Posters

Palliation of obstructive jaundice can be done with surgical bypass, endoscopic stent insertion percutaneous transhepatic stent insertion. Self expanding metal stent have recently been proposed as better alternative for treatment of bile duct obstruction. This study was set up to evaluate follow. up results of the metal stents in our hospital. MATERIAL AND METHODS.33 Patients with obstructive jaundice treated with percutaneous transhepatic metal stent insertion at the Doce de Octubre Hospital, Madrid, Spain were reviewed. There were 12 women and 21 men, aged 37-87 years(mean age 64.4 years). Biliary obstruction was caused by pancreatic carcinoma (n= 7), cholangiocarcinoma (n= 9), gallbladder carcinoma(n=4), metastatic lymphadenectomy (n=5), hepaticojejunostomie strictures(n=4) and others (n=4). The histopathological diagnosis was proven in 21 patients. The indications for stent insertion included 4 hepaticojejunostomie strictures, 16 advanced diseases, unresecable tumors, medical opinion, 2 high ASA. External or internal biliary drainage was established during first session in all patients. Stent insertion was successfull in 32 patients. RESULTS. Effective biliary decompression was accomplished in 23 patients, but only of them had complete relief of jaundice. Early morbidity was 17.1% (bacteriemia 3, wound infection i, hemobilia i) and late complications were 12.1% Cholangitis 2, stent oclusion 2). 30-day mortality rate was of 12.1%. The overall mean survival was 58 weeks 19.5 standard desviation. The median post stent hospital stay was 9.1 (range 1-33 days). CONCLUSIONS. Metal stent in biliary tree is useful palliative treatment for those patients with malignant obstructive jaundice when estimated operative risk is high there is advanced disease. Hospital stay is low and quality of survival is better with relief of jaundice and pruritus. OBSTRUCTIVE JAUNDICE DUE TO NODAL METASTASES SHOULD WE PALLIATE BY PERCUTANEOUS STENTING? N Do.c.tor, Helen Whiteway, A Salamat, J Dooley, R Dick, B Davidson. Hepatobiliary Unit, Royal Free Hospital, London

Palliation of obstructive jaundice can be done with surgical bypass, endoscopic stent insertion percutaneous transhepatic stent insertion. Self expanding metal stent have recently been proposed as better alternative for treatment of bile duct obstruction. This study was set up to evaluate follow. up results of the metal stents in our hospital. MATERIAL AND METHODS.33 Patients with obstructive jaundice treated with percutaneous transhepatic metal stent insertion at the Doce de Octubre Hospital, Madrid, Spain were reviewed. There were 12 women and 21 men, aged 37-87 years(mean age 64.4 years). Biliary obstruction was caused by pancreatic carcinoma (n= 7), cholangiocarcinoma (n= 9), gallbladder carcinoma(n=4), metastatic lymphadenectomy (n=5), hepaticojejunostomie strictures(n=4) and others (n=4). The histopathological diagnosis was proven in 21 patients.
The indications for stent insertion included 4 hepaticojejunostomie strictures, 16 advanced diseases, unresecable tumors, medical opinion, 2 high ASA. External or internal biliary drainage was established during first session in all patients. Stent insertion was successfull in 32 patients. RESULTS. Effective biliary decompression was accomplished in 23 patients, but only of them had complete relief of jaundice. Early morbidity was 17.1% (bacteriemia 3, wound infection i, hemobilia i) and late complications were 12.1% Cholangitis 2, stent oclusion 2). 30-day mortality rate was of 12.1%. The overall mean survival was 58 weeks 19.5 standard desviation. The median post stent hospital stay was 9.1 (range 1-33 days). CONCLUSIONS. Metal stent in biliary tree is useful palliative treatment for those patients with malignant obstructive jaundice when estimated operative risk is high there is advanced disease. Hospital stay is low and quality of survival is better with relief of jaundice and pruritus. Patients with disseminated malignant disease may ocassionaly present with obstructive jaundice due to extra-hepatic ductal obstruction. Whether useful palliation is obtained by stenting is controversial. We have analysed the outcome of percutaneous stenting in this patient group. Over a 3 year period 8 patients (5 Male) mean age 56.7 years(range 39-77) with symptomatic obstructive jaundice due to nodal metastatic adenocarcinoma (stomach(4), ovary(I), breast(2), salivary(I) were referred to the Hepatobiliary Unit for percutaneous endoprosthesis insertion. All patients had undergone surgical resection, month to 10 years previously. Three had previously failed an endoscopic stent insertion. In 4 of the 8 patients nodal metastases were the only known site of disease recurrence, the others having liver (2), lung(l) and peritoneal(I) disease.
Percutaneous stenting was successful in 7 patients(87%), one being referred for surgical drainage. Acute cholangitis occurred in 4 patients following stent insertion (57%) but responded to antibiotics in all cases. All patients were discharged from hospital. Four patients were re-admitted with stent related complications (blockage+/cholangitis). One responded to antibiotics alone whilst the other three required stent change with success in one. Follow up (mean 7 months) was available in 5 of the 8 patients, 4 of whom had symptomatic relief of biliary obstruction (80%). We would conclude that useful palliation may be obtained by stenting selected patients with jaundice due to metastatic malignancy. Solingen, Germany. In pts with sphincter of Oddi (SO) dysfunction, the benefitial role of endoscopic sphincterotomy (ES) is still a matter of controversial discussion, especially in biliary type II and III groups. The aim of the prospective study was to investigate the value of ES in pts with abnormal resting pressure of SO > 40 mm Hg]. The patient material comprised 31 [m:f=3:28, age range:30-72 y.] subjects. All pts who had underwent a cholecystectomy 1 to 45 years before entry to the study, suffered from biliary type of pain Ultrasound, EGD, colonoscopy and ERCP was performed as a primary diagnostic work-up  Between 1990-93 we performed 5 289 ERCP. We found 49 /0,9%/ patients with beni postoperative biliary strictures. They comprised 17 men and 32 women with a mean age of 60,8 years.
In all cases were performed ERCP for diagnosis and site of stricture and the presence proximal biliary calculi. The most frequent strictdre locations were common duetsite of cystic duct stump and distal common duct. 12 patients had calculi proximal to the stricture. We attempted endoscopic therapy in 28 patients by the placement of one or multiple end oprosthoses. The rest patients was reccomended for surgical repair. The endoscopic procedure was succesfull in 20 out of 28 patients. The stents were exchanged usually at 3-monthly intervals to avoid clogging of the stent. Follow up study during a period of 3-36 month's after stent removal of 9 patients showed 3 reccurent stones and 2 re strictures. We prefer multiple /2-3/ stents to avoid restenosls. Endoscopic treatment of postoperative biliary strictures it should be the initial therapeutic modallty owing to the difficulty of reconstructive biliary surgery and its associated morbidity and mortality. Endoscopic stenting is a satisfactory treatment for patients with distal biliary tract obstruction who are unsuitable for surgery. However, for those in whom an endoscopic approach has failed the optimum management has not been established.
Over a 3 year period 133 patients were referred to the Hepatobiliary Unit for percutaneous endoprosthesis insertion. Of this group 29 patients (16M, 13F, median age 72 years, range 38-87) with distal biliary tract obstruction had previously failed an endoscopic attempt at stent insertion (failed cannulation (n =24), duodenal stenosis (n 2), duodenal diverticulum(n=2) and previous gastric surgery(n=1)). All patients were jaundiced whilst 20(69%) had pruritus and 9(31%) abdominal pain. Two patients (6.8%) had acute cholangitis at time of referral. The aetiology was carcinoma pancreas (n=15), bile duct (n=8) or ampulla (n=3), nodal metastases (n=l) whilst two patients had benign strictures. Percutaneous stent placement succeeded in 25 patients (86%). Of the 4 failures 2 patients with advanced cancer died following the procedure (acute cholangitis(1), bleed from inoperable rectal cancer(I)). In the other two patients (with liver metastases) the guidewire failed to traverse the stricture. There was one in hospital mortality in the group successfully stented (4%) due to pseudomembranous colitis. Five of the 25 patients,with successful stent insertion developed acute cholangitis following the procedure (20%). All responded to antibiotics. Of the 26 patients discharged from hospital 8 (31%) were readmitted with stent blockage, 6 with acute cholangitis. All were successfully managed by stent change (endoscopic (6) percutaneous (2) The therapeutic ERCP, is an alternative method for the management of the post-operative biliary fistulae, in some patients, apart from the classic surgical procedures involved.
This study includes 13 patients (7M, 6F). All patients were operated during the last 4 years for hydatid disease of the liver, and all suffered post-op chronic cholorrhea due to communication of the residual cavity and a large intrahepatic bile duct. All fistulae, were of high output (> 400 cc/24h). Common characteristic of these patients was: 1) type of operation, 2) moderate calcification of the cystic wall, (z lcm), 3) long existance of the cysts and 4) the location (mainly in the Rt Iobe-VI, VII, VIII segments). Diagnostic ERCP was performed in all patients, as to demonstrate the location of the fistula or possible obstruction of the extrahepatic biliary tree. Nasobiliary drainage applied initially in 7 patients, stenting (10 Fr) in 4 pts, whereas in 2 others a combination of both.
Definitive stopage of the output observed in 8 pts whithin five days. In 3, this happened in about 10 days and in pt the initial application of the nasobiliary drainage decreased the cholorrhea remarkably, but the stopage achieved finally by stenting. Finally in one patients it was impossible to eliminate the cholorrhea neither by nasobiliary drainage nor with stenting. This patient was operated and an atypical Rt hepatectomy was performed. The endoprostheses, stayed in position approximately 4 weeks and the nasobiliary drainage 10 days, after the final fistulae's occlusion.
We did not observe any complication and the healing was successful in 92,3% of the cases. In conclusion, the endoscopic management of the post-op high output, biliary fistulae seems to be a safe and effective method before any surgical re-intervention. Pancreatic endocrine tumors (PET) are rare but important disease because of it is curable when it was diagnosed accurately. Localization of the tumor is difficult with the imaging procedures used up to now, such as CT, US, scintigraphy, angiography, and venous sampling, and fails in up to 40-60% of cases. Endoscopic ultrasonography (EUS) seems to be more sensitive for preoperative localization of these tumors.
Five cases with PET were diagnosed at our EUS Laboratory in the last one year. We present these five cases. Two of 5 were female and the other 3 were male. Mean age was 29.2 years (range 21-58). Alhought one case had been performed pancreatic resection she had suffered hypoglycemic symptoms after the operation. In all cases CT and US had not determined the tumor. All cases had elevated C-peptide levels.
Tumor localization was in the pancreatic tail in 2 cases, in the corpus in 2 cases and in the uncinate process in case on EUS. Tumor diameter was between 9-15 mm. Tumor was hypoechoic in 4 cases and isoechoic in the other one. The surgeon couldn't detected the tumour in one case whose had been operated previously and had tumor in the uncinate process. In this case operative ultrasonography was performed and tumor was enucleated. Tumors were detected by surgeon in the localization as had been defined by EUS. Pancreatic tail resection was performed whose had tumor in the pancreatic tail, in other four cases tumor were enucleated. Post-operative histopathologic examination revealed PET in all cases. EUS is more sensitive than other conventional diagnostic procedures for determining the PET. EUS bears less complication than other invasive procedures (angiography, venous sampling). EUS also provides more information for determining the lymph nodes, metastasis, venous invasion including the tumor in the gut wall. ureteroscope and the process ef stone removal is then performed under direct fluoroscopic vision and TV monitor control using the continuous flushing and Dermla basket. Whenever difficulty ef extraction is encountered wide rigid renoscope Is introduced instead ef the flexible Following the clearance ef the blllary tract tube is re-inserted and fixed in the tract ef the T-tube and through which control percutaneous cholangiography is performed in the 2nd postoperative day. This procedure had been applied 12 times successfully, with no major complications mortality. The authors conclude that by using "vTC :he surgeon may safely manage complicated bfllary problems and give the chance for the patients to avoid re-operations especially in those The purpose of this study was to evaluate the clinical, imaging, endoscopic and management data, as well as to report the follow up of patients with carcinoma of the ampulla of Vater.
Twelve consecutive cases of ampullary carcinoma, 8 males and 4 females, aged 43-82, were diagnosed in the last 3 years in our Gastroenterology Department. In all patients were performed a duodenoscopy, a US and a CT scan. Ten out of 12 patients were jaundiced, 4 had pruritus, 5 cholangitis, 9 anemia. Elevated levels of transaminases were observed in 9 and of -GT and alkaline phosphatase in 11 patients. The. duration of symptoms was from one week to 14 months. In the US, hepatic petastases were found in 2 patients, as well as in the CT scan. Additionaly, in the CT scan there was a suspicion of a ampullary carcinoma in 2 patients and of a pancreas head cancer in other 2 patients.
In 10 patients the Vater tumor was clearly visible and in 2 the infundibulum was protruding. In 7 patients duodenoscopy was completed with biopsies, in 8 with ERCP, in 5 with a sphincterotomy and in 4 with stent placement. In 3 cases the endoscopic biopsies P013 P014 SURGICAL TREATMENT OF HEPATIC HYDATID DESEASE V.Koubishkin, R.Ikramov A.Vishnevsky Institute of Surgery, Moscow, Russia The results of the evaluation of early and remote results of various methods of surgical treatments of echinococcosis of the liver in 171 pts permitted us to propose principles of the choise of optimal operative technique. In our practice,we used various methods of echinococcectomy (58), excision of the echinococcal cyst together with its fibrous capsule (36), hepatic resection (25), percutaneous aspiration (8) and combinations of these methods (44) in cases with of multiple cysts. 19.7 of pts also underwent procedures on the biliary tract. In .accordance with our observations,any operative technique of echinococcectomy without the excision of the fibrous capsule,even if the small bile ducts are undersewn,carries with it the risk of the development of external biliary fistulae and abscess formation,which we observed in 31 o of cases. In our view this explains the advantage of excising the echinococcal cyst along with its fibrous capsule,as following such a procedure in 16 of our patients we observed only abscess formation and there were no biliary fistulae.We consider hepatic resection for echinococcosis an agressive surgery and it was necessary to perform it in the form of hemihepatectomy in 7 of our pts and as resection of 1-2 segments in 18. Percutaneous aspiration was performed in pts with increased operative risks, who had uncomplicated solitary cysts measuring up to 10cm. The prospects of this method is evidenced by its good early effects. No deaths were observed amongst all the operated patients. During a follow-up period of 2-8 years no recurrences of disease were observed.
HSP AND ANTI-HSP IN PATIENTS WITH HYDATID DISEASE. Paparo B.S.,Teggi A.,Teichner A.,Franchi C.,Gammaitoni A.L.,Sinopoli M.T., Leri O. Department of Infectious Diseases, University "La Sapienza", Rome, Italy Heat-shock-proteins (HSP) are highly conserved, immunogenic molecules produced (on the cellular surface) in response to variety of environmental and chemical stimuli (such as bacteria, virus, parasite). The aim of this study was to investigate the stress response of Hydatidosis; in fact recent studies have demonstrated there is chronic, immunologic stimulation in patients with hydatid cysts. We have measured the circulating antibodies to HSP-70 family (tested by ELISA according to Bahr et al 1988) in 18 patients 10 M/8 F range 15-60 years affected by liver hydatidosis. 25 healthy subjects, blood donors, age and sex matched, served as controls. The sera positive were expressed as mean+2 standard deviations (SD) of the control group, assuming as cut-off 0.69 Optical Density (OD) for HSP70 antibodies. HSP-70 Antigen (StressGen Biotechnology Corp. (Sidney, British Columbia, Canada) and hydatic antigen (collected from fluid of fertile sheep cysts) have been investigated by isoelectrofocusing (I.E.F.) as described by Righetti. Then we have performed western-blot against the sera of patients that resulted positive to HSP-70 antibodies and the serum of a healthy blood donor. HSP 70 Ab was found in of 18 sera (5.5,4). Western-blot showed prominent protein band at approximately 66 kD, not observed in the control group. Our preliminary data could suggest that the presence, in infected patients, of HSP 70 Ab may be due to hydatic HSPs, which act as triggering factors in the development and persistence of the chronic inflammation.

PO15 PO16
GIANT HYDATID CYSTS OF THE LIVER P. Vrachnos, N. Christoforides, V. Skountzos, L. Papastamatiou 2nd Dpt of Surgery. "Apostle Paul" Hosp.-KAT, ATHENS HELLAS Although Hellenic surgery is familiar to echinococcosis, mortality rates remain high (2-3%) depending on various factors. One of the most important factors is the big size of the cyst, causing operative difficulties, intrahepatic rupture of the cyst and intraabdominal recurrence of the parasitosis.
Fifteen patients, 9 men and 6 women aged 22-67, with giant (>20 cm) hydatid cysts of the liver were treated during the last 10 years. Pain was the main symptom, but jaundice, cholangitis, septic fever and deteriorating clinical picture in cases of intrahepatic rupture of the cyst were the causes of emergency admission In 10 cases a mass was easily visible at the right hypochondrium Immunologic investigations were positive in all patients and radiology. ultrasonography and CT-scans confirmed the diagnosis and determined the dimensions of the cysts. The greater diameter ranged from 32 to 21 cm. The operative technique included wide exposure of the liver through abdominal or thoracoabdominal incision, aspiration, incision and careful evacuation of the cyst, partial capsectomy or total pericystectomy sacrificing liver parenchyma up to a typical segmentectomy. Cholecystectomy, exploration of the common bile duct, removal of daughter cysts and debriments and choledochoduodenostomy in the cases of intrahepatic rupture of the cysts was added.
Suture of bile communications, drainage and omentoplasty of the liver cavity completed the operation in each case. One elderly patient died because of cardiovascular complications and another two were reoperated 4 and 6 years later because of recurrence of the disease.
It is concluded that total pericystectomy is the best operative procedure to prevent morbidity. Mortality in elderly patients remains high while recurrence is depended on contamination during aspiration and evacuation of the cyst. We report our experience from the surgical treatment of 22 patients with multiple hydatid disease of the liver. Ten men and twelve women (mean age 61 years) among 374 patients who underwent surgery for hydatid liver disease during the last 22 years, were found to have multiple cysts in the liver. These were located in the right lobe in 16 cases (Group A) whereas the disease was bilobar in 6 cases (Group B). From the Group A a minor liver resection was performed in 5 cases, cysts unification and omentoplasty in 4 cases, partial or total pericystectomy of one cyst with omentoplasty of the otehr in 6 cases, and simple drainage of the cysts in one case. From the Group B partial cystectomy of one cyst with omentoplasty of the other was performed in 3 patients, Iobectomies in one patient and left lobe resection with omentoplasty or partial pericystectomy with unification of the cysts was performed in 2 cases. In all patients cholecystectomy with cholangiography was performed which revealed a communication between the cysts and the biliary system in 5 cases. Common bile duct exploration was made in all these cases and migrated hydatid material was cleared from the common bile duct through a choledochotomy in 3 of them. One patient died (4.5%) during the immediate postoperative period and the morbidity was 18%. The mean hospitalization time was 30 days. In conclusion, multiple hydatid liver disease constitutes an uncommon clinical entity and the surgical intervention requires experience since cystobilliary communications often exist. The aim of this study is to analyze our results in the surgical treatment of hepatic hydatidosis.Beetween 1989 and 1993 89 patients with hepatic hydatidosis were operated.
Our results suggest that every diagnosis,before the appearance of complications,with the use of current surgical techniques allowed successful treatment of the disease.The best results,when it is possible,give total cystopericystectomy.
The rupture of the echinococcus cyst of the upper sudace of the liver to the hemithorax or the development of an hepato-bronchial fistula are conditions unusual but rare that need immediate diagnosis and surgical restoration.
The last two years we treated two pulmonary surgical complications in our department after rupture of an echinococcus cyst of the upper surface of the liver. The first case was a 68-years old farmer whose main complaint was a productive cough with billious expectoration. He had had a CT of the upper abdomen which revealed a cystic mass in the upper surface of the right lobe of the liver with peripheral calcification and a small shadow in the adjacent part of the lower lobe of the right lung.
Because of the history this caused suspicion of bronchial communication of the echinococcus cyst and the base of the right lung.
The patient was operated on through a right thoracotomy the fistula was resected and the echinococcus cyst was extracted through the diaphragm.
The second case was a 30-years old builder who presented in the outpatient's clinic of our department urgently under shock. The x-ray of the chest revealed collection of pleuritic fluid. The patient was urgently intubated under local anaesthesia of the right hemithorax and a quantity of about 1000cc of purulent liquid was collected. The patient's condition was automatically improved.
The CT of the upper abdomen revealed an echinococcus cyst of the upper surface of the liver that was ruptured to the hemithorax. He had had a right thoracotomy, the echinococcus cyst was resected through the diaphragm and the cystic wall was closed, using a MENTEs, Mustafa KORKUT The HPB Surgery Unit, Department ofSurgery*,AegeanUnIversity Faculty of Medicine, Izmir, TURKEY A retrospective study was planned to identify factors that may be responsible for complications that arising after for the surgery for the hydatid disease of the liver. Data were obtained from the hospital records of 387 patients that were operated at the Aegean University Hospital, for hydatid disease of the liver during the last decade. Twenty-five variables determined during the preoperative period were evaluated in multivariate analysis. The nature of the cyst content and the type of operation performed were added as operative variables.
Patients having hydatid cysts of the liver were treated with simple drainage in 35 cases, with omentoplasty in 248 cases, with introflexion in 61 cases, and with cystectomy in 43 cases. Mortality was observed in 6 (1.6 %) patients mainly due to coagulation disorders (2 patients), biliary sepsis (2 patients) and coexisting medical diseases such as cardiac and renal failure. Major complications were encountered in 24 6.2 %) patients, (mainly bile fistula, wound disruption, pneumonia) and minor complications were observed in 16 (4.1%) patients (wound infection, pleural fluid collections, urinary tract infection). The overall morbidity was 10.3%. Higher serum bilirubin levels (p<0.001), the presence of ascites (p<0.001), bilober hydatid disease (p<0.001), multipl cysts (p<0.001), extraabdominal cysts (p<0.01), and coexisting medical diseases(p<0.01) such as chronic lung disease, and cardiovascular diseases were risk factors likely to lead to complications during the postoperative period. The t319e of the operation performed and the nature of the content of the hydatid cyst had no predictive effect on morbidity.
The important variables forthcoming from the multivariate analysis suggest that the intrahepatic extension of the disease besides the functional reserve entrapped by the hydatid disease has an important role on the postoperative period. Combined treatment strategies may be reasonable in patients with such advanced hydatid disease states.
It is concluded that hepatic hydatidosis and its complications consists still a surgical problem, with long hospitalisation time mainly due to postoperative complications. In elderly, mortality rates remain high, underlining the severity of this parasitosis. Ultrasonography is considered to be very useful diagnostic technique in investigation of the liver and allows direct visualization of hydatid cysts in this organ. The purpose of study was, using this diagnostic method, to describe the morphological appearance of hepatic hydatid cysts and to define the changes following chemotherapy. The sonogaphic images of hydatid cysts in the liver studied in 67 patient with echinococcosis. Thirty patients treated with albendazole and 36 with mebendazole. The hydatid cysts examined before initiation of chemotherapy to analyse the ultrasound and to classify the patterns of cystic lesions. The changes in ultrasound appearance of the cysts undergoing medical treatment evaluated during therapy and follow-up period. Before therapy four types of cyst appearance observed. The greatest number of cysts less spherical in shape with fluid collection and pletely anechoic. A limited number of cysts also with fluid collection but with split walls, causing detachment of membrane, other showing multicystic appearance due to development of daughter cysts. The fourth type of cysts, less frequent, characterized by hyperechoic appearance with thick and calcified walls. Following chemotherapy anechoic cysts became hyperechoic. Separation of endocyst from ectocyst observed, producing ultrasound water lily sign. Cyst size reduction and/or deformation occurred later, predominantly in smaller cysts. Some cysts with daughter cyst, with mixed echostructure, later increased their echogenicity due to rupture of daughter cysts. The most The rupture of echinococcal cysts into the biliary tract is a common and severe complication of liver hydatid disease. There is a number of patients in whom the presence of the cysts is not diagnosed during the initial operation. Five such patients were referred to our Clinic and were succefully treated. Three patients, 2-3 years after the initial operation, presented with biliary colic and jaundice The echinococcal cysts were found during the biliary tract exploration andthey were treated by T tube placement and continuous infusion of hypertonic saline in the biliary tree or choledochoduedonostomy. The fourth patient was operated for choledocholithiasis and the presence of the primary cyst was diagnosed by T tube cholangiography and was reoperated and submitted to evacuation of the cyst and omentoplasty. The fifth patient was referred for a biliary fistula and the diagnosis was established by ERCP and was treated by sphincterotomy and continuous infusion of hypertonic saline through the fistula. CONCLUSIONS: 1) Undetected rupture of echinococcal cysts is a serious complication, whith many diagnostic problems. 2) Diagnosis is established either by ERCP or intraoperatively 3) Treatment of the residual daughter cysts in the bile ducts is achieved either by ERCP and sphincterotomy, or operatively by T tube placement or choledochoduedonostomy and further continuous infusion of hypertonic saline in the biliary tree. 86 protoscoleces with sequale. One of the most commonly recommended and employed to prevent dissemination is to pack the operating field with sponges soaked with scolicidal agents. Howewer its effectivity has been investigated clinically experimentally. In invitro model tested the efficacy of scolicidal agent soaked sponges, lxlcm pieces of sponge cut and soaked with hypertonic saline (3%,I0%,20%), hydrogen peroxide, povidone-iodine I0%, ethyl alcohol 95% and normal saline control. A drop of scolex rich hydatid fluid obtained from public slaughterhouse sprayed n sponge pieces.
After 15 minutes they put into test tubes filled with PBS and shaken vigorously. After sentrifugation, the sediment placed slide and stained with 0.1% Eosin in order to determine protoscolex viability. Living protoscoleces do not take up the dye. Sponges soaked with hypertonic saline(20%), ethyl alcohol, povidone-iodine and hydrogen peroxide found to be effective in terms of killing the scoleces. Hypertonic saline(3%,10%) and control group found ineffective. The  rapture in most instances, unlocated biliary leaks into the cyst space frequently causes problematic postoperative complications, lntraoperative detection of such leakage points is always based on visual inspection of the cavity after evacuation of the cyst contents. However, in patients harbouring cysts, at unsuitable (atypical) locations for direct inspection, decisions on surgical treatment modalities may be blindfolded.We report eight patients with hydatid liver c?ysts at atypical locations who were evaluated by intraoperative endoscopic evaluation of the hydatid cyst cavity for the diagnosis of cystobiliary communication. Four patients had cysts at posterior diaphragmatic locations at the right lobe, two patients had cysts deeply seated within the liver substance intraparenchymall.v and one patient had medium sized cyst under the portal pedicle. Another patient had deep recegs at the wall of cyst, extending into the liver proper which did not allow direct inspection. Five of the patients had infected cysts, oue palicnt had bile stained cyst contents and one patient had history of anaphylaxis, in ,one of the patients was biliary communication demonstrated by preoperative diaguostic studies, lntraopcrative endoscopy revealed biliar}.' commuuication iu three patients and suggested biliary leakage in another. The success rate of intraoperative intracystic endoscopy ",,,'as 100% There were no complications. The data on 37 alveolar echinococcosis patients who attended the Hepatopancreatobiliary Surgery Unit of the University of Istanbul Medical Faculty between January 1979 and December 1994 were reviewed. These cases constitute 7% of all echinococcosis patients treated at the unit during the same period. The operative procedures were radical resection in 8 patients (22%), debulking surgery in 6 (16%) and biliary diversion in another 6 (16%). No intervention beyond exploratory laparotomy was possible in 10 cases (27%). Surgical exploration was not performed in 7 patients (19%) with obviously inoperable lesions. One patient, in whom the lesion had infiltrated the vena cava, the right and middle hepatic veins, died perioperatively following resection due to uncontrollable haemorrhage. There was no recurrence in the other 7 patients who underwent radicat resection (follow-up range: 2 months-5 years). Five patients who underwent a biliary diversion were asymptomatic while one was lost to follow-up. Nine patients were lost to follow-up and 7 died during this period. Long-term albendazole treatment was given to all the patients in whom radical resection was not possible.
Radical surgery is the only chance for cure in this lesion which behaves like a slowly progressing malignant tumor. Unfortunately, this is frequently impossible due to delays in diagnosis. Medical therapy should be preferred only in the inoperable cases. The analysis is done from a follow up ranging from 3 to 20 years and it is concluded that the treatment of this condition may need in many instances, the refer ral to a special HPB unit. The frecuency and morbimortality rate of biliocystic comm unications(BC) render them of great importance in hepatic hydatosis.
Review of our experience with 216 patients operated by hepatic hydatosis over the last 17 years, with 59 cases of BC(27,3%). The BC were clasified according to the moment of the diagnosis in intraoperatives and postoperatiyes and were analized the age, the sex and the morbimorta lity according to the surgical tecnique used over the cyst and over the biliary tree.
The BC were diagnosed during the operation in 44 cases and on the posoperative in 15 cases. On the intraoperative BC the tecnique over the cyst with most posoperative fistule was the marsupialization over tube (70%) and the tecnique with least fistule was the cystepericystectomie total (9%). The tecnique over the biliary tree with most posoperative biliary fistule was the only suture of BC(24%) and the tecnique with least fistule the sphincterectomy(0%). On the BC posoperatives, the fistule is presented after: Hepatectomie(O%),Cystepericystectomie total(1%),Cysteperi cystectomie partial(6%),Marsupialization(25%).
The mortality rate in our serie was of 1.6%.
Conclusions: Over the cyst the best surgical tecnique was the cystepericystectomie total, over the biliary tree the best results were obtained when the sphincterotomy was The aim of this study is to Present the experience of 3rd Surgical Dpt on seven cases of Unuscal Locations of exh]nococcosis. We present four cases of echinococcosis of the Liver and the spleen one case of multiple echinococcosis of the liver the spleen and the left femur.
One case with echinococcosis of the liver and thyroid gland and one case of echinococcosis of the liver and the scapFla as well. Also we present two cases of echinecoc, alveolaris. Diagnostic methods surgal technique that we used and post operative follow up are presented. The hydatid disease of the liver has a characteristic variable ultrasound(US) appearance depending on some well determined factors. The aim of this study was the presentation of various nteresting pictures emphasising on differential diagnosis(DD) between hydatid disease and other liver diseases. Our study indicated that echinococcal cyst might be seen on US as: (a) Simple,unilocular cyst. Differentiation from solitary non parasitic cyst is impossible. (b) The usual picture of cystic multiloculated lesion due to contained multiple daughter cysts. DD from cyst adenoma. (c) Impact lesion because of ablation of membranes from the cyst wall. DD from hepatoma, metastasis, adenoma and focal nodular hyperplasia, abscess and hematoma. (d) Partial or complete calcification of the cyst wall. The latter indicates inactive disease. (e) "Crescent sign", when the ablation of the laminated membrane(endocyst) from the adventitia(ectocyst) is partial and local; "floating water-lily sign",when it is more extended; "cyst into cyst" when it is complete. (f) Thickened wall and impact lesion,because of infection and abscess formation. DD as in (c). In conclusion, it seems that US is a simple, safe and inexpensive diagnostic tool,which could evaluate all the variety of the disease giving useful information. In 1994, 8 patients underwent laparoscopy for cysts in the abdominal cavity; there were 2 males and 6 females (mean age 43 yrs and 57 yrs respectively). Five patients had one or two cysts (congenital) in the liver, one had a parasitic liver cyst, while the remaining two patients presented with a splenic cyst and a diaphragmatic cyst respectively. All the above mentioned cysts were diagnosed by ultrasonography. Three patients were symptomatic, and two of them were admitted for symptomatic gallstones. The aim of the study was to determine the advantages and efficacy of laparoscopic treatment. Unroofing of the cyst was performed in 7 patients. In one patient total pericystectomy combined with cholecystectomy was accomplished laparoscopically. The recovery of all 8 patients was ineventful. They were discharged from hospital on the 4 th postoperative day. Follow-up ultrasonography 2-6 months after surgery showed a recurrent cyst in 5 patients while two were without signs of recurrence.
In summary, the recurrence rate in our series of laparoscopic treatments for abdominal cysts was 62%. Therefore, we have to conclude that the indication for laparoscopic treatment is rather questionable even in symptomatic cysts. In comparison with fine-needle aspiration, the laparoscopic method enables us to investigate histologically the excised roof of the cyst. This possibility could be regarded as advantage in suspicious cases. Although postoperative pain in laparoscopic cholecystectomy (LC) much less than open surgery it increases postoperative morbidity and complications. THe aim of the study is to find out whether local anesthetic (LA) infiltration of the trocar sites during LC could decrease postoperative pain and also to find out the correct timing for LA. Seventy patients undergoing LC randomized into three groups: The first group (n=25) the control and 3 0.9% NaCI was injected around the each of 5 mm.trocar sites and 4 around IO trocar sites subcutaneously. In the second group (n=20) the same volume of LA (Bupivacaine 5%) injected at the beginning of the operation. In the third group (n=25) LA infiltrated at the end of opera- In 21 observatlon (10 acute, 11 chronic) the laparoscopic procedure was converted to open cholecystectomy. The comparatlve study of the 2 groups prove a lower rate of hospital stage after laparoscoplc approach but the cost can't be accourately compared (because repalng of lnvestltion In equlpment for laparoscopic approach). Unsuspected CBD stones were found in 18 patients. Stones were removed intraoperatively using a small choledochoscope through the cystic duct in patient. ERCP and EST were performed in 17 patients with successful stones removal in all. CBD access was possible in patients after a needle-knife papillotomy and nasobiliary tube was used in 7 patients. One patient developed mild pancreatitis which was treated conservatively. 52 patients had abnormal preoperative liver function tests.
It is concluded that normal liver function tests reduce the risk of associated CBD stones (p=0001) without reducing it to nothing. Preor post-operative ERCP, EST and CBD clearance combined with Laparoscopic Cholecystectomy is a safe and effective treatment in patients with gallbladder and CBD stones. Laparoscopic cholecystectomy has become the procedure of choise for surgical removal of the gallbladder and it is more popular than the traditional procedure. Five houndred twenty seven laparoscopic cholecystectomies were done in our department between June 1992 and December 1994. In 16 patients (3 percent) the operation was converted to conventional open cholecystectomy. The most common reason was the inability to identify safely the cystic duct and the cystic artery (11 cases). Other reasons were: injury of the common bile duct (2 cases); injury of the junction between cystic and common bile duct (one case); diverticulum of the common bile duct (one case); cancer of the gallbladder (one case). The mean hospital stay for the patients was 1,1 days. We perform laparoscopic cholecystectomy since 1990 (n>1500). The conversion rate from endoscopical to conventional cholestystectomy remained constant. Our aim was to investigate different factors influencing the decision for the change of the surgical approach.
The decision whether minimal invasive or conventional cholecystectomy is to be performed takes account of age, individual risk factors, etc. However, besides technical difficulties and/or anatomical variations also intraoperative complications (bleeding, bile duct injury etc.) occured in some patients. Although it seems to be impossible to avoid every conversion of the surgical method, exact history and preoperative diagnostic examination may reduce the number of laparotomies.
In our patient group, we observed in tendency, that previously performed abdominal surgery represents the only factor indicating a higher risk of severe adhesions leading to technical problems during laparoscopic surgery. The  Though Laparoscopic Cholecystectomy has become the gold standard treatment for Gallstone disease, Laparoscopic management of malpositioned gallbladder is difficult and the technique needs to be improved for successful cholecystectomy. Though June 1991 to October 1994,1250 patients gallstone disease were treated by laparoscopic method. 11 patients had abnormally placed gallbladder. The Mal Position as follows: A.Situs inversus totalis-1, B.Left lobe 3 C.Quadrate lobe-4 and D.RT Lobe liver-3. The problems: a,Difficult traction of liver b, cystic duct joining the Left Hepatic Duct in 6 patients. Trocars were positioned in different places for good exposure. In left lobe and quardrate lobe gallbladder extra port was made to lift the quadrate lobe and the working port was made in the left mid clavicular level. In situs inversus, trocars were placed as mirror image of the standard technique.
Retrograde cholecystectomy was performed in 5 patients where cystic duct joining the left hepatic duct deep in the hilum in four and liver plastered to the chest wall in one.. Modified subtotal cholecystectomy was performed in 4 patients by dividing the gallbladder at the infundibulum and the neck 'qe cystic duct was covered by suturing the flap.
In all the 11 patients laparoscopic cholecystectomy was performed successfully. patient had bile leak treated conservatively. Post operative recovery was similar to standard Laparoscopic Cholecystectomy. bladder cancer 4 ), and cholecystoduodenal fistula ). Of the remaining 1229 laparoscopic cholecystectomy, approximately 15% were considered difficult. These included chronic contracted gall bladder with acute attack 68 ), gangrenous cholecystitis 31 ), exam-large stone without free lumen of gall bladder 35 ), porcelain gall bladder 21 ), embedded gall bladder 23 ), short cystic duct 19 ), stone impact/on at the cystic duct 25 ), anatomical variation of cystic duct and/or cystic artery 24 ), severe adhesion from previous upper abdominal surgery 81  Currently the laparoscopic cholecystectomy (LC) has been adopted by many surgical centres as the method of choice for the therapy of cholelithiasis.
Over the past three years LC has been undertaken on 221 chololethiasic patients, which was successful in 208 of those (179 females and 29 males, 17 to 78 years old, average age 47.58 years old). Criteria for selection of this method were the absence of obstructive jaundice in the past history of the patients and previous operations in upper abdomen. In thirteen patients (5.8%) the laparoscopic method was converted to open operation due to the thickness of the gallbladder wall and to the solid adhesions in Calot's triangle. Hasson's procedure was used in 78 patients because of previous sub-umbilical laparotomies, and laparoscopic cholangiography was performed in 9 cases. LC by the fundus was carried out in five cases due to difficulties in preparation of cystic duct and artery, which were ligated after the gallbladder was mobilized. Serious intraoperative complications were not observed and the mean operative time was 2 hours. Postoperative complications occurred in four patients (1.92%). One patient required prolonged exploration due to bile leak after a presumed diathermy injury of the CBD. Bile leak was observed in a second case caused by bad application of clips on cystic duct, DV-I in a third case and subcutaneous emphysema in another one. In all the patients antibiotics were administered perioperatively, anti-thrombotic agents were also given and sub-hepatic drainage was established in all patients for 24 hours. In the rest of the patients, the post-operative recovery was uneventful, the average time of hospitalization was 2.6 days and the patients returned to their normal activities after one week.
In conclusion, laparoscopic cholecystectomy has now become a method of choice for the treatment of chololethiasis. This method, for its advantages, is embraced with confidence by the patients, because it rids them of their disease avoiding the trouble of open cholecystectomy.

92
COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY in 1090 cases 87.2 %), acute c; olecystitis in 111 8.8% and gallbladder polyps in 4(. 0.3 %). The diagnosis was confirmed in all cases by ultrasound. Because of presumed pathology on ultrasound, suggestive for common bile duct stones or papillary stenosis 63 patients 5% had preoperative ERCP. In all patients with calculi n= 40 endo scopic stone removal was successfully performed with sphincterotomy. Morbidity was 1.6% after ERCP. The procedure needed conversion in 21 cases 1.7 %) The reasons for conversion were severe adhesions 9 ), CBD stones found by IOC 3 ), CBD injuries 2 ), Gall bladder cancer 4 ), and cholecystoduodenal fistula 3 ). Other ntraoperative complications which did not require conversion included bleeding 11, perforation of the gallbladder 223, laceration of the cystic duct 3, stones left in the abdomen 45 etc. Morbidity rate varied between o to 7.2%. Mortality rate was 0%. Technical complications in 4 cases. Six patients required reoperation dislodgement of cys tic duct clips 1, bleeding of liver bed 1, bleeding of trocar place 2, and bile leaks 2. Follow up showed 21 patients with retained stones. Minor  The authors present 250 laparoscopic cholecystectomies as compared to a similar number of conventional cholecystectomies. The analysis comprised the length of stay in hospital, the time of convalescence and return to professional activity, the necessity of postoperative antibiotic administration, as well as the cost of the operation surgical tools and other equipment, sutures and dressing materials ), anaesthesia, postoperative therapy and accommodation. Also assessed were such subjective effects as the look of the scar, peri-and postoperative stress and the time of return to full vital activity.
It was proved that laparoscopic cholecyscectomies had substantial advantage over the convential ones, i.e., they facilitate shorter hospitalisation time, quicker return to work, much lower costs of medicamental therapy, reduced stress and better cosmetic effects. I"HE INCIDENTAL GALLBLADDER NEOPLASIAS SEEN DURING LAI'AROSC()PIC CHOLECYSTECTOMY; IS IT A DILEMMA ?
The incidental diagnosis of gallbladder neoplasias during cholecystectomy is said to be seen in one percent of symptomatic cholelithiasis, in 15-30 % of these cases diagnosis can only be made during histopathological study postoperatively.
The incidence of such neoplasias seems to have decreased in the published series, following the widespread use of the "gold-standart'" iaparoscopic cholecsytectomies. The question is whether there is a true decrease in the rate or some neoplasias are being overlooked. This paper is a prospective study concerning 100 endoscopic surgical interventions. We have seen two cases with incidental neoplasias without any symptoms prior to operation. In one of these cases the pathologist had to confirm the diagnosis only after histopathologic study, where both cases were classified as pT2. The influence of shunting or sclerotherapy on the development of hepatic encephalopathy has not been clearly defined. Results from several studies vary considerably. The problem of post shunt encephalopathy has been revived in the 90's with the introduction of TIPSS which has an incidence of encephalopathy between 15 and 25%. We report the incidence of hepatic encephalopathy in a prospective study comparing mesocaval interposition shunt and endoscopic sclerotherapy in the prevention of rebleeding from oesophageal varices.
Material and methods: 24 patients were randomised to shunt and 21 to sclerotherapy. All Child's classes were represented. Encephalopathy was evaluated by EEG with spectral analysis and a battery of psychometric tests.
Results: 9 patients exhibited mild to moderate encephalopathy preoperatively.
All these patients remained encephalopatic, two of them detoriated post shunt. In the sclerotherapy group 13 patients were encephalopatic. In both groups the patients were encephalopatic before start of study and remained so through out follow up. The psychometric tests showed that patients in the shunt group performed significantly poor in tests measuring verbal ability, visual performance and logic inductive capacity and intellectual capacity.
Conclusion; We could find that the shunt group had a significantly poorer performance in three psychometric tests during follow up but this did not influence the total score of all psychometric tests in that it did not create any significant difference between the shunt group and the sclerotherapy group.

MATERIAL AND METHODS
We've performed in 4 cases esophageal transection with a Biofragmentable Ring associated to splenectomy and gastric disconection. CONCLUSION We've achieved control of bleeding situation, withno complications directed related to the procedure.
We assess the Biofragmentable Ring with daily X-Ray and contrast esofagogastric X Ray 10 days after Surgery.
Endoscopy was performed two weeks after surgery, we haven found any leakage or significative stenosis, and we've realise the disruption of the ring by 12 day after surgery. We think in emergent situations it is an easy and efective procedure to performe but only to control bleeding esophageal variceso Bleeding esophageal varices is the leading cause of death in patients with schistosomal portal hypertension. The objective of this study was evaluate the effectiveness of a non-shunt operation associated with endoscopic sclerotherapy for the elective treatment of schistosomal portal hypertension.
From August 1988 to August 1993, 84 patients with hepatosplenic schistosomiasis (confirmed by liver biopsy) and history of upper gastrointestinal bleeding were prospectively studied. The surgical procedure was always performed by midline laparotomy and consisted of splenectomy, devascularization of the abdominal esophagus and proximal part of the stomach and esophageal fundoplication. The sclerotherapy was performed by intravariceal injections of ethanolamine, the first session done two months after the operation and continued at three-monthly intervals till obliteration of varices was achieved.
The authors conclude that esophagogastric devascularization associated with endoscopic sclerotherapy represent a good alternative for the elective treatment of schistosomal portal hypertension.

Zabrze, Poland
The most dramatic complication of portal hypertension is oesophageal varices haemorrhagia. Surgical treatment tends to control this in spite of hypertension decrease in portal system or inflow portal blood reduction to oesophageal varices. In our surgical department in 1986-92 36 patients with portal hypertension caused by praeor intrahepatic block were treated by surgical operation. In anamnesis, before operations patients reported one or more cases of haemorrhagia from oesophageal varices. In Child's scale three of them were in C-level, 25 in B and eight in A. Till 1988 in treatment of portal hypertension vascular operations were performed and operations called "non shunt", from which assent oesophageal transsection with following anastomosis with front wall of stomach bottom with devascularization underdiaphragmatic part of oesophageus, bottom and trunk of ventricul, with pyloroplasty and splenectomy by abdominal entrance. In the begining, transsection and oesophago-gastro anastomosis was made by a traditional method. For four years transsection (with ILS appliance) complemented by spleno-renal anastomosis by Linton method have been made both of kinds of operations simultaneously. Combination of both operation techniques leads to the reduction of portal hypertension and also prevents rebleending from oesophageal varices. In 14 cases simultaneous operations were performed. From this group 3 patients died before the 14th day after operation. In 11 cases under observation from 6 to 52 months no broaden of portal or splenic vein were noted in ultrasound examination. In control gastrofiberoscopy in two cases there was ascertaining presence of oesophageal varices and in nine variceal changes have completly retracted. In postoperative control biochemistry examinations (albumins level, GOT, Girl", GGTP, bilirubine, time and content of protrombin) show moderate level of hepatic function handicap. Alterations in splanchnic hemodynamics play key role in the development of portal hypertension and it's complications in liver cirrhosis. The aim of the study was to evaluate results of serial determination of hemodynamics in 30 cirrhotic patients (Child class B-18,. C-12), who undergone splenic artery occlusion (SAO) and subsequent endoscopic sclerotherapy (ES). ES began 14 days after SAO and repeated every 6 month. Measurements were performed before and after SAO and ES using duplex Doppler flowmeter system (ml/min) and included the following parameters: splenic arterial flow (SAF), splenic venous flow (SVF), portal venous flow(PVF) and hepatic arterial flow (HAF). P values < 0.05 were considered significant (*).
Preoperative indices were the following: SAF-436.1, SVF-776.6, PVF-846.1, . Postoperative studies (10-12 days after SAO) revealed reduction of SAF-213.1*, SVF-522.0', and PVF-541.0*, whereas HAF increased to 150.8'. The efficacy of long-term injection sclerotherapy (IST) in eradicating oesophageal varices after endoscopically proven variceal bleeding was assessed prospectively in 204 patients between 1984 and 1989. Data were analyzed in December 1994 to allow a minimum 60 month follow-up. The 204 patients (127 men, 77 women; mean age 50.3, range 16-82 years) underwent 1022 emergency and elective injection treatments with 5% ethanolamine oleate using a combined intra and paravariceal technique during 1860 endoscopy sessions during the study period. The majority (167;82%) had cirrhosis, mainly due to slcohol (131 ;64%). The Pugh-Child's risk grades were A:26, B:94, C:84. Seventy-five (37%) of the 204 patients had a total of 130 bleeding episodes after the first hospital admission before eradication of varices (0.03 bleeding episodes per patient month of follow-up). Rebleeding was markedly reduced after eradication of varices. In the 100 (87%) of 114 patients who survived >3 months, varices were eradicated after a mean of 5 injections and remained eradicated in 47 [mean follow-up: 71.5 months; range:5-120 months]. Varices recurred in 53 patients and rebled in 18 of whom only 8 rebled from oesophageal varices. Cumulative survival by life table analysis was 55%, 42%, and 32% at 1,3 and 5 years. 113 patients (55.4%) died during follow-up. Liver failure was the most common cause of death. Of the 236 complications which occurred in 139 (68.1%) patients, mucosal slough (137 patients) was the most common. A Iocalised injection-site leak occurred in 9 patients and oesophageal stenosis developed in 23 patients of whom 14 required dilatation (mean:4; range: 1-7 dilatations). Free oesophageal perforation occurred in 5 patients, 4 of whom died. Repeated fibreoptic IST eradicates oesophageal varices in the majority of patients with a reduction in rebleeding. Complications related to IST were mostly of a minor nature but became cumulative with time. Group I of 33 pts underwent proximal SAE with coils. Splenectomy (mostly with omentohepatopexy) was performed in 19 pts of Group II. Both roups were fully comparable. The mortality was % in Group I (.variceal bleeding and sepsis each I) and 5% in Group IX(sepsis I). The complication rates were 24% (splenic abscess 2, left-sided pneumonia-3, increase of ascites-3) vs 10% ( subphrenic abscess and operative bleed'ngeach I ). In Group I, the platelet count (PC) increased significantly I mo later but then returned o the pre-AE level. In Group II, signigicant improvement of PC during 3yr period of fellow-up. The 5yr sival rates in Groups I and II were 35% and 80% (.05 P .). These results showed that surgical splenectomy is more effective than proximal SAE in correction of hyperspleniam in patients with nonadvanced hepatic cirrhosis. oreover, splenectomy has at least equal or even less morbidity and mortality. was made with Ivalon/Gelfoam followed 2 weeks later by ultrasound-guided local sclerotherapy with 50% to 99% ethanol and/or thrombin. FAH was performed in 10 patients with 22 CHL. 1anetic particles I M.m to 10 Bm of Ba2Fe206 (2 to 40 g, mean 12 g) were injected directly into the tumor under local external manetia field. Local hyperthermia using ultra-high frequency machine was made. I to 3 weeks later. Aseptic necrosis and vascular thrombosis was seen in to 3 months after each treatment with followin fibrosis 3 to 24 months later.
Clinical improvement in all but 2 cases and 10% to 50%. tumor decrease was seen during 5 to aO month follow-up. It may be concluded that both treatments ES anf FAH are egually effective, and seem to be useful in the managemenu of selected patients with highly symptomatic inoperable CHL. The sonographic parameters in portal hypertension (PHT) were examin in a consecutive population of 100 patients who had PHT, diagnosed using specific endoscopic, sonographic and Doppler signs. A patent or enlarged paraumbilical vein was found in 85% of the patients overall and 82% of the patients with variccs, indicating a relatively high sensitivity. A portal vein of diameter 13 mm was found in only 42% and 15 mm in only 18% of the patients. A thrombosed portal vein and reversed portal vein flow were present in 4% and 6% of the patients, respectively. These signs have only been reported in the context of PHT and are felt to be specific for PHT, but both have very low sensitivity. Portal vein velocities were highly variable, suggesting that this is not a useful predictor of PHT. Splenomegaly was found in only 54% of the patients, demonstrating its poor sensitivity as a sign of PHT. Variccs were found in 76% of the patients overall and in 100% of the patients with patent or enlarged paraumbilical vein combined with ascites.
We conclude that the presence of a patent or enlarged paraumbilical vein is a practical, useful and sensitive ultrasound sign to look for in the diagnosis of PHT. We report the of 16 year old male patient who experienced winter sports accident (sledge collision) with blunt abdominal trauma. Primary treatment of the intraabdominai haemorrharge was by emergency laparotomy; control of bleeding was attempted by application of intraabdominal perihepatic swab packing. 16 hours after the trauma, the patient was refered to institution for definitive treatment. He presented with hypovolaemic shock, hypothermia and coagulopathy. After adequate fluid replacement, correction of coagulopathy and stabilisation of vital parameters, further radiologic evaluation (CT-scan, angiography) revealed large intrahepatic haematoma with ongoing intrahepatic arterial bleeding from branch of the right hepatic artery; control of bleeding was achieved by repeated selective coiling of the ruptured vessel. After stable interval of 12 hours, relaparotomy was performed with complete removal of the package, lavage and definite abdominal closure. The patient remained haemodynamically stable thereafter, but developed progressive swelling of both lower limbs; suspected compartment syndrome was confirmed by pressure measurements, and bilateral complete fasciotomy was immediately performed. The ethiology of the compartment syndrome was most propably severely compromised venous outflow during the abdominal packing period, possibly intensified by prolonged shock and hypothermia. Repeated operative debridement with removal of avital muscle was necessary. The patient required 13 days of ICU treatment and treatment was continued in the unit of reconstructive traumatology. The further clinical course was largely uneventfuli; small bile fistula could be diagnosed by endoscopic retrograde cholangiography but resolved spontaneously. The patient recovered completely from his intraperitoneal injury but has residual handicaps in his lower limb function.
All patients had melaena, 5 had haematemesis and RUQ pain was present in 8 patients. Only 2 patients were jaundiced. Bleeding from the ampulla was identified in 2 patients during ERCP. Endoscopy identified fresh blood in the second part of the duodenum in 7 of 10 occasions. A liver lesion was identified in 6 of 10 patients who underwent either CT scanning or liver ultrasound. Selective hepatic angiography demonstrated an intrahepatic bleeding source in 13 patients. An arteriobiliary fistula in the gallbladder in patient was not identified by angiography. Selective hepatic arterial embolization using either gelfoam pledgets or Gianturco coils controlled bleeding in 10 of 12 patients. Embolization failed in 2 patients (1 with segmental liver necrosis required a right hepatic Iobectomy and a second patient underwent surgery and ligation of the left hepatic artery). Bleeding from the gallbladder in patient was treated by cholecystectomy. Selective hepatic artery embolization was not attempted in patient who underwent a left hepatic Iobectomy.
Selective hepatic artery embolization was successful in 10 of 12 patients (83%) of whom patient developed subsequent complications. Selective hepatic artery embolization provides definitive control of liver bleeding with a low incidence of complications and should be considered the primary treatment of choice for intrahepatic haemobilia. Despite it's protection by the lower rib cage, the liver is frequently injured by blunt mechanisms because of its large size and relative inelasticity.
We present the results of 6 months follow-up of a large central posttraumatic hepatic haematoma. This developed as a result of blunt abdominal trauma and was diagnosed with C.T scan. Monitoring was based on Uitrasonography and Computerized Tomography. The significant change in the echographic pattern and the change of size of the haematoma in the C.T scans indicated its organization.
The purpose of this study was 1) To show the U.S and C.T findings in the hepatic haematoma in relation to the time after trauma. 2) To suggest that in haemodynamicaUy stable patients with intrahepatic haematoma, where the diagnosis can radiologically ascertained, conservative treatment is a safe and reasonable option. At the first step management of the 23-year old patient in a regional hospital only inadequate tamponade of the liver injury and occlusion of the Rhumle's tourniquet had been performed. Transportation to our department had taken unexpectedly long time (2,5 hours) and additional vascular occlusion (35 minutes) was needed to perform liver resection (V.,VI.,VII. and VIII. segment). Long duration of vascular occlusion was caused by exceptional circumstances at that time in our country. Data of managements, events and laboratory findings are presented. There were no major complications and the patient was discharged the day 20 th after the operation.
Two years after the accident and the right hepatectomy the patient is well and healthy, weighting 95 kilograms and working as a Hepatic injury occurs as frequently as does splenic injury in children and it is caused mainly by vehicle accidents and falls. Selective nonoperative management is based on the experience that about one half of patients operated on for hepatic trauma require only drainage of a non-bleeding laceration. The aim of this study is to assess the efficiency and the reliability of the conservative treatment in patients with liver injury. Twelve patients with blunt liver trauma were treated in our Department during a nine year period. Ten of them were treated successfully without operation, but two children required laparotomy on admission because of hypovolemic shock due to intraabdominal hemorrhage. Ten patients were diagnosed on admission by ultraonography or CT scanning and they were submitted to the concervative management with excellent results. Our protocol for this treatment is as follows: d rest for about ten days, close monitoring of the vital signs, serial hematocrit and hemoglobin evaluations and blood transfusions up to 50% of blood volume as needed to maintain hemodynamic stability. At the 10th day the U/S or CT scanning was repeated in order to evaluate the course of the hepatic trauma. All patients who were treated nonoperatively had an uneventful course, as well as one of the two operated patients who had additional renal damage. other patient who was operated on for multiple deep hepatic lacerations needed reoperation for a hepatic abscess. Based on our experience we believe that non-operative management of hepatic injaries is the treatment of choice in precisely selected patients submitted to close monitoring; it is effective and safe method without cmplications following laparotomy. In order to evaluate the tolerance and postoperative course of major hepatectomy in ederly patients we retrospectively studied an homogenous subgoup of 16 patients aged > 70 years who underwent a RH (segment V, VI, VII and VIII).
In conclusion, this work shows that in selected patients, the clinical tolerance of RH seems not to be according to age despite a more important impairing and a longer recovery of the liver function in the group age > 70 years. Both safety and feasibility of major hepatic resection have been considerably improved by the use of hepatic vascular exclusion (HVE). However, extended left hepatectomy remains a challenging procedure with increased risks of biliary damage. We therefore retrospectively reviewed our experience of such hepatic resection with particular regard to biliary complications.

P072
From Jan 1986 to Nov 1994, out of 320 hepatic resections, 13 patients (6 men, 7 women) of mean age 49.2 12.3 yrs (range: 25-67) underwent a left extended hepatectomy, i.e. resection of segments II, III, and IV plus either segments V-VIII (n=6), or segments I-V-VIII (n=5) or segments I-V-VI (n=l) or segments V,VI,VIII (n=l). Indications were the following: intrahepatic biliary carcinoma (n=5), hepatocellular carcinoma (n=3), secondary malignant tumours (n=3) benign tumours (n=2). Portal fibrosis was present in 3 cases and cholestasis in 1. The procedure always began with section of the left portal pedicle. The parenchymal transection was done under HVE in 11/13 cases (median duration: 50 min, range: 5-70). Tile portal pedicle of the left paramedian sector (i.e. supplying segments V ano VIII) to be ligated was localized using a probe introduced through the left bile duct. When resection was completed, methylene blue was injected in the bile duct to detect leakages from the transected surface. Two patients also had bile duct resection and hepaticojejunostomy on the bile ducts of segments VI and VII.
No postoperative death occurred. Six biliary complications occurred in 5 patients: bile leak (n=5) and stenosis of the right bile duct (n=l). Bile leakages resolved spontaneously in less than 3 months in 2 patients, required percutaneous drainage in 2 patients and reoperation in patient. Right bile duct stenosis required hepaticojejunostomy 9 months after hepatectomy.
Biliary stenosis recurred and was treated by transhepatic dilatation. In these patients, early CT-scan did not show any parenchymal ischemia of the remnant liver. The 2 patients who had intrahepatic hepaticojejunostomy did not experience any biliary complication.
In conclusion, this study shows that the incidence of biliary complications is especially high after left extended hepatectomy. The mechanism which accounts for bile leak is likely to be an ischemia of the right lateral bile duct due to intraoperative injury of its blood supply. The biological pattern of liver failure after liver surgery resembles that of sepsis. Several cytokines are involved in the acute phase response to sepsis and surgery. Aim. To investigate the systemic cytokine response to major liver surgery as the basis for potential novel therapeutic strategies. Methods. Thirteen patients undergoing elective liver surgery entered the study. All patients underwent operation using total vascular exclusion (TVE) of the liver. Samples of venous blood were taken from a central line preoperatively, intraoperatively six minutes after TVE, and during the first four postoperative days. Endotoxin, interferon gamma (IFN), Tumour Necrosis Factor alpha (TNF), Interleukin-1 (IL-1) and Interleukin-6 (IL-6) were measured. A clinical scoring system was used to evaluate the outcome of the patients during the postoperative periott.
Results. There were 6 right hepatectomies, 2 right extended hepatectomies, 4 segmental resections and left hepatectomy. Time of total vascular exclusion of the liver was 32 + 2 minutes. Endotoxin levels were raised in 3/13 patients before surgery and in 6 patients during the postoperative period. TNF concentrations were undetectable. IFN and IL-1 responses followed a low and inconclusive pattern. IL-6 showed a significant increase from 6 h after operation to the third postoperative day, peaking at 699 + 277 pg/mL at 24 h after surgery. Two patients who died had the highest levels of postoperative IL-6. The intraoperative IL-6 level correlated with the change in the organ dysfunction score.
Conclusion. There is a marked systemic IL-6 response to liver surgery under TVE that correlates with the postoperative outcome and might be used as an indicator of the response to specific treatments in this type of surgery. Therapeutic interventions which minimise the IL-6 response to major liver surgery may be of value. It is well known the correlation of H. pylori (HP) and peptic ulcer disease (PUD) and the high prevalence of HP in healthy Greek population (70%) as well.
It is also well known the increased frequency of portal gastropathy (PG) and PUD in cirrhotic patients (CP). But it is not known the prevalence of HP in this subset of population. For this purpose we studied 46 CP who didn't have any evidence of PVP. 39 were males and 7 females Mean age 58,3+10 years (37-78). 23 had alcoholic cirrhosis, 10 posthepatic HBV, 9 posthepatic HCV, posthepatic HBV and HCV cirrhosis, primary billiary cirrhosis, cryptogenic and autoimmune cirrhosis. 16 of pts were classified as having Child A cirrhosis, 20 child B, and 10 child C. All pts had an upper GI endoscopy and biopsies for CI..O test were taken. The prevalence of HP and its correlation with cause and severity of cirrhosis (Child system), the patient's age, the sex and the coexistence of PUD and PG were studied. For statistical analysis chi-square test was used.
H.P. w-as detected in 6 pts (13,5%). All were males 5 were classified as child B and one as child A. In HP positive pts 4 had posthepatic B cirrhosis and one alcoholic cirrhosis. 5 pts had mild PG while in Hp-negative group of pts 4 had severe PG, 34 mild PG and one had duodenal ulcer.
In conclusion;the prevalence of HP in CP is low (13,5% versu 60% in Greek population) but is mildly increased in pts with child'cirrhosis (p=0,005) and in pts with posthepatic B cirrhosis (p=0,002). Finally there is no correlation with age, sex and coexisting PG or PUD.

ROLE OF PROSTANOIDS IN REGULATION OF HEPATIC BLOOD FLOW AND MICROCIRCULATION IN CHRONIC HEPATITIS AND CIRRHOSIS PATIENTS
A.Yagoda, I.Shestopalova, Y.Radtsev Department of Internal Diseases No. 1, Medical Academy, Stavropol,

Russia
Products of unsaturated fatty acids metabolism prostaglandins (PG), prostacyclin, thromboxane can contribute to regulation of the hepatic blood flow. The exact role which these vasoactive substances play in the impairment of hepatic circulation in chronic hepatitis (CH) and cirrhosis (C) patients remains unclear. A total of 62 patients with chronic persistent hepatitis (CPH, 27), chronic active hepatitis (CAH, 13) and cirrhosis (C, 22) were studied. Hepatic blood flow (HBF) was tested using the dye (ueviridin) dilution techmque, and the condition of the microcirculation was assessedby a biomicroscopy of the conjunctival blood vessels with subsequent calculation of the ,conjunctival index,> (CI). In liver specimens, the levels of prostaglandins (PG) PGE, PGF2a, 6-keto-PGFla, thromboxane B2 (TB2), along with their synthesis from 3H-arachidonic acid were assayed by the RIA. 17 healthy volunteers served as controls. A significant decrease in HBF with boost in microcirculatory disorders level (CI), consistent with the severity of the disease, was observed in the patients with CH and C. The patients with CAH had decreased tissue contents and/or scnthesis of PGE, 6-keto-PGFla, and increased levels of PGF2a synthess (compared to those with CPH). The relative increase in the levels and synthesis of TB2, PGF2a, along with decrease in PGFla and PGE contents and/or synthesis took place in C patients. In all the groups tested (in CAH especially), the pattern of correlative interrelationship of TB2 and PGF2a with the CI parameters was straight, and with the HBF index reverse. On the other hand, tissue levels and synthesis of PGE and 6-keto-PGFla were directly related to the HBF index, and reversely to the CI indicator.. The results of the study give ground to the possibility that the groups of prostanoids could alternatively affect the hepatic blood flow and the microcirculatory vessels. The impairments of microcirculation and HBF in CAH and C patients could be also related to the unbalanced hepatic synthesis of PGs and thromboxane. The results of the surgical treatment of 45 patients with the liver cirrhosis were observed. The postoperative mortality was 17,8%, complications 43,2%, in which purulent-septic complications were more often met in virus cirrhosis. In the complex investigation the immunological criteria prognosis of the outcome surgical intervention was recommended. Analysis of the death cases after operation gives the possibility to determine more significant decrease of Tlymphocytes level (0,420_+0,039. 109/1) in the blood, on the given category of patients, with the hyperproduction of Ig(3 (9_2,56 :t: 3,91 g/l) and IgA (3,03 + 0,63 g/l). At the same time, lgMthe marker of the primary immune answerwas decreased (1,00 + 0,19 g/l). The deep depression of the neutrophile phagocytic function was observed (phagocyte index 44,38 +__ 2,47; phagocyte number 2,21 +_ 0,19). The disturbance in the immunoregulatory lymphocytes with hyperstimulation production immunoglobulins of the G (26,45 +/-4,57 g/l) and A (6,53 _+ 0,91 g/l) classes, the complement decrease and deficit of the polymorphonuclear leukocytes phagocytic function progressed after operation. In these cases, immunoglobulins of the main classes intensified the spontaneous aggregation of thrombocytes and also aggregation, which had been evoked by ADP, adrenaline and collagen.
Therefore Purpose ofthe study: The study was conducted to evaluate whether new imaging techniques had influenced or even substituted older routines for liver, biliary tract and pancreatic diagnostics.

Material and methods:
For the period between 1075 and 1993 files from five Norwegian hospitals were analysed retrospectively.

Results:
In all hospitals, X-.ray based examinations ofthe biliary tract, oral cholecystography and intravenous cholangiography, disappeared completely as ultrasonography (US) came into use. Likewise, an extensive use of scintigraphic examinations ofthe liver disappeared after introduction of both computed tomography (CT) and US, which in tum reduced the number of CT examinations ofthe liver substantially. With regard to pancreas, CT being the method of choice for some years also seems to have been replaced by US.

Conclusion:
The present study confirms that new imaging techniques rapidly are adopted into clinical routines not only as a supplement, but as a real substitute for older, more risky and more unreliable methods. This study was performed to assess the feasibility and success of combination of lymphosorbtion and medical therapy vs medical therapy alone in liver cirrhosis complicated by ascites. Combined treatment was utilized in 28 patients with Child-Pugh class B (5 pts) and C (23 pts) liver cirrhosis (Group Lymph purification and reinfusion (500 ml to q500 ml dayly) was performed using chronic external surgical catheterization of the thoracic duct. h.e carbon dsorbent with fibers of 8x10-to 12x10-3 mm in diameter and 2ma/g external geometric surface was used for lymph purification. Control Group 2, 7B and 29C class of cirrhosis patients, received only conventional medical therapy. In 2 weeks after beginning of the treatment, decrease of ascites was seen in all pts of Group 1 vs 70% of Group 2. Their diuresis was +1100 ml/day vs +200 ml/day and their weight loss was 7 kg vs 1.5 kg, respectively. Gastroesophgeal varices decreased in 50% vs 0%, and encephalopath diminished in 90% s 30% of pts, respectively.
These data showed that lymphosorbtion combined with medical therapy is more effective than medical ther.ay alone .n the mnagement of patients with lver cirrhosis ana ascites. Hepatocyte growth factor/Scatter factor (HGF/SF) is produced mainly by fibroblasts. This study was to determine the regulatory effect of cytokines on the production ofHGF/SF by fibroblasts.
We conclude that MRC5 human fibroblast production of HGF/SF can be regulated by cytokines, some are stimulatory while others inhibitory.
This may be important in the regulation of generation ofHGF/SF in vivo and therefore regulation of cancer cells in the metastasis in the liver. In 8 patients with signs of virus replication AC activity and cAMP contents in liver tissue were lower than in those who had the integrative stage of B-viral infection (pl < 0.02; p2 < 0.001). GC activity in these groups d"d not differ, while tissue cGMP levels in patients with virus replication was higher than in those who had blood markers of the integrative stage of the disease (pl,2< 0.05). The AC/GC and cAMP/cGMP ratios in.CH patients within the replicative stage of HBV were decreased, and the tissue levels of CD was enhanced in comparison with both groups of patients with the integrative stage of virus development.

HEPATIC ADENYLATE AND GUANYLATE CYCLASES SYSTEMS
Thus, the stage of virus replication in CH patients could be characterized as leading to the disproportions in intracellular messengers' systems. The exact mechanism, by which the replicating virus can alter the cyclases' activities, is probably related to either direct or indirect damage of the hepatocytes' membranes and excessive accumulation of lipid peroxides, which leads to inactivation of the membrane-bound enzymes (adenylylcyclase and, probably, cGMP phosphodiesterase).  Thirty nine patients with intrahepatic lithiasis (IHL) were treated between 1974 and 1993. There were 21 women and 18 men with a mean age of 38 years (range 11 to 75). The clinical presentation was of cholangitis, and the most frequent symptoms were abdominal pain (100%), jaundice (97.4%) and fever (87.1%). More than half of the patients had been already submitted to a biliary surgery. Routine laboratory tests showed raise in serum gamaglutamyltransferase (88%), alkaline phosphatase (78%), bilirrubins (48%), aminotransferases (47%) and leukocytosis (37%).
Radiologic investigation with ultrasonography, CT scan and cholangiography were performed with 82.1%, 100% and 97% of sensitivity, respectively. In 64.1% of the cases stones were bilateral and in 23.1% were located only in the left lobe. We adopted a systematic approach in the treatment of these patients with a tailored surgery according to the presentation of the disease. Surgery was performed in 37 patients, including biliary drainage procedures and hepatic resections. Two patients with liver cirrhosis, were submitted to endoscopic papilotomy. Biliary infection was present in 86% of the cases. There was no operative mortality. Best late results occurred in patients with unilobar disease with 92.8% of good results, specially in cases where an hepatic resection was performed. In bilateral disease symptoms recurrence occurred in 47.5% of the cases. Overall good results were observed in 70.2% of the cases after a median follow up of 46 months.
INTRODUCTION: Hepatic Adenoma (HA) and Focal Nodular Hyper plasia (FNH) are the most common non-vascular origin benign lesions of the liver and other neoplasias are extremely rare. Regression of HA after withdrawn of oral contra.ceptives has been documentedm but malignant transformation is possible. Moreover, it is not always possible to differentiate with certainly between HA, FNH and well differentiated hepatocarcinoma. The aim of this study is to report our experience with this type of tumors.
We review the clinical features, laboratory tests, and imaging studies (US, CT, angiography and isotope scan). We obtained histopathologic studies prior to definitive surgical treatment in 14 patients. All patients underwent sur gical treatment. RESULTS: The mode of presentation and laboratory results were unspecifics. The differents imaging studies revealed "hepatic mass". The sensitivity for the imaging studies were: US: 0% for all the cases; CT: ii.i % for HA, 0% for FNH and 7.6% for both lesions; angiography: 20% for HA; isotopic scan: 0% for HA and biopsy: 25% for HA, 50% for FNH and 37.5% in group. The resectability rate was 100%.
Only two patients presented morbidity (pleural effusion) and there was no mortality,. Only the postoperative anatomopathologic report gave an accurate diagnosis. No recurrence has been detected. Pyogenic hepatic abscesses are tncommon. We report our findings in 51 patients with pyogenic liver abscess treated from 1975 through 1992. Twenty-eight patients were men and twentythree were women. The median age of patients was 45 years (range, 13 to 77 years). Fever was present in 100% of patients, abdominal pain in 58.8% and jaundice in 39.2%. Twenty eight patients (54.9%) had leukocytosis; 45% hiperbilirrubinemia and 35.3% high serum level of alkaline phosphatase. The most common cause of abscesses was biliary tract disease (66%), followed by portal origin (14%), idiopathic (10%), endocarditis (6%) and trauma (4%). The culture of abscesses was postive in 82.5% of patients with prevalence of gram negative bacteria. Thirty-seven (64.7%) were surgically treated and thirteen underwent percutaneous drainage with 90.4% and 69.2% of good results, respectively. Mortality was 9.6% in the surgical group and 0% in the percutaneously drained group.
A review of literature ofthis condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.
Although the major manifestations of amebiasis are enteric in location the pathogenicity of the organism is not limited to the intestinal tract and other anatomic sites may be affected.
We present a case of hepatic amebic abscess which ruptured in the abdominal cavity following motorvehicle accident. The victim was 52 year old male driver, who was adnitted in the emergency room an hour after the accident, in unstable condition. The initiative examination showed pain and tenderness in the upper abdominal wall, hetocrit 37%, BP: 110/80, RR: 25, P:120. The ultrasound examination showed the presence of fluid in the abdominal cavity while the peritoneal lavage resulted in the discovery of blood, bile and puss. According to the n=dical history of this patient, he had fever (38 C) and pain in the right upper quandrant of the abdominal wall, for the last weeks. He had being receiving antibiotics with no positive results. The patient was adnitted to the operating room for exploratory laparotomy. We found large ruptured central Liver abscess in segment 8, with diameter of 12 cm. There were no other injuries to the other abdominal viscera. We performed a partial closure of the abscess cavity and inserted drainage tube into it, followed by suction and irrigation of the abdominal cavity. The postoperative period was normal, without any ccplications and the patient discharged from the hospital on the 13th day. The Liver is the most cannonly involved extraintestinal organ in amebiasis, and hepatic abscess is a major complication, which if untreated, often proceeds to a fatal outcome. Amebic abscess of the Liver is well-known entity that is frequently observed in many countries of the world; if amebic abscess of liver is diagnosed while confined, present modes of treatment are curative. Cyclic AMP levels in lymphocytes of CPH patients were within the normal values ..... while in CAH and C patients they were found decreased (p_< 0.05).

PROSTAGLANDIN E1 AND E2 EFFECTS ON CYCLIC NUCLE-OTIDES LEVELS IN LYMPHOCYTES IN LIVER DISEASES
cGMP contents and cGMP/cAMP raUo dd not sgnificantly differ from that of the control group. T-lymphocytes of the patients with CAH and C had higher cAMP levels than B-cells, in comparison with those of healthy subjects and CPH patients. PGE1 and PGE2 in vitro caused significant increase in cAMP levels and cAMP/cGMP ratio in lymphocytes of the healthy people and CH patients. Adenylylcyclase (AC) system of the C patients showed no reaction to exogenous PGs at all. In vitro loading of the T-cells with PGE1 and PGE2 resulted in high cAMP levels only in healthy subjects and CHP patients, while all the groups tested showed marked Bcells response, cGMP levels in common pool and in lymphocyte subpopulations did not respond to PGs load.
Decreased cAMP levels in patients with CAH and C reflect high <,immunological activity, of the lymphocytes, especially of the B-cells. The possibility of the PG-induced B-cell suppression in these patients combines with their limited impact on cellular mmunity. <,Inertiab pattern of the AC-cAMP system reaction to the PGs, refers to inability ofthe PGs to control the lymphocyte function in patients with cirrhosis as a possible explanation and could be regarded as one of the factors affecting the disease progrediency.

P091
LIVER SURGERY AND FUNCTIONAL HEPATIC RESERVE REFLECTED BY ANTIPYRINE METABOLISM A.Grieco_, S. Marcoccia,S Alfieri*.A Giancaterini,G Addolorato, F Crucitti*. G Gasbarrini. Internal Medicine & *Clinical Surgery Depts. Catholic University ,ROME, ITALY Surgery is the only approach that offers the possibility of a radical cure for primary and metastatic liver tumors, but patients with cirrhosis are considered poor candidates for hepatic surgery. We used the antipyrine metabolism test to investigate the prognostic role of cirrhosis in patients subjected to hepatic resection. Patients and methods: Twentythree patients (II females,l: males, range 18-64 yrs:) scheduled for hepatic resection were studied: 6 had liver metastases without cirrhosis (Group A): $ bearing hepatic echinococcosis (Group B)' 9 had hepatocellular carcinomas and cirrhosis (Group C). Antipyrine metabolism tests (18 mg/kg in water p.o., blood samples drawn 3.74 hrs after administration. spectrophotometric measurement of serum levels) and routine liver-function tests were performed in all patients before surgery and on post-operative days 7 and 28 All patients were operated on by the same surgical team. : No significant differences were observed among the three groups as far as pre-and post-operative liver function indices were concerned.
Mean pre-operative values for antipyrine clearance were not significantly different among the groups: Group A: 34.84 +__ ml / rain; Group B: 30.34 *__ 2.7 :Group C: 22.3 +_. 2.7, but the mean half-time for Group C (27.9 . _ _ 4.9 hrs) was significantly greater than those for Groups A and B (respectively 14.4 +__ 1.8 hrs and 14 5., 1.5 hrs) (Scheffe F test: 4.3). On post-operative day 7, clear,race was increased in GroupA (39.12 +_. 4.6 and B 31.6 3.3) and decreased in Group C (15.i 4 4 ,Scheffe F 5.17). Three patients from the latter group died from liver failure during the p,)st-operative period (1 post-segmentectomy. 2 postbisegmentectomy).Concl.u.ios: Cirrhosis represents a crucial pre-,perative risk factor even for limited hepatic resection. The increase in hepatic microsomal oxidative activity that n,rma.lly occurs during the early post-.operative period is not observed in patients with cirrhosis. It has long been known that hypocholesterolemia characterizes critical illness and poor prognosis, however this phenomenon has never received adequate explanation. This study has been performed to asses the correlates of CHOL in 530 measurements (full SMA-12, hemtocrit, coagulation profile) in 145 patients after major abdominal surgery or in concomitance with major con plications. CHOL correlated well with prothrombin activity (PT, % of standard), cholinesterase, iron binding capacity (r = 0.41 to 0.20) percent hematocrit (HCT, r== 0.14) and alkaline phosphatase (ALP, nv 79-280 UI/L; r== 0.37) (p<< 0.01 for all). The following "simplt best fit" was selected by regression analysis: These data indicate that there is a cumulative effect of factors commonly associated with poor prognosis (inacleluacy of hepatic protein synthesis, hemorrage) in lowering C-IOL; this may contribute to explain the r=gative prognostic value of hypocholesterolemia and to improve use of CHOL for clinical purposes. Ouantification of the relationship between CHOL and ALP, as provided in this study, may ackJitionally help in the evaluation of the effect of cholestasis on CFDL. with innocent tumours.8,6% patients with liver tours am,d 27,1% patients with innocent turnouts had adenoma. 19 patients with liver adenoma were observed. They were made resections.In 9 cases the tumours were identified by palpation,in 10 case the tumours were sound with the help of adjuvant methods of examination. It was sound that liver adenoma is developing with small msmifestation and can. be discovered before, operation by the ultrasoum.d investigation,computer thomography and an.giography. Liver adenoma is a rare illness it should be operated.The choiceof operation is the liver resection.Cryosurgical techniques improve the results of the operation,quar,tees less recidivation of the illness.
Ozdemir, A. Tezel Departments of Gastroenterology and Radiology, YOksek lhtisas Hospital, TURKEY Membranous or segmental obstruction of vena cava inferior (Primary Budd-Chiari Syndrome) is uncommon, but treatable form of Budd-Chiari Syndrome. Interventional radiologic methods are curable and encouraging. In this article 8 primary Budd-Chiari cases who were treated by interventional radiologic methods are presented. One patient was applied Rotacs membranotomy and balloon angioplasty, three patients balloon membranotomy and four patients percutaneous transluminal angioplasty (PTA). PTA was insufficient in one patient who was inserted metallic stent in fight hepatic vein later. All interventional methods were successfully completed. Restenosis occurred in two patients after one and fourteen months. These patients had undergone to balloon angioplasty. Stent occlusion had occurred in one patient in whom surgical interventions were also unsuccessful. A second metallic stent was replaced in this patient. All cases were followed-up 5-30 months (mean 17 months).
All patients showed clinical regression, and all symptoms regressed. Clinical regression was also confirmed with ultrasonography, duplex Doppler and angiography. These results show that the interventional radiological methods can be effectively and safely used to treat the Primary Budd-Chiari Syndrome. A group of 38 patients with portal hypertension caused by hepatic cirrhosis who underwent surgical treatment was the subject of this study. 17 patients after oesophageal transsectomy and 19 after venous spleno-renal shunts were treated with intravenous infusions of glucose and fatty emulsion (group I) and the next 10 patients with only glucose i.v. (group II). Several routine biochemical tests like GOT, GPT, alcaline phosphatase, serum bilirubine and glucose, total protein and fat acids level in serum were done. Intravenous fat tolerance test and the nitrogen ballance measurement were also performed. As a result of these teste we came to conclusion that the postoperative i.v. fatty emulsion infusions didn't worsen the analysed biochemical factors. The higher rate of clearance of fat emulsion after operation in comparison with preoperative period indicates that fat retention in these patients didn't exist during the postoperative period. Nitrogen balance was almost the same in both groups of patients. The aquired results suggested that i.v. administration of fat emulsion didn't worsen the liver function in cirrhotic patients. Ultrasound(US) is claimed as a useful non-invasive method in the assessment of diffuse fatty infiltration of the liver(DFL).We developed a study comparing the accuracy of hepatic ultrasonography with hepatic histology in the detection of DFL. 122 subjects enroled in the study underwent an US-examination using 3.5 and 5 MHz transducers followedby liver biopsy using Menghini and Tru-Cut needles within 4 days of the US assessment. There were 83 male and 39 female patients,mean age 46.3 yr.,allocated as ethanol abusers (71), diabetes mellitus (17),obesity(23),corticotherapy (8),parenteral nutrition(3).We defined 3 US grades for DFL.Histology was assessed and classified in three grades of DFL.US had a good sensitivity and specificity in the detection of DFL when compared with hepatic histology: overall accuracy 85% with 91% sensitivity,and 58% specificity.The accuracy of the detection was correlated with the degree of DFL,increasing to 97% in severe cases (grade III),p 0.001,and did not correlated with the ethiology of DFL.We conclude that US is a Schistosomiasis is a leading cause of portal hypertension in Brazil. Hepatic hemodynamic in this disease is still controversial. The authors have measured the hepatic blood flow in 12 patients with hepatosplenic mansonic schistosomiasis by analysis of the disappearence curve and hepatic extraction of indocyanine green (ICG).
Seven patients were female and five were male, with mean age of 40 years (+12,6). All patients have portal hypertension and history of upper gastrointestinal bleeding and the diagnosis confirmed by liver biopsy. ICG was injected in a peripheral vein (0.1 5 mg/Kg body weight) after drawing a baseline plasma sample. Simultaneous blood samples were taken from indwelling catheters in the aorta and the right hepatic vein at 1,2,3,4,5,7,9,11,16 and 21 minutes after the ICG injection. ICG plasma concentration was measured by spectrophotometry. Total hepatic blood flow was calculated on basis of the ICG clearence and hepatic extraction and corrected for the haematocrit.
The mean hepatic blood flow was normal. The great individual variability could be explained by heterogeneous liver and splanchnic circulation derangement caused by the disease. Hepatic portal index (HPI) was calculated from the arterial and portal slopes of hepatic radioactivity vs. time curves after injection of 25 mCi (925mBq) of 99mTc-pertechnetate. Results: Groupl -PVT meanHPl: 11.17%+9.00% Groupll -HC meanHPl: 23.29%+8.52% Group III-HMS Nonparasitic cystic liver disease is a rare clinical entity which arises from developmental abnormalities in the liver parenchyma of the intrahepatic and extrahepatic biliary system. We herein report our experience from the surgical management of 15 patients with simple liver cysts..Four men and eleven women (mean age 53 years) with simple hepatic cysts have been operated in our department during the last eight years. Preoperative diagnosis was made in 12 of them who operated electively, whereas 3 patients underwent an emergent surgery (rupture of the cyst in the peritoneal cavity which resulted in acute abdomen in two and in intraperitoneal haemorrhage and hypovolemic shock in one patient). The location of the disease had a right lobe predominance (10 out of 15 patients. The diameter of the cysts was between 5 to 22 cm. Three patients were subjected to total excision of the cysts, 9 patients to partial excision with drainage and 3 patients to drainage with omentoplasty. Pathologic examination revealed that cysts originated from distended branches of the billiary tree with moderate to heavy inflammatory changes.One patient died during the immediate postoperative period whereas the morbidity was 20%. The mean hospitalization time was 14 days. In conclusion, simple hepatic cysts, represent developmental abnormalities that originate from the billiary tree. They may be quite large in diameter and may cause an acute abdomen because of their rupture. The diagnosis of the disease is rather easy and their surgical management without any particular difficulties. Focal nodular hyperplasia (FNH) is a benign liver tumour. Treatment often is surgically, especially when the tumour is larger than 5-6 cm. Long-term follow-up studies after conservative treatment (stopping oral contraceptives) are rare. To analyse the diagnostic work-up and both treatment modalities, all consecutive patients (27 female/4 male) with a histological proven FNH lesion in the liver diagnosed between 1979 and 1993 were analysed. These patients were invited to visit the outpatient clinic where history, physical examination, ultrasonography (US) and serology (anti-HCV;anti-HBc) were performed. The mean age was 37 years (range 20-61), 45% (n=14) of the patients were asymptomatic on presentation. In these patients FNH was discovered during laparotomy for non-liver related causes. Regression of hepatic adenoma (HA) after stopping oral contraceptives occurs, however malignant transformation and rupture has been documented. The choice between conservative (i.e. stopping oral contraceptives) and operative treatment is often debated. The aim of this study is to review literature and our personal experience with this presumed benign liver turnout. Between 1979 and 1993, fourteen patients (11 female/3 male) with HA in the liver were treated. Diagnosis was histologically proven with needle biopsy specimen or hepatic resection. Clinical features, imaging studies, laboratory results and treatment modalities were studied. All patients were invited to visit the outpatient clinic were history, physical examination, ultrasonography (US) and serology (anti-HCV/anti-HBc) were performed. On presentation, five (36%) patients were asymptomatic, one patients was in shock due to bleeding of the tumour. Imaging studies and laboratory results were not useful to predict the diagnosis. Ten women (91%) used oral contraceptives for a mean period of 13.2 (2-25) years. Seven patients were treated conservatively with frequent follow-up. In two patients transformation to a hepatocellular carcinoma occured, both men had hepatitis B. Other patients did not show tumor progression on followup US. Seven patients underwent hepatic resection without postoperative deaths. One patient died two years after an incomplete resection due to metastasis of a hepatocellular carcinoma. Other patients did not show new lesions at follow-up US. No evidence of hepatitis B or C was found in the patients at follow-up. In conclusion the diagnosis is hepatic adenoma is difficult with imaging techniques, laboratory results and histology, especially in patients with hepatitis B. A solitary hepatic adenoma lesion in the liver should be resected, because malignant transformation and rupture is not uncommon. Conclusions: Obstructive jaundice significantly increased the levels of free radicals,diene conjugations,anna in blood serum and hepatic bile.Antioxidant activity decreased.These changes strongly depend on the level of plasma bilirubin.In postoperative period the decrease of these toxic products was more intensive in blood serum than in hepatic bile.

EXPERIMENTAL ASPECTS IN CREATION OF BILIODIGESTIVE ANASTOMOSIS
A. The main purpose in a creation of biliodigestive anastomoses (BDA) is, that the anastomosis has to be permanent and with the lumen which is enough wide for a biliodigestive derivation of the gall. To performed this is needful good indication and good surgical procedure. In a prevention of strictures in BDA it is important to have right selection of suture material used in a creation of BDA.
In a exact experimental procedure which is performed on 16 dogs we analyst the toleration of tissues to used sutures of different origin in contact with the tissues.
In a experiments were used the anastomoses holeciste with a jejunum or duodenum. In a study was investigated the behaviors of suture materials: a) Prolen O00-monofilament, b) Dexon 000, c) Vicryl 000, d) Flax fibre No. 90 and d) Hrom-Catgut 00. The relaparatomia was made 15 and 30 days after beginning of experiments. On the base of results obtaining in our study we could conclude that: 1) the reaction of the tissue around the suture implanted in the duodenum is more reactive than the reaction in tissue of jejunum, 2) the reaction was largely appear in digestive organ while the reactions on holeciste were less or without reaction, 3) the reactions to Monofilament Prolen were always less in BDA, 4) Dexon 000 gave moderate reactions followed by the gigantic cells, 5) Vicryl 000 gave the similar reaction as reaction produced by Dexon 000, 6) Flax fiber No 90 produced large reaction followed by mononuclear and neutrophil cells, and 7) Hromic catgut in its decomposition gave much more moderate infiltrations of mononuclear and gigantic cells in all spaces of BDA. It was performed by cholecystostomy,common bile duct ligation and jeounostomy in seven dogs.All animals received intramuscular 3 mg/kg injections of Ranitidin twice per day from postoperative first day for i0 consecutive days.Daily bile secretion was collected, measured and given back through jejunostomy. In the 5th and lOth postoperative days,total bile acid, cholesterol,phospholipid were measured in i0 ml of bile.The results were compared with control values obtained peroperatively.
From the measurements of bile analysis either in the study group or in the control group bile acid was not significantly different.The cholesterol concentration was significantly increased and phospholipid concentration was significantly decreased.The lithogenic index was not significantly different.
We conclude that ranitidin may alter in gallbladder the bile composition.And also can make bile lithogenic and facilitates the formation of bile stones. The metabolic response to trauma following laparoscopic cholecystectomy is diminished compared with the open approach. This study was undertaken to examine whether surgical dissection with laser, in comparison with diathermy, influenced the size of the metabolic response to trauma as measured by changes in serum interleukin-6 (IL-6) and C-reactive protein (CRP) concentration. Twelve consecutive patients, with symptomatic cholelithiasis, underwent elective cholecystectomy with pre-operative randomisation to the use of laser (SLT-CL MD, Fuji Electric Co. Ltd. Japan) or monopolar diathermy (Force 4, Valleylab, UK.) as the method of gall bladder dissection. Venous blood samples were collected from each patient pre-operatively and at timed intervals during the 24 hours after the first incision. Serum IL-6 and CR1 were measured by enzyme-linked immunosorbent assay. There was no significant difference in the age, sex distribution, mean length of operation or intravenous fluid administration between the two groups of patients. Recovery was uncomplicated with no episodes of pyrexia or obvious sepsis.
Pre-operative serum IL-6 and CRP concentrations were undetectable in all patients. There was no significant difference in the mean postoperative serum IL-6 reponse between the diathermy and laser groups (163.5-a:18.4 v 168.3+/-21.5; mean area under the curve+SEM, p 0.81; Mann-Whitney U test respectively) while the CRP concentration at 24 hours was significantly higher in the diathermy group compared with the laser cholecystectomy group (20.3+/-1.6 v 11.8+/-0.7 mg/dl, p 0.004 respectively). These observations suggest that patients undergoing laparoscopic cholecystectomy with diathermy dissection have a greater activation of the acute phase response as measured by serum CRP, despite having a similar serum IL-6 response, compared with the laser dissection group. Obstructive Jaundice affects hepatic cell function, with significant effects on organ metabolism. Duration ofjaundice has direct implication with detrioration of metablic function. The present study evaluates the effects of bile duct ligation (BDL) of different durations (1 or 7 days) on hepatic mitochondrial respiratory function. Adult Wistar rats (n=32) were randomized into 3 groups: CTL(n=12-sham operation), Jaunl (n=10-BDL for day), Jaun7 (n=10, BDL for 7 days). BDL was performed under anesthesia. Livers were excised and mitochondria extracted and studied in vitro at $3 and $4 phases of mitochondrial respiration. We also determined interphase rates $3/$4 (ACR), as well as ADP consumption rate per oxygen consumed (ADP/O Obstructive jaundice affected mitochondrial respiration early in the course of the disease (within 24 hs), with significant decrease of the production of high energy bonds. The early hepatic mitochondrial dysfunction could explain the high incidence of severe metabolic disturbances observed in the jaundiced patients, gevrsal of bile duct obstruction might affect positively the outcome of these patients. The aim of the present research was "to study the effect of exogenous EGF on endocrine pancreatic secretion, wistar rats were given a 0.1ml i.p. injection of 10g/kg EGF or saline t.i.d./week. Insulin, glucagon and somatostatin was determined in the blood and in the pancreatic tissue isolated soon afterwards. Pancreas was homogenized, diluted and centrifuged at 3000 rpm for 20min at 4C. The supernatant was processed by RIA for insulin, glucagon and somatostatin. Part of the tissue was fixed and cell immunostaining for endocrine component was performed. No difference in body and pancreas weight was observed. As compared to controls, only blood level of somatostatin was significantly higher in rats treated with EGF (p<0.05). Glucagon and somatostatin tissue level showed a significant increase (p<0.05) Cell counting/mm of both A-cell and D-cell was 2to 5-fold hgher in treated rats (p<0.01). The present data show that EGF, employed at near to physiological level, enhances pancreatic population of either Aand D-cell thus promoting either tissue and blood levels of these hormones. It could be suggested that EGF indeed exerts a physiological DNA and RNA synthesis effect on endocrine pancreas whose specific receptors have to be identified yet. Pancreatits following ERCP is a recognised complication, more common after therapeutic ERCP or pancreatic duct injection. We report 14 cases of ERCP-related pancreatitis observed over a five year period with 4 deaths (29 % mortality). The diagnosis of pancreatitis was based on an elevated serum amylase in the presence of clinical or radiographic evidence. The ERCP was performed under elective conditions for suspected choledocholithiasis, with antibiotic prophylaxis, by experienced endoscopists. Pre-ERCP serum bilirubin was above the upper limit of normal 17/mol/1) in all cases with a mean of 62 (range 22 97/mol/1). Gallstones were confirmed in 12 patients, with choledocholithiasis at the time of ERCP in 10 patients. These 10 patients underwent endoscopic sphincterotomy and bile duct clearance by basket or ballon catheter methods, with successful duct clearance in 7 patients. In the remaining 3 patients, the stones were considered 'small' by the operator and deemed able to pass through the sphincterotomy. Pancreatic duct injection was inadvertently performed in 6 patients. We aimed to evaluate the effect of trimetazidine (TMZ), which has scavenger activity on free oxygen radicals, on histologic improvement and decline in hyperamylasemia in ceruleininduced pancreatitis in rats. METHODS: Male Wistar rats weighing 240-255 g were used, Group (n=ll): Saline + Placebo, Group II (n=10): TMZ (2.5 mg/kg body weight/day, ip, for week) + Placebo, Group 111 (n=10): Saline + Cerulein (20 lag/kg body weight, sc hourly, 4 times), Group IV (n=l 1): TMZ + Cerulein. Twelve hour later of the first cerulein injection blood was drawn via an intracardiac punction, and the animals were sacrificed by cervical dislocation, and pancreas was taken out. RESULTS: Pancreas weight and serum amylase activity in Group [] (Saline + Cerulein) were significahtly higher than those in Group (p<0.001), II (p<0.001), and IV (p<0.05). These parameters were also higher in Group IV than those in Group (p<0.05) and II (p<0.05). Oedema and neutrophilic inflammatory response in pancreas were more pronounced in the animals in Group [] (Saline + Cerulein) than those in Group IV (TMZ + Cerulein) (p<0.01). Malondialdehyde concentration in pancreas was highest in Group 111, lowest in Group and [I, and medium in Group IV. CONCLUSION: TMZ pretreatment protects the evolution of cerulein induced pancreatitis in rats. It decreases pancreas malondialdehyde concentration, suggesting that this preventive effect may result from the elimination of free oxygen radicals. The aim of this study is to analyze hepatic lesion following acute pancreatitis (AP) with hepatic mitochondrial function study. We studied 54 Wistar rats divided in six different groups. Acute pancreatitis was produced with injection of 0.5 ml of 5% sodium taurocholate in the bile-pancreatic duct. The hepatic mitochondrial function evaluation was polarographically determined using the Clark's electrode with determination of 02 consumption with ADP (state 3-activated) and in the absence of ADP (state 4), using potassium succinate as substract. Respiratory control ratio (RCR) and ADP/O2 ratio (ADPR) were calculated.
There were significant alterations in RCR, state and 4 of mitochondrial respiration and alterations in the ADPR and 4 hours after the induction of acute pancreatitis.
This data show that in the early phase of AP (2 and 4 h), where the hepatic lesions seems to be dependent on depressive action of toxic substances released during AP, there is mitochondrial uncoupling manifested by increasing of $4 and decreasing of RCR and ADPR. Twelve and 24 hours after AP, RCR is the same as of the control group. 48 hours after AP, we observed decrease of RCR, $3 and ADPR, suggesting degenerating and necrotic process, characteristic of cellular ischemia.
We conclude that the mitochondrial alterations are bifasic: early alterations characterized by uncoupling of oxydative phosphorilation, may be the result of distant action of enzymatic products while late alterations seems to be the result of tissue ischemia. The aim of this study was to analyse cytokine gene expression in islet isografts undergoing autoimmune 13-cell destruction accelerated by cyclophosphamide (CP) injection. Foetal pancreatic islet tissue after week of culture was transplanted under the left kidney capsule of prediabetic, 67-69 days-old NOD/Lt female mice, one week later mice were injected with CP 300mg/kg or saline (controls). Blood glucose was monitored starting at the day of CP injection (day 0), at day 7 and day 17. Seven and 13 days post CP injection left kidneys were removed by nephrectomy and the grafts processed for RNA isolation, reverse transcription and PCR amplification of cytokines. At day 17 all animals were sacrificed and their pancreas examined histologically for infiltration.
Non of the 4 control mice became diabetic whereas 3/12 CP injected mice had blood glucose levels >17mmol/L at day 17. Pancreas sections of CP injected mice showed a severe lymphocytic infiltrate leading to complete (diabetic mice) or partial (non diabetic mice) islet destruction whereas control mice had mostly either intact islets or only mild insulitis. Three grafts from each group (controls, CP injected non diabetic and CP injected diabetic mice) were selected to analyse cytokine gene expression at day 7 and day 13 post CP injection. IL-12p40 and INF-, were both expressed generally in all tested isografts as well as in ungrafted kidney tissue, in contrast TNF-tx and were expressed in grafted tissue only at both time points. IL-2 and IL-12p35 were expressed in 3/3 day 7 isografts but only in 1/6 day 13 isograft. In this same graft (CP injected animal) IL-6 expression was detectable whereas all other grafts were negative for IL-6 message. IL-10 expression was completely absent in all tested grafts and control tissue. The pattern of cytokine gene expression of immune cells infiltrating the foetal pancreatic NOD/Lt isografts after CP injection does not predict the risk of progression to diabetes for each individual mouse, at least with the tested cytokines. Intercellular Adhesion Molecule-1 (ICAM-1) is a cytokine inducible endothdia/antigen. Graft preservation induced injury is associated with higher rates of acute cellular rejection (ACR).
The aim of this study was to elucidate the distribution of ICAM-1 on liver allografts after overnight cold storage and reperfusion: correlating expression with post-operative outcome.
Following cold storage (723 + 31 rains) and reperfusion (at 90 mins), liver biopsies from 30 grafts were snap-frozen. 5#m frozen sections were stained immunohistochemically for ICAM-1. Expression of ICAM-1 was analysed by light microscopy. Liver from resection margins of benign tumours were used as controls: demonstrating weak sinusoidal staining.
Twenty-one of the 30 grafts, biopsied after storage, had induction of ICAMon sinusoidal endothelium and hepatocytes. Of these, 14(66.6%), recipients had 3 or more rejection episodes (no non-rejecters). In 9/30 recipients with no ICAM-I induction, 6 had one episode of ACR (3 nonrejecters).The difference between these two groups was statistically significant (p <0.001, Fisher's Exact test). The expression of ICAM-1 on reperfusion biopsies showed further increase in staining intensity on hepatocytes and sinusoidal endothelium. Further material is being collected currently, to evaluate larger numbers of biopsies. Cytokine activation of ICAM-1 occurs during graft storage and is further increased after reperfusion. Induction of ICAM-1 on sinusoidal endothelium is likely to contribute to increased adhesiveness of circulating leukocytes. ICAM-I inductign may well enhance the immunogenicity of the graft. Our results suggest that induction of ICAM-1 following graft storage, contributes to increasing risk of acute cellular rejection post-transplantation. Infection of necrotic tissue and abscess formation are the most serious complications in acute pancreatitis, responsible for 80% of the mortality associated to acute pancreatitis. The frequent finding of negative gram bacteria in this tissue is suggestive that intestinal tract is involved as a source of this infection.
We studied 90 Wistar rats divided in eight different groups. Acute pancreatitis was produced with injection of 2.5% taurocholic acid in the bilepancreatic duct (0.1 ml/100g rat weight). Bacterial culture of blood, pancreas, mesenteric lymphonodes, peritoneal cavity and cecum were performed within 6h, 2411, 48h and 96 hours after induction of acute pancreatitis.
We conclude that bacterial translocation is an early phenomena, already present six hours after acute pancreatitis xvith maximum at 24 hours, decreasing after that time. Cadmium (Cd) is a rare element that is nevertheless widely distributed throughout the biosphere and its toxic effects are becoming potentially more serious, due to industrialization. Liver regeneration can be considered as a spectacular example of controlled tissue increase. The purpose of this study was to document liver regeneration after partial hepatectomy (PH) in a model of acute liver injury due to Cd treatment and to determine whether the administration of exogenous putrescine affects the regenerative capacity of hepatocytes. Putrescine is a polyamine that has been reported to stimulate liver regeneration in animal models of acute liver failure.Cd pretreatment, 24 hours prior to PH, resulted in decreased regenerative capacity of hepatocytes compared to that observed in simply partially hepatectomized rats (p<0.001). Tritium thymidine incorporation into liver DNA, thymidine kinase activity into the hepatic tissue and mitotic index were used as indices of liver regeneration. The intraperitoneal administration of putrescine, at doses of 1 and i0 mg/Kg body weight, at the time of surgery and at 4 and 8 hours after PH in Cd-pretreated rats, partly restored the liver regenerative capacity (p<0.001). The results of this study indicate that hepatic DNA synthesis is impaired in Cd-pretreated rats after PH and that exogenous putrescine administration enhanced liver regeneration in this model of acute liver disease. The aim of this experimental protocol was to evaluate the morphological and functional characteristics of isolated pig livers, perfused in an extracorporeal liver assist circuit. The circuit has been developed in our department and consisted of the graft liver.a membrane oxygenator, a heater, a centrifuge pump and a fluid reservoir. Twelve pig livers, weighing 780 (610-870) gms, were perfused for a mean of 5.2 (4.5-9) hours. Perfusion was terminated when morphological and functional signs of decreased viability were present. Inflow to the graft liver was performed at a pressure of 16 (12)(13)(14)(15)(16)(17)(18)(19)(20)  Phagocytic index, 0 2 free radical (OFR) production, and metabolic response of the rafts peritoneal macrophage were evaluated in D-galactosamine liver injury after LPS and LB pretreatment. D-galactosamine increased the OFR response in the luminometer, which was unaffected by LPS, but highly potentiated by LB pretreatment. Metabolic response in the calorimeter was also increased after D-galactosamine administration and was unaffected by LB, but absent in the LPS pretreatment. Phagocytic response was lower than normal in all experimental groups and was unaffected by any pretreatment. In rats increased tumor growth in the remnant liver after partial hepatectomy (PH) was found. Growth factors responsible for liver regeneration could also influence tumor growth in the remnant liver. In liver regeneration both endocrine and paracrine mechanisms play role. In this study we analyzed the effect of portal and systemic serum obtained from PH or sham operated rats on proliferation of colon carcinoma cells (CC 531) in vitro. The effect of adding hepatocytes to these cultures was also studied. Cell proliferation was measured by 3H-thymidine (3H-thy) incorporation. Sera were withdrawn at intervals of 1,3 and 14 days after 70% PH or sham operation. Cultures  In the group with hepatic resection, baseline total and HDL-cholesterol were normal (5.0-2-_0.5 and 1.2+0. lmM respectively). Over the next few days there was a rapid decrease in total (day 3, 2.9+0.3) and HDL-cholesterol (day 3, 0.79+0.12mM). However, these changes could be explained by fasting and surgical intervention since a similar phenomenon was observed in the control subjects (TC, pre-op, 5.3+0.3 vs day 3, 3.2+0.3mM; HDL-C, pre-op, 1.22+0.12 vs day 3, 0.81+0.08mM). In patients undergoing liver transplantation, TC decreased over the next few days but had fully recovered by day 40 (pre-op, 3.8+0.5, day 1, 2.2+0.2, day 40, 5.2+0.3mM). Triglycerides were low preoperatively and rose over weeks to months (data not shown). HDL-C was very low pre-operatively (0.47+0.12mM), dropped further in the early post-operative period (nadir, day 3, 0.16+0.05mM) and had returned towards but had not reached the normal range by day 40 (0.9+0.1mM). Apoprotein (a) was low preoperatively (30x/+l.4IU/l, geometric mean x/+ tolerance factor), remained low over the first week (day 3, 24x/+l.8IU/l) but had risen by day 10 (day 40, 64x/+l.5IU/1). Importantly, apoprotein (a) at day 40 correlated with the apo(a) level of the donor (r=0.80,p<0.01) but not of the recipient's pre-operative level (r=0.19,p=0.57).
In conclusion, the liver has a large reserve and is able to maintain lipoprotein production and removal despite greater than 50% removal. The major cause of reduced lipid levels in the post-operative period relates to other factors such as fasting and handling of the gut during surgery. In liver transplantation, apoprotein (a) levels resemble those of the donor within 2 weeks of organ A reliable and reproducible model for the study of hepatic medal vascular changes in vitro during pathological conditions of the liver has yet to be described. This study was conducted to determine whether it was possible to develop an in vitro isolated rat liver preparation perfused through the portal vein (PV) and the common hepatic artery (HA) initially under control conditions. Hepatocyte growth factor/Scatter factor (HGF/SF) is a tumour cell motility and invasion promoter, which is mainly produced by fibroblasts,. This study was to determine the effects of gamma linolenic acid, an agent used in anti-cancer treatment, on the production of HGF/SF by fibroblasts. Human fibroblast cell line, MRC5 was used. The cells were cultured in the presence or absence of fatty acid (FA) at a range of concentrations (1-1001aM) for 24 hours and HGF/SF production was quantified by the MDCK bioassay. In this study, gamma linolenic acid (GLA), its water soluble lithium salt (LiGLA), linoleic acid (LA), arachidonic acid(AA), and eicosapentaenoic acid (EPA) were used. HGF quantity is shown in the following GLA, LiGLA, and EPA showed a concentration dependent inhibition ofHGF/SF production without causing cytoxicity (determined by MTT assay). Linoleic acid and arachidonic acid had no effects.
We conclude that the parent form of n-6 EFAs gamma linolenic acid can inhibit the production of HGF/SF from human fibroblasts and this may have important implication in the mechanism controlling the initiation and growth of liver metastasis. Hepatic resections with vascular occlusion are used with increased frequency in the treatment of hepatocarcinoma. The aim of this study is to evaluate the limits of normothermic liver ischaemia in different degrees of liver function in the rat. Hepatic cirrhosis was induced in male Wistar rats, weighing 120-140 g, using Carbon tetraclorure in water. Hepatic function was graded determining ATIII, albumin, bilirubin in plasma and the presence of ascites. Rats were divide in four different groups, using the modified Child-Pough score: Group Control (non cirrhotic), Group A well compensated cirrhosis, Group B decompensated cirrhosis, Group C decompensated cirrhosis with ascites. All groups were different between them p<0.05. Liver ischaemia was performed using the model of ASAKAWA for periods of 0, 30, 45, 60 and 75 minutes. At the end of procedure the non ischaemic lobes were resected. Survival for the different times of ischaemia is shown in the Several agents known as gastrQc aoid inhibitots have been introduced in clinical use,more or less recently.Among them,the omeprasole has a very strong acid supporting effect, acting directly on the protongated in the secretory membrane of the parietal cells.The investigations of their reactions with the process of drug elimination by interfering with hepatic micosomal oxidation system, gave us a lot of statements about H-receptor blockers, but a few about the omepasole. The purpouse of this study was to establishe the effects of the antisecretory dose of omeprasole on the activity of the enzyms in the microomal oxidasing system 40 male Wistar rats (200Z20G) were treated by Mol/kg/tt by intragastric instilation up to 5day from the begining of the experiment.There was control group of animals (5) and three experimental groups (12 rats in each) formed aeordito the duration of the treatment._he sacrificing of the animals was done on and 56 day of the experiment.The semples of the liver tissue were immediately prepared for enzymehistochemical detection of the activity of NADPH cytochrome P-$50 reductase and cytochrome P-$50. Our results show decreased activity of the enzymes tested, which was time dependent and was most expressed iu the third group.Significant differences in the enzyme activities among the animals of the same experimental group was atributed to the existence of multiple izoensimes of citochrome P-$5, that may be differently affected by omeprasole. Nitric oxide has many biological roles. It will be formed from the amino acid Larginine. Studies suggest that nitric oxide has a protective effect on the liver during endotoxemia and chronic inflammation. The mechanism of this action is not dear. We therefore studied the effect oforal arginine supplementation on the extent ofliver injury and the associated bacterial translocation in an acute liver injury model. Sprague-Dawley rats were used. 2 % arginine has been supplemented daily by a nasogastric tube for 8 days in the experimental group. Acute liver injury was induced on the 8th day by intraperitoneal injection of D-galactosamine (1.1 gm/kg body wt.) In the control group of acute liver injury, saline was given by the nasogastric tube during the same period. Blood samples were collected 24 h after induction of the liver injury. Levels of Alkaline Phosphatase (ALP), bilirubin (bil) and Aspartate Aminotransferase (ASAT) was significantly reduced by arginine supplementation compared to the acute liver injury control group. (ALP 11.58+1.15 vs 16.12+1.82 p<0.05; bil 7.31+0.64 vs 14.66+2.48 p<0.01; ASAT 20.96+4.48 vs 33.66+5.0 p<0.05). Arginine supplementation also reduced bacterial translocation to aerial blood, liver and mesenteric lymph nodes with a significant differance in the liver (447.5+226.2 CFU/grn vs 5112.9+1766 CFU/gm p<0.05) On histological examination the liver in the arginine supplemented group exhibited scattered areas ofhepatocellular necrosis and inflammatory cell infiltration compared to the control acute liver injury group which showed more and widespread hepatocellular necrosis and more inflammatory cell infiltration.
The results ofthis experimental study show that oral arginine supplementation significantly improves the level of liver injury and bacterial translocation after galactosamine induced liver injury. The HLA and liver transpalnt (OLT) relationship is still unclear in contrast to other solid organs such as kidney and heart allograft where the role of HLA complex has been widely studied. It is possible that the low antigenity of the liver and its inability to activate naive allogenic T-cells could explain the lack of clear association between HLA compatibility and rejection.
In this work, we review a total of 118 OLT performed from October 1989 to December 1993 in the Hospital Virgen de la Arrixaca in Murcia, (Spain) and we selected series of 81 OLT, in which the HLA A, B and DR match between receptor-donor pairs and the cause of transplant were known in all cases. On the other hand, the incidence of viral infections such as CMV, HCV and HBV (including fulminant hepatitis) was also studied in each patients. The graft in which the HLA was unknown (n=20) or when the transplant was performed in the AB0 incompatibility (n=l), dead (n=9) or retransplanted (n=3) in the first days postransplant, were excluded. We observed that the acute rejection rate was not influenced by the differences in Class or Class II compatibility (0 vs. or more matches). However, the presence of viral infection correlated with acute :rejection (p<0.05) and this relation was dependent of Class compatibility: Concurrence of viral infection and a partial Class match (1 to matches in A+B loci) was associated with acute rejection (p<0.01) but, none of these circumstances without the other carries a significant risk of acute rejection.
In conclusion, these results suggest that in liver transplant the simultaneous presence of partial class match and viral infections might lead to an increased allograft antigenity and trigger the allogenic response INTRODUCTION: Surveillance cultures (SC) are a common practice in the follow-up of patients undergoing liver transplantation (LT), though, their utility has not been clearly clarified. The aim of our study is to analyze the diagnostic yield of these post-LT SC, assess their microbiological aspects and their financial cost.
PATIENTS ANB METIIODS: The clinical records of the first 139 consecutive LT performed in 121 patients in our hospital were analyzed. Standard immunosuppression included cyclosporine A and steroids. Selective bowel decontamination was performed during the first 21 post-LT days with oral quinolones, associated with nystatin (n=95), or fluconazole (n=44). SC for bacteria (anaerobes included) and fungi were routinely performed on daily basis during the first post-LT week, and times a week thereafter until hospital departure and also when clinically indicated. Gram-positive cocci (GPC) were isolated in 90.5% of the LT (mainly coagulasenegative Saphylococcus, n=619); fungi in 61% (mainly Candida sp., n=453); and gram-negative bacilli (GNB) in 49% (mainly Pseudomonas sp., n=lS0). Overall, the most common pathogens were GPC (63% of those isolated), followed by fungi (21%), GNB (15%) and others (1%). The choice of antiinfectious therapy was based exclusively on the SC and was determined prior to clinical onset in only 7 of the 197 infectious episodes recorded. Despite the SC, 13 of the 21 patients with invasive mycosis died; in cases (24% of the mycoses), diagnosis was not obtained until autopsy.. CONCLUSIONS: The low diagnostic yield of the bacterial and fungal SC and their high financial cost, make their utility in LT questionable. the reported incidence of bacteremia or fungemia in liver transplantation (LT) exceeded 70%. Nowadays, it concerns between 26% and 39% of patients. The aim of our study is to analyze the incidence, etiolggy, source, and related mortality of bacteremia and fungemia during the first post-LT months in a series of 139 LT. PATIENTS AND METHODS: The clinical records of the first 139 consecutive LT performed in 121 patients in our hospital, (March 1, 1986 to January 1, 1992), were analyzed in order to identify those with blood cultures presenting bacterial or fungal positivity. Immunosuppression therapy consisted of cyclosporine A and steroids.

RESULTS
Rejection episodes were treated with a 3-day steroid pulse and recycling. The monoclonal antibody OKT3 was employed for treatment of steroid-resistant rejection. SBD was performed during the first 21 days post-LT with oral norfloxacin (400 .mg/d, n=108) or ciprofloxacin (250 mg/d, n=31), associated with nystatin (2x10 U, n=95), or fluconazole (100 mg/d, n=44). Blood cultures were obtained only when clinically indicated.
2.-Mean number of AR episodes per patient was lower in group C (0.8 +/-0.8 AR episodes) and higher in group A (1.5 +/-1.2 AR episodes).
3.-Group A patients also experienced significantly higher incidence of steriod-resistant AR episodes/patient than group C patients (0.66 +/-0.8 0.24 +/-0.5).   (Secci6n de Inmunologia, *Servicio de Medicina Digestiva, Servicio de Cirugia General, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.) Different species have consistently shown that the liver behaves as an immunologically favoured organ. However, the influence of HLA in liver transplant remains uncertain in contrast to other solid organ allografts. In addition, it is reported that certain DQ alleles could be implicated in the induction of immune responses in several autoimmune diseases. The aim of project was to study the DQ phenotypes expressed by liver transplant recipients and establish their relationship with acute rejection episodes.
A non radioactive SSOPs to screen PCR-amplified DNA from peripheral blood lymphocytes to analyse the polimorfism of HLA DQB was used. Forty-five liver recipients were studied, whose diagnosis of acute rejection was based on the conventional clinical and anatomopathological criteria. The exact Fisher test was used to contrast HLA DQB frequencies in patients with acute rejection (AR) and those without acute rejection episodes (NAR). The significance level was set to 0.05.
Significant augments were observed for DQBl*0302, in the AR group compared to controls (p<0.01) and NAR group (p<0.01). On the other hand, DQBI*0301 allele appeared significantly decreased in the AR groups when compared to the NAR group (p<0.05). However, although DQBI*0301 seemed decreased in the AR group when we compared it to controls, no significant differences were observed in this case. In contrast, the NAR group showed a similar distribution to the control group.
The observed results, suggest that the DQB, specially DQB 1"03 alleles, locus could be implicated in the regulation of the allogenic immune response in liver transplant recipients. S,steraic vascular resistancesd,n.sec.crn'5 541+ 179 b 698+130 b p<0.05, b p<0.02 After liver devascularisation elevated baseline CI decreased whereas low initial SVR and MAP significantly increased.These modifications occurring without variations in cardiac filling pressure and in the absence of vasopressive agents. Conclusion: The hemodynamic benefit after devascularisation of a failing liver suggests that total hepatectomy with a temporary portacaval shunt may be indicated to stabilise some patients with a threatening hemodynamic condition. RECIPIENT  The inferior mesenteric vein (IMV) cannulation for veno-venous bypass during orthotopic liver transplantation (OLT), for decompressing the portal system, has been used in 6 selected liver transplant recipients. From May 1, 1985 to January 31, 1993 total of 2667 liver transplants adult recipients were performed. IMV cannulation has been used in 6 patients (5 M, F) with age of 39.3 years (range 21-60). Four patients underwent primary OLT for end-stage liver diseases. The reason to use IMV cannulation for veno-venous by-pass was because of difficult hilar dissection in 5 cases and because of portal vein thrombosis after Hgraft portocaval shunt in Main hemodinamic parameters like heart-rate, cardiac output, mean arterial pressure, central venous pressure, pulmonary artery pressure, monitored before during and after the IMV bypass in this group of patients. Arterial blood gas data, Na+, K+, Ca++, glucose, osmolarity and lactate also monitored. Similarly, these parameters monitored in group of 6 liver transplantations during which performed the portal vein cannulation technique for the bypass. Total bypass time, temperature change, bypass flow, total intraoperative transfusion of PBRC (units) and urine output recorded in both groups. Statistical analysis was performed using ANOVA test. The statistical analysis of all the parameter values showed significant variation before during and after the veno-venous bypass in the IMV cannulation group well in the portal vein group. Furtherly, significant difference was found between the two study groups for those parameters. Four patients are alive and well respectively with 8.5 years, 2.3 years, 14 months and 9 months. Two patients died; weeks after the operation because of multiorgan failure and sepsis, the other one, year later because of multiorgan failure. Difficult hilar dissection or portosystemic shunt with portal vein thrombosis the main indications for the IMV cannulation for bypass system. Our intraoperative results confirm that good hemodinamic stability is obtained using this modified technique. In conclusion, IMV cannulation for veno-venous bypass is an effective procedure for early decompression of the portal system in of an impossible portal vein cannulation. Split-liver transplantation presents an interesting concept to alleviate the organ shortage for children with end-stage liver disease. The procedure has, however, not gained wide acceptance yet. This is not only related to the complexity of the procedure, but also to the less good results and the complications reported on the right side graft.
We report on a first case in which we applied a new concept for splitting. The liver was splitted in-situ in the heart beating cadaveric donor using the technique of living related liver procurement, with the aim of reducing the problems with the right side graft. The two recipients (one adult with alcoholic cirrhosis and one child with Crigler-Najjar-Syndrome II) are alive and at home six months postoperatively. The child has a progressive worsening graft function following portal steal by native liver with ischemic damage to the graft. This procedure makes splitting of the liver possible without compromising the hilar structures, with the possibility to judge perfusion and to achieve optimal hemostasis. Therefore, in-situ splitting of the liver has the potential of making splitting of liver grafts the rule rather than the exception, thus increasing the organ pool significantly. Standardization of reconstruction procedures in liver transplantation led to an improvement of graft and patient survival. Arterial reconstruction remains the "Achille's heel" of the procedure inferior vena cava (IVC) reconstruction has been modified recently by introduction of the "Piggy-back" procedure in which the recipient's IVC is conserved. We focalized our study on those tow aspects. We review a series of 165 consecutive orthotopic liver transplantations performed in 146 patients including 3 children. Recipient's IVC was conserved in 32 transplantations. IVC complications occured in 5 cases (3 thrombosis, Budd-Chiari syndrom and stenosis), always when the recipient's IVC was not conserved. The rate of arterial complications was 11% with 8 stenoses, 5 thrombosis and 5 pseudoaneurysms 4 patients underwent a new transplantation and 7 died. Biliary complications were more frequent in case of arterial complication, specially when the arterial blood flow was interrupted (thrombosis or surgical ligature of a ruptured pseudoaneurysm). In conclusion, the Piggy-back procedure is now routinely used for IVC reconstruction. Arterial complications have severe consequences, specially on the biliary tract. Early recognition of such complications is essential. P145 P146 Kand pH Activity on the Liver Surface: Determination of Graft Viability and Preservation Quality during Liver Transplantation J. Kurzbach, A.Visser, M. Gundlach, R. Kuhlenkordt, X. Rogiers, C.E. Broelsch Dept. of Surgery, Univ. Eppendorf, Martinistr. 52, 20246 Hamburg, Germany Introduction: It is known from experimental and clinical studies, that tCand pH are indicators for graft viability and preservation quality, in a first preliminary study we tested a system based on ionselective electrodes for K* and pH during liver transplantation. Patients and Methods: Measurements were taken on the liver surface of segment 3, 4 and 5 in (n=27) donors and (n=19) liver recipients: before explantation; at the end of cold ischemia; 45 min. after reperfusion of the liver graft. For preservation UW solution was used. Postoperative follow up included SGOT-Scoring and transplant biopsies. Results: The measurements showed no significant difference between accepted (n=19) and refused (n=8) grafts, of whom 7 were discarded because of clinical parameters, fatty liver or fibrosis. There was no correlation between K +and pH levels and the fat content of the liver. Measurements before perfusion did not correlate with donor complications (e.g. Hypotonia, Diab. insipid). As well no correlation with reperfusion injury was found. K* increased significantly (p<O.05) with the duration of cold ischemia. Most transplants showed normal levels of K +and pH levels after reperfusion. In two grafts poor distribution patterns of I indicated a reduced postoperative liver function. Conclusion: Measurements of ICand pH in donor livers provide no additional objective parameters for the selection of liver grafts. In individual cases there is a correlation of the measurements with perfusion and reperfusion injury. More cases have to be studied to show whether K*and pH changes correlate with perfusion and reperfusion injury.

Greece
Familial amyloid polyneuropathy (FAP) transthyretin (TTR) related disease is a disorder of protein metabolism with a fatal course. FAP is a autosomal dominant disease, associated with progressive autonomic and peripheral neuropathy because of amyloid's deposition. Replacement of the liver to correct this metabolic deficit, that causes damage to other organs, has been reported previously. A 33 years old female Greek patient had developed sensorimotor neuropathy and autonomic symptoms of diarrhea, difficulty in swallowing and mild urinary retention as well as orthostatic hypotension and weight loss. Amyloid affected the kidney, liver, small bowel and heart as confirmed by biopsies. Molecular analysis by PCR amplification of genomic DNA followed by Nsil digestion was performed. The data documented the presence of the TTR Met-30 variant. Our patient underwent orthotopic liver transplantation (OLTx)in September 1993 being,the first case of liver replacement for metabolic disease in Greece. The patient had an uneventful recovery. During the follow-up period she manifested two episodes of mild rejection (15th postop, day and 9th postop, month). The patient 15 months after OLTx presents with improvement of shooting and throbbing pain in the lower limbs and disappearance of nausea, vomiting, urinary retention, inappetence and orthostatic hypotension. Sensory deficits in arms and legs, distal motor weakness in the legs has slightly improved during the course of the last few months. Body weight has increased (+6 Kg). OLTx seems to have benef's in FAP, but multidisciplinary clinical studies are required to determine the role of liver replacement. RBCs transfused during OLT were 6,4 (0-26) and mean Fresh Frozen Plasma were 16,7 (0-47). Post operative mortality was 8,3%

INTEREST OF TRANSJUGULAR INTRAHEPATIC
(1 case) secondary to air embolism. "TIPSS" constitute an interesting helpfull mean before OLT It can prevent & treat. complications related to PHT. Baloon dilatation can be done in unsuccessful "TIPSS". It avoids abdominal aproach for treatment of PTH, source of surgical difficulty during OLT. It facilitates dissection during OL-I" & minimize peroperadve hemorrage. But its proper morbidity seems to decrease by experience. The aim of this study was to compare liver allograft A.M. expression following reperfusion with degree of preservation injury classified by serum levels of aspartate transaminase (AST). Following reperfusion (at 90 mins), liver biopsies from 28 grafts were snap-frozen. 5tm frozen sections were stained immunohistochemically for Intercellular adhesion molecule-1 (ICAM-I), E-Selectin, Platelet and endothelial cell adhesion molecule (PECAM) and Vascular cell adhesion molecule (VCAM). Intensity of stain and distribution was analysed by light microscopy and compared to normal liver.
Levels of AST were measured upon arrival in the ITU. Patients were placed into 2 groups: those with AST> 1000 i.u. classified as moderate/severe preservation injury. AST < 1000 i.u. were classified as minimal preservation injury. 12 patients had AST> 1000 i.u., of these, 8(75%) had all four A.M.s expressed at a greater intensity than normal controls with de novo appearance of E-selectin on endothelial cells, ICAM-1,PECAM and VCAM on sinusoids and ICAM-1 on hepatocytes. In the group with AST < 1000 only 2/16 had all four A.M.s increase in intensity.
Moderate/severe preservation injury is associated with a higher intensity of expression of cytokine inducible cell A.M.s. providing evidence of endothelial cell damage. This is probably related to Kupffer cell activation. Attraction of inflammatory cells into the graft together with cellular damage result in poor early graft function. Aim: The purpose of this study is the first to our knowledge to investigate liver blood flow perfusion intraoperatively in a population of patients with end-stage liver disease during OLT. To allow a more accurate assessment of liver perfusion, we have modified a Clark-type oxygen electrode. We used an electrode with high oxygen consumption thus rendering it more sensitive to blood flow rather than to oxygen partial pressure (Po2), and this was achieved by having a large cathode (silver, 3 mm in diameter) and a membrane with high permeability to oxygen (12.5 pm Teflon).
Method: In 16 patients, with mean age=51_+11 years the electrode was applied to the liver surface and in one patient an electromagnetic flowmeter (EMF) was applied to the portal vein (PV). Continuous readings of perfusion from the surface of the liver were examined with respect to (a) effects of PV perfusion up to 30 min. after revascularisation of the PV blood flow, (b) effects of hepatic artery (HA) perfusion up to 30 minutes after revascularisation of the HA blood flow.
Results: There was a good correlation between liver tissue perfusion using oxygen electrode against EMF in stepwise clamping of PV (r=0.953, p<0.001). Re-perfusion of the transplanted liver with venous blood was accompanied by an immediate increase in liver blood flow perfusion. Over the subsequent 10-30 minutes there was no significant increase in flow and re-perfusion of the graft with arterial blood did not increase liver blood flow perfusion. The optimum timing f.or s.urgical intervention in acute gallstone cholecystitis(AGC}still remains amatterof debate. Early surgery during the acute phase is followedbyhigher morbidity and mortality rates than conservative management which, in its turn, seems to be time and money consuming. The aim of this prospective clinical study was to .investigate the effect of a combined therape.utic protocol(conservative originally followed by surgery) upon the overall morbidity and mortality rates, in cases of AGC, and its cost effective impact.
Between 1990 and 1994 in 37 consecutive patients with AGC (13 males-24 females, m.a.62,5yrs) the conservative management resulted in full cli.nical and labora.tory recovery within 7 on average days (range 6-12 days). All these patients we_re discharged and were readmitted for _appropriate surgery after 4-6 weeks. The mean perioPerative hospitalization lasted lOdays oq av#rae, ll?e. overall morbididv rate was 14,5% and was excluslvey oue to superficial %hrombophlebitis which was developed during the acute phase from TPN intravenous. catheters in 6 out of 37 patients. There were no deaths throughout this serries. It is assumed that the beneficial results obtained with this therapeutic regimen, especially by being applied on a relatively high-rlsk group of patients, may form a basis for comparison with other therapeutic modalities and for future reference.  (BD) in 10. Pain shifting into the right lower qudrant presented in cases, jaundice in 8,epigastric right upper abdominal tenderness in 24, diffuse tendemess and rigidity in 13 and abdominal distension in 13. BP complicating acute cholecystitis or/and cholangitis operatively demonstrated in these 24 cases, being preoperatively misdiagnosed acute appendicitis (AA), perforated peptic ulcer, acute pancreatitis, upper gastrointestinal blecding acute BD. There various of BP in which acute BD is mostly reponsible, To diagnose BP generally not difficult, but not easy in belonging to the subacute and chronic groups and also in the elderly, The misdiagnosis in patients included miss of diagnosis of BP (11 cases) and of peritonitis misinterpreted(13).
Chief factors contributing to postoperative BI included: (1) Indication of CD wrongly chosen(3) with intrahepatic stone stricture, repeated cholangitis resulted. (2) Retrograde biliary reflux (RBR). Repeated chemical stimuhtion to BT is harmful and BI unavoidable, favorable to the formation ofgallstones. BII and DJ could effectively prevent and treat the RBR. (3) "Blind lump." End-to-side CD simply eliminates this phenomenon. This study was performed to investigate the role of prostaglandins (PG) and bile protein in pathogenesis of gallstone formation. PGI and TXA in gallbladder mucosa in patients with chronic cholecystitis and gallstones were determined by RIA of 6-keto-PGFla and TXB a. Bile protein was measured with fluorometric and amino acid analysis. Pathological and histochemical changes in gallbladder mucosa were observed to estimate the degree of inflammation and glycoprotein synthesis. The results show that increased PGIa, PGI2/TXA values and bile protein were consistent with the degree of gallbladder inflammaton and staining grade (PAS,AB) for glycoprotein. The values of PGI 2, PGIflTXA in the cholesterol gallstone group (30.07_+5.36, mean_+se) were significantly higher compared to the groups with pigmented stones (11.53_+1.76) and acalculous cholecystitis (15.35_+4.41), (P<0.05, Student's unpaired t-test). Bile protein in the group of cholesterol gallstone (1.64_+0.14) was much higher than the pigmented stone group (0.77_+0.14) and control (0.95_+0.11), (P<0.01). The conclusion is that PGIa, PGI2/TXA and bile protein were related to the progress of gallbladder inflammation and glycoprotein synthesis and probably plays a significant role in cholesterol gallstone pathogenesis. This study deals with 132 such cases, out of a total of 1098 simple cholecystectomies (12.09%) performed over the last 10-year period. Sex ratio was female 2.3:1 male and the mean age 61.2 years (43 97 y). Wrinkled intrahepatic gallbladder 54c. Hydrops 14c. Acute cholecystitis 22c. Gangrene 11 c. Empyema 13 c. and Choledocholethiasis 21 c. The above operative findings necessitated modifications of the operation and postoperative treatment. This controversy between preoperative estimation and operative findings is mostly due to long standing lithiasis without acute symptoms in correlation with advanced age of the patients. Another 296 cases were promptly estimated as complicated preoperatively.
It is concluded that in a respectable percentage of "simple" The primary goals in the management of intrahepatic lithiasis (IL) are: 1) remove the stones from the intrahepatic bile ducts; 2) reestablish a good biliary flow; 3) prevent recurrences. Aim of this study is to demonstrate that the surgical treatment is the best solution of the problem. Material and Methods: Since 1982 37 pts (22m, 15F, mean age 53 years, range 24-78) have been observed. In one case the etiology was primitive while in the rest it was secondary to anatomical disorders or to stone migration from the extrahepatic ducts. The intraoperative workup with cholangiography and ultrasounds revealed the exact location of the stones in 100% of the cases while the preoperative diagnostic assessment was exact only in the 62.8% of the cases. The hepatic diffusion was multiple (MD) in cases and segmental in 29 (SD). Patients wityh MD were treated with lithectomy, associated to a wide biliary digestive anastomosis (BDA) at the hilum in cases, in one the BDA was completed with a cutaneous stoma, while in the remaining 2 cases the BDA was intrahepatic. Of the 29 pts with SD 5 were treated with lithectomy, associated to papillosphincterotomy and to BDA in 16 of which one was intrahepatic. In the remaining pts was performed an hepatic resection.
Results: One patients died in the post operative period for hepatic failure. Four had specific complications for which 2 cases needed reintervention. Lithectomy was not complete at surgical intervention in cases (8%) one of them was successfully treated with ERCP. The rest of the pts are to date in good clinical conditions without recurrence.
Conclusions: To date surgical management is the gold standard for intrahepatic lithiasis: it permits a precise localization of the stones; a definitive solution of the problem; low recurrence rate and small percentage of incomplete lithectomy although always curable with a non surgical approach.  We followed-up I8 patients during 4,5 5 years In 9 of them formation of stones took place relatevely earlyin 13 to I4 months mean-II months). In the other 9 patients, who did not manifested formation of stones in these terms, gallstones were not found during following examination u to 4,5 years (mean 36 months). None of different dietic and  In recent years, alternatives to surgery for difficult CBD stones have been developed. Routine endoscopic measures fail in about 10% of patients, while advanced endoscopic procedures such as laser, electrohydraulic lithotripsy or dissolution by solvents, require a skilled endoscopist or a close and effective physical contact with the stone, therefore these procedures are technically difficult and sometime uneffective. ESWL can be used to disintegrate stones and since1989 has been applied in CBD stones. To verify the usefulness of ESWL in biliary tract stones, we treated, from 1990 to 1994, 26 patients (16 F-10 M), mean age 67+20 yrs (range: 34-89). 16 (62%) had multiple stone and size range:10-25 (mean: 18 mm). We utilized the Dornier lithotripters HM4 (X-ray guide, n=16) or MPL 9000 (US guide, n=10). 1513+ 521 shock waves (range:260-2226) was delivered in 68.8+25.4 min (range: 28-104) at 22+2.5 Kv (range:18-25), triggered by an ECG. All patients have had an endoscopic (n=22) or surgical sphincterotomy (n=4). In pts treated by HM4 the stones were visualized by contrast medium injected through a nasobiliary tube (n= 8), a postsurgical drain (n= 4; 2:T-tube, l:transcystic and l:cholecystostomy) or a PT catheter (n=4). In 4 pts i.v. opiate analgesia has been necessary. In all pts endoscopic or radiologic routine or advanced measures had previously failed. 20 pts riad CBD stones, in 2 pts (7.6%) the stones were localized in the RHD, in 2 pts in the LHD, in pt at the carrefour and in one at the CHD. 2 pts had a massive lithiasis and in one pt GB was insitu. 31% of pts needed two ESWL sessions and 2 pts three.Our results showed a mean stone size of 5 mm in 12 pts, 7 mm in 10 pts and no fragmentation in 4 pts. Complete clearance was obtained in 23 pts (88%) after one or more sessions either by endoscopic (n=17) or percutaneous extraction (n=6) of the debris; in the remaining 3 pts, in 2 a bilio-duodenal stents was placed and in one EHL was performed. Moreover, we report a 23% (6 pts) of transient mild hemobilia, microhematuria in 15% No mortality was reported. In conclusion, in anatomic or size-related difficult biliary stones, ESWL, is an additional nonoperative option to resolve the failure of routine endoscopic measures. Moreover ESWL in contrast of the advanced procedures presents certain advantages: direct contact with the stone is not necessary, treatment is rapid, safe and highly effective.

FIVE YEAR'S EXPERIENCE WITH ESWL FROM A SINGLE CENTER
i. (zman, G. Avc, S. Bora, J. Erdamar, H. G01ay Dokuz Eyl01 University Medical Faculty General Surgery Department, 35340, inciralt=, izmir-TURKEY Between July 1989 and April 1993, ESWL + litholytic therapy was performed in 167 patients with symptomatic gallbladder stones. One hundred and seventeen patients were female and 50 were male with ages ranged from 23 to 78 years (mean of 56.8 years). The number of gallbladder stones were 1,2,3 and multiple in 137, 13,11 and 6 patients respectively. The number of ESWL sessions were one in 61 patients, two in 59, three in 38, four in 7 and five in 2 patients. ESWL therapy was discontinued when the fragments of stones were lesser than 4mm. in diameter. In 114 patients (68%) the fragmentation was achieved while in the rest ESWL had failed. After successful ESWL treatment, chenodeoxycholic acid (CDA) was used as the chemolytic agent for 6 to 14 months (mean of 11 months).
During the follow-up, 53 patients became stone-free but in 16 of them (30%) stone recurrence was detected between 3 months to 5 years after and treated with cholecystectomy. transverse incision of up to 5 cm, based on the preoperative clinical and ultra-sonic studies of the position of the gall bladder.) 4. The limitation of cost and hospital stay (the patient is fully motile by evening and is released the following day). 5. It has the added advantage that it can be done with spinal anaesthesia or even local anaesthesia. In conclusion we report that in our 67 selected cases, we had only two cases with post-operative complications. in one case, due to bleeding, the mini laparotomy was extended to laparotomy. In another case, we re-admitted the patient, because of a small retained gallstone, which passed using conservative treatment. The widespread use of laparoscopic surgery has resulted in decreased use of conventional methods in hepatobiliary tract diseases. This retrospective study is a report on 112 patients with hepatobiliary tract disease, who underwent open surgery during January 1988 and June 1992.
Of all the patients, 86 (77%) were cholecystectomized and 26 (23%) had common bile duct exploration in addition to cholecystectomy. All of the operations were performed from the left side of the patient, in 95 cases we preferred a midline superior incision. There were 96 females and 16 males, with a 1/6 male to female ratio. The mean age was 46.8 years. In 96.4% of the cases the underlying cause of the disease was cholelithiasis, where in one case it was neoplasia of the gall bladder, a polypoid lesion in one and acalculous cholecystitis in another.
The reason for common bile duct exploration was gallstones in 24 cases, choledochal cyst in one and hydatid disease in another. 29 cases underwent surgery in more than one organ system during cholecystectomy. We have observed anatomic variations of the biliary tract in 23 cases. 83  Background: Although complications in cholecystectomy are infrequent, bile duct injury following cholecystectomy is one of the most serious complications in surgery. Numbers are increasing with laparoscopic procedures. Methods: The auhtors report on iatrogenic lesions of bile ducts injuries occured in Teaching Hospital Maribor, which were followed up in a prospective study between 1980-1989 and between 1990-1994. In the first period (1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989) 6646 open cholecystectomies were done (1927 men, 4179 women, average 52.6 years, range 14-91). In the second period 2646 open cholecystectomies and 235 laparoscopic (starting year 1992) procedures were performed. Results: In the first period 8 cases (six women, two men, average 62 years, range 28-75) of iatrogenic bile duct injury occured. There were no iatrogenic injuries in the second period. Analysing the first period, seven lesions were detected and treated in the case of surgery, once lesion was overlooked. All lesions occured before intraoperative cholangiography was carried out. In partial lesion direct suture was applied once and three times suture over the T tube. In complete transsection termino-terminal reconstruction over the T tube was performed. In patient with overlooked lesion after six months stricture developed. She was reoperated and biliodigestive anastomosis by Roux was performed. In two female patients reoperations were required after primary reconstruction over T tube. In both cases fmaly biliodigestive anastomosis after Roux was done. All patients are now without complaints. Conclusions: In the first period there was injury in 830 operations (0,12%). No iatrogenic injuries occured in the second period. It is stated that prospective follow up of iatrogenic bile duct injuries may decrease the morbidity alter reconstruction. Even more, it may lead to disappearance of iatrogenic bile duct injuries. During the past 3.5 years, 657 patients were operated for bile stones in our clinic. In 83 of these patiens the common bile duct was explored as they had the suspicion for carrieing a stone. Patients who had had choledochotomy were assessed using 13 parameters, and their efficacy for the diagnosis was evaluated. The criteria were: age, sex, jaundice, pancreatitis, acute cholangitis, cholecystitis, palpation of stone, the diameter of common bile duct, small stones in the gallbladder, patent cystic duct, hyperbiluribinemia, alkalen phosphatase,and ultrasound findings.
In 24 of the eigthythree patients one or more of the criteria were found to be positive, but in their exploration no stones were detected. Three oF the parameters (palpation of the stone, jaundice, and alkalen phosphatase) were found to be efficant for detecting the common bile stones (p 0.01). When the diameter of the common bile duct is accepted as 12 mms., the width of the common bile duct has no value for dianosis; but when the cut-off point is taken as 15 mms. this parameter is effective in detecting the common bile duct stones. Injury of the extra-hepatic biliary system lesion is infrequent, occurring in approximately 3.5 % of all patients with blunt and penetrating abdominal trauma. The incidence of this injury due to blunt abdominal trauma is rare.
The aim of this study is the analisys of 5069 patients with abdominal trauma treated at the Department of Surgery University of Silo Paulo (Brazil) over a sixyear period to identify those with injury of the extra-hepatic biliary system. Forty five patients with gallbladder and extra-hepatic ducts injury were identified (0.89%) and divided in two groups according the nature of trauma: 12 due to non-penetrating injuries and 33 due to penetrating injuries. Records, including operative and pathology reports, were reviewed to study the site of injury, associated intra-abdominal injuries, incidence, trauma scores, treatment, morbidity, mortality rates and correlated with the nature of the trauma. Overall mortality was 24.4%. The incidence was greater in the patients sustaining penetrating abdominal trauma (p<0.05). Forty of the 45 patients (88.9%) had liver lacerations, the most commonly seen injuries. The patients with blunt abdominal trauma had significant different trauma scores (p<0.05) than those with penetrating trauma, indicating greater severity in this group of patients.
We conclude that there is relation between severity of trauma and incidence of extra-hepatic biliary system injury. However in the penetrating trauma, the incidence of trauma is correlated with the direction of the wound and there is no relation with the severity of trauma. The greater mortality seen in the patients sustaining non-penetrating injury (p<0.05) supports.this idea. The spillage of stones is a frequent event during laparoscopic cholecystectomy, and initially, it was considered as a harmless operative incident. Some experimental studies have shown that stones leaved in the abdominal cavity induce immflamatory changes with a low incidence of intrabdominal abscess. Since 1991 to date, 50 cases of intrabdominal complications secondary to retained stones has been published and most of the required a reintervention to treat this complication. Case report: A 45-yold-male diagnosed of symptomatic cholelithiasis, in which an ultrasonography revealed a gallbladder with a 4 mm wall and stones larger than 30 mm. Laparoscopic cholecystectomy was performed uneventfully but the gallbladder ruptured and several stones fell under the liver and it was not possible to retrieve one stone. The patient evolved satisfactorily. Two and a half y. later, the patient presented swelling in the right flank. X-ray examination showed a calcified image in the right fossaand a CT scan showed a round, well defined bilobular collection with an image compatible with a stone. The patient was operated and a well defined cavity containing sterile serohematic fluid was opened and a 30x15 mm stone were recovered. The patient evolved satisfactorily and is free of symptoms. Comment. Stone spillage has been not considered an indication of conversion of laparoscopic cholecystectomy, but is now accepted that is a source of infrequent but severe complications that may require a reintervention for treatment. Thus, is recommended that any effort should be made to retrieve all the spilled stones and prolong the surgical procedure until this is achieved, in order to reduce one source of unpredictable morbidity. In selected cases, a large number or big stones are lost, open retrieval should be considered.

INJURIES ON EXTRAHEPATIC BILIARY TREE
L. Lapidakis, L. Papastamatiou, D. Kalokerinos, A. Zarzali 2rid Dept. of Surgery "Apostle Paul" Hosp.-KAT. ATHENS -HELLAS Injury on the extrahepatic biliary tree (EBT) associated to complex liver trauma is not often and as isolated injury is extremely rare. Biodynamic mechanisms and intraperitoneal conditions are responsible for EBT trauma.
Exact preoperative diagnosis especially in multiinjured patients is practically impossible. Moreover intraoperative recognition of EBT trauma is sometimes difficult, due to associated major visceral or vascular injuries. Therefore, early relaparatomy is "acceptable" for overlooked EBT trauma. This report deals with 24 cases of EBT trauma detected in 160 cases of liver injury (15%), after blunt (22 cases) and penetrating (2 cases) abdominal injury, in the last 10-year period. In 18 cases injury was to the gallbladder, in 2 cases to the bile ducts and in 4 cases in both structures. All injuries were recognised during the emergency intervention, but chance was of great help in 2 cases of ductal trauma. All patients underwent cholecystectomy and either bilioenteric anastomosis or primary repair with T-tube for ductal injury. Modality rate was high (54,2%) associated to coexistent injuries. One patient with penetrating isolated ductal injury died after sepsis and multiple organ failure. Three of the survivors developed early (bile leakage) and 2 of them late (stricture) complications, treated conservatively.
It is concluded that the detection of bile duct injury in multitrauma patient is not easy. The type of the operative repair is dictated by the location and the extent of the ductal injury, but the operative technique applied is personalised by the choice of the Iatrogenic biliary tract injuries are not uncommon, and their management remains a significant challenge. The management and outcome of 33 consecutive patients with iatrogenic biliary tract injuries in a tertiary referral centre over a 21 year period are analyzed. The mean age was 43.5 years. The median time to diagnosis of the injury was 2 weeks (range 0 11 years). The median time from original operation to referral was 3 months (range 0 17 years). Thirty patients (90.9%) had undergone an open cholecystectomy, 7 ofwhom had exploration ofthe common bile duct; 2 patients had a laparoscopic cholecystectomy, and patient had undergone revisional gastric surgery. Fifteen patients (45%) had undergone one or more subsequent operations prior to referral. Five patients (15%) had established secondary biliary cirrhosis, portal hypertension and variceal bleeding when referred. Percutaneous transhepatic cholangiography was the radiological investigation of choice. Six patients had percutaneous dilation, and 23 had surgical procedures in this unit, some patients requiring both radiological and surgical intervention. One patient is awaiting surgery and patient died prior to intervention whilst undergoing investigation. Five patients in this series have been re-referred to other specialist hepatobiliry centres for further advice on management. Fifty per cent of those treated by balloon dilatation have subsequently required surgery. Of 23 patients who have had surgical reconstruction in this unit, only 2 have required revision surgery. Mean follow-up has been 5.7 years. We recommend early referral of patients with iatrogenic injuries to units experienced in dealing with such injuries, with no attempt at repair prior to referral. were divided into three groups according to the injury, time of diagnosis and time of corrective procedure. The first group consisted of 18 patients in whom reconstruction of the bile ducts was performed during the primary operation. The second group comprised nine patients in whom injury was diagnosed in the early postoperative period. The third group of 27 patients had restenoses after reconstruction performed in other hospitals. The primary operation, localization of the injury, diagnostic procedures and operative treatment of the bile duct injures were analysed in each group. Thirty-two patients reviewed from 3 to 20 years after corrective surgery were studied as long-term follow-up group. According to clinical examination, laboratory tests, radiography and biliary scintigraDhy, long-term results were satisfactory in 24 patients.
The authors consider hepaticojejunostomy Roux-en-y to be the procedure of choice in the majority of patients with iatrogenic bile duct injuries. This study was undertaken to assess the effect of Nutritional Therapy in the management of external biliary fistulas. During a seven year period  7 patients, average age 66,8 years,were treated in our Department suffering from external biliary fistulas developed as s result of surgery in the hepato-biliary system. There were two high-output and 5 low-output fistulas whlcll appeared 1 to 15 days after surgery. Four patients had moderate to severe malnutrition at the time of presenting of the fistulas. Five patients were treated with Total Parenteral Nutrition via:a central venous catheter, and 2 patients with lowoutput fistulas have taken Total Enteral Nutrition via a fine naso-duodenal tube. All the fistulas closed after 7 to 17 days of treatment, except for one patient with high-output fistula who died from uncontroled sepsis. The nutritional status remained unchanged at the end of the treatment in one patien, whereas it imp]:oved in allthe other No serious side effects were noted during the nutritional therapy, it is concluded that artificial Nutrition plays a significant role in the conservative treatment of the external biliary fistulas because it improves 5he nutritional status of these patients and maybe shortens the spontaneus closure time. Roux-en-Y(15%),in particular when no stent was used across the anastomosis(8%).The hosp, ital mortality rate was 2(5%)of l and overall mertality,7(17%)of l.The lowest mortality rate(9) was associated with hepaticoejunostomy Roux-en-Y.Low rate of recurrence and mortality are correlated to early referral.Patients with iatrogenic bile duct injury should be referred early to a competent center,where adequate treatment of infectioh,reconstruction with a hepaticojejunostomy Roux-en-Y without stenting,and lifelong follow-up can be performed. First Department of Surgery, Venizelion General Hospital, Iraklion Crete Greece. The occurence of external biliary fistulas after liver surgery for hydatid cysts is not rare. On several occasions their frequency ranges from 3.8-5.7%. Therapy is often troublesome especially in Hospitals where there is no possibility of endoscopic treatment (nasobiliary tube, sphincterotomy). There are studies in which it is claimed that the administration of synthetic somatostatin decreases the production of bile by approximately 30% due to its inhibitory action on the composition of biliary acids, cholesterol and phospholipid.
Considering the above, synthetic somatostatin was used to treat the external biliary fistulas complicating liver hydatid disease surgery. Over the past five years, ten cases of large hydatid cysts of the right hepatic lobe of have been operated on our department and partial capsectomy with drainage of the remaining cavity was carried out. External biliary fistulas developed in four cases, three of which had an output of 400-600 ml per day. Treatment was conservative and synthetic somatostatin was administered. There was positive response to the conservative therapy with gradual decrease of output to zero in 22, 17 and 28 days respectively. It appears that synthetic somatostatin has a major role in the theatment of external biliary fistulas. However, further studies are required to confirm its effectiveness. PATIENTS AN] FETHODS: Fom Novee 1973 to Fay 1992 we operated upon 27 ie with biL7 Uy, 47 of m with i b' fistula (incidence: 1.74%). The clinical pesentation was as gallstone ileus in II patients (23.4%) and as a biliary fistula in anothe 36 patients conf at opeFation. The mean age of this series was 65.9 years (nge: 393 years), 27 w wsm and RESULTS: The clinical f'wiings were: abckminal pain in30 patients (64%), jndice in 9 (4/o), feve in 8 (Ir/), ding in 6 (L%) and dydm-. tion in 5 (11%o). By means of radiological studies (plain films, oral cholecystogy, i.v. cholangiogaphy, gastodmdel barium atydi, ultmy aml CT) we (pubia, sb) irely diagnosed a bi]ary fistula in 10 cases (24). The confirmation of the fistulas was at operation, and the location was: cholecystoduodersl in 23 patients, cholecystocholedochal in 11, cholecystic in 4, dlecystogestzic in I, dlecy-lic inl, and olecystodledochalco]ic inl. In five patients we dd not classify the fistula because we did not disect the fistulous tract (gallstone ileus). In the dummy in 2, T- Thirty-tree patients with gallbladder stones wcrc evaluated prospcctivcly in rcspcc! of their hormonal status. Eight male, 25 fenmle patients wcrc included into this study. Serum cholesterol, estradiol and testosteron levels were detected preoperatively in all patients. After a cholecystectomy, pathologic spccimes wcrc prepared from the apex(f), body(c) and neck(i) of the gallbladder. Estrogen and progesteron receptor status were determined in all specimens at all three locations stated above. Male and female patients were compared to each other in respect of serum estradiol serum cholesterol ratios and the reseptor status. Serum cstradiol choleslerol ratio in female and male patients vere 0.23 + 0.09 and 0.34 _+ 0.04, respectively. There was no statistical difference between the two gro,p of patients. Estrogen respetor levels vere 0.1710.06(f), 0.1710.09(c) and 0.28 0.09(I) in females and 0.35tO. 10(f), 0.37:L-O.08(c) and 0.5210.19(I) in males while progesteron rescptor levels were 0% in all patients. There was statistically significant difference between these two groups in respect of the estrogen rescptor status (p<0.05). We conclude that, decrease in the sensibility to estrogen rescptors may be responsible for the tendency to cholelithiasis in males. Exfoliative bile and brush cytology has greatly improved our ability to determine the nature of biliary tract strictures but the sensitivity of these techniques is rarely over 60%(1). This study has analysed the effect of tumour type and differentiation to the results of biliary cytology. Data was analysed on 79 patients (50 Male, median age 65 years, range 19-85) who had both biliary cytology (92 samples taken at ERCP) and tissue available for routine histopathology. Cytology was reported as positive or negative for malignant cells. Tumour type and differentiation was obtained from histology of resected specimens (n=30), percutaneous or intra-operative biopsy (n=45) or post mortem examination (n-4). Twenty three patients had pancreatic, 29 bile duct, 20 ampullary and 6 gallbladder cancers. In one case histology showed no evidence of cancer despite a positive cytology. Tumour differentiation was well (n-20), moderate (n=27) and poor (n=21)(1 Ca in situ, 9 differentiation not known). The overall sensitivity of cytology was 55% (43/78) and the positive predictive value of the test was 98%. There was no significant difference in the sensitivity of cytology by tumour differentiation (well 13/20(65%) moderate 14/27(52%) and poor 10/21(48%)). There was, however, a significant difference in the sensitivity of cytology by tumour type being highest for ampullary and bile duct cancers (59 and 80% respectively) and lowest for pancreatic and gallbladder (30 and 50%). This study has clearly demonstrated the influence of tumour type to the results of biliary cytology but that this is not related to tumour differentiation.

THE INFLUENCE OF TUMOUR TYPE AND DIFFERENTIATION TO THE
p<O.05, X test 1) Kurzawinski

Moscow Medical Academy, Russia
The exocrine liver function after cholecystectomy changes in increasing choleresis (85,7 %) through both bile-acid-dependent and bile= acid-independent fractions. A considerable increase of bile volume has been observed in biliary desease and has been connection with increasing of the secretion in ductules and canalicules.
To investigate the change of bile secretion after cholecystectomy, an attempt has been made to analyze the participation of most known gastrointestinal hormones (glucogon, bombesin, VIP, somatostatin) in regulation of bile-acid-independent fractiofi. (30 patients with cholelithiasis before and after cholecystectomy, 10 healthy). HCI-stimulator and secretin has been used.
Glucogon, VIP, bombesin influence stimulatory on bile flow of healthy patients. A linear relationship of a high an average correlation has been observed between the blood hormone concentration and the stimulated bile flow. Somatostatin inhibits bile flow. Patients with cholelithiasis have some changes in hormonal regulation: an increase of basal level of bile stimulators (glucogon by 85,8 %, VIP 27,6 %, bombesin 33,9 %), a change of character and degree of correlation between the blood hormone concentration and bile flow as well as the character of interactions between hormones. After cholecystectomy they remained. But considering the similar hormone kinetics in patients before and after operation one can assume, that a considerable increase of choleresis after cholecystectomy is determined by local factors (infection, mechanical factor etco), which change the sensitivity of cells to some hormone action.
TRUNCAL VAGOTOMY WITH GASTROJEJUNOSTOMY AFFECTS GALLBLADDER EMPTYING Xynos E, PechhVanidcs G, Fountos A, Zoras O, Tzovaras G, Chrysos E, Pctrakis I, Epanomcwtakis E, Koutsoubi E, Vassi/akis JS Department of General Surgery, University Hospital of Heraklion, Greece Background: Gallbladder emptying has been studied by seintigraphy after a variety of antiuleer gastric operations, including highly selective vagotomy, truneal vagotomy with pyloroplasty and Billroth and II gastrectomy. The a/m of the present study was to estimate gallbladder emptying by scintigraphy in patientts with mmeal vagotomy and gastrojejunostomy Patients-Method: In 8 patients after truncal vagotomy with gastrojejunostomy (TV-GJ), gallbladder emptying was estimated by HIDAseintigraphy. The results were compared to those of 28 healthy controls.
Thirty min after i.v. injection of 2 mCi of 99mTe-HIDA, an initial abdominal scan was obtain, and then the subjects drank 300 ml of fresh milk (lipids: 4%). Thereafter serial scans of 60 see, every 5 rain and for one hour were taken. By plotting gallbladder radioactivity (measured at all time points and expressed as percentage over the initial count) against time, emptying curves were obtain. From those curves the duration of lag phase, the ejection fraction (peak to least activity) and the pattern of gallbladder emptying were estimated.
Results: In 2 controls radioactivity partitioned into the gallbladder over the abdomen was <25% at the initial view, a phenomenon attributed to spontaneous gallbladder emptying. These subjects were excluded from further assessment. TV-GJ significantly increased the lag phase duration (8+3.5SDmin) and reduced the ejection fraction (50+6SD%) as compared to controls (1.5+4SDmin, p<0.0001 and 81+8SD%, p<0.0001 respectively). All controls exhibited a type pattern (exponential curve) of gallbaldder emptying. On the contrary, out of the 8 patients after TV-GJ (p<0.03) exhibited a type II pattern (multiple emptying and refilling events) of gallbaldder emptying. Conclusions: Truneal vagotomy with gastrojejunostomy significantly affects gallbladder motility, by delaying the duaration of lag phase, reducing the extent and altering the pattern of emptying. This could be attributed to the fact that emptying gastric contents bypass the duodenum, after gastrojejunostomy, resulting thus to reduced release of eholecystokinin during the intestinal phase. A total of 40 patients were assigned to either PTBD followed by surgery (Group A,n=20) or elective surgery (Group B, n=20).
Mean duration of jaundice in PTBD was 54.5 days and 49.5 days in Group B.
PTBD was performed under ultrasound guidance. The mean duration of drainage was 42.5 days.
Both the group were similarly prepared for surgery. The aim of the study is the assessment of the gallbladder (GB) contractile function in 8 controls (Cs), and in the postgastrectomy patients: 10 early (EPG) and 10 late (LPG) after total gastrectomy as well as after Billroth (partial) resection (BI).
In conclusion, after total gastrectomy with vaotomy and excluded duodenal transit, impairement of the GB motility early and recovery of the physiological contractile function late after operation might be attributed to the establishment of the hormonal mechanisms (CCK). In the patients with partial gastrectomy, without vagal denervation and preserved duodenal tranzit, GB motility remains undisturbed. This study deals with the bile duct drainage procedures due to benign biliary tract diseases. We studied 64 patients, 30 males, 34 females whose ages re ranging from 24 to 91 years (Mean age was 72 years). These patients wre treated in the last five years (July 1989-November 1994 in our department. The first group oonsisted 26 ients who undet an elective operation.The group consisted of 38 patients who had an urgent operation. In the first group the indications for operation wre: bile duct stones, left hepatic duct stones,retaining stones of the bile duct and pancreatic pseudocyst.
In the second group the indications for operation wre: Obstructive jaundice, suppurative cholangitis,hdrops of the gallbladder and acute cholecystitis.
Fifty of both group patients had a side to side choledohoduodenostcmy and the remaining 14 had a Roux en Y choledohojejunost(my. One patient of the second group had also a transverse colectcmy. Three of them had bile leakage and undt a reoperation.Tw patients presented postoperatively evisceration, while 2 more died.As a conclusion drainage procedures of the biliary tract are eonmon and safe. Morbidity and mortality is dramatically increased when perate on an emergency basis. Although the pathogenic role of pregnancy and gallbladder (GB) motility and biliary stasis in gallstone formation has assumed increasing importance only a few studies have analysed GB emptying in pregnant women. The aim of this study was t6 investigate the GB emptying in pregnancy. GB fasting volume (FV) was measured ultrasonographycaly in 48 healthy nonpregnant women, 120 healthy pregnant women and 146 pregnant women with cholecystities.
The FV was larger in pregnant women with cholecystities in the 3 trimester of pregnancy (54,4 + 5,6 ml), then in healthy pregnant women in the 3 trimester (33,7 + 4,0 ml) and healthy nonpregnant women (17,2 + 5,2 ml). The emptying of GB in pregnant women after fatty meal was retarded in comparison with nonpregnant women, the residual volume increased also, and the percentage of emptying lowered significantly. In parallel with GB contraction the levels of blood progesterone were mesuared and it was seen the straight correlation.
Thus, this data show that pregnancy itself impair GB contractility, and this fact can be a potential pathophysiological risk for gallstone formation in women. (1,2), which are considered irreversible. We report a case in which a 12 month therapy of UDCA resulted in significant regression of radiologic abnormalities.
A 17-yr-old woman presented in June 1992 with severe epigastric pain during the last month. The liver function tests revealed high levels of transaminases (2-4x), alkaline phosphatase (4x) and -GT (8x), with normal bilirubin. WBC was elevated (15.500) as well as CRP (3x). On US and CT scan there were no abnormalities. An initial ERCP showed multiple strictures of the intra and extrahepatic biliary ducts with a beaded appearance, consistent with PSC. Oral UDCA at a dosage of 500 mg a day was initiated. The patient was symptom free and the hepatic function tests were normal after one month. On September 1992 an ERCP was performed, which showed a remarkable improvement of the abnormalities of intra-and extrahepatic ducts. Therapy with UDCA was continued for the next 10 months, when the patient, who was now a student, discontinued the treatment. On July 1993 a third ERCP was performed, which showed a complete resolution of the abnormalities in the common bile duct and only slight changes of the intrahepatic ducts. The patient feels well, liver tests remain normal after an adittiona116 months of follow up. It is concluded that almost total regression of the cholangiographic changes of PSC is possible, at an initial stage, with UDCA therapy.
All the patients underwent surgery and an appropriate biliary drainage procedure was performed depending on the pathology. Excision of choledochal cyst was performed in 6 and a cyst-enterostomy in one.
Choledochoduodenostomy was performed in patients with corrmon bile duct tuberculosis. Local ampullary excision was performed in patients with ampullary tumours with reconstruction. Three patients (9%) died two with chronic pancreatitis and one with intrabiliary hydatid disease; the others are alive and well on follow-up. We conclude that these uncorrmon aetiologies should be kept in mind in managing patients with surgical jaundice and the surgical procedure appropriately planned. In the series of long-term investigations (1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994), carried out at Moscow Medical Academy, in a group of patients with ulcerative colitis (UC-164) and Crohn's disease (CD-97), primary sclerosing cholangitis (PSC) was found in 25 (15.2%) and 13 (13.4%) of patients accordingly, that makes up 14.6% from the total number of patients with inflammatory bowel diseases (IBD). In 10 cases (US-4, CD-6) PSC was diagnosed at the early stage without clinical manifestations of the disease according to biochemical indices proving the initial symptoms of cholestasis. During this observation progressiv PSC has been found in 4 of these patients followed by 2 lethal cases (one patient ha got cirrhosis of the liver, the other has developed cholangiocarcinoma). After diagnosing PSC in 28 patients (UC-21, CD-7) they have demonstrated both biochemical Indices disordes and pronounced symptoms of the above mentioned disease. By the end of observation 6 patients had died of hepatic failure resulting from PSC followed by cirrhosis of the liver and patient of cholangiocarcinoma. 9 patients developed slow progressing PSC and transplantation of the liver was performed for two of them; 4 patients have been enlisted and waiting Although antibiotic prophylaxis is effective in reducing postoperative infections following biliary surgery, there is a controversy on patient selection, antibiotic choice or duration and timing of administration. This prospective study is based on 1098 consecutive operations for benign biliary diseases. Definition of risk factors for septic complications were determined as follows: age over 65, obesity in relation with diabetes, bile duct exploration and acute cholecystitis. The clinical material was classit-d in 3 groups: Gl:no risk factor (292 cases), GI1:1-2 risk factors (469 cases), Gill: 3-4 risk factors (267 cases). Antibiotics used were 2nd generation cephalosporin.
No antibiotic administration to the patients of GI.
Perioperative administration of one(preoperative) or three doses to the patients of GII. Administration for 72 hours postoperatively to the patients of Gill. In all cases of acute cholecystitis 3 doses or 3 days administration was applied, in relation to operative findings.
Septic complication rate was 1,7% for GI, 3,2% for GII and 9,4 for Gill. The data of these series permit the following suggestions: 1) In contrast to recent data, no prophylaxis for GI is needed.
2) Minimal prophylaxis of one single dose, -2 hours prior to surgery is suitable for GII. 3) Maximal 3-days administration for Gill. 4) Acute cholecystitis obliges to 3 doses or 3 days antibiotic prophylaxis. Antibiotic of choice: 2nd generation cephalosporin and only in the presence of inflammatory pancreatic reaction, use of 3rd generation.
It is concluded that this approach to controversial recommendations is hoped to be of medical and economic benefit in biliary surgery.

P195 P196
INDICATIONS FOR PERIOPERATIg-E CHEMOPROPHYLAXIS IN HEPATOBILLIARY SURGERY N.Djordjevi6, G. Stano jevi6, D. Stankovi-Dordevi Interventious on the billiary tract are followed by high frequency postoperative infectious complications,expecialy in patientes with bacteria present in the bile.The incidence of septical complications is reduced by antibiotic prophylaxis in billiary surgery,but it is useful only in patientes with contaminated bile.Intraoperativ gram staining the bile is easy and useful method for determination the presence of bacteria in the bile and for antimicrobial drugs selection for sistemic chemoprophylaxis.This action avoid unnecessary antibiotic aplication,give a chance to make a regular antibiotic choice,reduce the frequence of postoperative septic complications.
We avoid unnecessary antibiotic aplication in 52% cases.
Perioperative chemoprophylaxis chould be carried out in the following cases:acute inflamatory pro cesses on billiary tract,early reinterventions, patients with icterus and calculosis of billiary duct and patientes with high risk factors.
By the application of perioperative chemoprophylaxis total frequency of postoperative infectious complications is reduced from 8,91% to 4,91%.
In the patients on which billiary-digestive anastomosis is done,this frequency has been reduced from 13,81% to 7,14%.  The aim of this announcement is to present the intestinum obstruction from gallstone because even today it endangers a patient's life due to the at ypical abdominal symptomatology which it presents. Diagnosis is based mainly on clinical symptomatol ogy and on the simple abdominal X-ray after taking a flacon gastrographin. PATIENTS AND METHODS In 1993 we operated on a 78 year old male patent for obstruction of the small intestine from a gal istone. The ultrasount of the gall bladder showed chololithiasis,while the simple abdominal X-ray (in upright position,after taking a flacon gastro graphin) showed obstruction of the small intestine with hydroaero levels.An emergency laparotomy enterotomy was performed as well as the removal of the stone from the small intestine. The enterotomy was closed in two 19yers.An incision of the gall bladder was done and the stones were removed rom the gall bladder.Cholecystostomy was also pe rformed. There was a cholecystoduodenal fistula which was left as it was.The post operative progress was very good.A cholecysto-cholangiography was done through the cholecystostomy-tube on the 2Oth postoperative day,with a good reproduction of intra and extra hepatic billiary tree. Dischage was given on the 12th postoperative day and the cholecystostomy tube was removed on the 25th post operative day. CONCLUSION Intestinum obstruction from gallstone constitutes rare cause of mechanical obstruction of the sm-all intestine. Diagnosis and indication for surgic therapy must be put forth as soon as possible aft er considering the clinical and labor-findings. Cerrahpa,a Medical Faculty, Istanbul-TURKEY Choledochal cyst is a rare congenital malformation of pancreatobiliary ductal system.The incidence ranges from in 13000 to in 2 million live births. Although, it is seen typically in paediatric patients (80 % ),the initial clinical presentation in adulthood age > 16 years occurs in less than 20 % of all patients.
A 17 years old young female patient was admitted to our hospital in September 1994 with a complaint of abdominal pain, mass in the right upper quadrant and jaundice one month alter the delivery at 28 th gestational week with severe postpartum bleeding Preoperative abdominal US demonstrated a Hydatid cyst originated from right lobe of the liver. Serologic tests were negative. In the peroperative exploration,a bile filled cystic lesion in the diameter of 18 22 cm., localized between the right lobe of the liver and duodenum was found. The gallbladder was not identified as well. The nature of the cystic lesion was not related to the hydatid disease. The cyst was extended from bifurcation of right and left hepatic duct to retroduodenal portion of common bile duct and considered to be giant type-I choledochal cyst according to Todani classification system. The cyst was excised from Hepatic duct bifurcation to retroduodenal portion of choledochus where cyst wall in a diameter of cm. remained in place Omega shaped end to side hepaticojejunostomy + side to side jejunojejunostomy was applied to restore the biliary-enteric continuity. The patient has been periodically controlled with uneventfull course. Choledochal cysts are uncomnon anomalies of the biliary system and probably they are originally congenital, The widespread availability of ultrasound imaging has led to more frequent recognition of this kind of disease, They usually consist in cystic dilata.tion of the extra biliary This localization and their appearing as cystic or focal dilatatlon consent to difference them fr om the post-amoeblc or pyogenic abscess which are more frequently intra hepati A great part of in_ formation about this patology is coming in the l_a st years from Japan, where its incidence is much higher than inoccidental countries. It seems most likely that

Dept. of Gastroenterology Sto Paulo University Medical School BRAZIL
Cholecystectomy is a very safe procedure and is regarded as the definitive treatment for symptomatic cholelithiasis. Some authors indicate conservative treatment for "high risk" or low symptomatic patients, but these methods leave a diseased gallbladder in place and expose patients to the risk of gallblaclder cancer.
The aim of this study is review the type, incidence and distribution of epithelial changes in gallbladder under routine histologic examination. INTRODUCTION: Laparoscopic surgery reduces postop, pulmonary complication, reduces postop. fatigue, and shortens hospital stay. However, the metabolic consequences of lap. surgery are largely unknown. Following open cholecystectomy the efficiency of the liver to convert amino acids to urea is doubled, indicating that liver plays a primary role for postop, loss of body nitrogen. This phenomenon is for the major part mediated by changes in glucagon and cortisol. AIM: To measure the hepatic efficiency of urea synthesis by the Functional Hepatic Nitrogen Clearance (FHNC), and to determine changes in glucagon and cortisol before and after lap. chol ecys t ec tomy. PROTOCOL: 8 ptt. undergoing elective lap. cholecystectomy were compared to a historical matched group of 6 patients undergoing open cholecystectomy. Both groups were investigated before surgery and on the first postop, day. RESULTS: Lap. cholecystectomy did not change FHNC 7.9 ml/s, pre/postop., p<O. 05). Glucagon and cortisol remained unchanged after lap. cholecystectomy, but increased by 50% (p<O. 05) and 75% (p<O. 05) respectively after open cholecystectomy. CONCLUSIONS: Lap. cholecystectomy ameliorates postop, hepatic contribution to postop. N-loss. This is probably due to amelioration of the increase in glucagon and cortisol normally seen after surgery. Intestinal metaplasia and especially dysplasia are predisposing factors of cancer. We study retrospectively the incidence of intestinal metaplasia and dysplasia as well as cancer of the gallbladder in 1416 cholecystectomies for cholelithiasis during the last seven years. In 15 patients (1%) cancer of th gallbladder was found. Mean age of these patients 69.2 = 7.63 (range 53-79). The incidence of this cancer from 0.87% during the 6 decade of life increases to 4% during the 8 decade (P<O.01). Intestinal metaplasia and/or dysplasia were observed in 74 patients (5.2%) of mean age 60.1 14.8 (range 13-86). The incidence of these predisposing factors of cancer increases from 2.2% during the 4 decade of life to 9.7% during the 8 decade (P<O.O05). The total incidence of cancer plus predisposing factors of cancer during the 8 decade of life is 13.7%, while during the 7m and 6m decades is 8.6% and 5.8% respectively (P<O.I, P<O.O05 respectively versus 8 decade). In conclusion, the cholelithiasis coexists with predisposing factors of cancer and cancer of the gallbladder; the incidence of these combinations is rised in the advance of age. This suggests that the early cholecystectomy in patients with cholelithiasis is the treatment of choice to prevent cancer and to treat radically the early cancer as well.
CARCINOMA OF THE GALLBLADDER B. Paizis, D. Panoussopoulos, B. Pararas, K. Karli, S. Papadopoulos, K. Toutouzas A' Propaedeutic Surgical Clinic of Athens University. 31 patients with carcinoma of the gallbladder, are presented. All patients were operated in our Clinic, and represent 0,74% of the total number of 4153 cholecystectomies, which performed during the period of 1989-1994.
The female to male ratio, was 22/31 and 9/31 respectively. None of these patients had a preoperative diagnosis of carcinoma of the gall bladder. In 23/31 (74,2%) the carcinoma was found and confirmed intraoperatively, whereas in the rest 8/31 (25,8%) the diagnosis was an incidental finding at histology.
In conclusion, carcinoma of the gallbladder is a rare nosological entity with limitations for radical surgical excision (< 10%) resulting poor prognosis.

P. Petrievi5
The Surgical Ward, General Hospital, Yugoslavia Up to a few years ago we met gall-bladder benign tumors rather rarely because the preoperative diagnostics was not an a high level with us.. Since 1990 six patients (3 men and 3 women, who se average age was 57 years) were operated on for 6all-bladder polyps. Five patients diagnoscared before the operation, one was operated on as an urgent case, because gall-bladder perforation threatened. Before the operation the diagnosis was made by ultrasonography. None of the patients had all-bladder calculi. Preoperative discomforts lasted from one month to three years. By gall-bladder exploration the number of polyps varied from 1-3. One of the patients had papiloma with metaplasm other patients had cholesterol polyps. One woman patient had adenomatous polyp. With all the patients cholecystectomy has been done, but we were careful not to distroy polyps with gall-bladder forceps. Conclusion: thans to ultrasonoraphic d+/-anostics and the doctors e.xerience we can discover gallbladder tumors, which we remove surgecally to prevent from turning into maligne dysplasia.
2nd Departmet of Propedeutic Surgery Athens University Medical School, Greece. Primary carcinoma of the gallbladder has a poor prognosis due to its non-specific clinical symptomatology which produces a considerable delay in diagnosis. The records of 38 patients with gallbladder carcinoma operated on between 1971 and 1994 were retrospectively reviewed. There were 26 women and 12 men,with an average age of 66.3 years (range 47-82 years).Clinical symptomatoogy consisted of abdominal pain, jaundice, nausea, vomiting and weight loss Ultrasonography and computerized tomography were most helpfulf in defining preoperative diagnosis and staging. In 24 cases (63.2%) associated cholelithiasis was present. The majority of cases were stage III and IV according to TNM system. Surgical procedures included cholecystectomy alone (I0 patients), cholecystostomy (5 patients) ,chlolecystectomy with T-tube insertion (4.patients),chlolecystectomy with hepatic wedge resection (one patient),biharyenteric bypass with or without gastroenteroanastomosis (6 patients) and exploration with biopsy (12 patients). Operative mortality rate within one month was 21%(8:38). No patient lived more than 2 years; mean survival in our series was calculated as 9.3 months. In conclusion surgical palliation in advanced gallbladder carcinoma has the potential to improve quality of life but offers no significant From these data it is concluded that every microscopical type of gallbladder ca:cinoma origined from specific kind of metaplasia.

INTRODUCTION
During the last decade functioning tumours of the pancreas islet cells have been reported with increasing frequency. These turnouts often discovered because of the "mass effect" that they the organs. Consequently, when first discovered, they have already reached considerable size. Here is described the of young with secreting islet cell tumours of the pancreas. When the majority of cystic lesions of the pancreas are inflammatory pseudocysts, 10 to 20% consists of tumours with a cystic appearance, that must be correctly diagnosed in order to propose the adequate therapy. Forty-two patients with cystic tumours have been recently followed in our department: serous cystadenoma 4, mutinous cystadenoma or cystadenocarcinoma 12, intraduetal mucinhypersecreting neoplasms (IDMHN) 26. The mean age was 61 years (23-82) and the sex ratio M/F=2/1. Signs and symptomatology were poorly specific. Serum amylase and lipase were usually normal for serous and mucinous tumours, but often increased in IDMHN. CT-scan and ERCP were the most contributive investigations: they precised the general architecture of the tumour, the cyst content and the aspect of pancreatic ducts. Cyst content aspiration during ERCP may be helpful.

CASE REPORT
Thirty-three patients underwent a surgical resection. Radical surgery (Whipple or pylorus-preserving pancreatico-duodenal resection, caudal resection) was performed in all cases of suspected IDMHN and mucinous cystadenocarcinoma. Local or segmental resections were reserved for serous and mutinous cystadenomas. Palliative surgery was the only choice in 3 cases of extended carcinoma. Serous tumours were always benign. Mutinous tumours and IDMHN respectively presented low grade dysplasia in 2 and 8, high grade dysplasia in 2 and 4, in situ malignancy in 0 and 2 and invasive malignancy in 8 and 3. The 1-year survival rate in malignant lesions is 54% (7/13). Conclusions: Cystic tumours of the pancreas are not that rare. Serous cystadenoma may always be considered as benign: it may be treated expectantly. Mucinous cystic tumours and IDMHN are malignant in respectively 50 to 80% and 25 to 50%: radical surgical resection is therefore highly recommended.
Glucagonoma is a solitary and usually large tumor of the pancreas which develops in the alpha cells of the islets of Langerhans and secretes excessive amounts of Glucagon. It causes a distinct syndrome characterized by dermatitis (necrolytic migratory erythema) glucose intolerance, weight loss and anemia.
We report a case of a large glucagonoma (diameter 7cm) in the head of the pancreas in a 52 years old woman without the characteristic necrolytic migratory erythema. The symptoms were epigastric and back pain, moderate diabetes mellitus, weight loss, anemia and duodenal obstruction. The final diagnosis of Pancreatic Glucagonoma was confirmed only after the surgicai resection of the tumor (pancreatoduodenectomy) and the immmunochemical study of the tumor. We discuss our results 32 months after the surgical resection of this neuroendocrine tumor of pancreas. In 1994, a 65-year old man was operated on for adenoma of the pancreatic duct papilla, which was diagnosed by ERCP; bioptic and histopathologic diagnosis was: adenoma tubulare gradus III-IV. The patient had semicircural pains in the upper abdomen. On surgery we found a papillary duct tumor 14x10 mm of size, originating from the pancreatic duct papilla; transduodenal excision of adenoma was done. Six months later the patient is free of pain, but shows a minor increase in serum amylase. In the literature we found one article describing villous adenoma excised from the pancreatic duct. Our patient had adenoma located at the pancreatic duct papilla, 15 mm below the papilla Vateri. The authors emphasize the importance of preoperative and intraoperative biopsy with histologic examination to perform adequate surgical procedure.
PANCREATICO-DUODENAL ENDOCRINE TUMORS WITH LIVER INVOLVEMENT. C. Pasquali, C. Sperti, G. Liessi, P. Gasperoni, S. Pedrazzoli. Semeiotica Chirurgica University of Padua, Radiology and 2nd Dept. of Medicine Castelfranco V. Hospital, Italy. From 1970to 1994 our Department were observed 128 patients with diagnosis of endocrine tumor of the pancreatico -duodenal area. According to the type of tumor or syndrome at time of presentation the patients were 63 insulinomas, 51 gastrinomas, 2 glucagonomas, 2 PP-omas, Somatostatinoma, Seventeen patients 13.3 %) had a liver involvement at time of diagnosis or during the follow-up: 41 63 insulinomas (6.3 %), 7/51 gastrinomas (13.7 %), 2 glucagonomas, 2 NF tumors, PP-oma and Carcinoid. Three out of 17 patients with liver tumor had a MEN syndrome (18.7 % of all MEN observed). Two more patients had a multiple hormones secreting tumor that caused an evident second syndrome due to a different active peptide (Insulin + Gastrin and Glucagon than Gastrin respectively). In 5 117 patients the liver mass was single and the site of the primary was known in 11 cases; in 5 ZES patients the site of the primary was unknown but 2 had diffuse peripancreatic lymphnodes involvement. Two patients had the liver mass detected but the nature (thought to be benign) unrecognized for 3 and 6 years respectively, and 2 patients had liver metastases mistaken for secondary from pancreatic cancer for and 2 years respectively; 3 had distant metastases, outside the abdomen, at time of diagnosis. Six/17 patients underwent resective surgical treatment: 2 right epatectomy and left bisegmetectomy, 2 liver atypical resections + left pancreatectomy; the last patient after DTIC chemotherapy had a left pancreatectomy. Seven out of 17 patients died within year, but 6 lived > 5 years range 8-13) after the detection of the liver tumor. No insulinsecreting tumor lived > 18 months. ZES patients showed longer survival (5/7 > 3 yrs.); those who underwent typical liver resection are still living 3, 9 and 10 years after surgery despite recurrence 1,1 and 5 years later. DTIC chemotherapy was effective to control cancer growth in 3 patients who survived 2, 3.5 and 8 years. Due to the slow growing tumor, survival > 5 years is not uncommon. Aggressive surgery helps to improve survival in patients with liver tumor from pancreatico-duodenal apudoma. Since 1973 to 1987 patients with pancreatic carcinoma have undergone surgery in our Clinics. Of these, 105 patients resections were performed on 32 (32%); 25 (25%) of whom underwent a curative resection based on macroscopic evidence. Four of whom underwent macroscopic curative resection survived for 6 years, giving a 6-year survival rate 16.5% and 13.5%. Seventy three patients underwent a laparotomy, including biopsy only (n=26). Biliary bypass (n=28), gastric bypass (n=l), biliary and gastric bypass (n=15). There were three treatment groups as treatment policies evolved in both categories (resected and not resected). Initially, patients were observed after surgery without adjuvant treatment (Group in resection category 10 patients and Group la in palliative surgery category 23 patients). Patients were offered adjuvant radiation therapy. Postoperatively (Group 2, 10 patients and Group 2a, 23 patients) and Group 3, 10 patients and 3a, 24 patients, received radiotherapy and 5-FU as an in bolus on the first 3 days of the first and fifth weeks of treatment. So, 33 patients were treated with chemosensitized radiation therapy following surgery using 96hour 5FU infusion during the first and fifth weeks of treatment. There were 5 postoperative deaths which are excluded from the analysis. Among evaluable patients of Groups 1, 2 and 3, local recurrences occurred in 9 of the patients in Group 1, 5 of the patients in Group 2 and 2 in Group 3. The 2-year survival was 33% in Group (3 patients), 40% in Group 2 (4 patients) and 50% (5 patients) in Group 3. Patients with involved surgical margins had a poor survivals only 2 of these 15 patients survived longer than 18 months. Among patients with negative margins, the 2-year survival was 40% in Group 1, 50% in Group 2 and 601o in Group 3. Although the number of patients is small, the 3-year survival was 20% in Group 1, 30% in Group 2 and 50% in Group 3. In palliative surgical treatment Groups a, 2a and 3a the median survival was 4 months, 6 months and 10 months. A correct preoperative staging of pancreatic cancer is needed to avoid unnecessary surgical, exploration. CT scan is the most widely imaging technique used to evaluate tumor's extension. In this study we evaluated the utility of serum CA19-9 assay in combination with CT for staging in 123 patients with histologically proven pancreatic carcinoma, observed from 1986 to 1992. Thirty-five patients were not operated and 88 undenent surgery: 19 radical resections, 21 non-radical resections, 45 biliary and/or digestive, by-pass, and 3 exploratory laparotomy. In 15 patients (12 %), CA 19-9 values were < 37 U/ml (cut-off level). In 8 of them CT showed a resectable tumor: 4 patients underwent radical resection and 4 biliary bypass. In 7 patients CT showed an unresectable tumor:l had a non-radical resection, 3 by-pass, and 3 were not operated. We report the results of pancreatic surgery in 75 consecutive patients with pancreatic and periampullary malignancy who have had operations in the last 8 years at this unit. Fifty-six (74.6%) of these patients had adenocarcinomas of either the head of the pancreas or ampulla, the remaining had other types of malignant tumours including neuroendocrine tumours and cholangiocarcinomas. Postoperative 30 day mortality was 2.7% and morbidity was 32%. Reoperation was necessary in 11 patients (14.7%). Actuarial five year survival was 30.6%. There was no difference in 5 year survival between the patients with adenocarcinomas of the head of the pancreas and those with periampullary tumours (p=0.14, log rank test). However patients with tumours other than adenocarcinomas had a better outcome (p=0.039). Lymph node spread and degree of differentiation were significant determinants of survival (p < 0.05).
The size of tumour, age of the patient and presence of portal vein infiltration had no effect on the outcome. The infiltrated portal vein was replaced with a cryopreserved venous graft in two patients. We believe that long term results, in a specialized centre, are very encouraging and justify an aggressive approach in a selected group of patients with pancreatic and periampullary tumours. Postoperative 30 day mortality is low but morbidity is still considerable. Twenty patients with carcinoma of the ampulla of Vater were studied with sonography (n--9) or both sonography and CT (n 11). The tumour was sho by sonography in 16 patients (80%) as a small, round or oval, fairly well delineated mass in between the dilated distal common bile duct and duodenum which was delineated due to luminal fluid or gas (n=13); or as a polypoid mass within the dilated distal common bile duct, resulting in abrupt obstruction (n=3). In then remaining four patients, the mass was not delineated. Bile ducts were dilated down to the level of mass or ampullary region in all cases (100%), while the pancreatic duct was dilated in five cases (45%). We believe that sonography is the technique of initial choice in the diagnosis of carcinoma of the ampulla of Vater as it identifies the mass at the distal end of the dilated common bile duct and/or pancreatic duct.  [1981][1982][1983][1984][1985][1986][1987][1988][1989][1990] were revieved to determine whether gastroenterostomy (GE) should be performed profilatically at initial intervention or on a therapeutical basis. Forty-six patients underwent biliary bypass 03BP) alone and on 39 patients a GE was associated with the BBP procedure. There were no statistically significant differences between the two groups as far as age, disease stage and clinical presentation are concerned. The addition of GE to the biliary bypass did not significantly increase perioperative mortalit3" (0% Vs 6.5% in bilioenteric diversion alone), morbidity (58.9% Vs 47.8%) nor length of hospital stay (14.8 Vs 12.8 days). The most common complication of the GE patients was delayed gastric emp.tying (28.2%). Although the incidence of chronic vomiting was similar in both groups (11.6% Vs 10.2%), no secondary gastroenterostomy was needed in patients submitted to GE as opposed to 9.3% in the biliary bypass group. These results recommend the simultaneous gastroenterostomy at initial intervention because it does not increase morbidity, mortality and length of hospital stay and helps avoiding secondary, gastroenterostomy. The treatment of pancreatic endocrine tumors (PET) in case of multiple endocrine neoplasia type (MEN l) remains controversial, because of multicentric tumors and frequent recurrence following surgery. We reviewed our experience of 6 MEN l-patients who underwent radical resection of PET. Methods. Between 1973 and1993, males and4 females with MENI aged 20 to 39 years were referred for PET. There were 4 Zollinger-Ellison syndromes, insulinoma and one non-functional apudoma. Associated endocrine disorders were hyperparathyroidism (n=5), pituitary adenoma (n=4) and adrenal adenoma (n=3). Hormonal measurements demonstrated hypergastrine.mia (n=5), hyperinsulinemia (n=1) and normal hormonal profile (n=1). Imaging studies included ultrasonography (n=6), computed tomography (n=6), and endoscopic ultrasonography in the last three patients. Indications for surgery were tumor 15 mm (n=3), uncontrolled Zollinger-Ellison syndrome (n=2) and severe hypoglycemia (n 1).
Results. Surgical exploration disclosed 4 to PET ranging from 4 to 30 mm. Preoperative imaging work-up underestimated the number of lesions in all instances. The removal of all macroscopic tumors led to left (n=3), subtotal (n=2) or total (n 1) pancreatectomy. There was no mortality. Complications included one post-operative diabetes (after total pancreatectomy) and one splenic infarct. lmmunohistochemical study showed multiple gastrinomas (n=4) associated with duodenal microgastrinoma and lymph node metastases in one case, insulinoma (n=l) associated with malignant gastrinoma (positive nodes), non-functional apudoma (n= 1). In both cases of malignant tumor, the largest gastrinoma was less than 15 mm in size. Four patients including the two with lymph node metastases had no evidence of tumor or hormonal recurrence to 13 years after surgery. patients developed hypergastrinemia (1 recurrence, de novo) and years after surgery without detectable tumor on imaging studies. Both are alive with stable clinical condition.
Conclusions. 1) Radical pancreatic resection in MEN l-patients can achieve prolonged disease-free survival with low incidence of post-operative diabetes. 2) The low accuracy of preoperative imaging studies and the risk of malignancy even in small tumors gives further support to an aggressive surgical approach. Despite a close spatial relationship, the various types of adenocarcinoma of the periampullary region (i.e. carcinoma of the pancreatic head, papilla vateri, or distal bile duct) have a distinctly different prognosis after surgical resection. We attempted to identify factors which may account for these prognostic differences. Ptients and Metho4$: Prospectively documented tumor and patieht dependent factors were analyzed in a total of 194 patients who had a partial duodeno-pancreatectomy for adenocarcinoma of the pancreatic head (N=90), papilla vateri (N=66) or distal bile duct (N=38) at our institution between 1983 and 1994. Median follow up is 42 months.
Results: Age and sex distribution, postoperative mortality, and tumor grading was not different between the patient groups. There were, however, marked differences in tumor size, rate of perineural invasion, the rate of node negative patients (pN0), UICC stage distribution, rate of complete tumor removal (R0-resection) and survival (see table). Long-term survival in patients with a proven histologically diagnosis of pancreatic carcinoma is virtually confined to those undergoing tumor resection. However, there is some doubt as to the number of long-term cures that result. The purpose of this study was to analyze the patients who survived 5 years or longer after operation for exocrine pancreatic cancer, and to determine factors that may have influenced the favorable outcome. From 1970 to 1992 a total of 536 patients with carcinoma of the pancreas were seen in our Department. There were 11 putative 5-year survivors: 2 after by-pass surgery and 9 after radical resection. Pathologic review confirmed primary carcinoma of the pancreas in 9 patients (all those resected) with a real 5-year survival rate of 1.6% (8% of 111 resected patients). The histologically proven survivors included 8 ductal and acinar cell carcinoma. Four tumors were located in the head, 3 in the tail, and 2 in the whole pancreas. Only 3 tumors were < 2 cm in diameter. In 3 cases, the tumor involved the duodenal wall, and tumor extended into peripancreatic fat. Histologically 7 were well,1 moderately and poody differentiated adenocarcinoma. Six showed lymphatic invasion, which was pedneural in 3 cases.No patient had lymph node metastases. Two patients died of their disease 7 and 8 years after surgery, respectively, with local and/or hepatic recurrence. Seven patients are alive and disease-free from 6 to 15 years. Six long-term survivors were operated until 1980, and 3 after this period.

Location of the
In conclusion, long-term survival in histologically confirmed pancreatic carcinoma is a rare event. Only few patients without lymphnode metastases are suitable for a favorable prognosis. Late tumor relapse is a possible event; so, 5-year survival is not a guarantee of cure for pancreatic cancer. This study was carried out to review the sensitivity and specificity of tumor markers (CEA, CA 19-9 and CA 72-4) for pancreatic cancer diagnosis in our institution.
Sixty patients with pancreatic cancer and 33 patients with benign disease were studied. Tumor markers were measured by radioimmunoassay (CIS bio international). RESULTS In pancreatic cancer gr.oup, 36 were men and 24 were women, the mean age was 61,5 years (39 to 83), curative resection were possible in only 11%. In benign disease group 23 were men and 10 were women and the mean age was 47,3 years (20 to 87  Between 1970 and1992, 63 patients underwent surgery for ampullary tumors. The group comprised 33 males and 30 females with a mean age of 64.8 +/-9.8 years. Surgical procedures included subtotal duodenopancreateetomies (n 40), total panereatectomies (n 3), ampullectomies (n 8) and surgical bypass or exploratory laparotomies (n 12). Reseetability was 68%. Pathology included 53 adenocarcinomas, undifferentiated lesion and 9 benign lesions. According to the MARTIN staging criteria tumors were classed as follows: stage 7, stage II 11, stage III 14, stage IV 21. All patients with stage I, II and III tumors underwent resection. Among the stage IV patients, 11 were resected and 10 had bypass procedures.

RESULTS
Mean hospital stay was 20.6 days. For the patients having undergone subtotal duodenopancreatectomies mean time of stay was 24.8 days (16.5 days when the postoperative course was uncomplicated). Overall operative mortality was 12.7%, and 7.5% after subtotal duodenopancreatectomy. Five-year survival for the entire group was 40%. Five-year survival for stage through IV tumors was 85%, 65%, 44%, and 8% respectively. For stage I, II, and III lesions, survival was significantly better following subtotal duodenopancreatectomy than after ampullectomy. For stage IV lesions, and 2-year survival following subtotal duodenopancreatectomy and surgical bypass was 70% and 25%, 20% and 0% respectively. We now consider subtotal duodenopancreatectomy rather than amullectomy as the treatment of choice for benign ampullary lesions, having reoperated on two patients with stage IV tumors who had undergone ampullectomy for benign lesions, 4 and 22 years previously. CONCLUSIONS Subtotal duodenopancreatectomy is the treatment of choice for ampullary tumors, even when these are benign.

Asturias-Espafia
The pancreatic cancer is nowadays a disease which treatment is not effective in the majority of the cases, so surgical techniques are necces ry in order to make better the life s quality of the patients;these tecniques can, also, increase the time of life.
With the intention of knowing the time of survival in the patients with pancreatic cancer who underwent the surgical paliation, we have done a analysis about our patients. Between 1.973-1.993, we have attended 559 patients. Only the 14 % underwent the surgical ex resis.
In 42 cases (7.4 %) that were undergone surgery it was not possible doing anything and the survi val average was 64 days.
In 325 cases (59 %) it was only done surgical paliation. The post-operative mortality in this group was 23 % Among the rest of patients of this group, we have analized i00 of them whose date of death was known. Between 1980 and 1994, 100 patients had operation for adenocarcinoma of the head of the pancreas(n:94), ampulla(n:5) and papillary adenom(n:l). 69 patients were men, and 31 were women, and the mean age was 59.8 (range:30-78). The patients were divided into two groups on the basis of two different time periods: those operated on from 1980 to 1990 (n:55) and those operated on from 1991 to 1994 (n:45). The rates of resection in the first and second group were % 3 and % 19 respectively. Hospital morbidity rate was 11%. Hospital mortality rate was 66% operated on during the first period and were 16.6% operated on during the second period. We had no patients who survived for five years. However, the importance of Whipple procedure reveals itself when the results of the second group are examined.
We studied different factors predicting long term survival.
From October 1985 to December 1993, 133 curative hepatectomies for hepatic metastasis from colorectal cancer were performed. It was an adenocarcinoma in all cases. The surgical procedures consisted in 98 major hepatectomies, 12 minor hepatectomies and 39 tumorectomies. The metastasis was unique in 73 cases and more than 3 in 13 cases. They were synchronous in 37 cases and metachronous in 89 cases. The average time of appearance was 18 months 0 to 120 months ). The diameter of lesions was less than 50 mm in 73 cases. Fifty four patients were treated with chemotherapy based on FUFOL (48 in the last 3 years ).
The postoperative mortality was 1,58 % 2 patients ). Sixty nine patients were alive with an average follow up of 23,5 months. The actuarial survival rate is respectively at 1, 3 and 5 years of 84,5 %, 50,7 % and 25,3 %. Seventy three patients presented a recurrence in wich 49 in the liver with an average time appareance of 12 months. Forty nine patients were alive without any recurrence.
Among the factors predicting long term survival CEA, Dukes stage, minor or major hepatectomy, number and diameter of metastasis and resection margin more than 10 mm ), the only one which was statistically significant was the major hepatectomy. Nevertheless, a survival rate of 25 % at 5 years confirms that a complete surgical resection, when possible, is the treatment of choice for hepatic metastasis from colorectal cancer. Out of 68 cases with progressive liver malignancy only explorative laparotomy or biopsy was performed, and 21 of them were lost postoperatively. 160 surgical intervention resulted in removal of tumorous mass. Lethality of this group was 3.1 percent, respectively.
Liver cirrhosis represents premalignant condition, therefore malignant tumors of the cirrhotic organ require special interest. 12 patients with liver cirrhosis and liver cell carcinoma underwent hepatic resection. One death occurred as a consequence of liver insufficiency.
The use of ultrasonic dissector, or its combination with partial or total liver exclusion diminishes intraoperative blood loss, and promotes extended resection of the liver. an intra-arterial port device for regional liver perfusion. Twenty patients had metastases from colorectal primaries, three adenocarcinoma of the breast, one carcinoid, one apudoma, one leiomyosarcoma and two primary liver tumors. All tumors were irresectable. All patients received celiac and mesenteric angiography; 25% showed relevant arterial variations. results: The carcinoid patient has been "cured" with 6 5-Fluoro-Uracil infusions, she is now 8 years disease-free. The overall response rate is 78%; response rate for the metastases from colorectal origin is 90% and 0% for the hepatic primaries. Catheter-related problems occured eight times, necessitating operative revision in four cases.In five patients we had to discontinue perfusion because of systemic toxicity. conclusions: The palliation we intend to achieve is worth the effort in the patient subgroup whose primary tumor was a B II colo-rectal carcinoma. Carcinoid tumor metastatic to the liver can be palliated for a prolonged time using regional liver perfusion therapy.  The aim o the study is the examination of the relative portal blood flow, by assessment of the hepatic perfusion index (HPI) in different degrees of hemodynamic alterations related %0 liver cirrhosis and some focal liver diseases. Hepa%ic radionuclide aniography (HRA) was performed with bolus inec%ion ef 70 MBq-99m-Tc-pertechnetate, during one minut (If/sec), using ROTA scintillation camera and Micro Delta computer (Siemens). HPI was estimated using Sarper's method of slope analysis.
Portal Surgical resection still represents the best chance of improving survival for some patients with hepatic metastases of colorectal origin.
The aim of this study is to compare the outcome of hepatic resection for metastases of colorectal cancer in two similar groups of patients using two different techniques of hepatectomy.
The group was constituted of 25 patients (15 men and 10 women, with mean age of 63.1 years range, 32 to 80 years). The surgical procedure was hepatic resection employing the posterior approach of the hepatic hilum technique with intermitent clamping of glissonian sheeths.
The group II was'constituted of 23 patients (12 men and 11 women, with mean age of 63.8 years range, 40 to 73 years). The surgical procedure was hepatic resection employing the conventional technique with in mass continous clamping of the hepatic pedicule.
Thei'e was no statistical difference between the two groups concerning sex. age and number of metastases. The total lenght of ischmia was superior in the posterior approach patients (group I) with a mean of 84.2 minutes against 37.5 minutes of the group II (p < 0.0001). There was no influence of the ischemia time in the postoperative hepatic function, postoperative course or recovering time.
The survival rate was superior in the group of the posterior approach technique: 778.8 + 410.2 days (group I) vs 572.5 + 349.7 days (group II). Although this difference, it was not statistically significant (p 0.14).
We concluded that the posterior approach procedure is a feasible and safe technique allowing to perform segmentary and subsegmentar}' anatomical resection. This new technique seems to improve the survival of patients with hepatic metastases of colorectal cancer. This results still has to be confirmed by subsequent series with greater number of patients. Benign liver tumors as hepatic adenoma (HA) and focal nodular hyperplasia (FNH) are uncommon, generally affect young women, but their pathogeny and outcome are totally different. The pre-operative diagnosis of this lesions is often difficult. Surgical resection of HA is advocated based on the incidence of bleeding complications, in some instances lifethreating. Moreover, neoplastic degeneration of HA have also been reported. In contrast, FNH is often an incidental finding and there is no proven cases of hemorrhage or malignant degeneration. For this reason it must be conservatively treated. The aim of this study was to evaluate 17 young female patients with benign liver tumors (10 FNH, 7 HA), trying to establish a pre-operative criteria for the differential diagnosis, avoiding therefore a laparotomy and eventual hepatic resection. In the present study, all patients were submitted to a surgical biopsy or to a hepatic resection. Based on clinical and laboratorial data we were not able to distinguish HA from FNH. Even with the development of imaging methods that were used in combination (ultrasound, computed tomography, scintigraphy with HIDA and sulfurcoloid, magnetic ressonance and angiography) the differentiation was not possible in most cases. Surgical biopsy is the only safe alternative for the differential diagnosis between HA and FNH and when in doubt, a hepatic resection can be safely performed.  We evaluated the concordance of ultrasonicallyguided aspiration cytology(AC)and biopsy histolo gy(BHin a study employing 46 patients with one or more intrahepatic masses.We aimed to correlate the concordance of AC(performed with Chiba 22 gauge fine needles)and BH(performed with Menghini and TruCut needles)with tumor's parameters: size(3 cm,3-5 cm,>5 cm-graded);histology(low,moderate and well differentiated tumor);and with the statement of the hepatic parenchyma:cirrhosis(31),chronic active hepatitis(4),normal(11). The concordance AC-BH was 35%,52%,79% in the case of lesions of 3 cm,3-5 cm,and > 5 cm and 24%; q8%,86% in well,moderate and poor differentiated tumors,respectively.We conclude that the concordance AC-BH is low in the case of small tumours and significantly increases with the tumor'size; is low in the case of well differentiated tumors (low accuracy of AC);did not varied with the underground state of diagnosis in the hepatic parenchyma(p<0.2).The accuracy of diagnosis significantly increased when the AC and BH are perfor med together when primary liver neoplasms are to be diagnosed: AC 53%; BH 76%; AC and BH 87%. Accurate puncture is very important for the diagnosis of small lesions in the liver, pancreas and so on by ultrasonically guided fine needle biopsy. We developed a new convex type puncture probe which was devised so as to push out the needle from the center of the transducer to three directions at the angle of 0, 18, 30 degree. This new convex type puncture probe made it possible to perform the biopsy in any part of the liver including subdiaphragmatic area through intercostal apace. Therefore, it also became possible to reach where it had been difficult to aim at for PEIT to treat small liver tumors by the previous probe. The clinical usefulness was investigated in 489 cases with small liver tumors admitted to our hospital from July 1990 to December 1993. Among them, indication for ultrasonically guided fine needle biopsy was confined to negative or indefinite cases by imaging diagnosis such as CT, MR or angiography. Fine needle biopsy using convex type probe showed higher diagnostic results than imaging diagnosis, especially for the nodules smaller than 2.0 cm in diameter or the well-differentiated type. Consequently, PEIT became possible after the liver biopsy for every lesion. It became also possible to pierce the lesions on the surface of the liver which was difficult until now. The newly developed convex type puncture probe is very useful as it has a wide indication of the area of 'the biopsy and is easy to operate. pts resections of 2 segments, 7 pts smaller resections. Two patients died postoperatively (I ruptured aortic aneurism, liver failure and sepsis). Minor complications (respiratory) occurred in 7 pts, hepatic insufficiency in 2 pts, bowel occlusion in pt: these complications occurred in 10 "ASA 3" pts and in 2 "ASA 1" pts (3 of these were cirrhotic). Comparison with the results of more than 100 resections performed in younger pts during the same period did not show relevant differences. These data support the concept that old age in itself, in the absence of associated diseases, is not a controindication for resective surgery of the liver. Techniques: Anatomical resections following the lobar or segmental division of the liver were more frequently done in cases of tumors appearing in normal livers whereas ultrasound guided radical non-anatomical resections indicated in cirrhotic patients. In 44 Pringle manouver was used during the hepatic parenchimal division. Frequently another type of operations were performed at the same time. Results: operative mortality has been of 8.2 %, most of patients died from liver failure (4.1%). Postoperative complications biliary leaks (7.5%), hemorrhage (4.1%) and infections (10%). Risk factor for morbi-mortality in our experience have been liver cirrhosis, cholestasis and major associated surgical tecniques. It has been suggested that obstructive jaundice increases the risk of liver resections because of reduced tolerance to ischemia and regneration capacities, increased operative bleeding and general effects associated with jaundice. Therefore, some authors recommend preoperative percutaneous biliary drainage. However, biliary drainage may lead to sepsis and tumor seeding along the catheter tract. From 1989 to 1993, 60 major liver resections (_> 3 segments) were performed. Eight patients (13%) had obstructive jaundice and underwent resection without previous biliary drainage. Mean serum bilirubin was 215+108 tmol/L (80-439). They included 3 hilar cholangiocarinomas, 3 intrahepatic cholangiocarcinomas extended to the hilus and 2 tumors with thrombus extension in the biliary tract. These cases were compared with 52 major resections in patients without jaundice. preop serum bilirubin 439 tmol/L, hypoalbuminemia, renal failure These results suggest that present liver resection techniques are applicable to most patients with obstructive jaundice without previous biliary drainage. In these patients, semi-urgent operation is required because of ongoing jaundice, a long and complex procedure is necessary and the incidence biliary fistula is high. Intraoperative bleeding, tolerance to ischemia and regeneration were not affected by jaundice in this series. Preoperative drainage may be indicated in selected cases (bilirubin > 300, prolonged jaundice, hypoalbuminemia, renal failure). Radical resection has proven to be the only effective therapy in hepatic metastization. Approximately half of the patients will develop hepatic recurrences during follow-up. In this nonrandomized study the influence of adjuvant regional chemotherapy on outcome after hepatic resection was evaluated in our patients.

RESULTS
Methods: From 1.1.1986 to 31.12.1993 radical hepatic resection was performed in 91 patients after colorectal (n 77) or other (n 14) primaries. 42 patients received an implantable port system for regional chemotherapy. Although implantation of the port was not predetermined, the groups with and without chemo-therapy were comparable regarding tumour stage and extent of resection. Our chemotherapy protocol consisted of six courses ofMitomycin C (first day) and 5-FU (five days) with intervals of one month.
Results: Due to several reasons only 30 patients were treated with three or more chemotherapeutic courses. Short term survival of this group was significantly better compared with untreated patients (1-year-survival 93 vs 75%), but follow-up resulted in similar surviva1 rates after three years (40 vs. 47%). Extrahepatic metastization was frequently observed in either group prior to death.
Conclusions: Adjovant hepatic artery infusion chemotherapy did not improve long-term survival in patients following radical hepatic resection for metastases.

144
MULTIFOCALITY OF HEPATOCELLULAR CARCINOMA IN CIRRHOSIS: A CLINICO-PATHOLOGIC STUDY M Schwartz MD Fiel MD, S Emre MD, P Sheiner MD, S Guy MD, C Miller MD The Mount Sinai School of Medicine, NY, NY USA Hepatocellular carcinoma (HCC) is known sequela of cirrhosis, particularly in the setting of underlying viral hepatitis; multifocali.ty is recognized to occur, but its incidence is not well-defined. This study was undertaken to better define the incidence ofmultifocality of HCC in cirrhosis. MATERIALS AND METHODS: The livers of all patients with cirrhosis and HCC who underwent liver transplantation at The Mount Sinai Hospital between 9/88 and 9/94 were studied. The nature of the underlying liver disease, and whether or not the tumor had been noted preoperatively, were noted. Livers "bread-loafed" in cm slices, and the presence, size. and number of tumors were recorded. Prior to 10/91, patients with known HCC 5cm were excluded fiom transplantation; thereafter, such patients were included in multimodalit5, protocol. RESULTS: Sixty patients with cirrhosis and HCC were transplanted. Underlying diagnoses were: hepatitis C-37, cryptogenic-7, hepatitis B-6, EtOH-5: bilia.'y ciThosis-5. Findings, broken down by size (< 5cm) and whether or not HCC was diagnosed before transplant, were as follows: candidates of the surgical treatment,regardless of the operativ e mortality, five year survival is 6-51% in different series. The HCC patients whose diagnose is spontaneus rupture is very rare and after surgica] treatment their survival are short, In this case report, a patient surviving for tltree years with spontaneus HCC rupture will be presented.
Male patient, 68 years old, admitted to emergency unit with acute abdomen, hypovolemic schock. Urgent laparotomy was undertaken. In exploration, spontaneus rupture in the right hepatic lobe was diagnosed and irregular right hepatectomy was performed including tumor mass. In pathologic study HCC was diagnosed, and. postoperativ ely no residual tumor mass is traced in CT. At the second postoperative year recurrence is diagnosed in the right hepatic lobe, and right regular hepatectomy was performed.
No recurrence is traced at the third postoperative year.
We support that when spontaneus HCC rupture is encountered either in emergency, resection with safe margins must be carried without any hesitation. Cytokines are products of activated leukocytes that mediate the inflammatory postoperative changes within the peritoneal cavity and may also be partly responsible for the systemic acute phase response to surgery. Aims. To investigate the peritoneal and systemic cytokine response to elective pancreatic surgery during the first 72 hours after operation. Methods. Six patients undergoing pancreatic surgery were studied (1 cholangiocarcinoma, 2 chronic pancreatitis, 3 adenocarcinora). Peritoneal fluid was sampleo through abdominal silastic drains venous blood was taken from a central line. A blood sample was taken preoperatively. Samples of blood and peritoneal fluid were taken at 6, 8, 10, 12, 36, 48 and 72 hours after the beginning of the operation. They were centrifuged at 2500 g for 10 minutes at 4 ,7 and the supernatant stored at -8'3" C until assay. Interleukin-1 beta (IL-Interleukin-6 (IL-6) and Tumour Necrosis Factor (TNF) were measured in plasma and peritoneal fluid using immunoassay.. Results. Operative procedures were 5 pylorus-preserving proximal pancreatectomy and choledoco-jejunostomy. Mean operative time was (mean + standard error) 5.3 + 0.3 hours. There was no postoperative complication. All peritoneal fluid samples had detectable TNF, IL-1 and IL-6, with maximum values: TNF 298 + 140 pg/mL at 8 hours after beginning of operation; IL-6 244 + 59 ng/mL at 12 hours; and IL-1 372 + 142 pg/mL at 12 hours. Plasma IL-1 and TNF concentrations were very low or undetectable (< 10 pg/mL). Plasma IL-6 levels were 300 fold lower than peritoneal levels, with maximum value of 836 + 548 pg/mL at 8 hours.
Conclusions. There is a high level peritoneal cytokine response to pancreatic surgery which is responsible for local inflammatory changes and probably also produces the secondary increases in Authors report the case of pancreatic hemangioma in a 38 year old female patient. The patient had been admitted to hospital with blunt, girdle-like upper abdominal pain where ultrasonography and CT scan revealed a solid tumor in the pancreatic body and eholeeystolithiasis. Choleeysteetomy, segmental resection ofthe gland was performed with endto-side pancreatieogastrostomy. The histological work-up of the specimen verified cavernous hemangioma ofthe pancreas. As far as authors know, this is the first ever report The administration of fatty emulsions during total parenteral nutrition (TPN) and its influence on exocrine pancreatic function has been recently discussed. To determine whether such influence exist and how it affects the postoperative pancreatic function was the goal of this study. The subject was group of 28 patients with pancreatic head cancer who underwent pancreato-duodenectomy. 15 of them were treated postoperativly with TPN (group I) and the other 13 were given limited i.v. nutrition without fatty emulsions (group II). The pancreatic juice was diverted from Wirsung duct by nasopancreatic catheter and collected in six-hour fractions. This juice was analysed for volume, protein, bicarbonate and enzyms like amylase and chymotrypsin. Slow increase of these values during the first three days after operation has been found in both groups. This rise of measured values, was slightly faster in group starting from the fourth day and became steady after 6 days. We found that juice volume was almost the same in both groups. Other values were a little higher in group (especially protein and amylase level), but the differences were not signifficant. According to the above data the two ways of parenteral nutrition seem to be of the almost the same value for pancreatic exocrine function. Pseudolymphoma has been described as occurring in a wide variety of sites including the lung, small intestine, stomach and gall bladder. We present a case of pseudolymphoma of the pancreatic body and tail. A 68-year old woman presented with weight loss, recurrent abdominal pain, accompanied by an elevation of serum pancreatic enzymes. Ultrasonographically there was a suspicion of pancreatic tumor in the body and tail. In CT scanning there was an enlargement of the pancreatic body with obstructed pancreatic ct accompanied by dilatation of the pancreatic duct in the tail region.
ERCP showed normal duct in the pancreatic head. In the pancreatic body there was a filiform stenosis followed by massive dilatation of the Wirsung duct within the pancreatic tail. Preoperative diagnosis was tumor localized in the pancreatic body with obstructive lesion in the pancreatic tail. During surgical exploration pancreatic body and tail were altered macroscopically comparable with a suspicion for malignancy. A pancreatic left resection was carried out. Histology revealed massive follicular lympatic hyperplasia based on the presence of hyperplastic follicles with germinal center and mixed infiltration of plasma cells and mature lymphocytes with no significant cytologic atypia. This is the 2nd case of pseudolymphoma of the pancreas in world literature (Hum Pathol 22:724-6;1991).
Pseudolymphoma of the pancreas seems to be a benign lesion which develops on the basis of chronic inflammation. 0ccuring at other GI locations in moderate frequency it obviously represents a rare entity in the pancreas.

MANAGING PANCREATIC TRAUMA
A.Agorogiannis and E. Naoum Surgical Unit.District General Hospital Of Larisa-Greece Pancreatic trauma presents a number of difficalt problems to the Surgeon.The aim of this study is to present and to discuss these problems and to find out the best treatment.
The last 16 years we operated on 614 patients with multiple abdominal trauma.2 patients had had trauma to the pancreas.The 30 patients were men and 12were women. The mean age of all thse patients was years.The 34 cases were due to blund abdominal trauma,, case to penetrating injury,3 cases to gan shot wounds,2 cases to horse kick and 4 cases to falling by trees.All the patients had associated injuries of the head 15 cases,liver trauma 10 cases,spleen rupture 10 cases,blund trauma of thethorax and multiple bone fractures.In 90.X of pancreatic truma there were asso ciated injuries.In our cases the injuries were classified as class I include contusions (28 cases),class 2 severe co ntusions involving parenchymal destruction (10 cases), class 3destruction of the major duct (2 cases) and class 4 involve injuries of the duedenum and the pancreas (4 cases) The contusions need only drainage of the aerea, the class 2 Nnaaa may need some sutures of the pancreatic parenchyma the class 3 needs resuture of the duct or more complicated operations and the class 4 maY need pencreatoduodenecto my.Conclusions:The pancreas is injured in 3Z to 12:.Most of the blund trauma is usually the result of steering wheel or seat belt injuries from motor vehicle accidents.Usually the re is an even distribution of injuries to the head,body,and tail of the pancreas.The head injury is associated with injury to the common bile duct,duodenum,liver,right kidney, and colon.These injuries are associated with highest mortality.The patient may complain of epigastric pain but is often asymptomatic.RCP define major duct injury.The most reliable is laparatomy. With the aim of aiding the accurate diagnosis and treatment of patients with pancreatic injuries, we reviewed the medical records of sixty-five patients, treated for traumatic pancreatic lesions at the Department of Surgery.
University of S,o Paulo School of Medicine in the 5-year period from 1989 through 1993.
Records, including operative and pathology reports, were reviewed to study the location of the pancreatic injury, associated intra-abdominal injuries, type of injury, trauma scores, treatment, complications and mortality rates.
There were 58 male and seven female patients with a mean age of 28.3 years (range, 2-77 years). Of the 65 pancreatic injuries, 45 (69.2%) were caused by penetrating wounds and twenty by blunt trauma. The most frequent site of lesion was the head of the pancreas (38.5%). Associated injuries were found in all but five of the patients. In the 65 patients, 170 intra-abdominal injuries were found or 2.6 per patient. Twenty-eight of the 65 patients (43.1%) had liver lacerations. Lacerations of major abdominal vessels (27 patients), gastric lacerations (25 patients) and colorectal lacerations (17 patients) were the next most commonly seen injuries. Fifteen of the twenty deceased patients died within two days after the accident of severe concomitant injuries. Simple drainage were performed in 33 patients, distal pancreatectomy in 17 and duodeno-pancreatectomy in six patients. Pancreasrelated complications occured in 20 (30.7%) of 57 patients who survived the initial operation.
We concluded that the type of repair employed in our series was related to the class of injury and clinical conditions (based on trauma scores). Therefore, whenever possible, conservative management (no pancreatic resection) was employed in patients sustained class and II injuries and pancreatic resection in class III and IV injuries. Fetal pancreas were studied at 26 embryos received from legal abortion on the development stage of 6, 0 and q weeks. In present work avid.in-biotln immunohlstochemical method was followed by imagine analysis and statistical investigation. N-cadherin antibodies were a generous gift by Prof. E. Bock( Protein Lab. Copenhagen ).
Ca-dependent cell adhesion protein N-cadherin was observed at eatch investigated stages of development in cell endocrine granules of tubular stractures and on the cell surface of ganglia cells in fetal pancreas. Langerhans islets cells which were clearly distinguished after 6 week of embryos development also have N-cadherin.The amount of N-cadherin in these cells was increased according to the developmen stage.
So N-cadherin could be a good marker for developing endocrine part of pancreas and probably this molecule take part into histogenesis of neuroendocrine complex in this organ.The data could be taken into consideration at the pathological development of Pancreas, particulary for undestanding of pancreatic neuroendocrine histogenesis. Dehiscence of pancreaticojejunostomy is a rare but dismal complication after Whipple's operation (pancreaticoduodenectomy (PD)). A completion pancreatectomy has been suggested as the treatment of choice, however, the results have revealed some controversy regarding this technique. Twelve patients developed a disrupted pancreaticojejunostomy after PD were treated by disconnection of the anastomosis, oversewing of the pancreatic stump with a continuous shuttling suture and decompression enterostomy. Although a high morbidity rate (75%) occurred after this procedure, ten patients survived reoperation. No recurrent pancreatic fistula or evidence of diabetes mellitus were noted among the survivors. We recommended this procedure as an alternative method for treating severe pancreatic leakage after PD, without the need for resection of the residual pancreas.
TREATMENT OF BILIARY AND PANCREATIC FISTULAS WITH FIBRIN SEALANT. V. Costantino, C. Sperti, A. Alfano D'andrea, C. Pasquali, $. Pedrazzoli. Semeiotica Chirurgica, Padua University, Italy Pancreatic and Biliary surgery are someting complicated by fistulas. We think that their treatment must include an adeguate drainage, the functional suppression of secretions, a careful evaluation of all nutritional parameters and surgical treatment in select cases.We performed all the above coservative techniques in order to achieve a good healing of the fistulas we observed. In addition we used a human fibdn sealnt to fill their tracts. Our overall experience in the treatment of fistulas with fibdn sealant includes 25 entedc, vaginal, pancreatic and biliary fistulas.In the last then years,13 pancreatic fistulas underwend fibrin sealing: 6 followed a pancretico-duodenectomy (2 for cancer, 2 for papillary carcinoma, 2 for endocrine tumors); 2 after left pancreatectomy for chronic pancretitis ,1 for cistoadenoma); followed pancreaticojejunostomy for chronic pancretitis; after excision of an insulinoma in the pancreatic head; 3 after a surgical procedure due to an acute pancreatitis (1 necrosectomy and drenage, percutaneous drenage of pseudocyst, cysto-jejunostomy); 2 biliary fistulas of liver after atypical hepatectomy due to echinococcosis. All our patients reseived an adeguate nutritional support and had their secretions reduced by pharmacological treatment.Morever ,they were all submitted to repeated X-ray controls in order to position an accurate and proper drainage. As soon as a regular tract and a low outflow were achieved, the patients underwend the sealing treatment. We used a double lumen catheter under X-ray control which permitted a selective injection of sealant at the origin of the fistulas up to the skin. The tract was thereby completely filled.Of pancreatic fistulas in 11 cases we obtained a good healing with a single injection, 2 patients required 2 treatments; in all 2 cases of biliary fistulas was required to repeteat three treatments. The sealant is self-shaping and its pressure prevents the out-flow of secretions through the fistulas, diverting them into their natural channels. Finally, the components of the components of the sealant support the growth of a good scar tissue. The results we obtained by this techique can be cosidered satisfactory as some patients recovered without any surgical treatment whic would have been otherwise required.

TREATMENT OF EXTERNAL PANCREATIC FISTULAS WITH
TOTAL PARENTERAL NUTRITION AND OCTREOTIDE V.Alivizatos, Ch. Kyrkos, V. Athanasopoulos Department of Surgery and Nutrition Unit, "St.Andrews" General Hospital of Patras, Greece This study was performed to assess the effect of Total Parenteral Nutrition (TPN) alone or in combination with Octreotide in the management of patients suffering from external pancreatic fistulasuring a 6 year period (88-93),4 patients, mean age 53,7 years, with postoperative external pancreatic fistulas were treated in our Department. There were 3 low-output fistulas (developed as a result of external drainage of pancreatic pseudocyst in 2 patients, and pancreatic injury due to abdominal surgery in one pati-ent), and one highoutput fistula as a result of surgical treatment of necrotizing pancreaiis. All the patients had moderate to severe malnutrition at the time of presenting of the fistula. Those with low-output fistulas were treated with TPN, resulting in complete closur of the fistulas within 12-21 days from the beginning of the treatment, respectivel The patient with hgh-output fistula was treated with TPN and subcutaneous injections of Octreotide (o,lmg every 8 hours).This form of treatment resulted in the decrease of the fistula volume ranging fom 30% o 60% of the initial output within the first five days of treatmenthereas complete clcsure was noted after 18 days from the beginning of the treatment. There were no side effects from the use of TPN and Octreotide. The results of our study suggest that PN is essential in the treatment of external pancreatic fistulas, whereas Octreotide seems to be a useful adjuvant agent especially in the management of the high-output ones. We performed this study to assess the efficacy of the, Somatostatin-analogue, octreotide, in the conservative treatment of high output (> 500 ml/day) pancreatic and billiary fistulas.
During the last 4 years, we treated 17 patients with fistulas, 9 with TPN alone and 8 with TPN and octreotide. The mean closure time was 18 days for the TPN group, and 10 days for the TPN plus octreotide group. The average cost was $ 760 and $ 661 respectively. We conclude that, the use of octreotide in the conservative treatment of the high output pancreatic and billiary fistulas reduses significantly the mean closure time and is a cost effective modality. Some Authors have suggested the use of Human Fibrin Sealant in pancreatic surgery to prevent fistulas. We performed a prospective randomized study in our institution including 97 patients 34 females and 63 males. 46 were affected by pancreatic inflammatory diseases and 51 had pancreatic or peripancreatic neoplastic diseases..AII the pathients were managed by the same surgical staff.Surgical treatment included 30 pancreaticoduodenectomy (PD), 40 pancreatico-jejunostomy(PJ) ,23 left pancreatic resections (LP) and 4 tumor excision(TE). The patients were randomized ,t the moment of the surgical treatment ,they were chosen and divided into 2 different groups: Group A, including 43 subjects who had intaoperative fibrin sealing in the anastomosis or pancreatic stump; Group B, including 54 patients who had not fibrin sealing during the surgical treatment. We considered only radiologically assessed fistulas.After surgery were observed 12 (12.7%) fistulas. 6 fistulas were found in group A and 6 in group B. Five fistulas (16.1%) accurred in patients with pancreatic cancer(3 Group A,2 Group B), 6 (13%) in patients with pancreatitis (3 Group A, 3 Group B); one occurred in a patient Group B) with an endocrine tumor According to the surgical procedure we observed 5 fistulas (16.6%) in cases of PD (4 A,1 B),5 (12.5%) after PJ 2 A, 3 B ,1 patient (B) after LP and (B) after TE. Our results dont show any statistically significant difference between the patients treated whit fibrin sealant and the controll group.The higest incidence of fistulas was observed in the patients with pancreatic cancer of group A (18.7%) and in the patients who undervend PD in Group A (25%).

Larisa-Geece
The aim of this studyis to verify the pathogenesis of pancretic pseudocysts (PP) and its possible locations.The last 16 years we operated on 4,150 patients with pancreatobiliary deseases.Of these patients 14 had PP. 10 were men and women.The mean ageof the patients was 39 years.The aetiology of the PP was alcohol abuse in patients,biliary deseases in 8 patients and blund abdominal trauma in 2 cases.Formation of the cyst propably follows pancreatic ducta/ obstruction be surrounding edematous parenchyme. The swollen duct ruptures,allowing pancreatic juice (with its proteolytic enzymes) to escape,ultimately through the orga ns capsule, in the surrounding tissue.PP are more commonly associated with inflamm-tory of the pancreas,ustmlly caused by alcholic abuse or biliary deseases.Many PP occur in the setting of chronic pancratitis from duct obstruction and pancreatic fibrosis,but they may also result in the aftermath of acute paucreatitis fron a process of autodige stion.Most PP are located within the omental bursa.The organs bounding the lesser peritoneal sac,coated by inflammatory dabris and fibrotic material,compose the pseudocyst wall.Although the epiploic foramen is usually sealed by the lesions fibrotic capsule,PP may dissect into the retro perotoneal space, the pelvis, or the thorax. Because of the risk of secontary complications,such as haemorrhage,infection or spontaneous rupture we recommend drainage when a pseudocyst persists after 6-8 weeks of conservative treatment and its wall at this time is thick enough to allow intarnal drainage.In nerarly all cases an internal drainage with a Roux-Y-limb was performed. Our follow-up examination showed that the majority of the patients had done well o9 satisfactorily postoperatively,with impovement in their general condition and a return to work.Before surge ry,patients with chronic pancreatitis also, need a ECP to asses the pancreatic ductal system and to identify tho se patients who are canditates for more detaiuled treatme P271 P272 True, unilocular cysts of the pancreas are very rare.
Therefore, little is known about their natural history, clinical characteristics, and treatment. To the few described cases we add a new one. The patient, a 39-yr-old woman, had a 2 years history of epigastric pain, radiated to the right abdomen. On ultrasound and CT scanning a cystic lesion of the neck of the pancreas, with a diameter fo 2.8 cm, was found. The patient looked to be healthy and was put on medical observation. In the meantime endoscopy of the stomach and a barium enema showed normal upper GI tract and colon. Finally the pain aggravated seriously and nausea, vomit and weight loss were added, so a laparotomy was desided. At the operation the pancreatic cyst was enucleated, without difficulty. The pancreas was sutured.
Besides the enucleation of the cyst a cholecystectomy was performed. The postoperative course was uneventful, aside from a transient hyperamylasemia. The histology of the cyst showed that was unilocular, and lined with cuboidal epithelium. The gallbladder was normal. The patient is asymptomatic two years after the operation. Our case shows that such cysts can cause symptoms, and excision seems to be the treatment of choice. Department of Surgc University of So Paulo, Brazil.
Chronic pancreatitis differs from acute or obstructive pancreatitis in that it is ditticult or impossible to halt its progression. The aims of surgical treatment are to relieve pain, treat complications and preserve pancreatic function. The appropriate surgical procedure to achieve these ends must be carefully chosen.
The aim of this study is to describe the indications and results of surgical treatment of chronic pancreatitis. We report our findings in 220 patients with complications resulting from chronic pancreatitis. 211 patients were men and nine were women. The main indication was persistent pain (54%) followed by pancreatic pseudoc3.'st (9%), pancreatic ascitis (8.6%) and obstructive jaundice (7.2%). The surgical treatment was established according preoperative protocol with the following principles: pain relief, ductal obstruction removal, minimal resection of pancreatic parenchyraa and return' of pancreatic enzymes back to the digestive system Pancreaticojejunostomy was performed in 111 patients, internal derivation of pseudocy,st in 59 patients, external drainage of pseudocyst in 25 patients, drainage of pancreatic abscess in 18 patients, bileenteric anastomose in 15 patients and pancreatic resection in 15 patients. The operative mortality of pancreaticojejunostomy was 1.8% with postoperative morbidity of 10.9%. Late complications were persistent pain in 9% and reoperation in 7.2%. There was no operative mortality in patients operated on for pseudocyst (86 cases). There was no morbidity among patients that underwent internal derivation (59 cases) and pancreatic resection (2 cases). From the 25 patients that underwent external derivation, 7 presented persistent pancreatic fistula that needed reoperation. The global results were good in 74% of patients.
The goal of surgical treatment is not to cure, but to reduce pain, overcome associated obtruction of the bile duct or duodenum, and to treat pancreatic duct disruptions including pseudocysts and internal pancreatic fistulas. Because continuing deterioration of pancreatic function is to be expected in chronic pancreatitis, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable. Pancreaticopleural fistulae are serious complications in the evolution of chronic pancreatitis. The incidence ranges between and 4% of all patients presenting pancreatic pseudocyst. The course of case with pancreaticopleural fistula is presented, the therapeutic approach discussed.
CASE REPORT 37 year old man was admitted to the department of medecine with the clinical signs of dyspnea and painful right hemithorax. From the past medical history chronic pancreatitis complicated by pseodocyst was known since 2 years. The diagnostic work up ruled out chronic pancreatitis of the head of the pancreas with right sided pancreaticopleural fistula. Conservative treatment including pleural drainage, stenting of the pancreatic duct and octeotride treatment was unsuccessful after 2 months. The patient finally underwent surgical treatment by means of Whipple's operation with excision of the pancreaticopleural fistula. The postoperative course was uneventful, the patient was discharged within 3 weeks after operation.

DISCUSSION
Chronic pancreatitis is complicated by pseudocyst formation in almost 10% of the cases. Out of these 1-4% develop pancreaticopleural fistula. Pancreaticopleural fistulae to the right hemithorax do occur in 20% of the cases only, 80% drain to the left side, bilateral fistulae are rare. 50% of pancreaticopleural fistulae can be treated successfully by non surgical procedures. The remainder do require surgery. However, at least 50% of the non surgically treated patients do require an operative intervention later, in most cases due to symptomatic pseudocysts. In the presence of pseudocyst an operative treatment should be performed after short trial of conservative treatment. Fistulae without pseudocyst may be better candidates for conservative treatment.
PERCUTANEOUS TREATMENT OF PANCREATIC PSEUDOCYST V. Ivshin, A. Yakunin, Yu. Makarov, I. Kuranov Tula Regional Hospital, Tula Center of Liver Surgery, Russia The purpose of this investigation was to evaluate the efficiency of non-surgical treatment of patient with pancreatic pseudocysts. 117 patients (82 men, 35 women) at the age from 26 to 76 years old got percutaneous therapeutic procedur with ultrasound guaidance. 110 patients had cysts caused by pancreatitis and patients had cysts caused by trauma of pancreas. Sizes, localization, the condition of cyst walls were investigated ultrasonically. 55 patients with cysts less than 3-4 cm have been treated by punctures with the aspiration of fluid. 37 of them underwent multiple punctures. The cysts of a lager size were drainaged. All patients underwent biochemical, bacteriological, cytological investigations and cystography. 67 patients who had the cysts of the size lager then 3-4 cm got percutaneous drainage with the use of original technique. The duration of drainage was from 14 to 62 days. 99 patients (85.3%) were treated successfully. 18 of all patients required surgery operation (4 because of the later developed complications, because of malignization cysts, 11 because of communication of cysts with pancreatic duct). patients got percutaneous pseudocystogasrostomy. We claim that percutaneous puncture and/or drainage is a safe and effective method for the treatment of pancreatic pseudocysts. 149