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Ten patients with gallstone ileus were studied to evaluate diagnostic and therapeutic procedures. The preoperative diagnosis was correct in four patients. All patients underwent laparotomy. In five patients, stones were removed by enterotomy and in three patients the obstruction was relieved by manual propulsion of the stones. One-stage small-bowel resection, cholecystectomy, and biliary enteric fistula repair were performed in two patients. Four patients had uneventful recovery. One episode of recurrent gallstone ileus was encountered. Three patients died of septic complications. It is concluded from the study and from a review of the literature that treatment should be aimed at relieving the obstruction, without performing additional surgical procedures, such as cholecystectomy and fistula repair. Secondary biliary surgery is to be performed only in patients with recurrent biliary disease.

Fifty PTFE (Goretex) femoropopliteal bypasses were performed for intermittent claudication (23 pts), rest pain (12 pts) or loss of tissue (15 pts). Thirty-one grafts occluded during the follow-up period up to 39 months, 19 grafts were patent. The two groups are compared regarding severity of ischaemia, outflow tract, distal anastomosis and ankle brachial ratio. Except for the severity of ischaemia, these factors showed a statistically significant difference between the two groups. A total of 51 reoperations were performed on 31 thrombosed grafts. Only one of the 24 thrombectomies was successful. A new PTFE or composed grafts never remained patent during the follow-up. Only four of the eight new venous bypasses had a long-term patency. Thrombosis of 31 PTFE femoropopliteal bypass led to amputation in 14 cases.

The influence of adaptive cell proliferation on colonic carcinogenesis was studied in male Fischer rats with a defunctioning transverse colostomy that was closed 4 wk later. Control observations were made in other rats after colonic transection, repeated at 4 wk, after laparotomy alone, or after permanent colostomy. Tumors were induced by 1,2-dimethylhydrazine (total dose, 300 mg/kg) over 11 wk, starting 2 days after the second operation. After creation of the colostomy, amounts of protein, RNA, and DNA in the distal colon halved in 4 wk (p less than 0.001), but returned to normal 7 days after restoration of colonic continuity. This reactive hyperplasia promoted the development of distal colonic carcinomas, as compared with rats having repeated transection of the bowel (incidence 32% vs. 6%; p less than 0.03). Although the amounts of protein and nucleic acid in the proximal colon were unchanged by transverse colostomy, values increased by 18%-59% 4 wk after colostomy closure (p = 0.05-0.002); nonetheless, the yield of tumors in this segment was unaltered. Suture-line cancers were commoner after repeat transection than after colostomy closure (76% vs. 39%; p less than 0.01). These data confirm the promotional effect of increased cell proliferation on intestinal carcinogenesis.

Using autoradiography after 1 h of pulsed labeling with tritiated thymidine in endoscopic biopsy specimens from normal-appearing mucosa, cell proliferation was determined at six predetermined sites of the whole colon in patients with neoplastic disease of the large bowel and was compared with that of subjects without macroscopic colonic pathology. The labeling index (the percentage of cells incorporating [3H]thymidine) was 8.6 +/- 0.5 (mean +/- SEM) in 13 patients with colon carcinoma (p less than 0.001 vs. 16 control patients whose labeling index was 4.9 +/- 0.2) and 9.1 +/- 0.4 in 11 patients with a large adenoma in the colon (p less than 0.001 vs. controls). Twenty-one patients with one or more small adenomas (diameter less than 1 cm) had a moderately increased cell proliferation compared with controls (labeling index 6.2 +/- 0.3, p less than 0.02 vs. controls). In patients with neoplastic disease an enlargement of the proliferative compartment was found, whereas 6 patients with Crohn's colitis had values for labeling index and a distribution of labeled cells along the crypt comparable to that of control subjects. An increased cell proliferation was found along the entire colon under each of the neoplastic conditions studied. These findings indicate that although neoplastic lesions develop in a limited area of the colon, the entire large bowel may be at risk for tumor growth.

In pigs, ischemic liver cell necrosis was induced by 6 hours' occlusion of the hepatic artery and the portal vein 3 days after construction of a side-to-side portacaval shunt and division of the hepatic ligaments. Two thirds of the liver of an MLC-compatible donor was heterotopically transplanted 13 hours (group I), and 3 hours (group II) after induction of liver failure. In group I (N = 11), three animals died of liver failure before or shortly after induction of anesthesia. Of the remaining pigs, two animals survived more than 2 weeks. In group II (N = 10), intraoperative hypotension was prevented by reduction of the interval between liver failure and transplantation and by thermodilution catheter monitored fluid replacement. A significant decrease in cardiac output and an increase of pulmonary and systemic vascular resistance were observed during auxiliary partial liver transplantation (APLT). In the immediate postoperative period, six pigs died of deficiencies in hemostasis that were caused by consumptive coagulopathy related to severe host liver damage rather than fibrinolysis. Two pigs in group II survived in good condition 12 and 42 days after APLT. In the longer surviving pigs of both groups, either the graft or the host liver recovered. Processes that might be responsible for the observed hemodynamic changes and coagulation disorders are discussed. These results indicate that APLT is technically feasible in severely ill pigs with acute hepatic failure.

In this retrospective study, we analyse the results of 94 partial liver resections performed between 1972 and January 1989. The resections were performed for malignant (48 patients) and benign (46 patients) liver tumours. Nine patients (9.6%) died of resection-related complications. Mortality was significantly lower in the patients with resections for benign liver tumours (2.2%) compared with patients with resections for malignant liver tumours (16.7%) (p less than 0.05). In the patients who survived the first 30 days, complications occurred in 25.9%. The 5-year survival of patients with a primary malignant liver tumour (57%) is significantly (p = 0.05) better than in patients with a secondary malignant liver tumour (19%). From this study we conclude that partial liver resections for primary or secondary liver tumours can be performed with an acceptable mortality and morbidity, and should be the therapy of choice for selected patients.

The occurrence of a hepatocellular carcinoma is described in a young woman who had been taking oral contraceptives for 2 1/2 years. She was treated by wedge excision of the tumor. At the time of operation, lymph node metastasis was present. After the operation oral contraceptives were discontinued. No evidence of residual or recurrent tumor could be demonstrated during a follow-up period of 6 years. This is the first report on long-term survival after nonradical resection of metastasized hepatocellular carcinoma associated with the use of birth control pills.

Recently extracorporeal shockwave lithotripsy (ESWL) has been introduced as a nonoperative treatment for gallstone disease. Except for lung damage, no significant adverse effects of ESWL of gallbladder stones have been observed in animals. In clinical use ESWL of gallbladder stones is now confined to 15% to 30% of symptomatic patients. To achieve complete stone clearance, ESWL of gallbladder stones must be supplemented by an adjuvant therapy. ESWL of bile duct stones is highly effective and can be considered in patients in whom primary endoscopic or surgical stone removal fails. Second generation lithotriptors allow anesthesia-free (outpatient) treatments, but the clinical experience with most of these ESWL devices is still limited. The likelihood of gallbladder stone recurrence is a major disadvantage of ESWL treatment, which raises the issue of cost-effectiveness. ESWL for cholelithiasis is a promising treatment modality with good short-term and unknown long-term results.

The effect of arterialization of the portal vein was investigated in cirrhotic dogs with a portacaval shunt. In dogs receiving a portacaval shunt only (PCS), the pressure in the intrahepatic portal vein fell to about 10% of the preshunt value, while the total hepatic blood flow was reduced by 63.9%. By contrast, in dogs with arterialization in addition to a portacaval shunt (PCS + A), the pressure in the portal vein was almost restored to preshunt levels, and the decrease in total hepatic blood flow was only 35.7%; this difference in the reduction of hepatic perfusion is significant (p less than 0.01). 2 weeks after the operation, PCS + A dogs had lower plasma levels of bilirubin and alkaline phosphatase, and a higher antipyrine clearance than PCS dogs (p less than 0.05). This improvement, however, was of short duration. The results of the ammonia tolerance test were not affected by the arterialization procedure.

Auxiliary heterotopic liver transplantation is theoretically attractive because it leaves the recipient's liver in place. The surgical trauma of hepatectomy is avoided, and failure of the graft does not necessarily lead to the death of the patient or a second, emergency transplantation. Another advantage is that matching the body sizes of the donor and the recipient is not mandatory, which increases the number of possible donors. However, previous clinical results of auxiliary liver transplantation have been poor. We performed auxiliary partial liver transplantation in six consecutive patients with end-stage chronic liver disease who were not accepted for orthotopic liver transplantation because they had massive ascites, deficient clotting function, cachexia, or poor pulmonary reserve. The donor liver was transplanted to the right subhepatic region after removal of segments II and III, and it was provided with portal and arterial blood. There were no major changes in hemodynamic measurements during surgery. The mean hospital stay after transplantation was 22.7 days (range, 14 to 29). After a mean follow-up period of 14 months (range, 5 to 23), all patients were alive, with good graft function as demonstrated by scintigraphy, Doppler ultrasonography, and synthesis of clotting factors. From these observations we conclude that auxiliary partial liver transplantation is an attractive alternative to orthotopic liver transplantation in high-risk patients. Its role in other patients who need liver transplants remains to be defined.

The results of 79 liver resections performed in the period January 1972 to May 1987 are described with emphasis on the role of intraoperative ultrasonography and ultrasonic liver parenchyma dissection. The aim of this study is to see whether these adjunctive techniques are able to lower mortality and morbidity. Resections were done for benign disease (44 patients) or malignancy (35 patients). In these patients, 24 major and 55 minor liver resections were performed. Six of these patients (7.6%) died within 30 days after the operation. In one-third of the patients, complications occurred. In 25 of the 79 resections, intraoperative ultrasonography and ultrasonic liver dissection were used. Intraoperative ultrasonography changed the planned resection in eight patients. No statistically significant difference in morbidity and mortality could be found in patients operated with ultrasonic dissection, compared to patients with conventional dissection techniques. From this study, we conclude that intraoperative ultrasonography is a useful adjunct in liver surgery.

Pancreaticobiliary secretions modulate compensatory hyperplasia after proximal small-bowel resection. To investigate the individual contributions of bile and pancreatic juice, levels of nucleic acids in ileal mucosa of the rat were examined 48 hours after performance of jejunectomy with selective exclusion of bile or pancreatic juice. Exclusion of bile alone inhibited the postresectional increase in levels of RNA and DNA. Exclusion of pancreatic juice (but provision of bile) did not inhibit a rise in ileal RNA or DNA levels after jejunectomy. Presence of bile seems to be one of the major elements in the early stages of adaptive hyperplasia of the ileum.

Endoscopic papillotomy may not be possible in patients who have previously undergone gastric surgery. We describe the successful treatment of such a patient with ultrasound-guided, percutaneous transhepatic biliary drainage, followed by balloon dilatation of the sphincter of Oddi and extracorporeal shock-wave lithotripsy. Combinations of new treatment forms may be necessary and effective when single forms of treatment fail.

Compensatory hyperplasia after extensive loss of functioning small or large intestine might predispose to the development of neoplasia in the residual adapted bowel. To test this hypothesis, male Fischer rats were randomized to receive 85 to 90% jejunoileal resection or bypass, subtotal colectomy, or no operation (controls). One week later, the first of six weekly s.c. injections of azoxymethane (15 mg/kg/week) was given. At the 36th week postoperatively, mean body weight after enterectomy or colectomy it was 78 to 79% of control. Adaptation after all three operations was characterized by 22 to 84% increments in villous height and crypt depth in the residual functioning ileum (p = 0.05 to 0.001); the depth of colonic crypts was unchanged. Fewer rats developed intestinal tumors after enteric bypass (36%) than after any of the other treatments (80 to 91%) (p = 0.01 to 0.001); the depth of colonic crypts was unchanged. Fewer rats developed intestinal tumors after enteric bypass (36%) than after any of the other treatments (80 to 91%) (p = 0.01 to 0.001). Compared with controls, bypass reduced the number of colonic tumors by 77% (p less than 0.001). Although resection did not affect colonic tumor yield, it tripled the incidence of tumors in the duodenum and jejunum (p = 0.025). Colectomy promoted rectal carcinogenesis (p less than 0.05). Anastomotic tumors were commoner after intestinal resection. the lower frequency of tumors after jejunoileal bypass contrasts with enhanced carcinogenesis after enterectomy or colectomy. Profound reduction in body weight may prevent the promotional effect of adaptive hyperplasia.

A case of anaphylactic shock after percutaneous liver biopsy is described. This was due to rupture of a large echinococcal cyst localized in the liver. Diagnosis and treatment with a review of the literature are discussed with emphasis on the complete removal of both the cyst and the surrounding capsule of fibrous liver tissue.

Auxiliary, heterotopic transplantation of 60% of the liver was performed in 24 beagles and 24 pigs. Operative mortality was low and graft survival was greatly improved by DLA-matching in the dog. The graft supplied by arterial and portal blood gave excellent metabolic support after the host liver was rendered ischemic by six hours clamping of the hepatic artery.

In pigs subtotal ischemic liver cell necrosis was induced 4 days after auxiliary transplantation of 60% of the liver of an MLC-compatible donor (ATPL group, n = 13). In control animals (n = 14) temporary liver ischemia was preceded by division of the hepatic ligaments and creation of an end-to-side portacaval shunt. In the ATPL group six animals died of gastric hemorrhage, intestinal strangulation, or sepsis. The remaining seven animals survived in excellent condition until sacrifice 26 days after the induction of liver ischemia. Excellent graft function was demonstrated by uptake and excretion of 99mTc-HIDA at cholescintigraphy, ammonia detoxification, synthesis of clotting factors and glucohomeostasis. EEG recordings in the animals that underwent transplantation did not change from preischemic levels. Evidence of hepatic regeneration was found in the transplanted livers but could not be demonstrated in the damaged host livers. The control animals died in coma within 72 hours. These results indicate that auxiliary transplantation of a partial liver provides metabolic support and improves survival in animals with induced acute liver failure.