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Cell encapsulation is an alternative to avoid rejection of grafted tissue, thus bringing an interesting alternative in cell therapy. It is particularly relevant in ailments where only the implant of small quantities of tissues is warranted. In such circumstances, the use of immunosuppressive therapy in patients implanted with tissues from donors is debatable, yet unavoidable at present in order to prevent rejection and/or sensitization of the host to the tissue, in turn jeopardizing the success of successive implants. Hence, a new line of thought, which aims to provide an immunoprivileged site for the grafted tissue, while at the same time insure its nutrition, as well as its survival and continued function, appears as a most attractive possibility. To achieve these goals, cells or tissues harvested for transplant could be encapsulated in biologically compatible matrices. Among the matrices currently in existence, sodium alginate is the most widely used polymer for tissue encapsulation.In the present chapter, we present a technique used to encapsulate parathyroid tissue, for use as cell transplant therapy in patients with secondary hypoparathyroidism. With this procedure, implanted tissue survives and remains functional for up to 18 months.

Laparoscopic techniques can be used for diagnosis, staging, and therapeutic procedures, both palliative or curative. Laparoscopy needs to be used in the context of algorithms of evaluation and management that consider the natural history and biology of the diseases at stake, concepts of evidence-based decisions, cost-effectiveness, quality of life, expertise available, and the philosophy of involved institutions. Accurate staging facilitates the selection of patients for resection, for neoadjuvant therapy, and selective planning for best palliation. The therapeutic role of advanced laparoscopic or laparoscopic assisted procedures is likely to increase (biliary bypass, gastro-jejunostomy, liver resections, cryosurgery, radiofrequency ablation, etc.). The place of laparoscopy in staging and treatment, however, has to be critically and continuously reviewed in the context of new developments in diagnostic imaging techniques, endoscopic procedures, and advances in oncology

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

The diagnosis and management of the patient with an acute abdomen remains one of the most difficult challenges for the surgeon. A thorough understanding of the anatomy and physiology of the abdomen are essential to properly generate a differential diagnosis and to formulate a treatment plan. While recent advances in technology can be extremely helpful in certain situations, they cannot replace a physician's clinical judgment based upon a good history and physical examination. This article provides a general overview of the evaluation of the patient with an acute abdomen. It will also suggest algorithms to consider in the diagnosis and treatment of these patients.

We reviewed the 46 gastric stromal tumors that were treated at our institution between 1958 and 1992. The most common presenting symptoms were gastrointestinal bleeding, pain, and fatigue or malaise. The tumors ranged from 4 to 150 mm, with surgery most often being a wedge excision or partial gastrectomy. Abdominal computed tomography was the most specific diagnostic test obtained preoperatively. Factors associated with decreased survival included size >/= 8 cm (p = 0.02), more than 0-3 mitoses per 10 HPF (p < 0. 001), positive margins or unresectability (p = 0.008), and tumor pathologic grade II or more (p = 0.004). These tumors have an unpredictable behavior. Surgical resection with negative margins remains the best therapy, but resection for palliation is sometimes indicated as it can be associated with prolonged survival.

A large number of laboratory tests, radiologic studies, and endoscopic techniques are available for the evaluation of the jaundiced patient. Similarly, the therapeutic options have increased with the development and improvement of endoscopic percutaneous and lapararoscopic procedures and the decreasing morbidity and mortality of open surgery. It can only be expected that new studies and techniques will be added to those currently in use. With limited resources, the challenge is and will be to select, on an individual basis, the most efficient and cost-effective evaluation and the management with the lowest morbidity and mortality and the best short- and long-term results. Studies should be requested only when they are believed to have a reasonable possibility of affecting decisions and outcomes. The goals of therapy (i.e., cure, palliation, quality of life) should be clear in each case and survival expectancy from the primary disease and associated conditions estimated. To achieve these goals, it is essential to have in-depth knowledge of the different possible underlying diseases, know the questions that need to be answered, and understand the benefits, limitations, costs, and complications of the different diagnostic and therapeutic maneuvers. The local expertise and the local socioeconomic reality where one practices are important variables to consider. Many studies are currently being conducted to evaluate cost effectiveness. In this article we outline some of the issues involved in the cost-effective management of these patients.

Patients with carcinoma of the pancreas continue to be associated with a poor outcome, with surgical resection representing the only possibility of cure. The classic operation described by Whipple in 1935 has undergone many modifications with Traverso and Long-mire reintroducing preservation of the pylorus in an attempt to decrease the sequelae from the gastrectomy and improve nutritional outcome. Since 1979, the Lahey Clinic has performed pylorus-preserving pancreatoduodenectomy for the management of pancreatic and periampullary tumors as long as the duodenal margin is free of tumor and the antropyloric area appears viable. This article reviews the pattern of pancreatic tumor spread and the margins frequently involved with tumor. The management of distal biliary obstruction, our technique of pylorus-preserving pancreatoduodenectomy and our results of 106 pylorus-preserving pancreatoduode-nectomies for pancreatic and periampullary carcinoma are discussed. We feel that pylorus-preserving pancreatoduodenectomy can achieve results as a cancer operation similar to the standard Whipple operation while eliminating the side effects related to gastric resection and improve the nutritional status of the patient. © 1995 Wiley-Liss, Inc.

Records of 92 patients with differentiated thyroid carcinoma presenting as cervical adenopathy without a palpable mass were reviewed to identify prognostic factors and to evaluate therapy. Patients were treated between 1940 and 1990 and were observed for 3 to 48 years (median 18 years). Follow-up data were obtained by chart review, correspondence, and telephone contact. Among the group, 20 patients had unilateral and 72 bilateral thyroid lobectomy, with node dissection in 77. Thyroid hormone was used in 50 patients and radioactive iodine in 20. Patients were younger than the overall population of patients with differentiated thyroid carcinoma, with more men and more multifocal thyroid disease. Risk group defined by age and sex was the most important determinant of survival. All women 50 years of age or younger and all men 40 or younger (low risk group) survived independent of the type of initial operation or use of thyroid-stimulating hormone suppression or radioactive oidine. Of the low risk patients, 16% had recurrent disease but were treated successfully with surgery or radioactive iodine; 28% of the older patients (high risk) died of disease. A trend for better survival was noted in high risk patients undergoing bilateral thyroideetomy and in patients receiving thyroid suppression. Of the high risk patients, 26% had recurrent disease, with a 71% mortality rate. Age and sex are the primary determinants of survival. Therapy should be based on risk factors. Low risk patients should have conservative thyroid surgery and modified or limited node dissection. However, bilateral thyroid surgery may facilitate the use of radioactive iodine when required. Use of prophylactic radioactive iodine or thyroid suppression should be selective. For high risk patients, we suggest bilateral thyroidectomy, modified or limited node dissection, thyroid suppression, and radioactive iodine.

Background. Ductal carcinoma in situ (DCIS) of the male breast is an uncommon disease, accounting for approximately 7% of all male breast carcinomas. Compared with invasive carcinomas of the breast, the prognosis associated with DCIS in men is excellent; however, clinical features, pathology, and treatment of this disease are not well defined in the literature. Methods. Records of 23 men with carcinoma of the breast treated at the Lahey Clinic from 1968 to 1991 were reviewed, revealing 4 patients with pure DCIS (17%). The reported management of DCIS in women is discussed in comparison with that of DCIS in men. Results. Of the four patients with DCIS, the presenting complaint was a retroareolar mass in three patients and a bloody nipple discharge in one patient. The pathologic subtype was papillary in one patient and intracystic papillary in three patients. Two patients were treated with partial mastectomy alone. Disease recurred locally as DCIS in both patients, requiring mastectomy at 30 and 108 months. No lymph node metastases were found in the three patients who underwent axillary dissection. All four patients were alive without disease at 133, 120, 36, and 32 months of follow-up, respectively. Conclusions. Although the sample size was small, our patients and a review of the literature suggest that most DCIS in men is of the papillary type and that mastectomy without axillary dissection is the preferred treatment.

Bile duct injuries remain a relatively uncommon but potentially devastating complication of both open procedures and laparoscopic procedures. They may present immediately after a given operation or take years to be recognized. Despite the best intentions of the surgeon, many of these injuries are imminently preventable. Recent advances in laparoscopic procedures have served to remind us of lessons learned from the prelaparoscopic era with respect to injuries of the bile ducts. To conduct any operation safely on or near the biliary system, the surgeon should be familiar with the anatomy and its variations, the nature of the pathologic processes that may enhance the likelihood of causing harm, and, most important, his or her own limitations and the limitations of the system with which he or she has to work.

Laparoscopic cholecystectomy has settled as the treatment of choice for patients with gallstone disease. Injury to the bile ducts, still the main drawback of the technique, is decreasing progressively with better understanding of the mechanisms of injury and adequate training. With the expansion of indications for laparoscopic cholecystectomy, more difficult operations are being performed. Adequate understanding of the obstacles that may arise during the laparoscopic procedure as well as knowledge of specific maneuvers to deal with the difficult operation are important for the success and safety of the procedure.

Endoscopic sphincterotomy has proven to be a safe alternative to surgery for selected types of biliary disease. Despite a relatively low morbidity, postprocedure complications are well described. This report presents an experience with three patients in whom acute relapsing pancreatitis developed as a possible complication of papillary stenosis after endoscopic sphincterotomy. None of the patients had a previous history of elevations in serum amylase levels before endoscopic sphincterotomy. After procedure, pancreatitis and subsequently acute relapsing pancreatitis with documented stricture of the pancreatic duct orifice developed in all three patients. After surgical transduodenal sphincteroplasty, no new episodes of acute relapsing pancreatitis occurred.

The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and known techniques of reoperative biliary surgery. Surgeons who operate on the gallbladder must be prepared to confront a host of unexpected and difficult operative problems. Bile duct injuries must be repaired properly at the first attempt. Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.

Careful patient selection and preparation for ambulatory inguinal herniorrhaphy combined with monitored local anesthesia result in a safe procedure with excellent patient acceptance. Factors contributing to early and late complications are presented, and the common methods of their treatment are reviewed.

We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver.

Records of 25 consecutive patients who underwent resection for proximal bile duct tumor (3 extended right hepatic lobectomies, 6 left hepatic lobectomies, 16 skeletonization resections) and records of 21 patients who underwent pancreatoduodenectomy for distal bile duct carcinoma were reviewed to assess the value of resective therapy. The operative mortality rate for patients with resected proximal bile duct tumor was 4 per cent (0 per cent for liver resection) and that of distal bile duct tumor, 4.6 per cent. The 3- and 5-year actuarial survival rates for patients with proximal bile duct tumor were 44 per cent and 35 per cent, respectively; all except one patient eventually died of disease. Survival was better for patients who had curative resection (margins microscopically free of tumor). The 5-year actuarial survival rate for patients with distal bile duct carcinoma was 58 +/- 12 (SE) per cent, with patients who had negative nodes surviving longer than patients with positive nodes. When major hepatic resection and pancreatoduodenectomy can be performed in selected patients with low operative mortality, patients with bile duct carcinoma should be assessed by an experienced hepatobiliary multidisciplinary group before a decision is made in favor of palliative, endoscopic, or percutaneous techniques because surgical resection appears to offer the best possible long-term survival and probably the best quality of palliation.

Thirteen patients who underwent extensive pancreatic resection and segmental autotransplantation and who have a median follow-up of 62 months are presented. Eleven patients had technically successful grafts. Three of six patients who underwent total pancreatectomy and three of five patients who underwent near-total resection remain insulin-independent. Those patients who require insulin require small doses and have stable diabetes. Pain has recurred in 7 of the 11 patients who underwent distal subtotal resection; 5 of them required pancreatoduodenectomy and completion pancreatectomy for pain relief. Because of the high rate of recurrence of pain after distal resection, we favor pancreatoduodenectomy as the initial procedure of choice. When distal near-total or total pancreatectomy is required, the addition of segmental autotransplantation offers definitive, although at times transient, benefits in glucose homeostasis compared with no transplantation.

Hilar cholangiocarcinoma has remained a challenge to surgeons because of its propensity for local invasion and its proximity to the portal vein, hepatic arteries, and liver parenchyma. Locally advanced disease at diagnosis and surgical inaccessibility have resulted in low resectability and poor survival. Recent advances in interventional radiology and endoscopy have made possible nonsurgical palliation of this disease. Consequently, some clinicians recommend that palliative biliary stenting supplant surgical resection as the standard treatment for patients with hilar cholangiocarcinoma. Although some patients with advanced disease or prohibitive surgical risk factors are best served by nonoperative biliary stenting, we believe most should be evaluated for surgical resection. Recently, many institutions with expertise in the management of patients with hilar cholangiocarcinoma have reported higher resectability rates without increased surgical death rates. 1–12 Japanese surgeons 13–16 have reported resectability rates as high as 80% in patients treated by combined bile duct and liver resection with caudate lobectomy. Although surgical resection has gained acceptance during the past decade as the mainstay of therapy for hilar cholangiocarcinoma, the acceptance of combined liver resection with caudate lobectomy has been slow, especially by American surgeons. Moreover, the higher resectability and survival rates in Japanese reports have stirred debates as to whether the tumors in Japanese patients are of a more favorable histopathologic type or are detected at an earlier stage. The surgeons at Lahey Clinic and Nagoya University have a long shared an interest in the management of biliary malignancies and have gained from each other’s experience through the exchange of visiting surgeons. This study was prompted by one of these exchange visits. The aim of this study is to identify factors in our management approaches to hilar cholangiocarcinoma that might explain the reported differences in resectability and overall survival between American and Japanese patients.

The management of patients with thyroid cancer can be optimized by developing multidisciplinary groups of highly specialized individuals. The completeness of surgery and its morbidity are mostly surgeon-dependent. Similarly, the decisions regarding selection of adjuvant treatments, doses, follow-up schemes, and so forth require depth of knowledge and understanding of the disease; its variables; factors that govern its course; and the values, limitations, and side effects of alternative therapies.

Pancreatic cancer afflicts nearly 27,000 people in the United States each year and is responsible for the death of most of these patients. It is the fourth leading cause of death by cancer in the United States. 20 The past century has seen essentially all of the growth in knowledge regarding the physiology of the pancreas and the ability to operate on the gland. Cancer of the biliary tree is considerably less common than is pancreatic cancer but remains exceptionally lethal. Nearly 4000 deaths occur each year in the United States as a result of biliary tract cancers. 67 More than half of these deaths are from cancer of the gallbladder. In some patients, gallbladder cancer is present in epidemic proportions. Gallbladder cancer is the leading cause of death by cancer in women in Chile. Biliary tract cancers include gallbladder cancer, cholangiocarcinomas, and unusual biliary tumors. These are discussed separately later. Operative extirpation of these tumors is the mainstay of therapy and provides the only hope for long-term survival. Over the past 100 years, numerous advances have been made that have allowed physicians to develop a multidisciplinary approach to better detect, evaluate, and remove these tumors. This article reviews the evolution and development of the advances and techniques on which physicians base therapy for patients with pancreaticobiliary neoplasms.

William S. Halsted published his report of local excision of a periampullary neoplasm in 1899. The patient subsequently died of metastatic disease. During the past nearly 100 years there have been tremendous advancements in the understanding of physiology, anesthetic and perioperative care, nutritional support, and surgical technique. These have served to improve short- and long-term survival for patients with these periampullary tumors. Despite the many advances in this arena there remains significant controversy as to how best approach these tumors. In this brief discussion we present the data from the most recent analysis of the experience with pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary neoplasms and a rationale for this approach based on the experimental and clinical data that are available. On the basis of analysis of 106 patients who have undergone PPPD for cancer over a 13-year period and the rapidly expanding world experience with this operation, we conclude that PPPD is an adequate operation for periampullary carcinoma, but has not been proven to be a superior operation to the “standard Whipple” procedure in controlled trials.

Objective: To assess the long-term outcome of patients following pylorus-preserving pancreatoduodenectomy (PPPD) for chronic pancreatitis. Design: Retrospective study with mean follow-up of 63 months (range, 1 month to 13.7 years). Setting: Tertiary referral hospital. Patients: Records of all patients who underwent PPPD for chronic pancreatitis at Lahey Clinic were reviewed. All patients who were alive were contacted by telephone. In cases where patients had died, information was gathered from family members and hospital records. Results: Forty-five patients underwent PPPD for disabling chronic pancreatitis. The mean preoperative duration of pain was 50 months, with 32 patients (70%) requiring daily narcotics. In one patient resection of the portal vein was required. One patient died within 30 days of the operation. Forty-one patients (92%) had improvement of pain at 5 years. The mean pain score (on a scale of 0 to 10) was 9.2 preoperatively and 1.5, 0.8, 1.1, and 1.1 at 6 months, 1 year, 2 years, and 5 years, respectively. Thirty-three patients (74%) had a postoperative weight gain to an average of 92% of their pre-illness weight. New-onset diabetes occurred in six patients (14%) by 6 months and in 21 patients (46%) by 5 years. Hypoglycemia was the cause of death in one patient who underwent total pancreatectomy. Four patients died of causes unrelated to PPPD. Marginal ulcers occurred in five patients (10%). Nine patients required late operations. Conclusions: In selected patients, resection of the head of the pancreas achieves long-term pain improvement in over 90% of cases. The early development of diabetes mellitus is infrequent, but over longer follow-up periods it reaches prevalence rates similar to those described in patients who have not undergone resection. Weight gain in this group was superior to that previously reported for our patients who underwent "standard Whipple" operation for chronic pancreatitis. (Arch Surg. 1996;131:247-252)

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P

Objective: To assess the adequacy of pylorus-preserving pancreatoduodenectomy (PPPD) as a definitive surgical treatment for primary malignant diseases of the periampullary region. Design: Retrospective review of the clinical records of patients undergoing PPPD for malignant diseases of the periampullary region. Median and 5-year actuarial survival by type and stage of cancer were determined. Survival data from this study were compared with those of patients undergoing a conventional Whipple operation. Setting: Lahey Clinic, Burlington, Mass. Study Participants: One hundred six patients undergoing PPPD for primary malignant disease of the periampullary region between November 1979 and June 1992. Intervention: Pylorus-preserving pancreatoduodenectomy was performed with curative intent in the 106 patients. Ninety-five patients underwent proximal pancreatectomy; 11 patients, total pancreatectomy. Resection of the portal vein was performed in 10 patients. Main Outcome Measure: Long-term survival following PPPD was analyzed with respect to the type and stage of cancer. Median follow-up was 30 months (range, 6 to 156 months). Results: Five-year actuarial survival rates were 45.4% for patients with ampullary adenocarcinoma; 6.6%, with pancreatic ductal adenocarcinoma; 33.3%, with distal bile duct adenocarcinoma; 75%, with pancreatic islet cell adenocarcinoma; and 0%, with pancreatic cystadenocarcinoma. An early cancer stage was associated with more favorable survival for ampullary and distal bile duct adenocarcinomas. For pancreatic ductal adenocarcinoma only, tumors less than 2 cm were associated with better survival. Duodenal resection margins were free of disease in all patients, while peripancreatic and retroperitoneal extension of the tumor was found in 20%. Conclusion: For patients with periampullary malignant disease, long-term survival following PPPD is similar to that following a conventional Whipple operation. The potential benefits of hemigastrectomy with perigastric lymphadenectomy are frequently obviated by the presence of positive margins and lymph nodes elsewhere, ie, in the retroperitoneum. We advocate PPPD as the procedure of choice for locally resectable malignant disease of the periampullary region, provided the duodenal margin is viable and tumor free. (Arch Surg. 1994;129:405-412)

We collected the records of 81 patients with biliary tract injuries occurring during laparoscopic cholecystectomy (LC) who were referred to 3 referral centers during a 33-month (May 1990 to March 1993) period. All records were reviewed to provide data concerning the anatomy of the lesion induced, method of injury, timing of injury detection, role of intraoperative cholangiography (IOC), methods of treatment, and outcome of these injuries. Injuries were classified by our own method as follows: (1) cystic duct leaks (n = 15), (2) bile leaks and/or ductal strictures (n = 27), and (3) ductal transections or excisions (n = 39). Peak occurrence by quarter of the year was 4th quarter, 1990 (Lahey), and 3rd quarter, 1991 (Mason), and 1st quarter, 1992 (Mayo). The majority (62%) of the injuries were recognized after LC. At the time of LC, 31 of 81 (38%) injuries were recognized and converted to open procedures. Data regarding IOC were available in 63 of 81 (78%) cases. In patients in whom IOC was not performed, 14 of 38 (37%) operations were converted; if an IOC was obtained and interpreted correctly, 13 of 21 (62%) operations were converted. Primary repair was attempted in 11 leaks and/or strictures, but 36% required additional treatment. Primary repair was used in six transections or excisions, and 17% have required further intervention. In patients who had biliary-enteric bypass (BEB) performed outside (17) versus at the referral institution (29), 94% (16 patients) versus 0%, respectively, required additional operative (e.g., revision of a hepaticojejunostomy) or nonoperative (e.g., radiologic or endoscopic stenting or balloon dilation) procedures. When used as initial therapy or after a primary ductal repair, stents (with or without balloon dilation) resolved 100% of simple cystic duct leaks and 91% of leaks and/or strictures. In conclusion, the peak incidence of LC-related biliary injuries appears to have passed. A completed and correctly interpreted IOC increases the chance of detection of biliary injuries intraoperatively and should assist surgeons who use routine IOC. Nonsurgical techniques allow treatment of most simple cystic duct leaks, major ductal leaks and/or strictures, and postoperative BEB strictures, although followup is limited. The poor results of pre-referral BEB is not surprising since all of these patients were selected for referral because their treatments had not been successful.

While hepatocellular carcinoma (HCC) is one of the world’s most common malignant neoplasms, with its highest prevalence in southeast Asia and portions of Africa, it remains a relatively rare malignancy in the western world. The incidence of concomitant cirrhosis is significantly higher in Asia, being over 70% [1–5] compared to less than 40% in western countries [6,7]. The overall 5-year survival after resection with curative intent in the West approaches 35–45% [8–10], whereas it ranges from 15% to 30% in the East [1, 2, 11, 12]. Recent implementation of mass screening programs using alphafeto protein and ultrasound in high-risk populations in Japan and China have identified increasing numbers of patients with small (

Although several studies have shown a low incidence of bile duct injuries during laparoscopic cholecystectomy, concerns remain because of the sustained increase in the number of referrals for biliary reconstruction after the procedure. Twenty-one patients have been referred to our institution because of major bile duct injuries after laparoscopic cholecystectomy. The injury was recognized during the laparoscopic procedure in only 6 of the 21 (29%). Nineteen patients underwent hepaticojejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcation was required in 10 patients (50%), at the bifurcation in 3, and below the bifurcation in 7. Nine of the eleven patients in whom the initial repair was performed at the local hospital presented with early stricture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps during laparoscopic cholecystectomy to avoid bile duct injuries are described. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.

The Cavitron Ultrasonic Surgical Aspirator (CUSA) may be used to remove mucosa of organs of the gastro-intestinal tract. A histological analysis was performed on gallbladders treated with a CUSA-mucosectomy to assess the extent and degree of mucosectomy and to evaluate parietal damage. The histological studies performed on three specimens of chronic cholecystitis revealed a complete mucosectomy except in areas where Rokitansky-Aschof sinuses were present. There was no evidence of parietal damage. The CUSA may be used to remove the mucosa of gallbladders without injury to other layers, and may have a potential application in procedures such as mucosal cholecystectomy.

• Records of 11 patients undergoing biliary reconstruction after laparoscopic cholecystectomy are reviewed. Ductal injuries resulted from failure to define the anatomy of Calot's triangle. Risk factors include scarring, acute cholecystitis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised. (Arch Surg. 1992;127:596-602)

• Duodenal adenocarcinoma, a rare malignant lesion, is associated with a poor 5-year survival. Few series have addressed differences between resectable tumors of the proximal and distal duodenum. We reviewed records of 17 consecutive patients with adenocarcinoma of the duodenum who underwent resection: 10 had adenocarcinoma of the proximal duodenum, and seven had tumors of the distal duodenum. Most patients underwent pancreatoduodenectomy. Five patients with adenocarcinoma of the distal duodenum underwent segmental resection. No perioperative deaths occurred. Six of 10 patients with proximal tumors died of metastatic disease. Of the seven patients with tumors of the distal duodenum, five are alive without evidence of disease, and two died of unrelated causes. The survival of patients with adenocarcinoma of the distal duodenum is surprisingly good, and segmental resection is the procedure of choice. (Arch Surg. 1992;127:557-560)

• We reviewed the cases of 52 patients with substernal goiters to examine clinical presentation, workup, technique of removal, malignancy, and outcome. Half of the patients were asymptomatic; half had at least one compressive symptom. Chest film was the most used; computed tomography or magnetic resonance imaging was by far the most useful study. Thyroid scans often failed to show the intrathoracic goiter. Fine-needle aspiration was not helpful because of the gland's inaccessibility. Seventeen percent (nine) of the thyroids showed malignancy, 21% (11) including incidental papillary carcinomas. These were not identified by duration of goiter, symptoms, or fine-needle aspiration. Except for lymphomas, prognosis was good after resection. Removal was almost always accomplished via cervical incision, with low morbidity and no deaths. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of substernal goiter is an indication for surgery. ( Arch Surg . 1992;127:609-613)

Experience in the United States of America with the use of radical operations for carcinoma of the gallbladder was reviewed. Four studies using the Nevin clinicopathologic classification were combined for analysis. The 5-year survival rate for patients with stage I disease was 59%; stage II disease, 40%; stage III disease, 9%; stage IV disease, 7%; and stage V disease, 1%. Only one study analyzed the results of surgical procedures according to Nevin staging. No conclusions can be drawn from retrospective studies on the value of operations more radical than simple cholecystectomy. Responses to a questionnaire sent to prominent North American surgeons emphasized the controversial management of patients with this disease.

To the Editor .—We read with interest the commentary by Easter and Moossa 1 in the April 1991 issue of theArchivesconcerning laser and laparoscopic cholecystectomy. We agree with their cautionary note regarding the controlled rate at which new treatments and technologies should be learned before being broadly applied; in this instance, lasers and laparoscopic cholecystectomy. However, we must take issue with their conclusion that bile duct injury during laparoscopic cholecystectomy can be blamed on lasers. The authors cite their own experience of having reconstructed the biliary tract in six patients for ductal injuries sustained during laparoscopic cholecystectomy. In five of the patients, lasers had been used. The authors commented on the remarkable absence of tissue between the ends of the remaining proximal and distal ducts, suggesting it had been "vaporized." In contrast to the experience of Easter and Moossa, the majority of patients referred to our institution with

• Perioperative data on 87 patients undergoing pancreatoduodenectomy for periampullary tumors were correlated with pathologic study of operative specimens to identify the accuracy of diagnosis and the factors affecting survival. Accuracy of endoscopie retrograde cholangiopancreatography and computed tomography in locating lesions was 75% and 44%, respectively. Histologie diagnosis before or at the time of resection was available in only 61% of the patients. Carcinoma was correctly diagnosed clinically by the pathologist or the surgeon in 95% (83/87) of patients with 4 patients found to have benign disease on final pathologic examination. Intraoperative diagnosis of site of origin was incorrect in 18% (16/87) of patients. In 28% (23/83) of patients, pathologists identified nodal metastatic disease missed by the surgeon. Survival correlated with nodal and margin status and tumor grade. Tumor size demonstrated no predictive capacity. Although preoperative diagnostic accuracy is less than optimal, surgeons can usually diagnose malignant lesions but more often fail to identify tumor origin and nodal disease. We continue to advocate resection for patients with periampullary lesions thought to be malignant and resectable without a positive histologie diagnosis. ( Arch Surg . 1990;125:723-726)

Cancer of the bile ducts continues to account for about 4,000 deaths yearly in the United States. Resection is often not possible, and overall survival is poor. In view of this, chemotherapy has been employed over the years in the hope of achieving enhanced response rates with increased survival. Despite the limitation of the approach, it does have a role as is indicated by a review of the literature. Systemic chemotherapy, employing such drugs as 5-fluorouracil (5-FU) and mitomycin C as single agents and the combination of 5-FU with adriamycin and mitomycin C (FAM), resulted in a collective response rate of 29% (28 of 97 patients).