Search

Abstract: Background: The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer. Methods: A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: <60 years (range, 14–59; 118 patients), and ≥60 years (range, 60–93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery. Results: Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out. Conclusions: This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.

Abstract: Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude <30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (2l%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21 % of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Clinicians typically make the diagnosis of gastroesophageal reflux disease (GERD) from the clinical findings and then prescribe acid-suppressing drugs. Endoscopy is usually done for persistent or severe symptoms. Esophageal function tests (EFTs: esophageal manometry and 24-hr pH monitoring) are generally reserved for patients who have the most severe disease, including those being considered for surgery. We hypothesized that EFTs are more accurate than symptoms and endoscopy in the diagnosis of GERD. This was a retrospective study undertaken in a university tertiary care center. Between October 1989 and November 1998, 822 patients with a clinical diagnosis of GERD (based on symptoms and endoscopic findings) were referred for EFTs. The patients were divided into two groups depending on whether the 24-hr pH monitoring score showed GERD (group A, GERD−; group B, GERD+). The groups were compared with respect to the incidence and severity of symptoms, presence of a hiatal hernia on barium x-rays, presence and severity of esophagitis on endoscopy, and esophageal motility. In all, 247 patients (30%) had normal reflux scores (group A, GERD−), and 575 patients (70%) had abnormal scores (Group B, GERD+). Eighty percent of group A and 88% of group B had been treated with acid-suppressing medications. The incidence of heartburn and regurgitation was similar in the two groups. Grade I–II esophagitis was diagnosed by endoscopy in 25% of group A and 35% of group B, and grade III esophagitis in 4% of group A and 11% of group B. Esophageal manometry showed that group B more often had esophageal dysmotility, consisting of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis. These data show that: (1) symptoms were unreliable for diagnosing GERD; (2) endoscopic evidence of grade I–II esophagitis was diagnostically nonspecific, and grade III was much less certain than claimed in other reports; and (3) pH monitoring identified patients with GERD and stratified them according to the severity of the disease. We conclude that esophageal manometry and pH monitoring are important in diagnosing GERD accurately. More liberal use of these tests early in patient management would avoid much improper and costly medical therapy and would help single out for special attention the patients with GERD who have the most severe disease.

Abstract: Pigment stones are thought to form as a result of deconjugation of bilirubin by bacterial β-glucuronidase, which results in precipitation of calcium bilirubinate. Calcium bilirubinate is then aggregated into stones by an anionic glycoprotein. Slime (glycocalyx), an anionic glycoprotein produced by bacteria causing foreign body infections, has been implicated in the formation of the precipitate that blocks biliary stems. We previously showed that bacteria are present within the pigment portions of gallstones and postulated a bacterial role in pigment stone formation through β-glucuronidase or slime production. Ninety-one biliary bacterial isolates from 61 patients and 12 control stool organisms were tested for their production of β-glucuronidase and slime. The average slime production was 42 for biliary bacteria and 2.5 for stool bacteria (P <0.001). Overall, 73% of biliary bacteria and 8% of stool bacteria produced slime (optical density >3). In contrast, only 38% of biliary bacteria produced β-glucuronidase. Eighty-two percent of all patients, 90% of patients with common bile duct (CBD) stones, 100% of patients with primary CBD stones, and 93% of patients with biliary tubes had one or more bacterial species in their stones that produced slime. By comparison, only 47% of all patients, 60% of patients with CBD stones, 62% of patients with primary CBD stones, and 50% of patients with biliary tubes had one or more bacteria that produced β-glucuronidase. Most biliary bacteria produced slime, and slime production correlated better than β-glucuronidase production did with stone formation and the presence of biliary tubes or stents. Patients with primary CBD stones and biliary tubes had the highest incidence of slime production. These findings suggest that bacterial slime is important in gallstone formation and the blockage of biliary tubes.

Abstract: Trocar injury is one of the most serious and potentially preventable complications of laparoscopic surgery. Use of a blunt rather than a cutting trocar could be expected to lessen the likelihood of this injury. Therefore complications related to laparoscopic port design were studied by comparing conventional cutting trocars with radially expanding (blunt) trocars. A multicenter, prospective, randomized clinical trial was conducted in 250 adult patients undergoing elective laparoscopic procedures at tertiary care centers and community hospitals. The patients were randomly assigned to one of two groups: group C, conventional cutting trocars; or group S, radially expanding trocars. Sixteen surgeons performed 244 elective laparoscopic procedures; six patients were removed from the study. One hundred nineteen patients were assigned to group S and 125 to group C. The groups were similar with regard to age, sex, and type of procedure. The following data were collected: intraoperative complications related to the trocars, abdominal wall bleeding, visceral or vascular injury, other complications, fascial closure, procedure time, trocar site assessment at 4 and 24 hours postoperatively, and visual analog pain scores at 4, 8, 12, and 24 hours postoperatively. Fascial defects from 10 mm or larger trocars in group C were closed; the fascial defects in group S were not closed. The trocar sites were checked for incisional hernias at late follow-up. Mean operating time was not different between the two groups (group S, 92 +-73 minutes; group C, 100 +-74 minutes). There were no episodes of intraoperative cannula site bleeding in group S compared with 16 episodes in 13 patients (P <0.001) in group C. Postoperative wound complications were fewer in group S (13 vs. 23; P <0.05). Although the pain scores were generally lower in group S, the differences were not significant. Only 3% of the patients in group S had fascial defects of 10 mm or greater that had to be closed. Within a follow-up period of 6 to 18 months, there have been no incisional hernias in either group. This study shows that radially expanding trocars are safe and effective, and less likely than conventional trocars to result in intraoperative or postoperative complications. The defects created by the radially expanding trocars do not have to be routinely closed.

Abstract: Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11 %). These 39 patients had been symptomatic for an average of 134 months. They were all taking H-blocking agents (21 %) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisonc (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antircflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.

Abstract:: Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. This procedure can also be completed making use of intragastric surgical techniques. Under standard laparoscopic observation, three intragastric ports are placed through the abdominal and anterior gastric walls, establishing working channels for a telescope and hand instruments. After the presence of pseudocysts is confirmed, the posterior wall of the stomach and the cyst wall can be incised by electrocautery. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided, the intragastric ports are removed and defects in the gastric wall are closed with sutures placed via the standard laparoscopic approach. This approach is much less invasive than the conventional approach, which entails a large gastrotomy in the anterior wall of the stomach. This procedure should be the method of choice when interventional radiology or endoscopic intervention fails to effectively drain retrogastric pseudocysts.

Until recently, pneumatic dilatation andintrasphincteric injection of botulinum toxin (Botox)have been used as initial treatments for achalasia, withmyotomy reserved for patients with residual dysphagia. It is unknown, however, whether thesenonsurgical treatments affect the performance of asubsequent myotomy. We compared the results oflaparoscopic Heller myotomy and Dor fundoplication in 44patients with achalasia who had been treated withmedications (group A, 16 patients), pneumatic dilatation(group B, 18 patients), or botulinum toxin (group C, 10patients). The last group was further subdivided according to whether there was (C2, 4 patients)or was not (C1, 6 patients) a response to the treatment.Results for groups A, B, C1, and C2, respectively, were:anatomic planes identified at surgery (% of patients) — 100%, 89%, 100%, and 25%;esophageal perforation (% of patients) — 0%, 5%,0%, and 50%; hospital stay (hrs)-26 ± 8, 38± 25, 26 ± 11, and 72 ± 65; andexcellent/good results (% of patients) — 87%, 95%, 100%, and50%. These results show that: (1) previous pneumaticdilatation did not affect the results of myotomy; (2) inpatients who did not respond to botulinum toxin, the myotomy was technically straightforward and theoutcome was excellent; (3) in patients who responded tobotulinum toxin, the LES muscle had become fibrotic(perforation occurred more often in this setting, and dysphagia was less predictably improved);and (4) myotomy relieved dysphagia in 91% of patientswho had not been treated with botulinum toxin. Thesedata support a strategy of reserving botulinum toxin for patients who are not candidates forpneumatic dilatation or laparoscopic Hellermyotomy.

Abstract: Barrett’s metaplasia can develop in patients with gastroesophageal reflux disease (GERD), and metaplasia can evolve into dysplasia and adenocarcinoma. The optimal treatment for Barrett’s metaplasia and dysplasia is still being debated. The study reported herein was designed to assess the following: (1) the incidence of Barrett’s metaplasia among patients with GERD; (2) the ability of laparoscopic fundoplication to control symptoms in patients with Barrett’s metaplasia; (3) the results of esophagectomy in patients with high-grade dysplasia; and (4) the character of endoscopic follow-up programs of patients with Barrett’s disease being managed by physicians throughout a large geographic region (northern California). Five-hundred thirty-five patients evaluated between October 1989 and February 1997 at the University of California San Francisco Swallowing Center had a diagnosis of GERD established by upper gastrointestinal series, endoscopy, manometry, and pH monitoring. Thirty-eight symptomatic patients with GERD and Barrett’s metaplasia underwent laparoscopic fundoplication. Eleven other consecutive patients with high-grade dysplasia underwent transhiatal esophagectomies. Barrett’s metaplasia was present in 72 (13 %) of the 53 5 patients with GERD. The following results were achieved in patients who underwent laparoscopic fundoplication (n = 38): Heartburn resolved in 95% of patients, regurgitation in 93% of patients, and cough in 100% of patients. With regard to transhiatal esophagectomy (n = 11), the average duration of the operation was 339 ±89 minutes. The only significant complications were two esophageal anastomotic leaks, both of which resolved without sequelae. Mean hospital stay was 14 ±5 days. There were no deaths. The specimens showed high-grade dysplasia in seven patients and invasive adenocarcinoma (undiagnosed preoperatively) in four (36%). These results can be summarized as follows: (1) Barrett’s metaplasia was present in 13 % of patients with GERD being evaluated at a busy diagnostic center; (2) laparoscopic fundoplication was highly successful in controlling symptoms of GERD in patients with Barrett’s metaplasia; (3) in patients with high-grade dysplasia esophagectomy was performed safely (invasive cancer had eluded preoperative endoscopic biopsies in one third of these patients); and (4) even though periodic endoscopic examination of Barrett’s disease is universally recommended, this was actually done in fewer than two thirds of patients being managed by a large number of independent physicians in this geographic area.

• We developed a new technique for performing laparoscopic jejunostomies using T-fasteners to secure the jejunum to the abdominal wall. The proximal jejunum is identified with laparoscopy. Four T-fasteners are introduced percutaneously into the jejunal lumen for retraction, and an 8F catheter is inserted through a peel-away introducer via a J-wire. The jejunum is drawn up against the abdominal wall by pulling on the T-fasteners. Tube placement is checked with laparoscopy and roentgenography. We performed laparoscopic jejunostomies in five patients using this method, and the results were excellent. Jejunostomies can be performed safely, easily, and reliably this way.(Arch Surg. 1993;128:105-108)

• The ultrasonic dissector disrupts tissues in proportion to their fluid content by ultrasonically induced cavitational forces. Since sturdy tissues are spared, the instrument tends to follow tissue planes and to dissect fat and other soft tissues selectively. We performed a prospective, randomized, controlled trial in 73 patients comparing the safety and efficacy of a prototype ultrasonic dissector with that of electrosurgery and laser during laparoscopic cholecystectomy. Randomization was as follows: ultrasonic dissector, 37 patients; electrosurgery, 21 patients; and laser, 15 patients. The results were not different with respect to patient characteristics, amount of blood loss, technical difficulties, length of hospital stay, or return to work. Subjectively, the ultrasonic dissector was thought to be of special value in isolating the hilar structures, particularly when they were edematous or embedded in fat. The ultrasonic dissector disintegrated the fat, which was rapidly cleared up the suction channel, allowing the cystic duct and artery to be bared with less risk of injury. We concluded that the ultrasonic dissector has unique attributes that contribute to the ease and safety of laparoscopic cholecystectomy.(Arch Surg. 1992;127:1195-1199)

• We analyzed 64 percutaneous endoscopic gastrostomy procedures performed by us between 1986 and 1990. Thirty patients had neurologic disease; 16 had head and neck cancers; eight had other malignancies; two had acquired immunodeficiency syndrome; and eight had other problems. Seven patients died within 30 days of complications (n=4) or the primary illness (n=3). Mean follow-up was 6 months; an additional patient died of aspiration and eight others died of their underlying illness. There were 19 complications (32%). Four wound complications occurred. Nine patients developed aspiration pneumonia within 3 days of the procedure, four of whom died in the hospital. Of the 24 patients with a history of aspiration, nine experienced aspiration during or after percutaneous endoscopic gastrostomy. Patients with a history of aspiration were more likely to have perioperative aspiration pneumonia, and patients who experienced aspiration were more likely to die.(Arch Surg. 1992;127:261-264)

• To reassess the role of laparotomy and extraserosal drainage in the treatment of patients with abdominal abscess, we analyzed the course of 79 patients who underwent 97 operations to treat 120 abdominal abscesses during a five-year period. In 66 clinical episodes the abscess was drained by the most direct approach. Sepsis resolved with a single operation in 80% of these patients, five patients (8%) required a second operation for drainage for an abscess, and eight patients (12%) died. In 31 clinical episodes, the abscess was drained by a laparotomy. Sepsis resolved with a single operation in 61% of these patients, seven patients (21%) had a second abscess, six patients (19%) required a second operation to drain a metachronous abscess, and six patients (19%) died. When the location or number of abscesses was diagnosed incorrectly, the success rate of therapy fell substantially. Since most abdominal abscesses can now be accurately diagnosed preoperatively, most abscesses should be drained by a direct approach. Exploratory laparotomy is indicated when preoperative localization is unsuccessful, when sepsis has not resolved after other methods of drainage, or when the patient has a concomitant abdominal condition that must be treated surgically.(Arch Surg 1983;118:646-650)

The essentials of management of benign biliary stricture are reviewed, based upon analysis of 40 years of experience at the University of California at San Francisco. Surgical therapy is the mainstay of treatment and the success rate is greater than 90 per cent. A history of one or more unsuccessful repairs does not preclude success after another attempt, but those with biliary cirrhosis and its complications, ineradicable intrahepatic stone formation, or rare injuries often have an unfavorable outcome.

• We studied the clinical course of 35 patients with refractory ascites who underwent 51 peritoneovenous shunts. Nine of them had hepatorenal syndrome (HRS). Operative complications included shunt malfunction, shunt infection, ascitic leak, fluid overload, and disseminated intravascular coagulation. Two of the patients without HRS died postoperatively. The survival rate in this group was 67% at one year and 43% at two years. Ascites was completely controlled in 83% of the survivors at two months and 50% at two years. Neither survival nor shunt patency were predictable. The shunt reversed HRS in three patients, but failed to do so in the other six. Late complications included shunt malfunction and infection. During the first two years of follow-up, five patients bled from esophageal varices. Liver failure was the sole cause of late death. Peritoneovenous shunt should be reserved for patients with truly refractory ascites, for whom it provides excellent palliation.(Arch Surg 1982;117:631-635)

• We analyzed the course of 79 adult patients treated for achalasia between 1977 and 1988. Sixty-six patients (84%) had pneumatic dilatation as the primary therapy. Fifty-three patients (80%) had immediate improvement in swallowing. Three patients required immediate redilatation, 2 developed pulmonary aspiration, and 8 (12%) suffered esophageal perforation. Esophageal perforation was treated by closure plus Heller's myotomy in 3 patients, closure only in 3, chest tube in 1, and antibiotics and nasogastric suction in 1. At 4 years' follow-up, 50% of patients who had dilatation remained asymptomatic, 30% had symptoms of gastroesophageal reflux, and 20% had persistent dysphagia. Eight Heller myotomies were performed, with excellent results in 7 and 1 postoperative death from respiratory failure. Seven additional patients with disabling esophageal symptoms after multiple operations for achalasia were ultimately treated by esophagectomy (n 5), hemigastrectomy and Roux-en-Y gastrojejunostomy (n =1), and repeated myotomy (n= 1). All recovered and are able to eat solid food. Thus, our experience indicates that pneumatic dilatation remains unperfected (ie, the line between undertreatment and overtreatment is finer than generally recognized), and unless improvements can be made, the role for surgery may need to be reexpanded.(Arch Surg. 1989;124:929-932)

• We examined the course of 51 consecutive patients who underwent pancreaticoduodenectomies between 1979 and 1987. Fifteen patients (30%) had a traditional pancreaticoduodenectomy and 36 (70%) had a pylorus-preserving procedure. Operative blood loss, resumption of oral intake, and time to discharge from the hospital were not different for the two operations. One patient (2%) died of complications of the operation, and 14 patients (27%) had nonlethal intra-abdominal complications. Two patients required reoperation: 1 had a hemoperitoneum and 1 had a breakdown of a choledochoenterostomy. Of the patients undergoing pancreaticoduodenectomy for cancer, 26 (74%) of 35 survived 1 year, 9 (47%) of 19 survived 3 years, and 3 (33%) of 10 patients survived 5 or more years postoperatively. Our data showed that (1) on a service where a large number of these operations is performed, the mortality rate of patients who have undergone a pancreaticoduodenectomy is substantially lower than in the past and that (2) the main reasons for these improved results are greater experience of a few surgeons who perform the procedure regularly and the availability of computed tomographic scans and skilled interventional radiologists, which allows postoperative infection and pancreatic fistulas to be controlled. Although pancreaticoduodenectomy is only palliative in most patients with cancer, it provides the best palliation and the only chance of cure, and the procedure can be recommended when performed in tertiary care centers that possess these elements of success.(Arch Surg. 1989;124:778-781)

• Gallstones from 82 patients were examined under a scanning electron microscope for evidence of bacteria, and the findings were compared with the clinical manifestations of the disease. Bacteria were present in 68% of pigment stones and the pigment portions of 80% of composite stones. These gallstones were referred to as infectious stones. No bacteria were found in cholesterol gallstones. Acute cholangitis was diagnosed in 52% of patients with infectious stones and in 18% of patients with noninfectious stones. Over half of the patients with noninfectious stones presented with mild symptoms. Infectious stones were more often associated with a previous common duct exploration, an urgent operation, infected bile, a common duct procedure, and complications. These data show that gallstone disease is more virulent in patients whose gallstones contain bacteria.(Arch Surg 1989;124:629-633)

We studied gallbladder bile flow before, during, and after cholesterol gallstone formation in the prairie dog using infusion cholescintigraphy with 99mTc-diethyl iminodiacetic acid. In 18 fasting animals partitioning of bile between gallbladder and intestine was determined every 15 min for 140 min, and gallbladder response to cholecystokinin (5 U/kg · h) was calculated from the gallbladder ejection fraction. Ten prairie dogs were then placed on a 0.4% cholesterol diet and 8 on a regular diet, and the studies were repeated 1, 2, and 6 wk later. The proportion of hepatic bile that entered the gallbladder relative to the intestine varied from one 15-min period to the next, and averaged 28.2% ± 5.1% at 140 min. Partial spontaneous gallbladder emptying (ejection fraction 11.5% ± 5.6%) was intermittently observed. Neither the number nor the ejection fraction of spontaneous gallbladder contractions changed during gallstone formation. By contrast, the percent of gallbladder emptying in response to cholecystokinin decreased from 72.1% ± 5% to 25.9% ± 9.3% (p < 0.025) in the first week and was 14.3% ± 5.5% at 6 wk (p < 0.01 from prediet values, not significant from first week). Gallbladder filling decreased from 28.2% ± 5.1% to 6.7% ± 3% (p < 0.01), but this change was only observed after 6 wk, when gallstones had formed. This study shows that (a) bile flow into the gallbladder during fasting is not constant; (b) the gallbladder contracts intermittently; (c) gallbladder emptying in response to exogenous cholecystokinin is altered very early during gallstone formation; and (d) gallbladder filling remains unaffected until later stages, when gallstones have formed.

A case of successful operative treatment of an intracavitary liposarcoma of the right ventricle is presented. Comparison with the only other reported case is made and methods of diagnosis and treatment are discussed.

• We examined the gastric emptying and small bowel transit of solid food in ten patients one to 45 months after pylorus-preserving pancreaticoduodenectomy. Gastric emptying and small bowel transit were measured by computer analysis of data from a scintillation camera using technetium Tc 99m—tagged chicken liver mixed with beef stew and were compared with the results in five control subjects. The nutritional status of the patients was also evaluated. Gastric emptying was normal in six patients, rapid in three patients, and delayed in one patient. Small bowel transit was normal in two patients, rapid in seven patients, and delayed in one patient. Most of the patients were asymptomatic, ate three meals a day, and gained weight after the operation. These findings show that after pylorus-preserving pancreaticoduodenectomy, most patients consume a regular diet and achieve an excellent nutritional status. Gastric emptying is normal, not slowed. Small bowel transit is faster than normal but is without clinical sequelae.(Arch Surg 1987;122:528-532)

Multiple endocrine adenomatosis was identified in 48 per cent of 25 patients with the Zollinger-Ellison syndrome. This figure is twice that in Ellison's series and is probably closer to the true incidence. Eleven patients had hyperparathyroidism, five had adrenal hyperplasia or adenomas, four had pituitary tumors, three had thyroid tumors, one had carcinoid tumors, and two had hyperinsulinism. It should be emphasized that a patient with hyperparathyroidism and peptic ulcer disease is likely to have ulcerogenic pancreatic tumors. All patients with the Zollinger-Ellison syndrome should be investigated for hyperparathyroidism. Diagnosis is often difficult with presently available technics. Positive information in the form of a high basal to maximal acid output ratio, bioassay positive for gastrin, or demonstration of an islet cell tumor is quite reliable. Negative information is less helpful in attempting to exclude the diagnosis.

Chemical dissolution of retained stones can be accomplished in about 70 per cent of cases by infusing cholic acid through the T-tube. Mechanical extraction with the ureteral stone basket has an equal record of success. Reoperation should be the last treatment considered in most cases.