals, and analyzed for ionized calcium, bilirubin, pH, total protein, and biliary lipids. The ratio of gallbladder to hepatic bile radiolabeled cholic acid specific activity (Rsa) was calculated as an index of gallbladder stasis. Cholesterol saturation index was calculated. The results demonstrate that increased gallbladder bile cholesterol saturation and total protein concentration precede cholesterol monohydrate crystal precipitation. However, changes in gallbladder ionized calcium, unconjugated bilirubin, pH, stasis, and absorption were noted only after crystals and gallstones had already formed. These data indicate that alterations in gallbladder bile calcium, bilirubin, pH, stasis, and absorption are not early changes, but occur simultaneously with or after crystal formation. Increased biliary protein, however, which was elevated prior to nucleation, may be an important mediator of cholesterol precipitation in cholesterol-saturated bile.

The absorption of water and electrolytes is an important physiologic function of the gallbladder which is altered during gallstone formation. Extracellular calcium and calcium channel antagonists are known to affect intestinal absorption, yet their effect on gallbladder absorption is less well defined. We, therefore, tested the hypothesis that changes in extracellular calcium or in calcium channels would alter gallbladder absorption. New Zealand white rabbit gallbladders were removed, filled with a modified Krebs buffer (Ca2+ = 0.7 mM), and suspended in an oxygenated bath of the same buffer. Water absorption was determined gravimetrically by obtaining serial gallbladder weights at 10-min intervals. After a 40-min control period, the serosal bathing solution was changed to one of four experimental solutions (n = 6 for each group): Ca2+ = 0.25, 0.7, or 1.2 mM or Ca2+ = 0.7 mM plus 0.1 mM verapamil. Absorption was determined during an 80-min experimental period with results expressed as the percentage change in gallbladder absorption compared to that of the control period. The 0.25, 0.7, and 1.2 mM Ca2+ groups did not show a significant change in absorption rate from their respective control rates. However, the verapamil group did demonstrate a significant (P less than 0.05) decrease in absorption rate of -69 +/- 8% by the end of the experimental period. These data demonstrate that verapamil inhibits gallbladder absorption while changes in serosal calcium concentration have no effect. We conclude that calcium channels and intracellular calcium may play an important role in modulating gallbladder absorption.

The association of Streptococcus bovis endocarditis and colon carcinoma has been reported previously in small series in the medical, but not surgical, literature. Although the fecal carriage rate of S. bovis increases with colonic pathology, no explanation exists for the development of bacteremia in these cases. To explore the possible contribution of hepatic dysfunction to the development of portal and systemic bacteremia, the incidence of both colonic pathology and liver disease or dysfunction was determined in 92 patients with S. bovis endocarditis and/or bacteremia. Colonic and liver evaluation had been undertaken in 47% and 93% of patients, respectively. Among these patients, colonic pathology was identified in 51%, and liver disease or dysfunction was documented in 56%. Either the underlying colonic disease or alterations in hepatic secretion of bile salts or immunoglobulins may promote the overgrowth of S. bovis and its translocation from the intestinal lumen into the portal venous system. A compromised hepatic reticuloendothelial system may then contribute to the development of S. bovis septicemia and subsequent endocarditis. We conclude that S. bovis bacteremia is an indication to the clinician of the possibility of underlying liver disease as well as colon pathology.

Ninety patients with periampullary tumors, staged by CT scan and believed to be resectable, were staged further by visceral angiography. Most of these patients (78) had carcinoma of the head of the pancreas. Visceral angiography was normal in 62 patients. Major vessel encasement (17 patients) or occlusion (11 patients) was identified in 28 patients. There were no complications related to angiography. Among the 62 patients with normal angiograms, 48 underwent a pancreaticoduodenectomy, for a resectability rate of 77%. Among the 17 patients with vessel encasement, the resectability rate was 35%. For the 11 patients with vessel occlusion, the resectability rate was 0%. Combined with CT scan, visceral angiography is a useful adjunct in the staging of patients with periampullary tumors. Major vessel occlusion precludes resection, and major vessel encasement makes resection unlikely. If visceral angiography is normal, it is very likely that the tumor will be resectable.

• Acute cholecystitis is well established as one of the high-risk factors bactibilia and wound infection. However, many patients with acute cholecystitis do not have bactibilia. Therefore, we analyzed 20 clinical and laboratory parameters in 49 patients with acute cholecystitis to determine which factor(s) predicted bactibilia. Twenty-one (42.9%) of 49 patients with pathologically proved acute cholecystitis had positive bile and/or gallbladder wall cultures. Univariate analysis suggested that a preoperative temperature greater than 37.3°C, a total serum bilirubin level greater than 8.6 μmol/L, and a white blood cell count greater than 14.1 × 10 9 /L were the best predictors of bactibilia. Multifactorial analysis demonstrated that the 17 patients with zero or one predictive factor had a significantly lower chance of having bactibilia than the 32 patients with two or three predictive factors (6% vs 63%). We concluded that the culture status of patients with acute cholecystitis can be predicted preoperatively. We propose that patients with acute cholecystitis and zero or one of the predictive factors receive a single preoperative antibiotic dose. In patients with two or three predictive factors, antibiotics should be continued until culture data are available. ( Arch Surg . 1990;125:261-264)

Ninety-six patients with proximal cholangiocarcinomas were managed surgically. Fifty-three patients (55 percent) were resected, 39 curatively (41 percent), and 43 (45 percent) underwent palliative stenting. The preoperative placement of Ring catheters and the operative use of silastic transhepatic biliary stents greatly facilitated the surgical management of these lesions. Sixty-three patients (66 percent) also received postoperative radiotherapy. Hospital mortality was 4 percent (four deaths). Hospital mortality was 2 percent after resection (1 of 53 patients) and 7 percent after palliative stenting (3 of 43 patients). All deaths resulted from sepsis. One, 3, 5, and 10-year survivals for the entire group were 49 percent, 12 percent, 5 percent, and 2 percent, respectively. One, 3, 5, and 10-year survivals in the resected group (66 percent, 21 percent, 8 percent, and 4 percent, respectively) were superior to those in the stented group (27 percent, 6 percent, 0 percent, and 0 percent, respectively). Radiotherapy appeared to significantly extend survival in those patients undergoing palliative stenting, but not in those undergoing resection. We conclude that surgical resection of proximal cholangiocarcinomas can be performed safely and that it significantly prolongs survival. Further improvement in long-term survival will depend on advances in adjuvant therapy.

Annular Pancreas (AP) in the Adult: Experience At a Large Pancreatobiliary Endoscopy Center Evan L. Fogel, Nicholas Zyromski, Lee Mchenry, James L. Watkins, Suzette Schmidt, Laura Lazzell-Pannell, Henry A. Pitt, Stuart Sherman, Glen A. Lehman Background: AP is a rare congenital anomaly, most often identified in children who present with duodenal obstructive symptoms, with an incidence of approximately 1:20,000 births. Literature examining the adult experience with AP has typically been limited to case reports. Pancreas divisum has been reported in 1/3 of these patients (pts) [Gastrointest Endosc 1985;31:25-8]. Aim: To review our experience with adult AP pts. Results: Of 9550 pts who underwent ERP from 2/94-11/05, 32 adult pts (0.3%; age 23-77; 24F, 8M) with AP were identified from our ERCP database. These 32 pts underwent a total of 74 ERCPs (mean 2.3; range 1-11). 8 pts were known to have AP prior to ERCP, and 4 of these had previously undergone duodenal bypass surgery. Indications for ERCP included acute/chronic pancreatitis (13 pts), suspected SOD (12), obstructive jaundice due to pancreatic cancer (3), ampullectomy for periampullary adenoma (2), CBD stones (1), and unexplained LFT abnormalities (1). 26 of the 28 pts without a prior history of duodenal bypass surgery were noted to have duodenal narrowing at ERCP. No patient had retained gastric contents, although 3 required balloon dilation to allow scope passage. The minor papilla was typically located just cephalad to this annular narrowing, or less frequently, on the inferior aspect of the narrowed segment, in the 2-3 o’clock position relative to the major papilla. The annular branch was seen arising from the ventral duct in all pts. At the initial ERCP, pancreatography was attempted in all 32 pts and was completely successful in 30 (94%). Complete pancreas divisum was identified in 12 pts (38%), and 3 additional pts (9%; total 47%) had incomplete divisum. Minor papilla sphincterotomy was successfully performed in 9/10 pts with a history of pancreatitis and pancreas divisum. 17/17 pts had successful biliary and/ or major papilla pancreatic endoscopic therapy for SOD (8), malignant biliary obstruction (3), pancreatitis (2), ampullectomy (2), and CBD stones (1). Long-term, clinical outcome of therapy was not assessed in this review. Summary: In this large series of adult AP pts, duodenal narrowing was observed in nearly all pts without prior bypass surgery, but retained gastric contents were not seen. Pancreas divisum was noted in 47%. Pancreatobiliary neoplasia (adenoma, carcinoma) was found in 5/ 32 (16%) pts. Conclusions: Annular pancreas is a rare congenital disorder that may be recognized in the adult population. The co-existence of pancreas divisum may be greater than previously documented. Endoscopic therapy success rates remain high at our tertiary referral center.

Background. Obesity and diabetes are major risk factors for the development of cholesterol gallstones, and the majority of obese people have leptin-resistant obesity. Previous studies from our laboratory have demonstrated that both leptin-deficient (Lepob) and leptin-resistant (Lepdb) obese diabetic mice have decreased in vitro gallbladder motility. We have also shown that leptin administration to leptin-deficient (Lepob) animals restores gallbladder motility and reverses obesity and hyperinsulinemia. However, the administration of additional leptin to leptin-resistant (Lepdb) mice would not be expected to ameliorate their physiologic parameters. In contrast, recent studies have demonstrated that ciliary neurotrophic factor (CNTF) can reduce weight and hyperinsulinemia in leptin-resistant obesity. Hypothesis. CNTF would cause weight loss, lower blood sugars, and restore gallbladder contractility in leptin-resistant (Lepdb) mice. Methods. To test this hypothesis, 20 C57b/6J and 20 Lepdb 8-week-old mice were injected intraperitoneally daily with either saline or 0.3 μg/g CNTFAx15 for 17 days. At 11 weeks, mice were weighed and underwent cholecystectomy. Intact gallbladders were mounted in 3 mL muscle baths and stimulated with acetylcholine (ACh) and cholecystokinin (CCK). Serum glucose levels were measured. Data were analyzed by two-way ANOVA. Results are shown in the table. Conclusions. These data suggest that daily administration of ciliary neurotrophic factor (CNTF) causes (1) significant weight loss, (2) improvement of diabetes, and (3) significant alterations in gallbladder motility which is decreased in lean nondiabetic mice and improved in obese diabetic mice. We conclude that ciliary neurotrophic factor may improve gallbladder contractility in leptin-resistant obese diabetes. TABLE—ABSTRACT 48. Strain Wt (g) Glucose (mg/dL) ACh 10−5 M (N/cm2) CCK 10−8 M (N/cm2) Saline C57 17 ± 0 110 ± 12 .39 ± .04 1.14 ± .13 CNTF C57 13 ± 0∗ 101 ± 7 .20 ± .04∗ 0.59 ± .08∗ Saline Lepdb 41 ± 2† 440 ± 26† .13 ± .03∗ 0.46 ± .08∗ CNTF Lepdb 22 ± 1‡ 200 ± 33† .54 ± .10‡ 1.02 ± .09‡ ∗ P < 0.05 versus Saline C57; † P < 0.01 versus other groups; Ddagger; P < 0.001 versus Saline lepdb.

Introduction: We have demonstrated that leptin deficiency and leptin resistance are associated with abnormal motility in the gallbladder. In addition, we have shown that serum glucose and insulin are inversely correlated with biliary motility and that administration of leptin to deficient mice normalizes gallbladder function. Thus, leptin administration may be therapeutic for biliary dyskinesia. However, no data are available on biliary leptin receptor levels. Therefore, we hypothesized that leptin receptors would be abundant in the gallbladder. Methods: 11 week old female lean control (C57Bl/6J, n = 12), leptin-deficient obese/diabetic (Lepob, n = 8), leptin-resistant obese/diabetic (Lepdb, n = 8) and non-obese, diabetic (NOD/LtJ, n = 8) mice were fasted overnight. The next day alimentary tissues including stomach, duodenum/jejunum, ileum, colon, gallbladder, liver and spleen were removed, and leptin receptor (Ob-Rb, long form) protein levels were determined by ELISA. Data were analyzed by Two-way and One-way ANOVA and by Student-Newman-Keuls for pair-wise multiple comparisons. Results: Leptin receptors were similarly abundant in the gallbladder of each strain (p ∗ . C57BI/6J Lepob Lepdb NOD Leptin receptors 22.6 ± 4.9 23.8 ± 3.5 24.6 ± 4.0 35.5 ± 8.3 ∗ ∗ p Conclusions: These data suggest that leptin receptors 1) are found most commonly in the gallbladder and 2) are increased in the gallbladder of non-obese diabetic mice. We conclude that alimentary leptin receptors are most abundant in the gallbladder and that leptin provides a link among obesity, diabetes, and gallstone formation.

Choledochal cysts occur most frequently in East Asian children and rarely in Western adults. Over the past two decades, pediatric treatment has been standardized, but relatively little information is available on the management of Western adults with choledochal cysts. Therefore the aims of this analysis were to compare the presentation, management, and late results of Western adults and children with choledochal cysts. Records were reviewed of patients with choledochal cysts at three academic institutions in Wisconsin. Fifty-seven patients were identified, and 51 of these patients (89%) were managed surgically. Thirty-one patients (54%) were adults, and the adults were more likely to be male (29% vs. 4%, P

Gallstones contain precipitated cholesterol, calcium salts, and proteins. Calcium (Ca) bilirubinate, palmitate, phosphate, and carbonate occurring in gallstones have variable morphologies but characteristic windowless energy dispersive x-ray (EDX) spectra. Previous studies of gallstone microstructure and composition using scanning electron microscopy (SEM) with EDX have been limited to dehydrated samples. In this state, Ca bilirubinates appear as either glassy masses, which predominate in black pigment stones, or as clusters, which are found mostly in cholesterol gallstones. The three polymorphs of Ca carbonate, calcite, vaterite, and aragonite, have been identified in gallstones by x-ray diffraction, however; the morphologies of these crystals vary in the literature. The purpose of this experiment was to study fresh gallstones by environmental SEM (ESEM) to determine if dehydration affects gallstone Ca salt morphology.Gallstones and bile were obtained fresh at cholecystectomy from 6 patients. To prevent dehydration, stones were stored in bile at 37°C. All samples were studied within 4 days of procurement.

Intestinal motility disorders are more common in women of childbearing age who are prone to iron deficiency anemia. The neurotransmitters nitric oxide (NO) and acetylcholine (ACh) play a key role in ileal smooth muscle relaxation and contraction, respectively. Iron-containing heme is known to be a cofactor for nitric oxide synthase (NOS), the enzyme responsible for NO production. Therefore we tested the hypothesis that iron deficiency would downregulate ileal NOS activity without affecting the ileum’s response to ACh. Twelve adult female prairie dogs were fed either an ironsupplemented (Fe+) (200 ppm) (n = 6) or an iron-deficient (Fe-) (8 ppm) (n = 6) diet for 8 weeks. Ileal circular muscle strips were harvested to measure responses to ACh and electrical field stimulation. Under nonadrenergic noncholinergic (NANC) conditions, Nω-nitro-L-arginine (L-NNA), an NOS inhibitor, and VIP10-28, a vasoactive intestinal peptide (VIP) inhibitor, were added prior to electrical field stimulation. NANC inhibitory responses are expressed as a percentage of optimal relaxation from EDTA. The excitatory response to ACh was similar in both groups (1.1 ± 0.3 N/cm2 vs. 1.5 ± 0.3 N/cm2, P = 0.45). The inhibitory response to electrical field stimulation under NANC conditions was greater in the Fe+ group (34.7 ±2.9%) compared to the Fe-group (23.9 ±3.2%; P

extrahepatic bile duct stones by analyzing MRC features. Methods: MRC was obtained using a single-shot fast spin-echo sequence in 38 patients with stones in both the common duct and the gallbladder. Two radiologists interpreted all MRC images independently and discrepancies were resolved by concensus. MRC findings were compared for gross characteristics and gallstone patterns between common duct stone and gallbladder stone pairs. The gross morphologic characteristics of gallstones on MRC were classified into oval, polygonal, round, rod, sandy, and mixed shape. Gallstone patterns seen on heavily T2-weighted images were categorized into one of six patterns : dark, faint, laminated, rimmed, sunburst, and heterogeneous signal. Results: According to the gross morphologic characteristics on MRC images, the appearances of common duct stones were oval (N=9), polygonal (N=15), round (N=6), sandy (N=4), mixed (N=3), and rod (N= I). Common duct stone and gallbladder stone pairs were identical in 60.5% of total cases (23 of 38 pairs), and concordance rate was significantly higher when common duct stones were oval or polygonal-shaped. The visualized MR signal patterns of common duct stones on heavily T2-weighted images were dark (N=20), faint (N=8), sunburst (N=4), heterogeneous (N=3), laminated (N=2), and rimmed (N=I). Identical gallstone patterns on heavily T2-weighted images between common duct stone and gallbladder stone pairs were observed in 58% of total cases(22 of 38 pairs). The signal patterns of common duct stones tended to be more similar to their paired gallbladder stones when heavily T2-weighted images of common duct stones showed dark or sunburst signal patterns. Conclusions: On MRC, the gross characteristics and gallstone patterns of common duct stones were similar to those of their paired gallbladder stones in 58 to 60.5 percent of patients, which suggests that a high proportion of extrahepatic bile duct stones are secondary when the gallbladder stone is present.

This prospective, randomized, single-institution trial was designed to evaluate the role of prophylactic gastrojejunostomy in patients found at exploratory laparotomy to have unresectable periampullary carcinoma.Between 25% and 75% of patients with periampullary cancer who undergo exploratory surgery with intent to perform a pancreaticoduodenectomy are found to have unresectable disease. Most will undergo a biliary-enteric bypass. Whether or not to perform a prophylactic gastrojejunostomy remains unresolved. Retrospective reviews of surgical series and prospective randomized trials of endoscopic palliation have demonstrated that late gastric outlet obstruction, requiring a gastrojejunostomy, develops in 10% to 20% of patients with unresectable periampullary cancer.Between May 1994 and October 1998, 194 patients with a periampullary malignancy underwent exploratory surgery with the purpose of performing a pancreaticoduodenectomy and were found to have unresectable disease. On the basis of preoperative symptoms, radiologic studies, or surgical findings, the surgeon determined that gastric outlet obstruction was a significant risk in 107 and performed a gastrojejunostomy. The remaining 87 patients were thought by the surgeon not to be at significant risk for duodenal obstruction and were randomized to receive either a prophylactic retrocolic gastrojejunostomy or no gastrojejunostomy. Short- and long-term outcomes were determined in all patients.Of the 87 patients randomized, 44 patients underwent a retrocolic gastrojejunostomy and 43 did not undergo a gastric bypass. The two groups were similar with respect to age, gender, procedure performed (excluding gastrojejunostomy), and surgical findings. There were no postoperative deaths in either group, and the postoperative morbidity rates were comparable (gastrojejunostomy 32%, no gastrojejunostomy 33%). The postoperative length of stay was 8.5+/-0.5 days for the gastrojejunostomy group and 8.0+/-0.5 days for the no gastrojejunostomy group. Mean survival among those who received a prophylactic gastrojejunostomy was 8.3 months, and during that interval gastric outlet obstruction developed in none of the 44 patients. Mean survival among those who did not have a prophylactic gastrojejunostomy was 8.3 months. In 8 of those 43 patients (19%), late gastric outlet obstruction developed, requiring therapeutic intervention (gastrojejunostomy 7 patients, endoscopic duodenal stent 1 patient; p0.01). The median time between initial exploration and therapeutic intervention was 2 months.The results from this prospective, randomized trial demonstrate that prophylactic gastrojejunostomy significantly decreases the incidence of late gastric outlet obstruction. The performance of a prophylactic retrocolic gastrojejunostomy at the initial surgical procedure does not increase the incidence of postoperative complications or extend the length of stay. A retrocolic gastrojejunostomy should be performed routinely when a patient is undergoing surgical palliation for unresectable periampullary carcinoma.

Objective This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy).

Cholesterol gallstones contain precipitated calcium salts and proteins which are often concentrated in stone centers. Up to 15% of patients with cholesterol gallstones possess a large solitary gallstone. Biliary transferrin, a potent pronucleator of cholesterol crystals, binds a variety of transition metals such as Fe, Cu and Zn. The purpose of this study was to compare the relative concentrations of Ca, Fe, Cu and Zn in the centers and peripheries of solitary and multiple gallstones. Therefore, solitary (S, n=13) and multiple (M, n=15) cholesterol stones were collected, washed, dried and stored at room temperature. Representative areas from each core and periphery were dissected. Powdered samples were subjected to acid digestion and prepared for quantitative elemental analysis by inductively coupled plasma analysis (ICP). Ca, Fe, Cu, and Zn concentrations from the core and periphery in each stone type were