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The incidence and significance of pancreas-related complications (pseudocysts, abscesses, and fistulas) were evaluated in 100 patients with acute pancreatitis. Alcoholic (40 percent), biliary (20 percent), and postoperative (15 percent) pancreatitis were seen most frequently. Eighteen patients had severe pancreatitis (3 or more Ranson's criteria). The overall mortality rate was 8 percent, and there were 16 pancreas-related complications. Pancreas-related complications developed in eight patients (53 percent), including two pseudocysts, four abscesses, and two fistulas. The incidence of pancreas-related complications was significantly greater in the postoperative group than in the overall 9 percent incidence in the other groups (p less than 0.005). Half of these patients required operation for their complications. Patients with postoperative pancreatitis are at a markedly increased risk of pancreas-related complications. Since these complications occur even in apparently mild cases of pancreatitis, these patients should be followed closely to detect pancreas-related complications.

The presence or absence of pneumoperitoneum may not be as reliable an indicator of visceral perforation as commonly thought. Visceral perforation as commonly thought. Visceral perforation resulted in pneumoperitoneum in only 51 percent of patients in this study. Pneumoperitoneum occurred in 14 percent of patients in whom the extraalimentary intraperitoneal air had sources other than a perforated viscus. These patients' clinical findings were often indistinguishable from those of patients with a perforated viscus, and three patients underwent celiotomy unnecessarily. The routine use of the left lateral decubitus film to detect pneumoperitoneum and the judicious use of gastrointestinal contrast studies should be part of the optimal management of patients with suspected visceral perforation.

Small bowel neomucosa has been grown on a variety of surfaces. The purpose of this study was to compare the rate of growth and function of neomucosa on colon serosa (CS) and abdominal wall muscle (AM) in New Zealand white rabbits. The terminal ileum was incised for 5 cm and patched with either adjacent CS (23 animals) or AM (19 animals) to create a 2 × 5-cm defect. Gross and histologic examinations of the specimens at 1, 2, 4, and 8 weeks revealed that the rate of growth was similar in both groups. There was minimal lateral ingrowth at 2 weeks, nearly complete coverage of the defects at 4 weeks, and complete coverage of the defect at 8 weeks in more than 85% of animals with mature villi and muscularis mucosae. The ileal diameter at the site of patching increased in both groups from 11.9 ± 2.6 to 16.3 ± 3.2 mm in the CS group and 11.3 ± 2.5 to 15.1 ± 1.8 mm in the AM group (P < 0.01). Glucose uptake was similar in both groups being 65.4 ± 24.1% of control in the CS group and 73.9 ± 29.8% in the AM group. Brush border enzyme activity of sucrase, maltase, and lactase was similar to controls in the AM group but in the CS group activity of sucrase and maltase were significantly less than controls (P < 0.01). Average body weight was increased postoperatively in both groups. There was one anastomotic leak in each group and two cases of partial intestinal obstruction in the abdominal wall group. Both colon serosa and abdominal wall musculature will support the growth of functioning neomucosa with a similar rate of growth and quality of the neomucosa. The use of either in clinical situations should be determined by availability and technical considerations.

U tube placement was employed as an adjunct to complicated biliary procedures in 14 patients. We found the transhepatic tubes to be useful for stenting biliary anastomoses, maintaining biliary drainage, delivering localized irradiation, and acting as permanent external conduits. The tubes remained in placed an average of 15 months and as long as 40 months. The frequency of cholangitis was minimized by frequent tube exchange. The U-shaped configuration makes tube exchange easy and inexpensive to perform.

It has been hypothesized that gamma-aminobutyric acid (GABA), the principle inhibitory neurotransmitter of the mammalian brain, contributes to the neural inhibition of hepatic encephalopathy. Eck fistulae were created in seven dogs and celiotomy alone performed in five dogs to determine plasma GABA levels, brain GABA binding, and synaptic membrane changes in dogs after creation of Eck fistulae. Eck fistula dogs lost 19 +/- 9% body weight, lost hair, ate poorly, and developed atrophic livers with classic hepatic histological changes. Control dogs maintained body weight, normal behavior, and normal liver histology. Plasma GABA levels were elevated significantly in the Eck fistula dogs (312 +/- 105.9 nM) both as compared to controls (154.4 +/- 69.8) and to preoperative levels (161.6 +/- 56.7, P less than 0.05). Brain GABA binding for animals sacrificed at 6-9 weeks was not statistically different from sham-operated dogs sacrificed at 6 weeks (1.87 +/- .54 pmole/mg protein vs 1.186 +/- 24, P less than 0.2). Synaptic membrane fluidity and cholesterol were likewise unchanged. Plasma GABA levels are increased significantly following complete portal diversion but do not correlate with the degree of encephalopathy. GABA binding to neural membranes are not significantly increased in Eck fistula dogs. These findings do not support a direct relationship between plasma GABA levels and neurologic impairment in Eck fistula dogs.

A 22-year-old white woman in whom multicentric papillary carcinoma of the thyroid developed two years after prophylactic colectomy for intestinal polyposis is reported. This association has been observed by others. Patients with familial polyposis coli are at risk for a variety of malignancies other than colonic, and careful life-long surveillance is necessary.

Incidental cholelithiasis was encountered at the time of celiotomy in 56 patients. Thirty-three of the patients underwent concomitant cholecystectomy. The overall morbidity and mortality were 27 and 3 percent, respectively, but only one complication (3 percent) was clearly related to the cholecystectomy. Cholecystectomy was not performed in 23 patients. Within 6 months of primary celiotomy, acute cholecystitis developed in 11 patients, 3 had attacks of biliary colic, and 2 became jaundiced. Fifteen patients (65 percent) underwent cholecystectomy and 6 of the 15 (40 percent) required common bile duct exploration. Concomitant cholecystectomy adds minimal morbidity to the operation and should be performed unless specific contraindications exist. Left untreated, cholelithiasis becomes symptomatic and leads to subsequent operation in most patients, which may require a more extensive procedure producing greater morbidity.

Exsanguination is the immediate problem when dealing with trauma to pelvic blood vessels. A case is presented to demonstrate a systematic approach for successful management. Embolization, arteriography, and externally controlled compression stopped the life-threatening hemmorrhage.

Excerpt INTRODUCTION The decision to administer anticoagulant drugs should imply familiarity with the indisputable complication of hemorrhage which they evoke. This report is concerned with factors...

I would not expect that many of you have had the need to review the constitution and bylaws of the Western Surgical Association. Article II of the constitution states that the objectives "of the Association shall be the cultivation, promotion, and diffusion of the art and science of surgery, the sponsorship and maintenance of the highest standards of practice, and the delivery of the best possible care to all people." This simple, direct statement of our aspirations places a responsibility on each of us. As I have witnessed the care with which these objectives are nurtured by our deliberations, and by our annual scientific program, I believe we can be pleased that generations of surgeons have been bound by this covenant. This article of our constitution is the springboard for some observations I would like to share with you today. They concern some of the factors affecting the health, the

We have utilized the subject outline for part II of the National Board of Medical Examiners Examination listed under surgery to identify the areas our students should learn and our faculty should teach. We have identified the essential elements of surgery by subdividing the above areas into segments of these broad anatomic and general categories. We identified each essential element as knowledge or skill. We developed these into two categories of expected expertise. We believe that self-paced individualized instructional packages are a valuable addition to education in surgery.