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Forty-two patients with acute cholangitis, as evidenced by fever (95%), jaundice (86%), and right upper quadrant pain (67%), were treated with fluid and electrolyte resuscitation, broad spectrum antibiotic coverage, and initial percutaneous transhepatic biliary drainage (PTD). Despite a 17% incidence of nondilated ductal systems, drainage was established in all patients using a 22-gauge "skinny" needle and "accordion" catheter. No attempt was made at definitive cholangiogram; only 1-2 mL of contrast were injected to confirm placement of the catheter. Sepsis began to resolve in all patients within 24 hours of PTD, after which definitive cholangiogram was performed. PTD was accompanied by a 7% (3/42) complication rate, none of which contributed to subsequent morbidity and mortality. Two patients in severe septic shock had PTD but died within 8 hours of admission, constituting a 5% mortality rate. Definitive therapy after resolution of sepsis included: surgical (16 patients), internal/external drainage (14 patients), balloon dilatation (10 patients), mono-octanoin infusion (1 patient), and ampullary dilatation (1 patient). The surgical morbidity rate was 18%. There was no mortality. PTD is effective in providing decompression as initial therapy for acute cholangitis with minimal morbidity. Accurate diagnosis provided by the definitive cholangiogram obviates the need for multiple surgical procedures. PTD provides a portal to the biliary tract for alternative procedures (i.e., internal/external drainage, balloon dilatation), especially in patients with medical contraindications to surgery.

Central venous catheter (CVC) vascular erosions are difficult to diagnose, and they cause serious complications. From 1985 to 1987, ten patients receiving the surgical services at the University of Florida suffered CVC vascular erosions. By chest roentgenogram, nine CVC tips were in the superior vena cava (SVC), although three catheter tips abutted the lateral wall of the SVC. One catheter tip was in the right atrium. All patients had sudden onset of symptoms, the most common of which was shortness of breath. Initial diagnosis was respiratory insufficiency in five patients, cardiac failure in three patients, pulmonary embolism in one, and sepsis in one. Four patients required intensive care. Two patients suffered pericardial tamponade, and pleural effusions developed in eight patients. One patient died of cardiac arrest. The average time interval from CVC placement to onset of symptoms was 60.2 hours, and from the onset of symptoms to the time of diagnosis, the interval was 16.7 hours. The mean volume obtained at thoracentesis was 1324 ml and at pericardiocentesis was 250 ml.

This is an analysis of 34 patients with carcinoma of the cervical esophagus treated with radiation therapy with curative intent at the University of Florida between September 1966 and May 1985. All patients have a minimum 2-year follow-up and 28 (82%) have at least 5 years of follow-up. Patients were staged according to the recommendations of the AJCC. Patients who died within 2 years of treatment with the primary site continuously disease-free were excluded from the local control analysis; all patients were included in the analysis of complications and survival. Irradiation resulted in control of the primary lesion in 1 of 2 patients who presented with T1 lesions, in 4 of the 12 patients with T2 lesions, and 3 of 17 patients who presented with T3 lesions. One patient with a T3 lesion that recurred locally was successfully salvaged by an operation. The 5-year absolute survival rates by stage were as follows: no patients with stage I lesions survived; of 11 stage II patients, one survived; and of 16 stage III patients, three survived. Interestingly, all four of the 5-year survivors were women.

Evaluation of gastric acid secretion and serum gastrin response to proximal or distal intestinal bypass and subsequent resection was undertaken. Ten dogs with gastric fistulas underwent control secretory studies consisting of basal acid output (BAO), maximal vagal stimulation (2 deoxy-d-glucose (2DG) 150 mg/kg iv), maximal histamine stimulation (160 μg/kg/hr iv), and test meal stimuli. Serum gastrin was measured basally and following gastric stimulation. Dogs were then divided into two bypass groups: Group I, distal bypass, leaving 40 cm jejunum and 4 cm ileum; and Group II, proximal bypass, leaving 4 cm jejunum and 40 cm ileum. Postoperatively, repeat studies were performed. Both groups then underwent resection of the bypassed segments followed by repeat secretory and gastrin tests. BAO was significantly increased in Group I dogs. BAO increased from a control of 0.04 ± 0.02 to 0.51 ± 0.19 meq H+/60 min (±SEM). No significant changes in BAO were observed in Group II following bypass. Acid secretion to maximal vagal or maximal histamine stimulation was not significantly different in either group. Serum gastrin response was unchanged in either group following a test meal. In Group I dogs, resection of the previously bypassed bowel produced a further significant increase in BAO (1.44 ± 0.4 meq H+/60 min). After resection of the bypassed bowel, there was no significant change in basal or stimulated gastrin. Gastric fistula BAO increased following 90% distal but not proximal bypass; subsequent resection of the bypassed segment produced a further increase in BAO. Acid secretory responses to both histamine and 2DG were not influenced by either bypass or resection. An increase in BAO without a change in the background of serum gastrin may suggest the presence of a gastric secretory inhibitor in the distal small bowel.

Limiting blood loss is a primary concern in hepatic resection. Torrential hemorrhage occasionally occurs and is often related to loss of control or injury to the hepatic veins or vena cava. Stapling devices, carefully applied, are presented as a safe and expedient means for controlling hepatic veins within the hepatic parenchyma.

From 1971-1986, 24 patients were diagnosed as having Zollinger-Ellison syndrome (ZES) and 22 patients had laparotomy. Of this group, gross tumor was identified in 15 of 22 patients. Ten of 15 patients had resection of their gastrinomas with the specific aim of curing the disease. This group had responded favorably to either cimetidine or ranitidine before operation. Preoperative transhepatic portal venous sampling (PVS) with gastrin determinations was performed in six patients; three patients had this procedure twice. The tumor was correctly localized by PVS in five of six patients. In four of six patients, the tumor was easily found at surgery. In two of six patients (33%) PVS was vital to intraoperative decisions. Criteria for biochemical cure are normal periodic fasting gastrin and secretin infusion tests. Of the 10 patients who had resection for potential cure, two patients failed within 48 hours of surgery on the basis of an elevated fasting serum gastrin level in one patient and a positive secretin infusion test in the other patient. Eight patients were considered cured with follow-up from 6 months through 15 years. Of the eight cured patients, the tumors were located as follows: four were extraintestinal and extrapancreatic, four were in the duodenal wall, one patient had a tumor located in the uncinate process of the pancreas, and one tumor was located in a lymph node along the lesser curve of the stomach. Two patients had mobilization of the pancreas and duodenum for a "blind" pancreatoduodenectomy based on preoperative PVS (2 procedures each patient). In one patient a 3-mm gastrinoma was enucleated from the posterior uncinate process. The second patient had pancreatoduodenectomy with findings of two duodenal wall gastrinomas. Both patients remained cured of ZES beyond 2 years. It is concluded that PVS does indeed locate some tumors before operation, even those not easily found at surgery. ZES can be cured by an aggressive approach combining preoperative tumor localization and tumor resection. Of the eight patients biochemically and perhaps biologically cured, follow-up was greater than four years in five patients, greater than two years in two patients, and beyond six months in one patient.

During the period from 1979 through 1984, 17 patients with benign biliary strictures underwent percutaneous transhepatic balloon dilatation. All patients presented with either hyperbilirubinemia and acute cholangitis, a history of intermittent chills and fever, or both. Balloon dilatation was most successful in those patients with intrahepatic strictures, sclerosing cholangitis, strictured biliary enteric anastomoses, and distal common bile duct strictures with retained calculi. Two patients with postsurgical common bile duct injury had treatment failure 3 and 18 months after dilatation and subsequently underwent elective hepaticojejunostomy. Although our longest treatment success is now more than 4 1/2 years in an 83 year old woman who is 15 years posthepaticojejunostomy, the mean follow-up of the entire group has only been 2 years. On the basis of our early experience and that of others, we now recommend an initial attempt at balloon dilatation in most patients with postsurgical benign biliary strictures. Further technical advances and longer follow-up in present and future series may certainly broaden the appeal of this nonoperative procedure.

VX2 carcinoma implanted inrabbits regularly induces hypercalcemia withoutdemonstrable bone metastases. The presentstudy was designed to determine the effect ofthyroparathyroidectomy on such hypercalcemia.The data obtained indicated that the parathyroidglands are not necessary to the developmentor maintenance of hypercalcemia in tumor-bearinganimals. These results support the conceptthat malignant tumors may elaborate hypercalcemia-inducing substances which act directlyon bone. (Endocrinology 80: 404, 1967)

Seventeen high-risk critically ill patients with suspected cholecystitis underwent percutaneous transhepatic cholecystostomy between 1981 and 1986 using Hawkins' needle guide system for gallbladder intubation. Acute cholecystitis was documented in 15 patients, including 1 with common bile duct obstruction. Two other patients had common bile duct obstruction secondary to metastatic cancer (one patient) and chronic pancreatic fibrosis (one patient). There was rapid resolution of the signs and symptoms of cholecystitis, sepsis, or both in 16 of the 17 patients. One critically ill patient with positive findings on blood culture and an organism resistant to triple antibiotic therapy died soon after percutaneous cholecystostomy. In the entire group of 17 patients, there was no evidence of bile leaks or other catheter complications. Six patients subsequently underwent successful cholecystectomy and two underwent common bile duct exploration without complications. One patient underwent cholecystojejunostomy, and in three patients, the catheter was removed with no sequelae of cholecystitis. Two remaining patients had the catheter in place and were awaiting operation at last follow-up. Three of four patients who died within 30 days of percutaneous transhepatic cholangiographic cholecystostomy died either from the terminal malignant condition (two patients) or from arrhythmia (one patient with cirrhosis). This review suggests that percutaneous cholecystostomy is a safe and effective procedure for resolving acute cholecystitis in high-risk patients. In addition, the technique of percutaneous transhepatic cholangiographic cholecystostomy appears well suited for percutaneous dissolution of stones, sclerosis of the gallbladder, or both in selected high-risk critically ill patients.

Eleven patients with well-documented hepatorenal syndrome were studied by measurement of blood volume, glomerular filtration rate, renal plasma flow, plasma aldosterone concentration, renin substrate concentration, and plasma renin activity. They were then given 750 ml of stored plasma, 750 ml of fresh frozen plasma, and then an infusion of angiotensin II, in random order on successive days. Infusion of fresh frozen plasma improved function more than did stored plasma and in addition returned a very low filtration fraction toward normal. Angiotensin II infusion increased filtration fraction, but decreased glomerular filtration rate, renal plasma flow, and urine flow sharply. Patients were then given a daily infusion of 1,000 ml of fresh frozen plasma for seven to 18 days to expand the blood volume to supranormal levels as assayed by serial measurement of blood volume. Plasma aldosterone levels decreased to a normal range, glomerular filtration rate and renal plasma flow both increased, and urinary excretion of sodium and potassium both returned toward normal. The effect of intraperitoneal pressure was then studied by measuring glomerular filtration rate, renal plasma flow, pressure in the vena cava, hepatic vein free flow, and hepatic vein wedged pressure before, during, and after paracentesis to reduce the intraperitoneal pressure from 30 to 40 cm H2O to 12 to 17 cm H2O. Venous pressures moved parallel to ascitic fluid pressures, and glomerular filtration rate, renal plasma flow, and urine flow all improved sharply; then, as ascitic fluid continued to form, reducing vascular volume, urine flow, glomerular filtration rate, and renal plasma flow all decreased slowly. Six patients then underwent placement of a LeVeen shunt. Improvement in glomerular filtration rate and renal plasma flow and clinical condition was dramatic. During postoperative observation of up to two years, progressive improvement in hepatic function has occurred.