bluuebunny/crossref_metadata_2025 huggingface dataset:
Long‐term evaluation of pylorus preservation during pancreaticoduodenectomy
Authors: Fink Aaron S. , DeSouza Luis R. , Mayer Emeran A. , Hawkins Randall , Longmire William P.
Published: May 2005

Although pyloric preservation can be performed during pancreaticoduodenectomy without increased morbidity or mortality or decreased survival, the long‐term benefit of this technique remains unproven. In this study, the functional status of patients recovered from pyloric‐preserving pancreaticoduodenectomy was evaluated by comparing 6 long‐term survivors of the standard Whipple procedure (1–7 years postoperative; mean, 4.7 yr) to a similar group of 6 patients recovered from pylorus preservation pancreaticoduodenectomy (1–7 years postoperative; mean, 3.0 yr). All patients completed a questionnaire evaluating postgastrectomy symptoms. Fasting blood specimens were obtained for hematologic and biochemical analysis. Ten of the 12 patients then underwent endoscopy; perianastomotic and midgastric biopsies were graded for inflammation. Gastric emptying of both liquid and solid phases was measured with an isotopically‐labeled meal. Gastric emptying data were compared between groups and also to a group of 7 normal controls studied previously using the same methodology. Analysis of questionnaire results and mean laboratory values revealed no significant differences between the 2 surgical groups. Serum carotene levels were low in most patients. Several patients demonstrated abnormal indices of iron homeostasis. No significant abnormalities were noted on endoscopic examinations and biopsy results did not differ between the 2 surgical groups. Liquid gastric emptying was significantly prolonged in patients following standard pancreaticoduodenectomy (t1/2=98.3±26.2 min) as compared to pylorus preservation patients (t1/2=37.5±10.9 min) or normal controls (t1/2=33.1±2.8 min). We conclude that, in the long‐term, pylorus preservation appears to be at least functionally equivalent to the standard pancreaticoduodenectomy. As such, we believe that pyloric preservation, obviating vagotomy and gastric resection, deserves consideration during pancreaticoduodenectomy.
Primary adenocarcinoma of the duodenum: Analysis of survival
Authors: Lai Edward C. S. , Doty Jeffery E. , Irving Christine , Tompkins Ronald K.
Published: May 2005

A survival analysis of 24 patients with primary adenocarcinoma of the duodenum managed at UCLA, Los Angeles, California, U.S.A. was made with reference to their pathological findings. Pancreaticoduodenectomy as a curative procedure was performed in 15 patients with 2 deaths postoperatively. Palliative surgery with either segmental duodenal resection (4 patients) or gastrojejunostomy (5 patients) had no complications. Metastatic disease to the paraduodenal nodes in close proximity of the duodenum, and distant regional nodes around the celiac axis, paraaortic region, and mesentery occurred frequently (63.6%). The extent of nodal disease significantly affected the survival of these patients (p=0.016). When the disease was confined to the paraduodenal nodes, the median survival was 16.47 months, which was less than that for those patients without nodal secondaries (median survival, 42 months) but much better than that for those who had metastasized to distant regional nodes (median survival, 5.97 months). The depth of transmural neoplastic penetration was also probably of prognostic importance since it correlated significantly with the extent of metastatic lymph nodes (p=0.04). Regardless of the paraduodenal nodal status, pancreaticoduodenectomy should be attempted for all patients with primary duodenal adenocarcinoma when careful examination has excluded regional nodal involvement and systemic dissemination.
Recurrence of hydatid disease
Authors: Little John M. , Hollands Michael J. , Ekberg Henrik
Published: May 2005

A series of 39 consecutive patients with proven hepatic hydatid disease have been followed from the time of presentation to Westmead Hospital with 6 monthly ultrasound examinations. In the 32 patients having surgery in this unit, it has been found that the standard operation—evacuation of the cyst in the plane of the laminated membrane, suture of bile duct openings, and omentoplasty—achieved good local control of liver cysts. Further cysts, mainly in the retroperitoneal area, were identified with increasing frequency as time passed. The recurrence rate reached 22% by 30 months. Recurrence was not seen after that time. The longest period of follow‐up was 7 years. Not all recurrences required surgical treatment. Small asymptomatic cysts have been simply observed, and some shrink without further treatment. Multivariate analysis showed that the single main determinant of recurrence was evidence of previous cyst rupture before operation.
A microbiological etiology for gastritis and peptic ulceration
Authors: Quintero Gustavo A. , Williams John D. , Wingate David L. , Newell Diane G.
Published: May 2005

The relationship betweenCampylobacter pyloriinfection and gastroduodenal disease was investigated using antral biopsies from 102 patients undergoing endoscopy.C. pyloriwas isolated from the majority of patients with histologically defined gastritis (89%), gastric ulcer (100%), and duodenal ulcer (94%), but only in 6% of patients with normal gastric mucosa. No obvious epidemiological association betweenC. pyloriinfection and recent travel, domestic pets, diet, dental hygiene, drug treatment or symptoms could be established. The susceptibility of 38 of these isolates ofC. pylorito 12 antibiotics was determined.

The serum anti‐C.pyloriantibody response was determined by an ELISA technique using an acid extractable antigen on the solid phase, in order to improve the sensitivity and specificity. There was a significant increase in antibody level (p=0.001) of patients with histologically defined gastritis over patients with a normal mucosa. The majority of patients (96%) with a culturableC. pyloriinfection had raised anti‐C.pyloriantibodies. However, some patients with neither C.pyloriinfection nor gastritis had serum antibodies. Possible reasons for this are discussed.

The results suggest that a serodiagnostic assay forC. pyloriinfection may be of value in the assessment of gastroduodenal disease.
Esophageal fistula
Authors: Ginsberg Robert J. , Cooper Joel D.
Published: May 2005

Esophageal fistulas, whether congenital or acquired, require a high index of suspicion for early diagnosis. Only simple investigative tools are required to confirm the diagnosis. Management requires individualization and is most successful in those patients treated early, before gross local contamination and generalized sepsis ensue.
Gastric and duodenal cutaneous fistulas
Authors: Tarazi Riyad , Coutsoftides Theodore , Steiger Ezra , Fazio Victor W.
Published: May 2005

Forty‐seven patients, 18 with gastric and 29 with duodenal cutaneous fistulas, managed at the Cleveland Clinic Foundation between 1956 and 1976 are analyzed. This is done with the intention of defining factors responsible for increased rates of morbidity and mortality. The location and number, output, associated sepsis, and nutritional status are reviewed. Treatment modalities ranged from nonsurgical medical treatment to conservative surgical and radical surgical treatment. Overall mortality rate was 29.8% with a 34.5% mortality rate from duodenal fistulas and 22.2% from gastric fistulas. A review of the literature and guidelines for management of gastric and duodenocutaneous fistulas are presented.
Postoperative fistulas of the small intestine: Therapeutic principles
Authors: Hollender L. F. , Meyer C. , Avet D. , Zeyer B.
Published: May 2005

Postoperative fistulas of the small intestine are a daunting and distressing complication in abdominal surgery. On the basis of a series of 54 observations and a review of the literature, the writers evaluated various factors, concluding that the following have a significantly unfavorable effect on prognosis: existence of an intraperitoneal septic focus, diseased fistulized intestine, a fistula exposed in an evisceration, complex fistulas, and the patient's age. The aim of treatment is to find solutions to 3 problems: sometimes that of peritonitis, frequently that of the loss of parietal substance, and invariably that of the fistula. If early surgery must be carried out, it will be regarded as a rescue operation, involving notably an enterostomy and sometimes a laparotomy. Otherwise, surgery will be deferred as long as possible (beyond the second month) and will be based on a single‐stage operation (resection‐anastomosis) or, more frequently, phased operations, precedence being given to treatment of the intestinal fistula rather than that of parietal dehiscence.
Factors influencing the outcome of treatment of small bowel cutaneous fistula
Authors: Fazio Victor W. , Coutsoftides Theodore , Steiger Ezra
Published: May 2005

A 20‐year review of 174 external fistulas of the jejunum and ileum led to the identification of factors affecting morbidity and mortality. The mortality rate for jejunal fistulas was higher as compared to ileal fistulas, whether treated by nonoperative means (41.7% and 29.4%, respectively), conservative surgical means (70% and 21%, respectively) or by radical, i.e., resectional surgical techniques (21.7% and 12.2%, respectively). Overall mortality rate in the series was 22.4% (39 patients). Respective mortality rates for high‐output (greater than 200 ml/day) and low‐output fistulas were 30.3% and 4.8%; where the presence or absence of significant intra‐abdominal sepsis could be clearly established on chart review, mortality rates were 29.6% and 0%, respectively. The presence of anemia, hypoalbuminemia, and malnutrition adversely affected outcome, with mortality rates of 30.7%, 41.9%, and 31.8%, as compared to the outcome when these features were absent (8.2%, 0%, and 3.0%, respectively). Etiological factors were also examined. High mortality rates were observed for fistulas arising due to radiation effect (45.4%), gangrenous intestine or evisceration (52.4%), and those secondary to surgery for ulcerative colitis (33.3%). Timing of fistula surgery had little impact on rates of fistula cure, but survival was highest when such surgery could be deferred beyond 6 weeks from fistula onset. Improvement in survival has been noted since 1970.

While many factors influence mortality rates, inadequately treated sepsis assumes primary importance. In favorable circumstances, intestinal resection and anastomosis is the procedure of choice. However, staging procedures such as resection of the fistula‐bearing segment without anastomosis or enterostomy with wide drainage of associated sepsis should be considered when local conditions in the abdomen indicate a likelihood of anastomotic breakdown. These local conditions invariably improve with adequate drainage and prevention of further contamination; total parenteral nutrition has provided a mechanism of sustaining the patient while this improvement occurs, allowing for elective intestinal reconstruction.
Long‐term experience with transection choledochoduodenostomy
Authors: Cuschieri A. , Wood R. A. B. , Metcalf M. J. , Cumming J. G. R.
Published: May 2005

A technique of choledochoduodenostomy involving transection of the bile duct at its junction with the trans‐pancreatic segment and an end‐to‐side anastomosis with the duodenum is described. The operation has been performed in 46 patients over a period of 14 years, 26 patients having had a follow‐up of 5 years or more. There has been no instance of anastomotic stenosis in the series, although one patient had a single episode of jaundice 3 years after operation.
Liver alveolar hydatidosis in the Xinjiang autonomous region
Authors: Ping‐li Yao
Published: May 2005

Five cases of human alveolar hydatidosis caused by the cestodeEchinococcus multilocularis in China were reported by us in 1965. Since that time, 31 male and 12 female patients, ages 14 to 52 years, have since been admitted and treated in our surgery department; 27 patients are of minority nationalities. The chief clinical manifestations were firm, round, and rough masses found on the upper right abdomen from 2 months to 7 years prior to admission. Jaundice developed in 10 of the 43 patients. Immunological diagnosis was done; all the 43 patients showed positive reactions in the Casoni intradermal test and 8 in the indirect hemagglutination test and immunoelectrophoresis. The patients also had eosinophilia. Other examinations were also done with ultrasound exploration, roentgenography, and radioisotope liver scan.

Radical resection of the mass with a portion of normal liver is commonly suggested; hemihepatectomy is usually performed in our cases if resectable. However, the resectability rate was low (5 cases), and a great number of cases had palliative resections when the mass was too large or if both lobes of liver were involved. Prognosis was good, and no recurrence was seen with the patients followed up for 4–17 years. Remarkable relief was achieved in 6 patients with palliative resection plus irrigation and drainage of the necrotizing cavity. Formalin (2–4%), 3% boric solution, or 0.1% Bromo‐Germinum was used as irrigation solution. The general condition of the patients improved with partial resection of the hepatic mass and the toxic symptoms were relieved, as seen in the 4 patients who had palliative resection.

Since the advent of the drug mebendazole in the trial treatment of hydatidosis, 13 patients in our series were given mebendazole. The dosage was 1,200–1,500 mg for adults, 3 times a day for 30 days as a course, with intervals of 1 week to 1 month. Mebendazole was administered as long as 16 months in 1 patient with no apparent side effects. The patient showed adequate improvement but was not radically cured. We stress high dosage and long, repeated courses of the mebendazole treatment. Praziquantel trials will be reported in a separate paper.

Although early diagnosis and radical hemihepatectomy constitute the most effective treatment of alveolar hydatidosis, it is hoped that efficacious drugs will be developed as adjuncts to surgical treatment, as numerous problems remain in the resection or enucleation of either the cyst or the hepatic mass in hydatidosis.
Decision‐making process in abdominal surgery in the geriatric patient
Authors: Reiss Raphael , Deutsch Alexander A. , Eliashiv Avinoam
Published: May 2005

The high rates of abdominal disorders in a growing population of geriatric patients and the greater willingness of the surgeon to cope with major problems in the elderly are factors contributing to a steady increase in abdominal procedures in this group. Four hundred consecutive major abdominal surgical procedures in patients over 70 years of age were submitted for computer analysis, the purpose of which was to determine the principal factors affecting mortality and morbidity. The etiological profile of abdominal surgery in the elderly was characterized by a high percentage of procedures related to the biliary tract, with the second largest group being those for intestinal obstruction due to benign and malignant conditions.

The decision‐making process in geriatric surgery is of great importance, requiring consideration of ethical, medico‐legal and economic factors in addition to the purely medical ones. Analysis of data presented in this series leads to the following conclusions:

There is a declining mortality rate in all elective operations in the elderly, in the absence of widespread malignancy.

Timing is all important in abdominal emergencies in the elderly, and early operations are usually more successful than either immediate or delayed operations.

Definitive procedures are sometimes both safer and more cost effective than minimal procedures performed under such circumstances.

The principal factors leading to high mortality rates are the presence of malignancy, generalized peritonitis, and moderate‐to‐severe involvement of life‐support systems.
Selection of a treatment plan in chronic atheromatous limb ischemia
Authors: Courbier R. , Bergeron P.
Published: May 2005

The treatment plan in chronic atheromatous limb ischemia can only be established after quantifying functional problems by noninvasive techniques and after comparing the risk of the natural progression of the disease with the risk and possible outcome of surgical intervention. When claudication is at an advanced stage, reconstructive surgery is indicated. Aortofemoral bypass is preferable to thromboendarterectomy, its mortality rate being lower (2–3%) and long‐term patency rate better (82% after 5 years and 72% after 10 years). Thromboendarterectomy must be reserved for segmental lesions of the common iliac artery. The extra‐anatomical bypass has a similar patency rate, but it should be reserved for patients in whom a direct approach is contraindicated. Direct surgery below the inguinal ligament gives satisfactory results when the internal saphenous vein can be utilized.

There is little difference in patency rate among the types of prostheses in use; it depends on the preoperative outflow and it decreases from 76% to 42% after 5 years if peripheral lesions are present.

In the case of rest pain or trophic problems, reconstructive surgery is obligatory. The revascularization of the profunda femoris artery ensures limb salvage. It is possible to avoid amputation of the leg if distal disease is present provided that 1 pedal arch is functioning. Indications for primary amputation still depend on the patient's age and general state of health.
What is Buerger's disease?
Authors: Shionoya Shigehiko
Published: May 2005

In analyzing our observations of 115 patients with Buerger's disease during a recent 4‐year period, the following results were obtained. First, Buerger's disease is primarily a disease of the small‐ and medium‐sized vessels of the extremity. The disease commences peripherally and reaches the infrapopliteal or forearm arteries within a short time after the onset of symptoms. The majority of the patients have 3‐ or 4‐limb involvement. Although the first ischemic manifestation is variable, a trophic lesion is the chief symptom at the first examination.

Second, in contrast to an incessant deterioration of the peripheral circulation, proximal extension is less frequent. The skip lesion plays an important role in proximal progression of the obstructive lesion in the main artery.

Third, although direct arterial surgery is infrequently feasible because of the distal occlusive process, successful arterial revascularization is most effective for healing of ulceration. All efforts should be concentrated on limb salvage.

Furthermore, microabscess consisting of giant cells, epithelioid cells, and leukocytes lends the most characteristic appearance to the thrombotic lesion at the early stage. General architecture of the vessel wall is well preserved at the healed stage.

Finally, the etiology remains unknown. In this regard, however, we have a very strong clue in the astoundingly close relationship between the use of tobacco and the occurrence of the disease. If the patient absolutely abandons smoking, the natural history of the disease is uneventful.
Acute necrotizing pancreatitis after distal splenorenal shunt
Authors: Mosimann François
Published: May 2005

Two cases of fatal acute necrotizing pancreatitis shortly after distal splenorenal shunt are presented. Instrumental injury to the pancreas during operation may have caused this complication. It is suggested that distal splenorenal shunt should not be performed when mobilization of the splenic vein is technically difficult.
How to use abdominal wall retractors at laparotomy in grossly obese patients
Authors: Tera Harry
Published: May 2005

A simple technique for applying laparotomy retractors to obese patients has been successfully applied in 25 patients. The procedure involves creating a “tunnel” through the subcutaneous fat tissue from a midline incision to a second skin incision, through which the retractor is introduced. No complaints were reported in 20 patients followed for 6–18 months, and except for slight redness in one wound, no complications from the extra incisions occurred.
The pancreatic cancer problem
Authors: Livstone Elliot M. , Spiro Howard M.
Published: May 2005

Pancreatic cancer has become a major diagnostic and therapeutic problem. The increasing incidence over the past decade seems to be real, but by the time the patient has symptoms and the physician begins to think about the possibility of pancreatic cancer, the disease has spread beyond hope of cure by resection, radiation, or chemotherapy. At present, no therapeutic program does more than extend life, and then only for short periods of time. It, therefore, makes more sense to use 2‐year survival rates rather than 5‐year survival rates to assess the impact of new treatments since no therapies to date reproducibly produce 5‐year survivors. We hope that the newer radiologic imaging techniques will lead to the earlier recognition of pancreatic cancer and an improved outlook.
Epidemiology of pancreatic cancer
Authors: Gordis Leon , Gold Ellen B.
Published: May 2005

In the United States the incidence of and mortality from pancreatic cancer have increased over the past several decades but have tended to level off in recent years. The rates are higher in blacks than in whites and higher in males than in females. Mortality rates increase with age but there appears to be a decline in elderly blacks, possibly on an artifactual basis. There is a suggestion that rates are higher in Jews. No consistent differences by socioeconomic status or by geographic location within the United States have been identified. Both genetic and environmental factors may be playing significant roles in this disease. Cigarette smoking may be etiologically related, or at the very least, may help to identify a group of patients at increased risk of pancreatic cancer. However, the relative risk estimated for cigarette smoking is much lower than that found for cancer of the lung. The leveling off in incidence and mortality rates for pancreatic cancer in recent years also differs from the time trends observed for lung cancer. However, this could result from differences in site‐specific carcinogens and from the fact that the lung is the first organ to be exposed to cigarette smoke in the highest concentrations and prior to the metabolism of any of its components.

Dietary factors may have an important role in pancreatic cancer, but further research is needed to clarify this relationship. In particular, the possibility that dietary fats may be implicated and that vitamins or fiber may be protective in this disease remains to be explored. Finally, there is suggestive evidence that specific chemical exposures may be carcinogenic for the pancreas. Many of the data are from animal studies, and the findings from human studies are not entirely consistent.
Serologic markers in the diagnosis and management of pancreatic carcinoma
Authors: Podolsky Daniel K.
Published: May 2005

The low prevalence of pancreatic cancer remains an inherent obstacle to the development of effective screening tools in an asymptomatic population. However, these difficulties do not warrant nihilism. Development of effective serologic markers still offers the potential for improvement in our diagnostic capabilities. The accurate identification of patients with pancreatic cancer and the exclusion of disease in those with benign disorders remain important goals. While alpha‐fetoprotein (AFP), human chorionic gonadotropin (HCG), carcinoembryonic antigen (CEA), and ribonuclease (RNase) can be largely dismissed as useful markers of pancreatic cancer, leukocyte adherence inhibition (LAI), pancreatic oncofetal antigen (POA), and galactosyltransferase isoenzyme II (GT‐II) continue to show promise. Each of these markers currently requires further technical improvements to permit more widescale evaluation. The further refinement of monoclonal antibody defined markers such as gastrointestinal cancer antigens (GICA) may provide even more useful markers in the future. The development of effective serologic markers may help identify patients with early disease, and provide an impetus to develop more effective therapeutic strategies. It remains to be seen whether improvements in diagnostic modalities can be translated into improvement in clinical outcome.
Contribution of computed tomography to patients with pancreatic adenocarcinoma
Authors: Wittenberg Jack , Ferrucci Joseph T. , Warshaw Andrew L.
Published: May 2005

While computed tomography provides an excellent non‐invasive evaluation of the pancreas, its utilization should be restricted to selected clinical problems in patients with suspected pancreatic malignancy. Computed tomography is the preferred initial examination in the nonjaundiced patient because of its high specificity and sensitivity and its capacity for providing valuable staging information. Furthermore, computed tomographically guided percutaneous biopsy will establish a pathologic diagnosis in 85% of patients, thereby avoiding exploratory surgery in the majority of patients. Alternatively, this examination has far less utility in the patient with jaundice since alternative noninvasive and/or invasive radiologic tests provide comparable accuracy and greater functional flexibility. In this group of patients, computed tomography plays only a limited role in defining the incurability of some malignant tumors.
Suspected pancreatic cancer presenting as pain or weight loss: Analysis of diagnostic strategies
Authors: Silverstein Marc D. , Richter James M. , Podolsky Daniel K. , Warshaw Andrew L.
Published: May 2005

Comprehensive strategies for the diagnosis of pancreatic cancer were evaluated with decision analysis for accuracy, cost, and invasiveness. An optimal strategy began with ultrasonography followed by a combination of computerized tomography, needle aspiration biopsy, endoscopic retrograde cholangiopancreatography, and laparotomy. The refined strategy established or excluded the diagnosis of pancreatic cancer with sufficient reliability for clinical decisions. This strategy had an overall sensitivity of 92% and specificity was greater than 99%. The number of invasive tests increased with the prevalence of disease in the population, but the frequency of diagnostic laparotomy was only 1–9%. The comprehensive strategy could not be significantly improved without marked increases in the utilization of invasive technology.
Preoperative and operative diagnosis of pancreatic cancer
Authors: Ihse Ingemar , Isaksson Gunnar
Published: May 2005

The aim of the investigation in the case of pancreatic cancer is to establish the diagnosis and to evaluate resectability. Improved diagnostic methods have made it possible in most cases to diagnose accurately the symptomatic patient with pancreatic cancer. Ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography (ERCP), and cytology are methods that often complement each other in the diagnostic workup. Percutaneous transhepatic cholangiography (PTC) is useful in the jaundiced patient, but is not as safe for the patient as ERCP. For patients in whom resection is contemplated, angiography is also of interest, as signs of major vessel involvement contraindicate surgery. Pancreatic function tests, tumor markers, and scintigraphy do not contribute enough to be used as diagnostic aids, and laparoscopy is only rarely indicated. At operation the final assessment of resectability is determined by documentation of spread to lymph nodes or to other organs and the invasion of neighboring vessels.
Endoscopic methods for relief of malignant obstructive jaundice
Authors: Cotton P. B.
Published: May 2005

Several endoscopic methods have potential value in the management of patients with biliary obstruction due to malignant disease. Jaundice can be relieved either as definitive palliation, or as preparation for surgery, by endoscopie placement of indwelling prostheses, or by sphincterotomy of tumors at the papilla of Vater. Blockage of prostheses remains a problem in some patients who survive for more than a few months, and improvements in materials are anticipated. Late duodenal obstruction is surprisingly uncommon. These techniques are valuable in many elderly and frail patients. The results of ongoing randomized trials will help define indications for their use in other contexts and for their roles relative to surgery and percutaneous methods.
Pancreatic resection for carcinoma of the pancreas: Whipple versus total pancreatectomy—An institutional perspective
Authors: van Heerden Jon A.
Published: May 2005

The collective term “pancreatic cancer” should be replaced by more specific terminology indicating the histological subtype, e.g., pancreatic ductal adenocarcinoma, ampullary adenocarcinoma, duodenal carcinoma, pancreatic cystadenocarcinoma, cholangiocarcinoma, and malignant islet cell carcinoma. Each of these tumors has its own inherent prognostic and therapeutic characteristics‐95% of ampullary lesions being resectable in contrast to ±10% of pancreatic ductal malignancies and comparable 5‐year survival figures for these two subtypes are 40% and 5%, respectively.

Since the results of adjuvant therapy (chemo‐ and/or radiotherapy) have been dismal, the only chance of cure remains resective therapy, either by the performance of a total or subtotal pancreatectomy (Whipple procedure). The operative mortality rate for these procedures at our institution has been 12% and 4%, respectively, with corresponding 5‐year survival rates of 2% and 4%. Despite earlier promise that total pancreatectomy only would be a superior procedure (elimination of the pancreatojejunal anastomosis, wider lymphadenectomy, irradication of multicentric disease), the operation has thus far not fulfilled these expectations.

The Whipple procedure remains the resective procedure of choice at our institution—total pancreatectomy being performed principally in those patients in whom a safe pancreatojejunal anastomosis cannot be constructed.

Value of early diagnosis in patients with ductal adenocarcinoma does not appear to imply improved prognosis. Energies should be diverted toward etiological identification of this lethal malignancy which is steadily increasing in incidence.
The place of total and extended total pancreatectomy in pancreatic cancer
Authors: Moossa A. R. , Scott Michael H. , Lavelle‐Jones Michael
Published: May 2005

The results of surgical treatment of pancreatic exocrine cancer are poor. There exists a definite small group of patients with early cancers in the head of the pancreas that are potentially curable. It is generally agreed that prolonged survival is obtained only with resection as opposed to a palliative bypass procedure. The only real controversy that remains concerns the extent of the resection. The 3 options available to the surgeon are Whipple pancreatoduodenectomy, total pancreatectomy, and the more radical regional pancreatectomy. Our opinion, based on previous experience, is that total pancreatectomy is the operation of choice for cancer in the head of the pancreas. This operation excludes many of the risk factors associated with the Whipple operation, with no evidence of increased morbidity or mortality. We feel that the case for extended total pancreatectomy is tenuous and yet to be proven, and that there is little or no place for this operation.
Surgical palliation of unresectable carcinoma of the pancreas
Authors: Sarr Michael G. , Cameron John L.
Published: May 2005

The results of palliative surgery for pancreatic carcinoma were reviewed in over 10,000 patients from the English‐language literature from 1965 to 1983. This collected series suggests that biliary‐enteric bypass relieves the sequelae of chronic extrahepatic biliary obstruction, prolongs survival, and provides symptomatic palliation. The more easily constructed loop cholecystojejunostomy is preferred over choledochojejunostomy unless malignant obstruction of the cystic duct is imminent. Chronic percutaneous internal biliary drainage offers reasonable palliation in the poor‐risk patient who is not a candidate for surgery. Routine concomitant gastroenterostomy is recommended in all patients with a reasonable life expectancy since operative mortality is unaffected, and the incidence of future duodenal obstruction is at least 16%. Intraoperative chemical splanchnicectomy is easily performed and appears beneficial in relief of pain related to advanced pancreatic carcinoma.
Treatment of pancreatic cancer by radiation therapy
Authors: Dobelbower Ralph R. , Milligan Andrew J.
Published: May 2005

The role of radiation therapy in the management of pancreatic malignancy was expanded dramatically in the last decade. Development of new tumor localization and dose delivery techniques permits safe delivery of increased radiation dose to upper abdominal tumors. Interstitial implantation of radioisotopes directly into tumors has increased the local control rate for pancreatic cancer as high as 80%, but the perioperative mortality rate of this procedure is as high as 25%, except in highly controlled situations. Early data from the high linear energy transfer (LET) treatment programs suggest higher than expected complication rates, yet survival seems no better than that reported from precision high‐dose (PHD) external beam regimens. Radiation as an adjuvant to surgery has been inadequately tested, but initial reports from preoperative and postoperative trials are encouraging. Intraoperative irradiation poses theoretical advantages over external beam therapy for pancreatic cancer. Chemotherapy seems an effective adjuvant to external beam radiation therapy for pancreatic cancer. Drugs other than 5‐FU have not been adequately evaluated in adjuvant studies, nor have newer radiation treatment methods been fully evaluated in combination with drugs.
Chemotherapy of pancreatic carcinoma
Authors: Harvey Jimmie H. , Schein Philip S.
Published: May 2005

Approximately 23,000 cases of carcinoma of the exocrine pancreas will be identified in the United States this year, and nearly all will die within 12 months. Surgery with curative intent has a 5‐year survival of less than 4%. In unresectable tumors, combination chemotherapy with 5‐FU and mitomycin‐C appears to have activity and increased survival duration. New combination regimens and trials of chemotherapy combined with radiation are currently under study and appear to offer survival benefit. The development of chemotherapeutic trials and future directions are discussed.
Cholangitis
Authors: Kinoshita Hiroaki , Hirohashi Kazuhiro , Igawa Sumito , Nagata Eiichi , Sakai Katsuji
Published: May 2005

Comparative study of the clinical features of 125 cases of acute cholangitis revealed that acute obstructive suppurative cholangitis (AOSC, 19 cases) was characterized by leukocytosis, high transaminase levels, bilirubinemia, and a marked thrombocytopenia. Most species of bacilli isolated from the purulent bile were gram‐negative and in 9 of 12 cases of AOSC that we checked, the same species were found in the blood as in the bile. In 12 of the 19 cases of AOSC, plasma endotoxin levels were assayed by theLimulus test and found to be elevated. Of the 22 cases of cholangitis other than AOSC, only 5 showed transitory positive results. Laparotomy decompression of the bile duct in 8 patients with AOSC resulted in 4 deaths from post‐operative complications. However, 7 of the 11 patients placed on emergency percutaneous transhepatic cholangio‐drainage (PTCD) recovered from shock and underwent successful surgery later. We confirmed in an experimental study the initiation of cholangiovenous reflux in mongrel dogs. The cholangiovenous reflux of bacteria or endotoxin seems to induce the state of shock in patients with AOSC. In conclusion, we recommend that emergency decompression of the biliary tract even for AOSC patients in shock be performed by a procedure less risky than laparotomy, such as PTCD.
Anomalies of pulmonary venous return
Authors: Stark Jaroslav
Published: May 2005

Total anomalous pulmonary venous return is a rare but life‐threatening congenital heart lesion. We present our experience with 48 consecutive infants operated on from 1977 to 1983. Improved results are due to earlier diagnosis, improved surgical technique, and meticulous postoperative care. Since 1980 some patients with this lesion were submitted to surgery on the basis of two‐dimensional echocardiography, thus avoiding cardiac catheterization and angiocardiography. The operative procedure should achieve a large unobstructed anastomosis between the pulmonary veins and the left atrium. Details of operative techniques currently used in our unit are discussed for each anatomic type of total anomalous pulmonary venous drainage. Although the results are improving, the overall mortality rate (hospital and late) remains around 30% in most series. Very young age (neonates), poor preoperative condition, and presence of associated cardiac and noncardiac congenital anomalies increase the risk. There were 12 hospital and 2 late deaths in our series of 48 infants (29%). Detailed analysis of the causes of death is presented.
Coarctation of the aorta: Current surgical management
Authors: Campbell David B. , Pae Walter E. , Waldhausen John A.
Published: May 2005

Progress in the management of coarctation of the aorta over the past 40 years is truly impressive. Nonoperative management of this condition has uniformly met with failure; however, a variety of surgical options is now available for the treatment of children and adults with coarctation. In recent years, significant advances have emerged in the treatment of neonates and infants that have resulted in low operative mortality rates. In addition, our own results with the subclavian flap angioplasty in these young patients indicate that the problem of failure of the repaired area to grow has been all but eliminated. The use of prostaglandin E1 has dramatically improved our ability to stabilize the decompensated neonate. Repair of coarctation in infancy is not only safe but desirable to minimize the late cardiovascular morbidity and premature death associated with hypertension.
Conduction tissue in congenital heart surgery
Authors: Ho Siew Yen , Anderson Robert H.
Published: May 2005

The anatomy of the cardiac conduction system in normal and malformed hearts reconstructed from histological serial sections is reviewed. The sinus node and its arterial supply are located in the right superior cavoatrial junction except in hearts with left‐sided juxtaposition of the atrial appendages, mirror‐image, and isomeric arrangements of the atria. In the presence of normally positioned atrial and ventricular septal structures, the triangle of Koch is a useful guide to the location of the atrioventricular node and the penetrating bundle. In hearts with “isolated” ventricular septal defects, it is necessary to distinguish between a perimembranous defect and a muscular inlet defect. The conduction axis runs in the area of fibrous continuity at the posteroinferior edge of a perimembranous defect but in the anterosuperior rim of a muscular inlet defect. In most hearts with tetralogy of Fallot, the danger area is the region of aortic‐mitral‐tricuspid fibrous continuity where the axis penetrates. In hearts with atrioventricular septal defects, the lack of contiguity between atrial and ventricular septum results in a posterior displacement of the nodal triangle and coronary sinus and an elongation of the nonbranching bundle. Hearts with abnormally located atrioventricular nodes and conduction axes are mainly those with atrioventricular discordance, ambiguous atrioventricular connection in presence of left‐hand pattern ventricular topology, hearts with univentricular atrioventricular connection to a morphologically left or indeterminate ventricle, and hearts with a straddling tricuspid valve. The location of the atrioventricular node is governed by the orientation of the ventricular septum and by the pattern of ventricular topology.
Surgical management of double inlet ventricle
Authors: Pacifico Albert D. , Kirklin James K. , Kirklin John W.
Published: May 2005

Surgical experience with the management of patients with double inlet ventricle (DIV) has undergone continued evolution over the past decade. We report our experience with all forms of surgical treatment for this malformation. Systemic‐pulmonary artery shunts were constructed in 55 patients with 1 hospital death (mortality 2%) from 1967 to 1982. The 10‐year actuarial survival was 85%, but onethird of the group required additional operations during the follow‐up period. Good late functional status was achieved from this procedure. Pulmonary artery banding was performed in 11 patients with no hospital mortality and their 10‐year actuarial survival was 74%.

Our overall experience with ventricular septation indicates that it remains the best definitive surgical option for those with mild or absent pulmonary stenosis. It is best advised for those with a dominant chamber of left ventricular morphology. The need for concomitant valve replacement, the use of an extracardiac conduit, and less‐than‐moderate ventricular enlargement have been associated with increased hospital mortality. In the absence of these, the hospital mortality rate was 6%. The Fontan‐Kreutzer operation was performed in 73 patients with 16 hospital deaths. Fourteen of these had DIV. A multivariate logistic analysis showed that young age at operation, primary cardiac anomaly other than tricuspid atresia, and complex additional procedures are incremental risk factors associated with hospital mortality. The overall 10‐year actuarial survival was 71%, and there was no difference among those with tricuspid atresia or other anomalies including DIV. This report presents our results and discusses our current management program for patients with this cardiac malformation.
Functional assessment after colectomy, mucosal proctectomy, and endorectal ileoanal pull‐through
Authors: Becker James M. , Hillard Alan E. , Mann Frederick A. , Kestenberg Abraham , Nelson James A.
Published: May 2005

Radiographic, manometric, and clinical techniques were used to assess the functional results after colectomy, mucosal proctectomy, and endorectal ileoanal pull‐through (IAP). In 40 patients with ulcerative colitis, Gardner's syndrome, or familial polyposis, anorectal manometry was performed before IAP and 2 months and 1 year afterward. At 4 weeks after IAP, a standardized water contrast radiograph allowed an estimation of the dimensions of the ileal pouch and the integrity of the ileoanal anastomosis. Radiographically, the mean ± SE length, width, and depth of the ileal pouch were 10.9±0.6 cm, 4.5±0.6 cm, and 3.9±0.2 cm, respectively. No anastomotic leaks were identified; however, 2 patients were incontinent to the contrast material. The mean maximal anal sphincter resting pressure decreased from a mean ± SEM of 87.1±3.2 mmHg preoperatively to 68.1±3.1 mmHg 8 weeks after operation, but by 1 year resting pressure increased to 72.3 ±4.9 mmHg. The change in sphincter pressure with voluntary squeeze was greater 8 weeks after IAP than before the operation (114.0±8.2 mmHg versus 97.7±6.2 mmHg) and increased further by 1 year. No patient experienced major episodes of incontinence. Mean ± SEM stool frequency per 24 hours decreased from 7.5±0.5 at 1 month after ileostomy closure to 6.4±0.7 at 12 months. Ileal pouch capacity increased with time and was inversely related to stool frequency. It was concluded that endorectal pull‐through of an ileal J pouch, by providing an adequate intestinal reservoir and preserving nearly normal anal sphincter function, results in anal continence and acceptable stool frequency.
Screening procedures for identifying patients after gastric operations at high risk of developing premalignant histological changes
Authors: Mosimann François , Donovan Ian A. , Thompson Henry , Fielding John W. L. , Harding L. Keith , Alexander‐Williams John
Published: May 2005

Thirty‐six asymptomatic patients at a mean time interval of 12.7 years after gastric surgery were assessed by endoscopy, intragastric pH measurement, and multiple biopsy at a single endoscopy and by99mTc Imino Diacetic Acid (HIDA) scanning for enterogastric reflux: 9 patients had had Polya gastrectomy, 10 patients truncal vagotomy and antrectomy (Billroth I anastomosis), 9 patients truncal vagotomy and pyloroplasty, and 8 patients proximal gastric vagotomy. In the resection group the 9 patients with histological evidence of mucosal risk factors (dysplasia, chronic atrophic gastritis, intestinal metaplasia) had a fasting intragastric pH of more than 4. However, fasting pH was of no value in predicting the occurrence of risk factors after vagotomy (6 of 17 patients). The amount and duration of enterogastric reflux as measured by HIDA scanning over 50 minutes did not correlate with risk factors after resection. The amount and duration of reflux after vagotomy were greater in the patients with risk factors but were not discriminatory. We conclude that HIDA scanning is of little value as a screening procedure and that single sample pH testing is useful only in patients after a gastric resection.
Surgical technique for repair of benign stricture of the bile ducts, preserving the papilla of vater
Authors: Okamura Takao , Orii Kazuo , Ono Atsushi , Ozaki Azusa , Iwasaki Yoji
Published: May 2005

From March 1977 to October 1983, we examined 6 patients with benign bile duct stricture. Four were female and 2 were male, ranging in age from 55 to 69 years. These patients were treated by operative methods in which the papilla of Vater was preserved. These operative methods were end‐to‐side anastomosis of the bile ducts, repair of the bile duct utilizing a part of the gallbladder or a remnant of the cystic duct, and repair of the bile duct using a patch of jejunal wall. The postoperative observation period is 8 months to 7 years and 4 months. It is our policy to preserve the function of the papilla of Vater when possible because with this method the flow of bile is uninterrupted. We especially recommend a jejunal patch for repair of the bile duct, when no remnant of the cystic duct is available. This method is applied when the bile duct stricture is less than 3 cm long. We have operated on 2 patients with this method and the results have been completely satisfactory.
Surgical treatment for malignant lesions of the distal part of the esophagus and the esophagogastric junction
Authors: Bertelsen S. , Aasted A. , Vejlsted H.
Published: May 2005

The treatment of 364 patients with carcinoma of the distal part of the esophagus and the esophagogastric junction is reported. Eighty‐two percent of the patients were subjected to operation and the resect ability rate was 52%. At operation 230 patients had lymph node metastases and 115 patients had distant metastases to abdominal organs. The resection rate was significantly higher in patients with squamous cell carcinoma than in patients with adenocarcinoma, and about two‐thirds of the resections were considered as “curative” treatment. The operative mortality rate for the entire period was high (24%), but the mortality decreased in the last 10‐year period. The 5‐year survival rate after resection was in the same level as in other series; the survival rate for patients with squamous cell carcinoma was considerably higher than for patients with adenocarcinoma.

If surgical resection is not feasible, surgical bypass of the obstructing lesion is indicated. This alternative procedure gives satisfactory palliation in the majority of patients.
Lesser curve ischemia after proximal gastric vagotomy and splenectomy: Conservative management with endoscopical surveillance
Authors: Choi Samuel , Wong John
Published: May 2005

A case of lesser curvature ischemia after proximal gastric vagotomy and splenectomy is described. Division of the right gastroepiploic vessels had caused further impairment of the stomach circulation. Deep seromuscular invagination of the lesser curvature was performed at the end of the operation to protect the ischemic area. Sequential changes were seen at repeated endoscopic examinations, and further operation was not necessary.