Abstracts Accepted by Title

During the last 12 years (Jan.1978 to Dec 1989) at the surgical department of our Institution 2220 patients were operated for gallsto-. ne desease of the biliary system.Among then 224 patients (10.09%) were operated and had gallstone acute pancreatitis (AP).Cholelithiasis and AP were documented in all patients by operation,clinical, x-rays and biochemical findings.Of the 224 patients in 47 the operation was done early and without improvement of their AP.This was done into the first week of their treatment (group A patients).In this group of patients the operation was done as a urgent procedure and it was also for the definitive treatment of their gallstone desease (i .e. cholecystectomy,choledochotomy usual ly,necrosectomydebridement of the necrotic pancreatic and peripancreatic tissue in some patients and multiple external drainage to all of the patients. In many of them the diagnosis for the first time was put during laparatomy.The laparatomy was done with the misdiagnosis of acute cholecystitis,perforated peptic ulcer or mesenteric infarction.ln this group A of patients we had 9 deaths and the mortality rate was 19%. One hundred and senenty seven patients were operated for their bil iary desease ellecti.vely,after the crisis of AP had subsided with the conservative treatment.Usually this group of patients (group B), was operated at the sameadmission to the Ho.spital and around the 15th day from the onset of the symptoms.ln these group of patients we had no deaths (mortality 0%). The timing of biliary surgery remains controversial in patients with acute panreatitis associated with cholelithiasis.We usually operate on these patients after the 15th day since the onset of their symptoms and always at the same admission to the Hospital .When there is no improvement with the conservative treatment of acute pancreatitis and when the diagnosis is put for the first time during laparatomy, we conclude in this parer,that the definitive surgery for the lithiasis of the biliary tract must be done at the same time.This technicaly has not difficulties for the experienced surgeon,does not adds to the complications and mortality,saves the patient by a second operation and protects him of recurrences of AP during the waitti ng time.

some patients and multiple external drainage to all of the patients. In many of them the diagnosis for the first time was put during laparatomy.The laparatomy was done with the misdiagnosis of acute cholecystitis,perforated peptic ulcer or mesenteric infarction.ln this group A of patients we had 9 deaths and the mortality rate was 19%.
One hundred and senenty seven patients were operated for their bil iary desease ellecti.vely,after the crisis of AP had subsided with the conservative treatment.Usually this group of patients (group B), was operated at the sameadmission to the Ho.spital and around the 15th day from the onset of the symptoms.ln these group of patients we had no deaths (mortality 0%).
The timing of biliary surgery remains controversial in patients with acute panreatitis associated with cholelithiasis.We usually operate on these patients after the 15th day since the onset of their symptoms and always at the same admission to the Hospital .When there is no improvement with the conservative treatment of acute pancreatitis and when the diagnosis is put for the first time during laparatomy, we conclude in this parer,that the definitive surgery for the lithiasis of the biliary tract must be done at the same time.This technicaly has not difficulties for the experienced surgeon,does not adds to the complications and mortality,saves the patient by a second operation and protects him of recurrences of AP during the waitti ng time. Be 3Cr and 6(7 of patients with gallbladder cancer present wth obstructive jaundice. Indeed, as many as 25% of patients with 'hilar cholangiocarcincma' n fact have gallbladder cancers which have spread to involve the hilar region. The relief of jaundice may be either surgical (bypass or intubation) or endoscopic (prosthesis). Endoscopic treatment is popular but the quality of survival may be poor as a 30-day mortality of over 2(7/, early cholangitis and tube blockage are not uncomDn. We present our experience with surgical pal laton. Betw. ]964-988, 55 jaundiced patients wth advanced gallbladder cancer presented as 'hlar cancer'. They comprised 36 and ]9 men of median age 60 yr (range 30-86 yr). All underwent surgical palliatlon by biliary-enteric bypass by intrahepat c anastzmDs s (st I II duct), hepatoanastxmDs s (Longnre) or surgical ntubatlon (T-tube or U-tube) ( Long-time survival rates in cases of pancreatic cancer are still different in international reports. An analysis of surgical procedures, complications and long-time survival of those patients, who underwent operation with palliative or curative intent in our department was therefore done from 1983 to 1989. The group consisted of 81 men (63+11 years) and 79 women (65+11 years). 132 patients suffered from pancreatic duct carcinoma and 20 from ampullary carcinoma. Operative procedures for curative intent were done as follows-Locat ion Resectabi ity rate n (5) Part. Postoperative mortality rate was 5,7 % in curative and 10 % in palliative operations Overall morbidity ,,as 355 with no significant difference between curative and palliative procedures. 14. patients (9%) had to undergo reintervention. Five-years-survival of 66 patients with radical surgery was 18 %., in cases with ductal carcinoma and 25% with ampullary carcinoma (Kaplan-4eier-method). On the contrary, no patient with palliative procedure survived more than 3 years.
In our experience morbidity is still high, whereas mortality has decreased in the last years in spite of a more aggressive approach. Survival rates are far from being satisfactory, but extensive surgery provides some hope, 538 B"' 0 0 5 THE BILIARY-ENTERIC ANASTOMOSIS C.Battersby Royal Brisbane Hospital Australia.
A variety of biliary structures (e.g. left hepatic duct, bile duct, gall bladder) has been anastomosed to parts of the G.I. tract including stomach duodenum and jejunum. "Although there is genera] consensus concerning the need for these procedures in selected patients there is no consensus concerning which technique is pref,'ob]e or under what circumstances internal drainage should be used." '; The appearance of endoscopic stenting procedures and endoscopic sphincterotomy has provided other alternatives.
Choice of procedure will depend upon the site and type of pathology present and the age of and fitness of the patient as well as the size of the biliary system (e.g. Roux-en-Y hepatic jejunostomy is the procedure of choice for benign high biliary stricture in a fit patient).
Recommendations are (1) The bile duct is superior to the gall bladder for anastomosis.
(2) Side-to-side anastomosis is technically easier and less catastrophic if there is a leak.
() The length of the Roux loop of jejunum should be at least 50cm.
(4) The loop is best brought up rerocolic or rerogasric, (5) Transhepatic stenting is not usually necessary. Four right hepatectomy; one extended right hepatectomy two left hepatectomy; four bisegmentectomy (segments II-III two segments IV-V two); two wedge resections and five cysto-pericyst ctomy without open the cyst were performed.
CystoRericystectomy has been considered mayor hepatic surgery beca se it poses equivalent operative problems (Pringle manoeuvre,digit clasia, intraoperative hemorrage, etc.). Overall morbidity rate was 22.2% with no postoperative mortality. The most frequent complication was persistent pleural effusion which required thoracentesis in two patients; none required reoperation.
Major hepatic surgery is an effective treatment for benign lesions and can be accomplished with acceptable morbidity and mortality pro vided that carefull selection of the patients and standardized operative technique are used. Bypass of bile ducts for malignant or benign (post-choleeystectomy su-icture and secondary cholangitis) stricture is facilitated by stenting biliary tree. Between [1984][1985][1986][1987][1988][1989] we have undertaken 16 such operations on 16 patients (8 M, 8F) with a median age of 46.8 years (range 25-71). There were 6 malignant and 10 benign strictures of the bile duct.
In 6 malignant strictures; 4 transmmoral stenting, 2 cholangiojejunostomy over stent were conducted on patients with obsmactive jaundice. In 5 patients with postcholecystectomy stricture; 2 reconstruction of common hepatic duct stenosis, one reconstruction of biliodigestive stoma (hepaticojejunostomy), one reconstruction of hepaticojejunostomy stoma plus cholangiojejunostomy were carried out over stent.
In three patients with secondary cholangitis due to intrabiliary rupture of hydatid cyst, transhepatic stent was used for daily washing out the biliary tree. In one patient, stricture of common hepatic ducts due to injection of formalin into hydatid cyst cavity was repaired with flap of cystic duct over stent. In one patient with intrahepatic stone, bilateral transhepatic robe splint was put to prevent obstruction of bile ducts with retained stones.
Transhepatic stents were hold continuously up to the end of the life in patients with malignant stricture.The others were removed at a me.an of 6 months (rangel-12 months). Clinical and laboratory findings showed that,sufficient and efective bile flow was obtained in all patients.There were three postoperative deaths. One patient developed hemorhage due to stenting.
In conclusion surgical transhepatic tube splint is convenient to solve obstructive jaundice in malignant stricture. It provides a chance for chemotherapy. Tube splint also prevents early bile leakage and stenosis of reconslructive procedures for benign stricture, and provides to wash out biliary tree in patients with cholangitis. Pancreatic ascites is a rather ill defined clinical entity, the pathogenesis of which is poorly assessed. Experimental reports dealing mainly with open duct pancreatic transplant failed to demonstrate tyrue pancreatic ascites in several animal species.
We decided to prepare some new experimental modes to ascertain: 1 The feasibility of producing pancreatic ascites in animals without any other cause of peritoneal effusion (lymphatic or hepatic damage) 2 The possible relevance of enzymatic activation in the disease.
As in cur first experiment with rats we did not obtain a clear-cut answer we decided to employ pigs, because of the opening of the Wirsung duct into the duodenum cxmpletely independent frcm the bile duct opening. Two groups of animals were employed. In the first the pancreatic duct was severed a few nm from the duodenum, the distal intraduodenal segment ligated and the proximal one left open in the peritoneal cavity (unactivated juice). In the second group a segment of few cm of duodenum distal to the bile duct opening was isolated, leaving the pancreatic duct opening in it untouched, and left free to pour pancreatic secretion, activated frcm contact with duodenal ncosa, in the peritoneum. The continuity of the duodenum was then re-established.
All the animals with unactivated pancreatic juice pcring into the peritoneal cavity showed acute necrotic pancreatitis, diffuse or focal, but not peritoneal effusion; while the animals of the second group (activated juice) showed peritoneal effusion (400 to 1900 ml) with very high amylase activity. Trauma to the extrahepatic biliary tract is rare but, if over looked or improperly managed, may be assosiated with significant morbidity and mortality.
Among ii00 patients (1970)(1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988) undergoing laparotomy for acute blunt trauma, there were 5 (0.45%) injuries to the extrahepatic biliary tract. 4 of them were due to Road Traffic Accident. In 2 cases common bile duct was injuried, in 2 cases right and in 1 case right and common hepatic duct. The indications for operation was shock due to an associated injury. Associated intraabdominal trauma was always present. Common bile duct ruptures were treated by cholopeptic anastomoses while the ruptures in bile ducts was treated by using stiches and common bile duct drainage by a T-tube. Rostoperative complications were two biliary leak. In one case the right hepatic duct injury was overlooked at the time of initial abdominal exploration. The mortality was due to associated injuries, 2 out of 5 patients died, their postoperative course were characterized by multiorgan failure. We conclude that in extrahepatic bile duct trauma, early recognition of the injury is essential if serious morbidity and mortality are to be avoided. Though at present a great number of studies are dedicated to pancreatic surgery, there are still a lot of problems concerning the surgery of this organ. The use of laser scalpel (C02-1aser) in pancreatic transection is very promising due to the fact that the laser beam can seal blood vessels and pancreatic ducts and sterilise the surface of the resected organ. A number of experinntal and clinical studies show the advantage of laser scalpel over the conventional instruments (scalpel, electrocautery knife). Unfortunately, according to bibliography, only 28 pancreatic resections have been performed in 5 surgical institutes in the USSR which give no opportunity to assess the peculiarities of this organ surgery. The aim of our study is to establish the influence of such factors as: complete hemostasis only by means of laser beam and in ccmbination with electrocoagulation and vessel litigation, unsutured pancreatic stump after its transection with 002 laser beam, pancreatic stunp plastics, suturing of the main pancreatic duct.
The work is performed in the Surgical Clinic and based on the results of the observation of 36 patients with'laser' distal pancreatic resection. All the patients were subdivided into 6 groups and the results wre cfmpared in the following way: i.
TRTNT O CICA JAIDIQE B.S.Brikln, A.K.Pelenky, I., Allmv, B.A.Rmzygm The Semashko Moscow Medical Institute 80 patients with mechical Jadice due to choledocholithiasis weze irradiated i%h low-energy lase over the ne iaed ae of spest. The Soviet AT-01 deviee was used. The @utput powez of izadiatlon Is 15 , power density 5m Vt/cm2. The iradiatlon was given before decompression of biiiy tac%s di 3-5 days and after decompression the patients had got 7-10 coses of irraaion with 5 minutes exposition. The duration of Jadice was more I0 days, blood bilibinemia exceeded 10 mol/i. The effectiveness of treatmen$ evaluated according to clinical plcte of the disease, dic of biochemical values, heohepaSegraphy.
Lase therapy before biliy tracts decompression gave positive effects resulting in impovi of me.$abolism and live micocirculatlon, which noalized hepatocyte function suggesting beneficial conditions fo biliy trac surgery. Afte decompression Lasez therapy increased the effect of treatment, contribmti disappeace of Jaundice, proving liver fctien and decreami complication rate and lethality. 61% of these attempt to salvage a damaged spleen, and a further 5% sometimes do so. The remaining 32% do not attempt splenic repair.
Following splenectomy, 28% reimplant splenic tissue, and 59% give Pneumococcal vaccine. Only 28% give prophylactic antibiotics to adults, and 59% give them to children. 74% of surgeons did not specify the duration of antibiotic usage, and the remainder stated periods from one month to i0 years, or up to a specified age for children.
These figures suggest increasing awareness of the importance of the spleen from attempts at salvage, but persisting uncertainty about management of the patient after splenectomy. The Blood vessels where the bleeding occurred were the splenic artery in four patients and the gastroduodenal artery in two patients.
The pre-operative diagnosis was estabilished in five cases by endoscopy, selective arteriography, ultrassonography, CT or ERCP. In one patient the diagnosis was made in the course of the operation.
Three patients underwent distal pancreatectomy with splenectomy and aneurismectomy, In the three other patients igation of pseudoaneurysm in was performed together with the side to side pancreatojej unostomy derivation.
In these six cases there were no complications after surgery and no mortal i ty.  Between 1981Between -1988 patients (27 men, 5 wonn) with a mean age of 54+15 years with chronic pancreatitis were surgically treated in ou depart. Alcohol abuse was present in 26 patients and biliary stones in ii. Jaundice or duodenal obstruction were responsible for surgical treatment in six cases, pseudo-cysts in nine, psesdo-neoplasic lesions of the pancreatic head in three, quilous ascitis in two and resistance to medical treatment in 12. A pancreatic resection was undertaken in 9 patients (3 Whipple procedures, 6 splenopancreatectcmies); a Puestow procedure was used in 5 patients, a wirsungoplasty and esfincteroplasty in a case of pancreas divisum; ten patients received isolated biliary tract procedures, associated in two with a gastroenterostemy. Pseudocysts were treated by internal or external diversion, resection or a Puestow operation.
Three patients died in the post-operative period; five presented ccmplications (infections or upper gastrointestinal bleeding).
Long term follc-up (25 patients) showed a marked improvement in mre than 80% of the patients. One died four years after a Wipple procedure with an unresectable hepatcma.  (14) presented with an acute haemoperitoneum due to HCC spontaneous rupture. All patients had non alcoholic liver cirrhosis. Two patients had right upper quadrant pain during the week preceding the acute rupture. On admission, all patients had abdominal pain and tenderness and were hypotensive.
Emergency laparotomy was carried out in all 5 patients. Liver resection was performed in 4 cases wedge resection (2 cases), segmentectomy (1 case), and right extended hepatectom, (1 case). One patient died of liver failure 10 days after surgery. Among the 3 other patients, 1 survived 6 months, another 12 months and the last one is alive 2 years after right extended hepatectomy but has now recurrent turnout in his remaining liver. The last patient had a non resectable bulky central turnout. Hepatic artery ligation was performed, but haemostasis could not achieved and the patient died intraoperatively.
These data suggest that emergency liver resection for ruptured HCC is effective in the control of bleeding and may permit prolonged survival. It could be the treatment of choice when technically feasible. 552 BTO 9 SURGERY OF PANCREATIC AND BILIARY CANCER S. ChlKoteev, V. ShantuPov Institute of Suey, IPKutsK, USSR DurlnE last decade carcinomas of pancreas and biliary system were diagnosed in 76 patients. There ages ranged from iS to 76 years. Normaly the dlasnosis was made by the use of ultrasonoEraphy, computed tomoraphy, endoscopic retrosrade clolansiopancreatography and anglo8raphy. Tumor was located at pancreas head in 9@, at body and tail in @, at main blllary duct in 2, at large duodenal nipple in Patients with pancreas head and main blliary duct cancer were always manifested as jaundice (8)  Carcincma of the gallbladder is a rare tumour, usually discovered at an advance stage. It is one of the abdc%inal neoplasia with the most serious prognosis because of its intrinsic invasiveness and the delay in which it is diagnosed. The etiology is unknown although risk factors are taken into consideration: lithiasis (but 1/4 of the neoplasia originate frc alithiasic gall bladders), chronic phlogosis, chronic use of scme drugs (antidiabetics, diasitics, antihypertensives etc. ), ulcerous colitis, several substances used in industry.
Takabayasei and others have discovered a possible connection between insufficient sulpboconjugation of the litbcolic acid normally present in bile and cancer of the gall bladder. Our experience, matured in 15 years (1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987) has enabled us to gather 63 cases of cancer of the gall bladder (41 wmn and 22 men average age 65.5 years). Our series has brought out scme particularly discouraging facts, as 57 cases were at the 5th stage, so the surgical approach was restricted to palliative operations or to a simple exploratory laporotcmy plus biopsy. Cnly 2 cases were at the ist stage with post-operative histologic diagnosis. 4 cases at the 3rd stage, in which cholecystectcmy was performed, a cuneiform resection of the liver and a lyec of the hepatoduodenal peduncle. Pancreatic abscess is a rare ccmplication of acute pancreatitis occurring in 1% to 4% of the cases of acute pancreatitis. Pancreatic abscess, if untreated, has a 100% mortality rate which drops to 50% 30 with an early diagnosis and rapid surgical treatment. In the period 1976-1988 we observed 14 cases of pancreatic abscess out of a total of 209 cases of acute pancreatitis, of which 58 were necrotic-haemDrrhagic. The overall mrtality rate was 28.5%. Biliary disease was responsible in 4 cases, alcohol in 2, surgical traumas in 4, peptic ulcer in 2 cases, the etiology remaining unknown in the last 2. The cultural test was sterile in 14.2% of cases. In 13 cases closed drainage with tubes and lamina was used, and only in one case suction drainage according to Redon. Post-operative complications arose in 5 cases: 3 re-operations for recurrence of the abscess collection, 1 case of stress ulcer treated with gastric resection, 1 fecal in the right colon treated wtih a hemilec of the right colon.
In 1984 we put into practice the following therapeutic protocol: naso-gastric probe, TPN, continuous infusion of scmatostatin for 12 days, H2 antagonists, wide-spectrum antibiotics, early laparot with drainage of the cavity of the abscess, possible reanimation therapy. We did not note any difference in the mDrtaility rate, compared to international surveys, between closed and open drainage (laparostcmy) of the abscess cavity, as long as an accurate debridement of the abscess cavity was performed.
To conclude, we consider that is is not so much the type of drainage used which modifies the course of the abscess as the very early diagnosis, the accurate localisation of the abscess (ecography, CT), immediate operation, and the continuous and adequate therapy of support and reanimation. The Authors show in this movie the technique of liver segmentectomy in a patient with cirrhosis (CHILD A G.).

References
Two small hepatocarcinomas were present in the Vlth and Vllth segment of the liver and the treatment of choise was a right lateral sectori ectomy.
Diagnosis making is herein discussed with particular regard to the use of lipiodol, CT scan, angiography and intraoperative U.S.
The surgical procedure was performed directly through the parenchima previous Pringle maneuver. re syndrome (only 155 cases reported up to now), a ly of the skin and sometimes of the viscera, is asombocytopenia, hypofibrinogenemia, deficiency of ors II, V, VII, VIII, X and elevated levels od FDP. nts presented with enormous hepatomegaly and aboracluded the above-mentioned hematologic changes. Howen and FDP levels reverted promptly to he hemangioma via a right extended hetomy, respecti vely. both specimens revealed cavernous he- The Authors point out the importance of diagnostic procedures such as ultrasonography, technetium-99m scintigraphy, CT, laparoscopy, FNAB for the work-up of this lesion and particularly focus upon the inconsistency of the angiographic study which showed an avascular lesion in both cases. In patients with pancreatic pseudocysts elective operation is performed if the pseudocyst is biger than 4cm and after unsuccessful conservative treatment for 6 weks.
The choice of olration depends on the size, nature, situation and t of cyst, as well as the general condition of the patient.
Internal drainage of the pseudocyst is refered.
In the 3rd Surgical Department of "EVAGELISMOS" Medical Center, 25 patients with pancreatic pseudocysts were operated dn the last 7 years (1983 to 1989). There w 14 women and 11 men. The age of these patients ranged between 25 to 65 years. The cause of the pseudocyst was acute biliary pancreatitis in 18 patients, trauma in 2 and unknown in 5. Five patients with spontaneous regression of the pseudocyst are not included in this study. Internal drainage was [rformed in 20 patients: in 4 patients a cysto-gastrostomy and in 16 a cysto-jejunostomy using a Roux-en-Y jejuDl loop was performed.
External drainage of the cyst was done surgically in 3 patients because of infection. From these 3 patients, 2 reoperated on after a few months, using a Roux-en-y jejunal loop and the other one has had spontaneous healing of the remaining cyst and the pancreatocutaneous fistulla. Two distal pancreatectomies without splenectonf were performed. There wre no postoperative deaths in this series. The postoperative con)lications, the choice of operation and the follow-up of the patients are discussed. It is concluded that the drainage using a Roux-en-y jejunal loop, is the teatment of choice. The surgical groups were similar preoperatively with a mean follow up of 82+13 and 78+18 nnths respectively (range: 60-120). The operative mrtality was low (3.3% for DSS and 3.1% for SGD).
Rebleeding occurred more frequently after SaGD (27%) compared to DSRS (5.7%, P(O. 05). Sclerotherapy salvaged 65% of SGD rebleeders. Encehalopathy developed significantly (PO. 05) more after DSRS (18.7%) than S&GD (7.3%), with no significant difference anng the current survivors. The difference in overall rebleeding and encephalopathy rates between procedures was statistically related to patients with cirrhosis and mixed lesions (P<0.05). DSS significantly reduced the endoscopic variceal size mre than S&GD (P(0.05). Prograde portal perfsion was 6bctmnted in 94% of patients in each group with a variable distinct pattern of portaprival flow. Cumslative survival was similar with 80% for DSRS and 79% for SSD (+ sclerosis in 23%). Hepatic cell failure was the cause of death in 46% and 50% respectively. Ho%ver in the schistoscmal patients, survival was better after DSRS (90%) than S&GD (75%) with no difference among the cirrhotic and mixed group (DSS 73%, SSD 72% ).
In conclusion: 1 Both DSRS & SGD have low operative mrtality 2 DSRS is superior to SaGD in the schistosmal patients 3 S backed up by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population. 562 Surgical Department of Semmelweis University MedicalSchool Budapest-Hungary In the treatment of the acute cholecystitis the urgent or so called early-operation is gaining more and more preference.
At our department we have preferred the urgent operative treatment of acute cholecystitis to the conservative therapy in the course of recent years.
The experiences of two consecutive two year period were compared. In the period of conservative treatment (first group) 27 patients were admitted with this diagnosis and were treated in conservative way. Out of them in 3 cases urgent operation was necessary within 2-4 days after the beginning of the conservative treatment because of the progression of the illness coming in spite of the treatment. 24 patient recovered without an operation. 15 out of them returned at the. appointed time in a so-called " froid" condition and underwent an operation. In 4 cases out of them an empyemic gallbladder were removed surprisingly (without any clinical or laboratory sign) 2 of them returned in jaundice, 4 suffered from regular cramps between the two hospitalisations.
In the past two-year period 31 patients were admitted with the same diagnosis. 26 patients underwent an urgent operation within 3-24 hours after their admission (second group). The beginning of their complaints was not. = J.az ther than 72 hours. Besides the patients mentioned above there were 5 others with whom the beginning of inflammation couldn't be determined, that is why conservative treat ment was carried out. We compared the complications and the finnancial ef fects of the. two different methods The time of the hospital-stay and being on sick list was the half in the first group as in the second. The same refers to expenses of medicaments which is 20.-40 % higher in the second group. The number of the minor wound complications were twice as much in the second group as in the first one. The overall success rates were 87,1% for endoscopic papillotomy, 86,2 for connon bile duct exploration and 87,2 for connon bile duct exploration with drainage procedure. In regar to the success of these procedures were evaluated the diameter of contain bile duct and the number of stones in the duct.
Although our results do not offer elements of certainy, they would suggest that the following indications are valid.
Endoscopic papillosphincterotomy is major improvement in elderly patients with one or a few stones (success rates 92,).
When operative exploration is advisable, we choose connon duct exploration; a choledocal T-tube is used in patients with normal sphincterial function and with thin walled ducts and daring suture.
The addition of a biliary-intestinal drainage (choledochoduodenostomy or choledocojejunostomy) provides better results in patients with a dilated bile duct (success rates 93,3%) or with multiple stones (success rates 9,7%).
When the apparatus of Oddi has lost its function, caused by an irreversible inflanmatory process, transduodenal papillosphincterotonj is justified. The aim of this study was a discriminating presentation of five cases of Mirizzi syndrome which were treated in our clinic in the last ten years.
This syndrome refers to obstructive jaundice caused by external pressure of the extrahepatic bile ducts due to various causes.
In our cases sizable gallstones in the gallbladder and especially in Hartmans pouch caused obstructive jaundice.
The above cases were treated surgically with excellent results.
The technical, diagnostic and therapeutic approach of the syndrome is discussed. Solitary non parasitic cyst of the liver is a rare disease, occuring at all ages, more frequently in the fourth to sixth decades of life, with a female to male ratio of 4-5 to i, involving the right lobe twice as often as the left. Cysts less than 8 to lO cm rarely cause symptoms and may be detected during ultrasounds or CT scan examinations, or at laparotomy. Symptoms are usually those of an upper abdominal mass, with fullness, nausea and occasional vomiting. Complications of the cysts are rare, and may include haemorrage, rupture or jaundice. CASE REPORT a 56-year-old woman was admitted to our Department of Surgery on November 1989 with a four-year-history of solitary non-parasitic liver cyst. The cyst, detected during an ultrasound examination in the sixth segment of the liver, had in 1986 a diameter of 2.5 cm. In 1987 the cyst was asymptomatic with a diameter of 4 cm. A sudden widening of the upper abdomen, associated to a fullness sensation began in September 1989. On November 1989 ultrasound examination and CT scan showed that the cyst was completely filling the right lobe,with a round-oval shape and a maximum diameter of 24cm, compressing the IVC and pushing the aorta to the left.A right hepatectomy was made using a right subcostal incision extended to a phrenothoracotomy. The cyst was filled with 4.5 liters of clear fluid. A small portion of the cystic wall fixed to the IVC had to be left in place. Uneventful postoperative course. The patient left the Hospital 14 days after surgery. Histology confirmed the diagnosis. Mayor hepatic surgery for cystic disease is erroneusly thought to be a too big operation for a benign disease. In fact, mortality rates are less than 5 percent in large series of hepatic resections. Moreover, resective surgery has a lower morbidity rate than non radical surgery. The open treatment of acute necrotizing pancreatitis, with daily reexploration and lavage of the open abdomen, is a method proposed by several Authors in recent years. We have used this method in three patients with histologically confirmed acute necrotizing pancreatitis. The open treatment was made in all three cases as second operation. A severe generalized sepsis was present, at 2, 3 and 5 weeks after the first operation. The sepsis was due to multiple large collections of pus in the peritoneal cavity and in the retroperitoneum. Careful and wide debridement of these areas and some necrosectomies were made, a peritoneal lavage was done and multiple drainages inserted. The abdominal wall was temporarily closed with a plastic zipper suture (ETHIZIP).
The patients were sent to the Intensive Care Unit, where daily exploration with zipper opening and debridement of pancreatic necrotic tissue, fibrinous adhesions and inflammatory secretions, was made. When systemic and local signs of sepsis had disappeared, the zipper was removed and the abdominal wall closed with one-layer interrupted nylon stitches (on 9th,llth and 12th postoperative day). All three patients survived. The mean stay in Intensive Care Unit was 14 days, and postoperative hospital stay was 34 days.
In It is well known that regeneration of nonligated lobe following portal branch (PB) ligation occurs as well as after partial hepatectomy. This phenomenon is applied to clinical field such as transhepatic PB embolization before major hepatic resection. The present study was conducted to investigate cell kinetics and plasma membrane fluidity of hepatocytes after PB ligation. Male Wistar rats weighing 200-250g were used. Ligation of PB corresponding to about 70% liver volume was performed, followed by liver samplings in a given time course. For cell kinetics, after a pulse labelling by 5-bromo-2'-deoxyuridine (BrdU), hepatocytes were isolated by collagenase perfusion method via inferior vena cava. And then, the isolated nuclei were used for flow cytometric analysis using two-color staining of anti-BrdU antibody and prop idium iodide. Liver plasma membranes were isolated by centrifugation and fluidity was estimated by measuring fluorescence polarization using 1,6-diphenyl-l, 3, 5-hexatriene as a probe dye. Results have been operated on using a portocaval laterolateral shunt by "H" interposition of a small diameter i0 and 8 mm ringed PTFE graft. This video shows all technical aspects of the differents steps of the operation: dissection of the vascular structures, interposition of a short and small diameter segment of ringed PTFE graft, vascular anastomosis, taking of portal pressures and comprobation of the shunt patency by means of echodoppler studies and transfemoral portography.We don't use portal collateral ligation to complete this operation. The analysis of the present serie shows that the operative mortality rate in hospital mortality) was 0 % in elective patients and 16 % in emergency setting. The portal liver perfusion was proved in 72 % of the cases. The cumulative survival rate was 50 % at 3 years and 40 % at five years and 27 % at seven years. The encephalopaty rate was 18 %. There was 2 early graft thrombosis. The long term patency of the shunt was 95 %. BT  Surgery of patients with Necrotizing Pancreatitis(NP) is often followed by many complications. The postopperative pancreatic fistula (PF) is one of the most frecuent. Since 1982 we have rewieved 42 patients operated on because of NP. Surgical treatment was based on sucesive necrosectomies and zipper laparostomy. The abdomen was closed when granulation tissue developed in the retroperitoneum. Two or three drains were placed in pancreatic area to control the infected zone. In 17 patients(41%) postoperative PF,defined as presence of persistent fluid with more than i000 U of amylase during one week,was detected. The cornerstone of treatment in PF was a complete drainage of pancreatic juice total parenteral nutrition and intravenous infusion of somatostatin. The mean duration of the fistulae was 2.9 weeks. The spontaneous closing after medical treatment occurred in 14 patients(82.3%).Two patients died(ll.7%),one after closing of the fistula.Two patients underwent surgical procedure because a chronic fistula. We conclude that PF is a frecuent complication following surgery of NP,but in the majority of cases the closing of the fistula can be achieved by consevative medical treatment. The era of cold-light flexible endoscopy basically changed the surgical diagnosis. As a next step, operative endoscopy opened up new vistas. Routine endoscopic papiilotcmy (EP) is an everyday tool practically all over the world. In the following case EP was successfully used for an unusual and probably unique indication.
On the 9th of May 1989, w operated upon a 33 year old male patient for a large echinococcal cyst, which was invading and occupying the entire right lobe of the liver. The remDval of the cyst practically corresponded to a right lobectcmy. After the remDval of the gallbladder and after division and ligation of the main anatcmic structures of the right lobe, bile leakage was observed on the remaining biliary tract and s meticulously closed by atraumatic stitches. On the 6th postoperative day a considerable bile discharge developed through the drain. Though the patient did well, was not jaundiced at all, and even had normal stools, the fistula proved to be resistant to all conservative efforts. On the 38th postoperative day we requested a papillotcmy. The ERCP was easily performed, and an endoscopic papillotcmy was carried out. Though the contrast material did not show any leakage, from the next day following the papillotcmy the biliary fistula abruptly closed, and the patient was discharged home. In the course of the follow-up his physical examinations, lab tests and ultrasonography were perfectly normal, and corresponded to the operation.
We believe, that decrease of the biliary pressure to a subnormal level by division of the sphincter mechanism was the cause of the imnediate success, so we believe in similar cases endoscopic intervention could be the method of choice, but much earlier than we decided. Cholecystectcmy is still the treat of choice for acute cholecystitis. The timing of surgery, early or delayed, is however controversial and also depending on duration of symptc%s (48 hours). The aim of this study was therefore to evaluate the results of early cholecystectcn for acute cholecystitis and the influence of duration of symptoms on morbidity and mortality. In a three year period 122 patients (F: 69; M 53) underwent "urgent" cholecystectomy which was 24% of the patients surgically treated for gallstones. The mean age was 64 years (range 29-i01 year). TWo pati.ents 88;89 years) died respectively 24 and 26 days postoperative from cardiac ccmplications. Morbidity according to the duration of symptoms is sunmarized in Table I  cysts in adult patient, classified (according to Todani and Watenabe classification) as three type I, two type IV and one type V. In five patients stones were present in the cyst and in one case histology revealed a carcinoma in the posterior wall of the cyst.
This videotape present shows the management of two type Ia cases, one complicated by lithiasis and the other by cancer. Cholangiography and intraoperative echography consent a very suggestive iconography.
The procedure consists in the complete removal of the cyst and according to us always be done wherever the lesion is located. Reconstruction is carried out with a bilio-digestive derivation with a wide anastomosis on normal tissue at superior biliary confluence level to avoid complications and consent the passage of eventual intrahepatic stones. In 14 cases this disease developed after hard pancreas injury (with the injury of the pancreatic duct in 9 cases) and as a result of cholelithiasis in 18 cases.
In most cases retroperitoneal phlegmon was observed to spread in the left and in 4 cases in the right pericolitis fat; in 2 cases the total lesion of paranephric fat was observed on the left side.
In 17 cases distal resection of the pancreas was implemented (in 2 of them there was a subtotal left-side resection). 15 patients were subjected to polyphocal irrigation-evacuation drainage of paranephric and pericolitis spaces.
In all cases the extensive necrosequestrectcmy was conducted during the operation. The obligatory operative component was either external or internal drainage of biliary ducts. 9 patients died in the group under examination (28.12%).
The mDrtality was mainly caused by generalised intraperitoneal infection and peritoneal sepsis. In this paper we describe the operative technique we used in i00 selective cases over the last 4 years.
i00 patients were operated upon for beniEn obstruction in the common bile duct.There was a male-female ratio of 1:2 and the aEe of the patients varied between 90 and 48,the mean aEe bein E 68.5 years. We used S. 0 vicryl stitches, 6 stitches all in one layer. The width of the cut on the common bile duct is 1.5 cm. and that of the duodenum about 0.7 cm.The "bite" of the stitch on :'%,'. the duodenum does not include the mucosa of the duode-L num-a point we think is very important.We take every precaution to avoid placinE any tension on the anastomosis.Through a stab wound we drain the area with a soft flat rubber drain, i , [ , ; / ' , ; , -Out of the i00 patients only 4 had any perce-,' ptible leakage of bile,and this for only 2 days;we were ble to remove the drain on the 3rd day.In the remaining 96 patients the drain was absolutely dry.The mean stay at the hospital was 6 days, and there were no deaths or postoperative complications of any kind The In order to prevent pancreatic fistula after distal pancreatectomy, we deviced a new method, that is, partial occlusion of the main pancreatic duct and its small ductules with prolamine.
After division of distal pancreas, partial pancreatic duct was occluded with 0.2 to 0.3 ml prolamine. The main pancreatic duct was ligated, and then, the divided cut surface of the pancreas was closed interrupted sutures. This method was performed in 40 cases of gastric malignancies prolamine-group ). This prolamine-group was clinically compared with other 30 cases without prolamine injection Non-prolamine-group Regarding the incidence of postoperative pancreatic fistula, prolamine-group(7.5%) was significantly lower than that of non- The most ccmon cause of occlusion of the splenic vein is pancreatic disease such as chronic pancreatitis or carcinoma of the pancreas. The chronic pancreatitis and the carcincma of the pancreas may involve not only the splenic vein but also eventually the splenic artery. Therefore the clinical features of occlusion of the splenic vein my be profoundly altered according to the nature of the underlying causes. In an attempt to clarify the pathophysiologic findings and hemodynamic mechanism of occlusion, the splenic vein associated with chronic pancreatitis or carcincma of the pancreas, five patients re selected frc our past experience.
Upon analyzing the clinical course of these patients three consecutive phases may be distinguished: Phase 1 is the insidious or latent phase: The splenic vein is partially occluded and gastric varices has not developed. The splenic artery is already and has beccme wide and tortuous.
Develnt of ascites is the characteristic clinical symptom.
Phase 2 is the collateral developing phase: The splenic vein is cfmpletely occluded, the splenic artery is abnomaally wide and tortuous, resulting in marked varices and splencmegaly and massive gastrointestinal bleeding. The authors describe the procedure which in their opinion should be adopted in cases of acute necrosing pancreatitis.
They base their conclusions cn 14 cases which they report, drawing attention to the clinical and biological signs which arouse suspicion of pancreatric necrosis and therefore indicate operation.
As regards the choice of operation, they prefer sequestrectcmy of the necrotic tissue, associated with one of the standard methods of biliary deccmpression, to formal resection of the pancreas.
The mDrtality, nevertheless, is high, exceeding 50%. The morbidity, which is also high, is mainly due to pancreatic fistulae, which as a rule heal spontaneously. In spite of marked improvement in diagnosis, pyogenic or amebic abscess of the liver still offers poor prognosis. We have analyzed the records of 12 patients with liver abscess in terms of diagnosis and treatment.
Over a 12-year period since 1978, 12 patients with liver abscess were admitted in our department. Eleven were pyogenic and one amebic. There were 9 men and 3 :men. Their average age of the patients was 51.3 years. Diagnosis was correctly made in ii cases (91.7%). The source of infection was biliary in 6 malignant in 3 cases ), cryptogenic in 3, appendicitis, iatrogenic and amebic in one respectively. The abscess was confined to the right lobe in 9 patients, the left lobe in one and both lobes in 2. Eight were single and 4 were multiple. The ccEmonest presenting symptoms were fever, abdcminal pain and hepatcmegaly. Bacteriological data were available in 9 patients. Positive cultures were obtained in 7 cases. The organisas identified were Escherichia coli, klebsiella, serratia and so on.
Treatment included percutaneous abscess drainage in 7 cases, surgical drainage in 5, left hepatic lobectcmy in one and antibiotics alone in one. All patients with benign diseases are currently alive and well except one. Three patients died of malignancy within 95 days after initial treatment.
In conclusion, early diagnosis and appropriate treatment which involves the use of percutaneous drainage and/or transperitoneal surgical drainage with broad spectrum antibiotics remain the prerequisites for cure. IVGTT revealed that at 5 or 7 weeks after transplantation, insulin response had tendency to be delayed, and biphasic reaction was observed, in spite of the slight deterioration of glucose tolerance. Fibrosis and destruction of exocrine pancreas was seen in the post 5 or 7 weeks transplanted pancreas by light microscopy. Electron microscopical examination demonstrated that islets of Langerhans were invaded by the collagen bandle with remarkable diminution of granules of B-cells. Whereas granules of A-cells were well maintained even at 7 weeks after transp lantarion.
In conclusion, this study suggests that slight deterioration of glucose toleranse and low insulin response after segmental pancreatic autotransplantation might be ascribed to the fibrosis of pancreas, decrease of granules of B-cells, and preservation of granules of A-cells. 586 DIAGNOSTIC AND THERAPEUTIC APPROACH OF VERNER-MORRISON SYNDROME.

ON OCCASION OF ONE CASE
A. Kakouri s, S. Karentzos Surg.Clinic Hosp.of "Patisia" and 1st Surg.Unit Gen.Hosp."Asclepieion",Athens The description of Verner-Morrison syndrome was published in 1958. Since then no more than 90-100 new cases have been published. Although the entity is thought to be rare, we believe that there is a real difficulty to understand and diagnose that. Some times the oncoming sickeness is misdiagnosed as ischemic colitis, various types of inflammatory enteritis or malabsorption disease. OUl ca severe loss o hypoka A tumo C.T. a fo rmed se was a female 57 years old with history of sudden onset of diarrhea, colicpain experienced in the lower abdoment and f body weight. Laboratory tests, afterwards, gave us severe lemia and elevated serum vasoactive Intestinal Peptid (V.I.P). r in the tail of pancreas was discovered by means of U.S., nd E.R.C.P. A left pancreatectomy and splenectomy was perby the second of the authors. The recovery was aneventfull (histopathology, radioimmunoassay and anosoimmunoassay of the tumor will be discussed in detail).
Conclusions" Verner-Morrison syndrome is a rare or difficult to diagnose entity. Since diarrhea as "pancreatic cholera", achlorhydria, hypokalemia and hypercalcemia is indicated; the possible diagnosis must be bear in mind. Elevated titles of vasoactive Intestinal Polypeptide (VIP) in serum, U.S. and C.T. can confirm the diagnosis. Left pancreatectomy is the operation of choise in case a single adenoma is founded in the body or tail of the pancreas, while near total pancreatectomy must be performed in the case of multiple tumors, if it is possible. In case of malignancy (40%),a;,palictive therapy be means of antiprostaglandine drugs may be of value. H.20 into the intrahepatic cuct of patients with severe obstructive jaundice. After 5 minutes, the existence of BSP was detected in the peripheral vascular system. In severe obstructive jaundice, the concentration of BSP ranged from 6.% to 11.5% and less than 1% in nonjaundiced patients. In addition, a contrast media, Urographin (45%) was given by intracholedochal injection into the same branch and a series of cholangiograms were taken. This contrast media was then found in the parenchyma and vessels, and then disappeared. Such a finding may indicate the existence of a direct communication between the circulatory blood system and the biliary system in severe obstructive jaundice.
Another thiryt-seven patients were studied on the anatomic ?outes of bile regurgitation by electron microscopy. The aim was to identify the relationship between the clinical results and pathway of bile regurgitation. These patients were classified into 3 groups; recovered, delayed, and fatal. Transcellular, paracellular, direct communication, necrotic hepatocyte and ruptured ductule pathway were found. In the recove.-ed group, the transcellullar pathway was most frequent with an incidence of 54.17%, and a direct convnunication pathway was found to be 54.55% in the fatal group with a significant difference between that of the recovered and delayed group. Longduration bile duct obstruction created bile regurgitation by way of direct communication between the canaliculi and Disse's space, and usually with a poor prognosis, since the serum bilirubin reached the high level of 22.65 rag%. Therefore, it is better to relieve the intrabiliaz pressure as early as possible to prevent the jaundace from producing the irreversible change of hepatic canaliculi and Disse's space. Ultrasonoraphy and computed tomoraphy were carried out directly after admission, and revealed lower common duct obstruction with no space occupying lesion in the pancreas head. Tapering-type obstruction just as the pancreas head cancer was found in the lower common duct on PTCD cholangiography, but not found bile duct injury. Furthermore, microscopic examination of the bile duct on ERCP showed no malignant cell. Neither supers el ective gastroduodenal arteriography nor portoraphy showed an arterial encasement or tumor staining in the pancreas or bile duct. Laparotomy revealed neither any abdominal bleeding nor particular findings of trauma or neoplasm. Therefore, judging the condition to be malignant neoplasm, pancreaticoduodenectomy was done. Histopatholoical examination of the resected tissues revealed a collagen fiber increase, inframatory cell infiltration and hemosiderosis arround the localized lower common duct only, and revealed no significant findings in the duct wall nor pancreas tissue. The goal of this operative technic is to treat the acute pancreatitis.This operative technic includes-The suction of ascites,we then surgicly free the two curvatures of stomach(greater and lesser)from the pyloric sphincter to the mid of the stomach body. After that we go on and separate surgicly the posterior wall of the stomach from the anterior surface of the pancreas.Lastly we wash very carefuly and very well the peritoneal cavity with normal saline. If there is lithiasis of the gallbladder we go on and we do Cholecystectomy. If we find no stones in gallbladder we do Cholecystostomy.On coexistance of jaundice we on with the exploration of Choledochus duct.At the end we drained the suphepatic region(Winslow Foramen) (Koussidis 1988). Patients and methods:We have operated under this operative procedure eleven patients aged from 42-88 year old. Eight of them were women and three were men.All patients had massive necrotic pancreatic and peripancreatic lesions and ascites. Results:Ten of the patients postoperative were in good health.They dismissed from the hospital on the seventh to towenty second postoperative day.The eleventh patient died on the fourth postoperative day, from massive pulmonary embolism.This patient was operated on the phase of anuria which continued after the operation. Conclusion:Patients with acute necrotic pancreatitis can be cured with a single operation,if they go under the operated procedure which we have illustrated above and if they will be operated the right time. Department of Surgery General Hospital of Chios. The common bile duct may be necritized from necrotic Cholecystitis or Cholangitis.The common bile duct also may be obstructed from sclerosive Cholangitis.The above pathologies cause obstructive jaundice.The up today theraputic operative approch is the choledochojejunostomy as in Roux-en-Y. (Braasch and Rossi 1985).Althrough this operative procedure is been used,this may not be able,to be done all the times because the tissue of common bile duct and the tissue of jejunum are very inflammated and in sclerosive cholangitis the truck may lead to stricture formation.Because of the above we have succefully introduced a new operative approch.We have made up a new truck of common bile duct. Technique proccedure-We first do a transduodenal sphincterotomy. Then we Follow up the common bile duct to the common hepatic duct.After this is done we cut the anterior wall of all common bile duct.Then in that cut we put a T tube(Kehr).Such as one side of it to be introduced in to the common hepa.tic duct and the other side is indroduced into the jejunum througt the ampulla of Vater. Then we close up the cut of jejunum and later we cover up the anterior side of T tube with epiploic tissue. (Meissner K,Meiser G.1987).After three months we remove the T tube.We have operated two patients under this operative treatment.One 36 years old woman who had necrotic Cholecystitis-Cholangitis and a man 74 years old who had obstruction from sclerosive Cholangitis.Both the woman four years later, she is doing well and the man a year later is very healthy and very active. Thirteen patients (9.2%) with a median age of 63, underwent resection. One patient is alive with disease 17 months after surgery. Median survival was 12 months; the longest being 40 months.

References
There were no 5-year s patients was 21.9%; 2 years resected, survival was 61.5 The median age (63) fo than the entire cohort (.70) obtained for those resected those not resected, 2, 2, a urvivors. One year survival for all 5.6% and 3 years 3.5%. For those %, 23.1% and 15.4%, respectively. r those undergoing resection was lower The 12-month median survival was significantly longer than for nd 5 months (p 0.05).
Pancreatic ductal carcinoma is a highly lethal clinical entity. Most patients have advanced disease at the time of diagnosis, with a resectability rate of approximately 10%. Resection, if performed with an acceptable mortality rate, appears to offer better palliation than either by-pass or stenting. The only pathological feature of apparent significance in the 5 patients surviving more than 3 years was the well-differentiated histology of the tumor. There s a coutroversy between nvestgators about routine cholocystectomy after hepatic artery ligaton in man. The purpose of this study is to evaluate the macroscopic and mcroscoplc changes of the gallbladder, following hepatic artery llgation in dogs.
In 18 dogs under general anesthesia the arterial blood supply to the liver was obliterated by complete excision of the hepatic artery. The animals were reoperated between the 8th and the 20th postop day and the gallbladder removed and studied macroscopically and by hstoIogcal examination.
The histological changes of the gallbladder wall in 15 out of 17 dogs, were those of acute cholocystitis.
We conclude that simultaneous cholocystectomy is not essentia! n dogs undergoing hepatic artery ligation. In the middle phase (4 to 15 days) six patients (30%) were operated for treatment of pancreatic necrotic tissue, with a mortality rate of 83%. Bacteriological growth in the peripancreatic fluid was observed in 83% of the cases.
In the late phase (after 15 days) seven patients (35%) were operated with a mortality rate of 42% and Bacteriological growth the peripancreatic fluid was observed in 85% of the cases. in The conclusion arrived at by the authors was that the mortality rate in patients submitted to surgery for acute alcoholic necrohemorrhagic pancreatitis is very high, with an overall mortality rate of 65%, and that these appears to be no relationship between the mortality rate and infection of necrotic pancreatic and peripancreatic tissue, especially in the early phase.
The study also concludes that surgery in the late phase presents the lowest mortality rates, in spite of the higher incidence of infection of necrotic pancreatic and peripancreatic tissue. anaesthesia. Before positioning the shunt, all the patients underwent 2 or 3 paracentesis with removal of about 80% of ascitic liquid which was replaced by physiological solution in the order of 50% of the amount of the fluid removed. A patients'thromboelastogram was always obtained nd compared with another one performed after addition of ascitic liquid in the ratio 3"I to the patients'blood; an abnormal variation of tromboelastogram width after addition of this liquid made necessary further diluitions of ascitic fluid, until the results were normal. Such technic standard was used in order to prevent an important complization of the peritoneovenous shunt that is the post shunt coagulopathy. This complication is liable to follow the infusion of ascitic liquid in the circulatory system. In fact recent studies showed that ascitic fluid contains plasminogen activator factor which, in contact with the )lood, causes a defibrination syndrome; this factor is inhibited by epsilonaminocaproic acid. The most common complication observed after the positioning of the shunt was its occlusion expecially at the venous extremity (8 ca es) and at the valve (9 cases). Of the 41 patients, l ave diedof which 3 during the immediate post-oper, ative Period (PSC, hepatic coma, oesophageal haemorrage) and the emaining 9 some months after the procedure (hepatic coma, hesophageal haemorrage, peritonitis). Duplex ultrasound (DUS) is effective in porto-caval shunts, but frequently fails to visualize spleno-renal anastcmoses. CT scanning is unreliable and spin-echo MR imaging is complicated by respiratory and flow-induced phase effects. We ccmpared the findings on sequential two-dimensional magnetic resonance angiography (MRA) to those on DUS in 2 patients with porto-caval and 3 patients with spleno-rental shunts. All patients wre clinically stable. For MRA studies, single-slice flow-ccmpensated images were acquired in nultiple planes and these were postprocessed to form 3-dimensional projection angiograms. Graphic information on flow direction was derived on MR by presaturation bolus tracking. MR studies were carried out on an IT imaging system and DUS examinations wre performed on a cuted sonography unit with color and pulsed Doppler capability. Patency and flow direction in the shunts was established in all 5 patients on MRA. The anastcmoses were clearly visualized in all cases and free rotation of the 3-dimensional imges optimized viewing angle. Both porto-caval shunts were visualized on DUS, but the splenorenal anastomsses were obscured by bowel gas. We conclude that MRA is a robust and effective technique for assessment of shunt patency and flow directionality. For these purposes, it may prove to be the method of choice. Both anastomotic and non-anastomotic biliary strictures following liver transplantation are frequently encountered. Surgical revision is well accepted for anastomotic strictures. These strictures can also be dilated with balloon catheters; however, restenosis is common. The use of permanent biliary endoprosthesis reported for benign and malignant biliary obstruction has not been reported following liver transplantation.
A patient who developed a choledochocholedochostomy anastomotic stricture following liver transplantation was balloon dilated at l, 6, and 8 months post-operatively. The stricture recurred and the choledochocholedochostomy was converted to a choledochoeunostomy. Subsequently, the hepatic artery thrombosed. He presented to our institution 4 months later with hyperbilirubinemia and cholangitis. Cholangiography revealed severe stenosis of the biliary-enteric anastomosis, proximal dilatation of the common hepatic duct which contained multiple stones, and segmental stenosis of the left hepatic duct. Using a percutaneous approach, the strictures were dilated and the stones manipulated into the intestine. Modified Gianturco self-expanding metallic stents were then placed across both the intrahepatic and anastomotic strictures. The patient became asymptomatic and hepatic enzymes and serum bilirubin returned to normal. Cholangiography 3 months later demonstrated wide patency of the previously stenotic segments, no stent migration, and no new strictures. The patient remains asymptomatic with normal laboratories and has had no complications at 6 months.
Modified Gianturco stents may provide long-term relief for post-transplant anastomotic and non-anastomotic biliary strictures and their pathologic sequelae. We compared the influence of hepatic arterial obstruction on the hepatic circulation and tissue metabolism between animals with and without partial arterialization of the portal vein. Mature mongrel dogs were divided into four groups: a group in which the collaterals to the liver were obstructed and the hepatic artery was dissected (hepatic artery ligated group); two groups in which a bypass was grafted between the femoral artery and portal vein, and blood was sent by a Biopump at a rate of 100 or 200 ml/min(lOOml/min and 200 ml/min portal arterialization groups); and a group in which laparotomy alone was performed (sham operation group).
The hepatic artery ligated group showed GO accumulation and and acidosis in hepatic venous blood, reduction of oxygen supply to 60-70% of" normal level, increase of oxygen consumption and marked increase of enzyme escape from the liver.
In the portal arterlalization groups, sufficient oxygenation of portal blood was noted, and the oxygen demand and supply and tissue metabolism were kept approximately normal.
The optimum flow rate for partial arterialization of the portal vein seemed to be about 100 ml/mn (approximately equal to the flow rate through the hepatic artery). At the flow rate of 200 ml/min, the original portal blood flow was reduced, leading to portal hypertension and elevation in GOT and GPT.
These results indicate that ligation and dissection of the hepatic artery during obstruction of collaterals to the liver markedly affects the liver function, and that partial arterialization of the portal vein preserves the liver function during nd in the early period after dissection of the hepatic artery. Needle biopsy of the liver is drone as a routine in the investigation of cases of cholestasis. With the introduction of the Menghini technique described by Mrris et al, the procedure is considered fairly safe. At times it beccmes extensively difficult to differentiate the medical cause of jaundice frcm the surgical cause on clinical grounds alone. In such situations liver biopsy may prove very helpful and obviate the need for ERCP or percutaneous cholangiography. Histcmorphology of the liver in 100 consecutive cases of jaundice was studied. The parameters evaluated wre lobular architecture, morphology of liver cells, Kupffer cells, degree and extent of cblestasis, severity and type of inflammatory infiltrate and changes in the portal triads.
In the ccnmlanication, we report our experience of the diagnostic value of liver biopsy in differentiating medical from surgical cause of jaundice. We also give the spectrum of disease pattern encountered in distinguishing various forms of extra-hepatic biliary cholestatis. Age ranged frc 17 years to 70 years with fmle/male ratio of 2.5/1. Chole6bcblithiasis was encourntered in 80% of patients.

References
Wound infection in tw patients (8%) and residual stone in one patient (4%) wre observed in TSP group. Residual stone was flushed by saline irrigation for one week through T-tube. In CDD group wound infection in two patients (8%) and prolonged biliary leak in one patient (4%) were seen. No other ccmplications or mDrtality re observed in either group. Liver function tests at the end of one mnth were observed in all patients of both groups. Barium cholangiography showed free reflux with pt emptying in all patients with CDD while in 80% of patients with TSP at the end of one mDnth. All patients in TSP group showed free flow of dye, unaffected by I/V morphine on the 10th postoperative day. Follow up period ranged frc fcr mDnths to three years. In this series both the procedures were found to be equally safe and effective methods of drainage of benign biliary tract obstructions.
References: Thomas  iar carcinoma by means oE uitrasound examination, FNA cytoiogy and eIevated aiphaEetoprotein. He had been diagnosed oE aicoholic iiver cirrhosis 20 years beEore and during the iast 2 years he suEEered severai episodes oE ascites. e decided to use a thoracic approach because he presented severai abdominai scars Erom previus iaparotomies Eor choiecistectomy, biie duct expioration and apendectomy and the tumor was iocated in the dome oE right iobe. A right posteroiaterai thoracotomy through the sixth intercostai space was perEormed and the abdominai cavity was entered through the right diaphragm. MobiIization oE the right iobe was done and expioration o the cirrhotic iiver couid not detect the tumor. A weii iimited hepatoma was Iocaiised in segments IV and VIII by means of the intraoperative uitrasound examination and resected under guidance oE the US. The median hepatic vein was dissected and severaI branches Iigated. Hemostasis was achieved with sutures, Tissucoi and coiiagen. An aspirative drainage was pIaced under the diaphragm and another in the thorax. The postoperative course was uneventui and the patient is aiive and weiI without evidence oE tumor recurrence nine months aEter the operation. The pathoIogy report showed a weii diEEerenciated hepatoceiiuiar carcinoma without vascuiar invasion and saEe surgicai margins. We present a Video of a 21 years old male inderwent a laparotomy for abdominaI tumor in aprii 1988.A huge intraperitoneai tumor sticked to the great amentum was found and resected.At the same time a tumor in the right iobe of the Iiver was found.Pathoiogy report was undifferenciated sarcoma.The patient was teated with chemotherapy during 9 months with partiai response at the begining. In march 1989 an increase in the size of the iiver metastases was observed in spite of the chemotherapy.Other metastases outside the iiver were ruied out by means of thoracic,craniaI and abdominai CT scans. A surgicai resection of the iiver metastases was proposed and accepted by the patient.
A right subcostal incision with a midiine extension was performed.A huge tumor occupying the right iobe and segment IV of the iiver was found,a smaii noduie was present aiso inthe inferior face of the ieft iateral segment. No other evidence of tumor was found in the abdominai cavity.First to aii the hepatic hiium was dissected, iigating the right hepatic artery, portai vein and biie duct.A firm tumor adhesion to the right diaphragm obiiged to perform a right thoracotomy and to resect part of the diaphragm.Then, the right hepatic vein as weii as other accesory hepatic veins were dissected and Iigated.A right hepatic trisegmentectomy was performed, transecting the iiver perenchima one cm. to the right of the faiciform ligament.The hemostasis was achieved with sutures, electrocautery and Tissucoi. Then we turned attention to the 3 cm. nodule iocalted in the ieft iaterai segment that was resected. Finaiiy the gastroduodenal artery was dissected and a catheter was placed connected to a subcutaneous reservoir for Iater regionai chemotherapy.
The. specimen showed a huge necrotic tumor occupying aii the right hepatic lobe with a peripherai noduIe in segment IV. We have now treated 8 patients with acute necrotizing pancreatitis in this way. All presented with severe attacks necessitating laparotomy, at which time gross infection, inflammatory exudate or necrotic debris were removed from the peritoneal cavity. No attempt was made to close the abdomen a mersilene mesh incorporating a standard domestic non-metal zip was sewn to the skin and the patient returned to the ITU. No drains were placed. Daily laparotomies were performed thereafter, unzipping the mesh, allowing a thorough lavage using 2-3 litres of warm saline. General anaesthesia was not required, the patients usually only needing intravenous sedation and analgesia. The procedure was repeated until the peritoneal cavity was considered clean and the mesh and zip were then removed about 5 days later. Wounds did not require suturing but closed by a combination of granulation and scarring.
Two patients died of multi-system failure and a further succumbed to an uncontrolled haemorrhage from an erosion into the inferior vena cava. The remaining 5 patients all eventually made a full recovery.
We found the procedures very convenient and they were well tolerated by the patients who were easier to manage as a daily check on the intra-abdominal infection status could be made. Most would certainly have required further formal laparotomies had this technique not been adopted, so thus we saw none of the traditional problems of continually resutured wounds such as tension, necrosis or dehiscence.
We believe that with careful patient selection this particular technique has much to commend it it is safe, well tolerated and provides a daily convenient means of assessment and an opportunity for removal of infective material as it accumulates. Cancer of the bile duct and gall bladder that obstructs the hepatic hilus is often invasive, and its radical operation is generally very difficult. At our institution, laparotomy was performed in 13 patients with cancer of the biliary tract obstructing the hepatic hilus namely 10 with bile duct cancer and 3 with gall bladder cancer, between April, 1983 andDecember, 1989. Resection of the lesion was possible in 7 patients with a resection rate of 53.8%. The surgical procedure was extended left Iobectomy in 2, hilar hepatectomy in 2, pancreatoduodenectomy in 1 with middle bile duct cancer invading the upper bile duct, and extended cholecystectomy with pancreatoduodenectomy in 2 with gall bladder cancer invading the hepatic hilus.
Concerning the remote results of the resected 7 patients, five has survived from 5 years and 4 months, to 5 months, but two died 11 months or one month after operation. Histopathological findings of lymph nodes were negative for metastasis in all patients with cancer of the upper bile duct or the hepatic duct, but metastases to mesoduodenal lymph nodes, lymph nodes posterior to the head of the pancreas, and those around the common hepatic artery were observed in some patients with middle to lower bile duct cancer or gall bladder cancer.
On the basis of these results, we currently perform the active radical operation. In this study, we will present clinicopathologically the choice of operative procedures on cancer of the biliary tract obstructing the hepatic hiluso The advent of the choledochoscope allowd closer examination of the bile duct with better diagnostic and therapeutic yield of CBD exploration. Operative choledochoscopy integrates with traditional CBD exploration adding to its accuracy and reducing the rate of retained stones and overlooked soft tissue lesions in the bile ducts. We perfornd this procedure in 18 patients in whcm CBD explortion was indicated, ii with bile duct obstruction, 2 for bile duct stones, 3 for pancreatic stones and 2 for ampullary stenosis. We had positive findings in all cases; 7 patients bd adenocarcincma of the extrahepatic bile ducts and biopsies were taken under vision, 2 had benign papillary tumcrs in the hepatic ducts and 1 had f ibrosing pancreatitis. 3 patients had bile duct stones and 3 had pancreatic stones. The 2 patients with papillary stenosis, one had patulous CBD with sludge and the other had benign shaggy frondy material remDved successfully.
There was one failure in a case of missed stone (5.5%) but no morbidity or mortality was recorded.
Cholebsccgy proved to be useful in visualization of lesions, observing their nature and extent, providing adequate biopsy mterial. We found that it should be used whenever CBD exploration is indicated. After exploration of the common bile duct the incidence of retained stones found on T-tube cholangiography may be as high as 10%. Accepted methods of removal of such stones include endoscopic sphincterotomy and Dormia basket extraction under fluoroscopic control (Burhenne technique). Both methods require some degree of expertise and may not be freely available in all hospitals. We present a simple method of stone extraction under direct vision that may be performed by general surgeons under simple sedation.
Four patients were referred with retained stones on Ttube cholangiography. The T-tube was left in-situ for six weeks without morbidity. Under intravenous sedation a flexible choledochoscope was inserted down the T-tube tract. Stones were removed under direct vision with a Dormia basket. Co=mon bile duct clearance was achieved in each case. in 1 4 sittings and confirmed with tube cholangiography the next day. Between procedures the tract patency was maintained by insertion of a Foley catheter. No complication from the procedures occurred.
Percutaneous choledochoscopic removal of retained common bile duct stones is an acceptable alternative to recognised methods of stone removal. Although it has been well known that non-absorbable suture material, used for l igation of the cystic duct, may find its way into the bile ducts and act as a nidus for stone formation, surgeons are still using such ligatures. This can occasionally result in serious postoperative problems that one could very easily avoid.
Purpose of this paper is to present three additional cases, where silk sutures used at cholecystectomy resulted in common bile duct stone formation.
On the basis of the above observations the use of absorbable sutures is strongly recommended for cystic duct and cystic artery l igation (Mackie D.B. et al 1973, Larmi T. andSilvennoinen E. 1968). In our Department Polyglactin sutures are used for l igations in the vicinity of bile ducts, although it is known that even absorbable sutures may form a nidus for subsequent common duct stones (Fink D.L., Budd D.C. 1983 Based on the results of evaluation in our patients, the preconditions at present of long survival in patients ith cancer of the pancreatic head seem to be 1) so(negative serosal invasion), 2) rpo(negative invasion to the retroperitoneal tissues) or e(-)(negative invasion in excisional edge) even if rpe(exposed invasion to the retroperitoneal tissues), 3) no lymph node metastasis or metastasis limited to the n group. Especially, though 4 of the 8 patients (50g) had rpe, no cancer invasion as observed in the exposed peripancreatic surfaces, demonstrating histologically curative resection.
This seems to have achieved by extended operation that attaches importance to extensive retroperitoneal dissection and resection of the nerve plexus of the pancreatic head. The therapeutic effects of a new synthetic scavenger made from an ascorbic acid derivative, CV-3611 (AAD) on a CDE-diet induced acute pancreatitis in mice were evaluated and compared with those of superoxide dismutase (SOD). The survival rate was observed in three groups; No treatment (N), Pretreatment (P), and Treatment (T) by the ascorbic acid derivative and by SOD.
The changes of three serum enzyme levels (amylase, lipase, elastase-I) were also measured in three groups by ascorbic acid derivative administration. Changes of plasma and pancreatic tissue concentration of AAD in normal mice were also measured by high performance liquid chromatography (HPLC) following the time course. Plasma concentration of AAD reached a peak level of 0.54 _+ 0.09/z g/ml at 1 hour and gradually decreased in 10 hours after subcutaneous administration. Pancreatic tissue concentration of AAD reached a maximum level of 425 _+ 33 ng/g. tissue at 3 hours and returned to near the non-detectable zone in 12 hours. The survival rate was significantly increased in the Treatment group (P<0.02) by the administration of AAD. The administration of SOD had no significant effect on the survival rate. The increases of three serum enzymes, amylase, lipase, and elastase-I, were significantly reduced at 48 hours in both the Pretreatment and the Treatment groups with AAD. These results indicate that a new synthetic scavenger (AAD), which has been proven to pass through the cell membrane and to have a long half life in plasma and tissue, revealed a remarkable therapeutic effect on the development of acute pancreatitis. These results also suggest that oxygen derived free radicals might play an important role in the development of acute pancreatitis.. This is a retrospective study of 36 out of 73 cases of cholanEitis seen at the University Hospital, Kuala Lumpur, between I80 1986. 21 were male and 15 female. The majority were above 0 years of aEe (17 above 60 years, 12 above 0 years) and most were from the low socio-economic Eroup.
In 25 patients, jaundice, pain in riEht upper abdomen an4 chill were the chief complaints, 16 Ei vin@ history of previous biliary surEery.
The majority were seen within the first week of onset of the disease.
On admission, most patients were Eenerally satisfactory but were found to be jaundiced with abdominal tenderness and fever f between 37 38C. The liver was tender and palpable in 15 patients.
InvestiEations revealed raised Elobulins in 22 patients, alkaline phosphatase in 32, SGPT in 20 and SGOT in 20. The prothrombin times were normal in 26 cases and 6 cases showed impaired renal function. Blood culture was positie in 12 cases and bile culture in 16 cases.
The most useful diaEnostic procedure used was ultrasonoEraphy, done on 29 patients with positive results in 20 cases. P.T.C. Eave the diaEnosis in 10 out of 11 patients. E.R.C.P. was useful in 3 out of 10 cases.
Nineteen patients underwent surEery, 12 treated conservatively, 5 refused operation and further hospital treatment. 13 were operated on emerEency bases and 6 electiely. Cholecystectomy was done on 10 patients, C.B.D. exploration in 17 cases and T-tube insertion in 1 cases. Stones were found in 13 cases. 2 patients had liver real i na.ci es Six patients developed wound infection, had residual stone, developed renal failure, 1 had D.I.V.C. and 1 acute pancreatitis.
There was 1 death. Ultrasonography is a bloodless and reliable procedure for the checking of cholelithiasis and jaundice, but its value declines in the presence of gas in the duodenum or the localization of stones in the distal part of the choledochal duct (Goldberg 1974).
Intravenous cholangiography provides an excellent diagnostic method for imaging the biliary tree anatomy, the presence of stones and any morphologic or functional disturbance caused by them. Limitation of the method is the presence of jaundice (Mujahed 1974, Eckelberg 1970. ERCP is indicated on jaundice or suspicion of pcreatic disease. During a four year period (1986)(1987)(1988)(1989)) 800 patients were operated on for calculi of the biliary tree. The pre-operative diagnosis was established with cholangiography and ultrasound imaging. The purpose of our study was to compare the diagnostic value of these tw procedures in reference to the operative findings. University of Athens, Athens, Greece Thirty-two patients with advanced measurable pancreatic adenocarcinoma were treated with a combination chemotherapy regime. Median age was 58 years. Twenty-three patients were male and 9 female. None had previous chemotherapy or radiation therapy. Treatment included Fluorou-2 racil 600mg/m I.V. days 1,8,29 and 36. Epirubicin 40 mg/ 2 m I.V. day 1 and 29 and Mitomycin-c i0 mc/m 2 I.V. day i. Cycles were repeated every 8 weeks. Partial responses have been noted in 7 patients (21,8%). Median survival from diagnosis was 8.2 months for responders and 5.5 months for non-responders. Toxicity included diarrhea (12%), myelosuppression (45%) and alopecia (82%). Pancreatic adenocarcinoma responds poorly to standard chemotherapy. New, active agents are definitely needed. Although an infrequent disease, gall stone ileus accounts for a significant percentage of bowl obstruction in elderly wonn, who also often had co-existant medical problems (Day & Mrks 1975;Deitz 1986).
Plain films showing air in the bile ducts and a stone changing position may help in the difficult and unclear clinical diagnosis (Ringler 1941). The proper treat is enterolithotcmy alone (Kvist 1979) or the one stage procedure (Van Lindingham 1982).
Between 1978 and 1989 we accepted II cases of gall stone ileus. 72% were women and 90% more than 70 years of age. In 72% the stone was visualized and in 45% air was detected in the bile ducts; 62% undt enterolithDtcmy alone and 38% one stage procedure. We have no ileus recurrence but 18.2% wound infections. The nDrtality rate was 9.9%. Our findings suggest that the one stage procedure is preferred %hen the general condition and the local findings allow. Although endoscopic papillotcmy, transduodenal papilloplasty and several types of bilio-enteric anastonDses are today in use for benign biliary obstruction, early and especially late results of these procedures reveal a wide spectrum of ccmplications.
Side to side choledochoduodenostcmy (CDS) is well documented as a procedure of cice in elderly patients, despite old objections related to the myth of ascending cholangiitis and the sump syndrcme, the fact that lege artis constructed CDS (2,5 cm stoma, absorbable one layer suture) results no early or late ccmplications, led to the use of this type of biliary bypass in young patients and independently of their age.
Twenty-eight patients under the age of 60 (18-57) underwent CDS from January 1986-December 1989. Surgical indications were: Cholecysto+choledoclithiasis, thick walled conmon bile duct, narrowed distal choledochus and/or anpullary stenosis in 19 patients. Recurrent secondary or primary choledocbolithiasis in 4 patients. Intrahepatic rupture of hydatid cysts in 2 patients. Ampullary stricture following endoscopic sphincterotomy in 2 and transduodenal papilloplasty in 1 patient. There was no mortality observed. An anastomDtic leakage dried up within 4 days. All patients were free of abdominal symptoms, cholangiitis, chronic antral gastritis or pancreatitis during follow-up period (6-42 months). X-ray examinations one year postoperatively showed a satisfactory retrograde duodeno-choledochal passage in 22 patients. No stricture of the anastcmosis was observed.
It is concluded that the lege artis choledochoduodenostcmry is a safe and relatively easy procedure with long term satisfactory function, with no mDrtality, low mDrbidity rates and prevention of choledochal obliteration. Ranson's criteria score was 6.4 points for the patients who underwent PPL, and 4.5 points for the remaining.

624
Operation was required at a median of 9.3 days after the onset of symptoms because of non-response to conservative treatment or because of acute abdomen formation. Nine of the patients developed hypovolemic or septic shock and 15 had simple or multiple organ failure. Four of the patients (18.2%) died of noncontrolled multiple organ failure dispite of surgical interventions, intensive supportive therapy and PPL. Necrosectomy is a suitable procedure for all patients with necrotizing pancreatitis. Furthermore in those who developed extended pancreatic and extrapancreatic necrosis with diffuse peritoneal development PPL seems to be a valuable contribution for their survival.

625
BTO 9 2 PALLIATIVE SURGICAL TREATMENT OF PANCREATIC CANCER C. Sperti, C. Pasquali, C. Militello B. Bonadimani, F. Cappellazzo, S. Pedrazzoli, Clinica Chirurgica 1-Padua, Italy Less than 20% of patients with pancreatic carcinoma may have a curative resection. Patients with unresectable cancer of the head of the pancreas nearly always need a palliative biliary by-pass. The role of a routinly performed prophilactic gastroenterostomy at time of initial surgical approach is still disputing. We reviewed our experience of palliative procedures for pancreatic carcinoma in order to evaluate early and late results and the usefulness of gastroenterostomy in such patients.
From 1964 to 1988, 208 patients underwent palliative surgery for cancer of the head (157) and body and the tail (51) of the pancreas. TNM staging of the tumor was II in 31 patients, III in 36, IV in 141 (67.8 %). The most frequent symptoms were jaundice (154), pain (40) and gastric outlet obstruction (14). 154 patients (74 %) underwent biliary by-pass (28 cholecysto-enterostomies and 126 choledoco-enterostomies), associated with gastro enterostomy in 47 cases. 26 had external biliary drainage, 20 had gastro-enterostomy only and 8 other type of procedures. Overall operative morbidity and mortality were 37.5% and 18.7%. In the group of biliary by-pass, morbidity and mortality rates were 37.3% and 15%. 12 patients required a second operation for gastric outlet obstruction, 7 in the early postoperative period and 5 in the late period (range 3-9 months) with 3 operative deaths. Median survival time was 2 months in patients who underwent cholecysto-enter stomy and 6 months after choledoco-enterostom. Relief of jaundice was better after choledoco-enterostomy.
In the group of patients with associated biliary by pass and gastro-enterostomy, morbidity and mortality rates were 38% and 21.2%. Median survival time was 4.2 months. Delayed gastric emptying developed in 18% of patients who had gastroenterostomy at first laparotomy. Biliary by-pass using common bile duct offers the best palliation for jaundiced patients. Gastroenterostomy should be performed on a selective basis only. 626 BTO 9 3 ROLE OF RESECTIONAL SURGERY FOR PANCREATIC CANCER C. Sperti, C. Pasquali, S. Catalini C. Militello, V. Costantino, F. Cappellazzo, S. Pedrazzoli, Clinica Chirurgica 1-Padua, Italy The management and prognosis of pancreatic duct carcinoma remains controversial. There is general agreement that radical resection offers the only chance of cure for patients with pancreatic cancer, and recently mortality and morbidity related to this procedure have been improved in many centers. Aim of this study was to evaluate our experience of resectional procedures for pancreatic cancer and the progress in management of this tumor. Among 406 patients with pancreatic cancer observed in our Department from 1964 to 1988, 84 underwent resective surgery 55 duodeno-pancreatectomy (DP), 13 total pancreatectomy (TP) and 16 left pancreatectomy (LP). 14 patients had vascular resection (7 DP, 6 TP, 1 LP) and 8 p1orus reserving pancreatectomy (7 DP and 1 TP). In the last six years, 17 patients underwent subtotal duodenopancreatectomy (StDP) as the procedure of choice.
Histologic examination showed 83 ductal carcinomas and 3 acinar cell carcinomas. Node metastases were found in 34 patients. The tumor was well differentiated in 50 cases, moderately in 24, poorly in i0. The resection was radical in 72 patients. Overall hospital mortality and urbidity were 14.3% and 42.6%. In the last 8 years hospital mortality.decreased to 3% and resectability rate increased from 16.4% to 34.4%, with no improvement in rate of localized disease. 5-years actuarial survival rate was 14.5% (13.8% after DP, 0% after TP). Survival was found to be related to lynph node status (p< 0.001), degree of differentiation (p< 0.05) and radicalty of resection (p< 0.05). Out of 17 patients who had StDP, operative mortality was 0, and median survival time was 12 months with a good quality of life. After vascular resection median survival time was 8 months. Actually pancreatic resection can be performed with a low acceptable mortality and morbidity rate. Altough long. term survival is a rare event, radical surgery is the procedure of choice for the best palliation of symptoms in patients with pancreatic cancer.  (14) and abdominal pain with weight loss (ii). 7 patients had history of chronic pancreatits (3 with pseudocysts) and 3 underwent laparotomy before admission in our department. 12 patients underwent explorative laparotomy only, 7 biliary bypass and 6 resective surgery (5 duodenopancreatectomy and 1 total pancreatectomy). Histology showed a well fferentiated tumor in 9 patients, moderately in 5, poorly differentiated in i0 and chronic pancreatitis in 2 (false negative). Linpl node metastases were found in 6 cases, liver or peritoneal spread in 12. Operative morbidity and mortality was 23 % and 11.5 % respectively. Actuarial survival rates were 11.5 % at 1 year and 0 % at 2 years, with a median survival of only 3 months. Ductal adenocarcinoma of the pancreas in young patients is rare but is more aggressive than in older patients with an extremely poor survival. Differential diagnosis with chronic pancreatitis is particularly difficult when the tumor is in early stage and 1/5 had an histology of chronic pancreatitis before tumor spread became evident. study revealed data of light microscopical and ultrastructural analysis of hepatic parenchyma after experimental exposure to envirormentally significant agricultural chemicals Nmethylopirolidon and ganm-butyrolacton.
Wistar rats 220-280 gr b.w. were tube fed with a solution of the chemicals mentioned above with a dose of 1/20 LD50 for the total period of 30 days. Samples of hepatic parenchyma were taken ediately after termination and embedded in paraffin and epoxy rasins for light transmission electron microscopy followd by morphcmetry. Serial 5 mkm thickness paraffin sections were ledhematoxylin stained and then prepared for ultrastructural investigation to ccmplete the morphological analysis of hepatic tissues.
Light microscopical investigation showed no difference in structure of hepatic parenchyma of control and exposed animals.
Electron microscopical study in both experimental groups revealed destruction of hepatocytes microvilli, increased vacuolization level of their cytoplasma (p<0.002), reduced Disse space (p< 0.005). Pretty remarkable changes were found in ultrastructure of erythrocytes within S-capillaries of hepatic parenchyma, Nmethylopirolidon as well as ganma-butyrolacton circumstained appearance of ccmplete wash out of the red blood cells matrix.
Multiform skeleton of erythrocytes originated as the result of the process. In this case ultrastructural investigation appeared to be indispensable to state the blood circulation syndrome diagnosis in case of chemically induced hepatic damage. controversly:the evaluation of resectability vades from center to center;the results of an aggressive surgical approach with liver resection did not lead to establish an overall accepted standarised procedure.Treatment by drainage is discussed alternatively because of its lower morbitity and acceptable quality of life by a two-year survival of neady one third of the patients.
Patients: Between July 1st 1982 and January loth 1990 24 patients with high bile duct cancer were treated operatively at the Dept. of Surgery,Technical University Munich. After exploration twelve patients (50%) underwent potentially curative resection, in 5 cases an additional liver resection became necessary to obtain tumor free margins. Reconstruction of the biliary enteric continuity was achieved by a hepaticojejunostomy Roux-en-Y. Eight anastomoses were splinted with tubes. In ten cases the tumor was unresectable because of local tumor spread, twice a palliative resection was performed.
Results: The operative mortality was 14% at 30 days. The median survival time of all 24 patients was 9,3 month (1.5-11month). Nine of the 12 patients with potentially curative resection died because of local tumor recurrence,three after recurrent septic complications.
Conclusion:Curative surgery in hilar cholangiocarcinama seems to be doubtful even in small tumors because of potentially associated tumor growing along perineural lymphatics into the third dimension at a distance from the primary; resective surgery with histologically clear margins to the proximal intrahepatic bileducts should be considered as palliative. The unoperability was assessed in 27 cases conservatively. The remaining cases underwent explorative laparotomy after P.T.B.D.
The Authors consider the results in terms of 30 and 60 days mortality,complications,and particularly quality of life,evalueted by the degree of self-sufficience. They conclude that the percutaneous tech niques allow an early diagnosis both morphological and by exfoliative cytology from P.T.B.D. of malignancy, and that they are the unique extreme therapeutical procedure in those cases where any kind of operation is contrindicated.These procedures allow a reduction in the number of exfoliative laparotomy,that in these cases are often useless and harmful. In according to the type and number risk factors and to the tumor characterizations can preoperatorly be identified different classes of patients.This allow to plan the therapeuti cal strategy and to establish the prognosis more precisely. 634 The presence of endometrial ectopic tissue in the liver is quite rare; only two cases are described in the international literature, and the Authors are now reporting another case they observed.
(1) In a 37-year old female patient complaining of epigastric pain, the C.T. and U.S. showed a neoformation at the level of the 2nd and 3rd liver subsegment, suspected of being an echinococchus cyst owing to its peculiarities. The surgical removal of this cyst, which turned out to be adherent to the diapghragm, involved a left lateral segmentectomy. This benign liver disease is quite rare and very little is known about it. It has not yet been demonstrated whether it is an attempt of remedial response to a parenchymal damage following a vascular arterial anomaly or real neoplasty.(l,4) What we are reasonably sure about is that it does not tend to degenerate and only very seldom gives origin to haemorrages due to spontaneous break.(l,2,3) The investigation methods, such as U.S., C.T. and angiography are often inadequate for diagnostic purposes and biopsy by thin needle does not provide sufficient quantities of tissue to carry out a differential .diagnosis with the  (Marcello and Zegal 1983). We are representing a new case.
The patient 45-year-old woman had been admitted with complaint of epigastric pain radiating to both flanks, and vomiting. She has been given conservative therapy for acute pankreatitis diagnosed on physical examinations and laboratory findings. An epigastric mass was found on the tenth day of her hospital admission. The mass was seen as pseudokidney on ultrasonografic examination. Barium enema disclosed stenosis of the lumen and luminal irregularity of the transvers colon. At laparotomy, three weeks after admission, the transverse colon and its wall were thickened and have a rubbery consistency, and serosal surface had multiple echimotic patches. This complication mimics colonic cancer but colonic stenosis is more commonly reversible. It is postulated that ischemia and pericolic inflamation is the cause of strictures (Hunt and Mildenhall). It would be reasonable to recommend a conservative approach in the majority of cases (Lazarou and Economopoulos 1984). In our patient abdominal mass had dissapeared in two months and pathologic changes on barium enema was improved. Departments of Surgery and *Medicine, univemity of Fiburg, The degree of any inflammatory response can be evaluated by determining the activation of cellular ar plasmatic systems. In previous studies with inflammatory parame in peritonitis, three substances turned out to reflect the severity of the inflammation with a remarkably high accuracy at an early point of the clinical course: Fibrinciptide A as a marker of the activation of the factor XII dependent systems, the C3 split product C3a as a sign of the activation of the cumplement cascade, and the elastase-1 proteinase inhibitor-cumplex as a marker of the activation of leukocytes.
Cut-off levels were calculated for these three parameters which predicted postoperative septic cumplications with a high accuracy so that an activation score frum 0 to 3 was determined.
In a series of 50 consecutive patients with acute pancreatitis the use of that activation score was evaluated prospectively in the monitoring of septic cunlications. In the group which developed clinical sepsis (n=13) i0 patients died and 5 needed more than one operation. A score of 3 was observed in 5 patients on day i, in 9 patients on day 3 and a score of 2 in i0 and 13 patients, respectively.
In the group with severe pancreatitis without sepsis (n=15) no patient died. A score of 3 was reached in 2 patients on day 1 and in 5 patients on day 3, with a score of 2 in 8 and i0 cases. In the group with less severe pancreatitis a score of 3 was never detectable.
Thus the occthTence of clinical sepsis could be predicted with a sensitivity of 69 % and a specificity of 86 % on the third day a admission. Grading the patients according to more than three Ranson's signs, a sensitivity of 92 % and a ificity of 59 % were found in this series. Instltute of Surgery, IKutsK, USSR 16 patients with bile duct carcinoma were Investigated by ultrasound in order to obtain a llver and biliary system assesment. There ages ranged from 5 to 8 years.
The male to female rates was 0:5.
The sonoraphl c findiss were: Intraluminal llypez-ecllosenlc mass without acoustlc shadow, bile ducts amputation, mass involvln the blllary ducts with disturbance of inner contour, bi I lary tree dllataltion, both narrow of dlstal and wide of proximal bile ducts and Increasin the echoenlcity of the flyer parenchlma.
UltrasonoElaphy had considerable precision to flnded the level of the obstaction In the blllay tact and to identify signs of spreadness of desease (distant metastasis, ascltes). Thereby ultasonoEx-aphy is a helpful pocedure to establlsh the px-eopeative diagnosis of blle duct cac +/-noma. Thls simple and non Invaslve method may locate the slte of blllaz'y obstz'uctlon, outllne the tumoz" Itself and also determine the staging of the cancer. Clinical. Materials: Sixty-one consecutive patients with HCC who erwen-t urat-ive -resection through 1970 were studied. Standard major hepatectomy (2 or 3 segments) was done for 15 cirrhotic patients and a limited resection than one segment for 46 cases.
Results: 1)Follow-up examination showed the major resection of cirrhotic liver promoted degeneration of the residual liver, and most of these died from hepatic falure rather than recurrence. There were significant differences in the mortality and survival rates between major hepatectomies and limited resection.
3)Pathologically, encapsulation appears to be complete as tumor grew. Portal vein tumor thrombus(12.5%) and/or satellite tumor (31.2%) were frequent in those wigh larger than 2cm in size.
4)survival rate of the group with small HCC was far better than that of the groups with HCC larger than 2cm(p<0.05).
Conclusion: Early detection of .the tumor without portal vein th'rombus and/or satellite tumor, and an adequate hepatic resection such as subsegmentectomy or segmentectomy are most important for the patient's survival. Several therapeutic modalities, such as peritoneal lavage, cimetidine, fresh frozen plasma, prostoglandins, indomethacin, glukagon, somatostatin, beta-adrenergic agonist drugs, and aprotinin have been used in the treatment of acute pancreatitis. But the mortality rate from acute pancreatitis remains high. Enzymatic autodigestion plays an important role in acute pancreatitis. Intrapancreatic activation of digestive enzymes such as trypsinogen can cause pancreatic damage. It was also suggested that lysosomes and lysosomal acid proteases may be involved in the pathogenesis of acute pancreatitis (Evander and Lindquist). Zinc is an essential trace element for human and animals. Zinc has a stabilizing effect on lysosomal membranes and reduces the liberation of acid hydrolases (Chvapil and Ryan). Aprotinin is a low molecular weight protein and complexes with proteolyti enzymes and results in their inactivation. We induc panereatitis in Mongrel dogs by injecting otolog bile 1 ml/Kg + 20,000 U chemotypdsine into main pancreatic duct. The study was carried out pancreatitis induced 5 groups of dogs, including control and pre and postoperative Zinc Sulphate; only postoperative Zinc Sulphate; pre and postoperative Zinc Sulphate + Aprotinin; postoperative Zinc Sulphate + Aprotinin treatment groups. We determined the degree of pancreatic damage by macroscopic and histopathological changes and biochemical investigations. In this study, therapeutic modalities after initiation of pancreatitis were ineffective. We suggest that pre and postoperative Zinc Sulphate + Aprotinin treatment gave the best results in this model. [RESULTS] i. The duration of the contraction phase (time from the injection to the maximal contraction) was significantly (p<0.05) prolonged by UDCA administration (from 15+2 to 32+4 rain), whereas the maximal contraction after the stimulation was not changed (from 35+7 to 31+4%). Serum total cholic acid concentration was significantly (p<0.05) increased (from 4.6+0.5 to 8.4+1.1 mol/L). Fasting GB area was insignificantly increased (from 14.6+2.0 to 15.4+1.6 cm2). 2. The maximal contraction after the ingestion was significantly (P<0.05) increased by UDCA administration (from 45+8 to 33+ 7%), whereas it appered to be delayed (from 63+22 to 96+22 min). The integrated response of plasma CCK was significantly (p<0.01) greater after the UDCA administration (from 212+126 to 542+165 pmol-180 min/L) with a significantly (p<0.05) higher value at 90 min after the ingestion. Serum total cholic acid concentration was significantly (p<0.05) increased (from 4.3+0.4 to 9.6+1.4 mol/L), whereas fasting GB area was insignificantly increased (from 12.6+ 2.0 to 19.2+3.7 cm2). [CONCLUSION] Chronic administration of UDCA slowed but did not impair exogenously stimulated GB contraction. Endogenously stimulated CCK release and GB contraction were enhanced and appeared to be delayed by UDCA administration. From the beginning of this century,the average human life has gained approximately 25 more years by means of the improvements in medical technology.So,it is guessed that in about 40-50 years in future,the elderly group will be more greater and will arrive nearly 50 milions in general population. In relation the number of operation which will be applied to that group will surely increase. The purpose of this study is to make a statement about the mor. tality and morbidity rates,in patients whom undergone cholecystectomy,over sixties,and to investigate what effects age has for choo lecystectomies.
This study is put out in SSK Ankara Hospital,I.surgery clinic from 1985 to 1989 and involves 511 patients whom undergone cholecystectomy.389 were women(76.13%) and 122 men (23.87%).The mean age was 49(from 16 to 99).All of the diagnosis stand upon the histopathological reports taken after the surgery.

RESULTS
The patients were examined in 3 groups: The numerical differances between the groups are found to be significantely meaningfull.(Student's "t" test) COMMENT It is seen that,the older a patient is at the time of cholecystectomy,the more likely it is for that patient to prevent with anacubiliery complication.Early cholecystectomy decreases the morbidity and mortality rates related with the naturel progression of cholelithiasis. Although non-operative menagement for asemptomatic or mildly semptomatic cholelithiasis has taken increasing attention,we can say that,early cholecystectomy or even a prophylactic application would prevent the morbiditiy,mortality andpostoperative complications of the gall stone disease. Acute pancreatitis is associated in mDst cases in western Europe with the presence of gallstones (Durr 1979). It is also well established that elimination of biliary disease reduces the recurrence frc 75% to less than 10% (Frey 1981). Ranson's signs detenuine the severity and disease mortality (Heiz 1985). Scme authors prefer early surgery (Acosta 1978, Heiz 1985 to prevent pancreatic necrosis, hereas others advocate initial conservative treat followed by elective surgery in the same hospitalization (Kelly 1988).
Between 1978 and 1989 we accepted 58 patients with acute gallstone pancreatitis who underwent emergency (31%) or briefly delayed operations (69%) during the same hospitalization. 17.5% had more than three Ranson's signs. Patients who had an early operation and more than three Ranson's signs had a significant increase in morbidity and nrtality.
We concluded that briefly delayed operations during the same bspitalization can be performed safely after resolution of acute pancreatitis. Acute renal failure is a serious complication of hyperbilirubinemic state. The liver is under hemodynamic and physiopathologic pressure of obstructive lesion in those patients. The paranchimal and functional derangement of liver accompanies to destructive effects of h yperbili rubinemi a.
In this experimental study,CDCA (choledochocaval anastomosis) model is created in 14 Mongrei dogs as described formerly by Green at all and the liver is protected against the cholestatic effects of obstruction.
The microscopical findings Centrlobular fatty degeneration and mimimal cholestasis in ii (78 ).The typical findings of biliary obstruction (Connective tissue increase, edema, proliferation of biliary canalicules,plugs in main biliary tractus,hairy degeration) were not present in any dogs except one.
Liver function tests were in normal ranges in preoperative and postoperative period.
Although this "innocent" liver, the histologic and biochemical findings of "destructed" kidney is found in 8 of this series as present in connected research.
These results suggest that the liver is not so responsible for destructive findings in hyperbilirubinemic state. In gallstone-related acute pancreat.itis the aim of a transduodenal sphincteroplasty is to decompress both,biliary and pancreatic ducts. In our experience, since 1985, among 21 consecutive patients,14(66,6%)underwent a biliary operation within the first week after the admission. Only in one case(4,76%) impacted stone was found and sphincteroplasty was performed. Two patients(9,52%) in whom free residual stones were present, received a bilioenteric anastomosis. In all of the others operated on(52,36%), only a cholecistectomy was performed, with the aim of preventing recurrent migration of gallstones. In chronic alcoholic pancreatitis the drainage of pancreatic duct by section of the ampullary system, can be considered also in cases presenting with most severe parenchimal diseases. Among our 39 patients operated on for chronic alcoholic pancreatitis, only 7(17,9%) underwent a retrograde duct drainage for the rarety of distal segmental obstruction. In none of our 18 cases of biliary obstruction due to enclosement of the bile duct in a fibrotic pancreas, stricture was cus. located in the terminal tr.act of choledo-Conclusions" Transduodenal surgical approach to the ampulla may be useful in selected partients(lO,2%,in direct experience) if submitted to correct indications,deduced from a complete preand peroperatory study. Many factors have been implicated in the pathogenesis of "post stress" cholecystitis,which is a rare pathologic entity of unclear aetiology. Since the first description(Duncan 1844)until 15 years from today,only 258 cases were reported.Recent diagnostic imaging procedures helped to detect the disease and a worldwide spectrum of another 208 cases are reported. (Cornwell 1989) As aetiology remains obscure, pronounced biliary stasis, shock,high viscosity of bile,disturbed hormonal regulation following parenteral nutrition,massive transfusions and endotoxemia,which activate pathways to gallbladder inflammation,regional hypoperfusion in the liver and gallbladder etc. suggested to be involved.
In a 4-year period,January1986-December 1989 eight out of 22 cases of acute cholecystitis were of acalculous form(AAC).Five cases developed among intensive care unit (ICU)patients and another three among multi-injured individuals.The clinical evaluation was rather difficult in all 8 patients(5 men-3 women).The time of onset of the disease varried from 8 to 23 days after trauma and/or operation. The ICU patients were still intubated and the other three under prolonged I.V. hyperalimentation.Dianosis was in two patients delayed and in another two a more fulminant course of the disease caused an early perforation. Emergency cholecystectomy was in all cases achieved. Two patients died because of sepsis.
It has to be pointed out that AAC is a rare phenomenon with fulminant course and high mortality,because exact diagnosis is not easy. As pain is hardly detectable in multi-injured and especially in intubated patients,fever and jaundice may be of diverse origin,lab exams are of secondary value and only repeated ultrasonography and peritoneal lavage may confirm the first clinical thought. This last has to be based on evaluation of predisposing factors rather than to clinical signs. Immediate cholecystectomy is the procedure of choice. Dept. of Surgery,University of Munich,FRG The only curative treatment for proximal bile duct cancer with involvement of both main hepatic ducts is liver transplantation. Most patients do not.. fulfill the requirements for liver transplantation.Our treatment strategy in adequate cases is palliative tumor resection and reconstruction of bile passage by sutureless bilioenteric anastomosis.In 12 patients this therapeutic regimen was followed,in 5 patients it was combined with intraluminal and percutaneous radiotherapy.One patient died of cardiac failure,no patient showed life-threatening complications,although the majority of patients exhibited serious operative risk-factors.Our treatment led to an effective decompression of the biliary system in 7 patients.2 patients exhibited a delayed decrease Of serum bilirubin and two patients did not have any benefit from this procedure.Analysis of tumor characteristics showed that this aggressive approach leads to effective palliation in selected cases,where the tumor mass can be reduced by surgical means to microscopic residual tumor.Lymph node metas tases or involvement of other organs do not influence the effect of operation.Survival times of our series compare favourably to survival after liver transplantation.Moreover our approach offers a reasonable quality of life after operation without long term drains. Pancreatic fistula is the mst dangerous ccmplication of pancreaticoduodenectcmy. In recent 5 years, pancreaticoduodenectomies without pancreatic fistula had been performed by us for 25 cases of pancreatic cancers or carcincmas of Vater' s ampul la.
Our technique was as follows: dissecting the pancreatic duct about 1 cm during transecting the pancreas; inserting a I0 cm long silicon tube with 3 or 4 side holes into the distal pancreatic duct, the diameter of the tube was similar to that of the dilated pancreatic duct; suturing the pancreatic duct orifice and ligating it to the silicon tube with a I/0 silk; dividing the pancreatic stump about 2 cm ben the pancreas and the splenic vein; making the end-to-end pancreaticoduodenostcmy with two layer silk sutures by invaginating the pancreatic stuap into the jejunal lumen (as a sleeve). About 8-10 cm distal to the pancreaticojejunostomy endto-side choledochojejunostcmy using a single layer suture was made, generally without T-tube drainage. About 35-40 cm distal to the second anastcmosis end-to-side gastrojejunostcmy was made. Sometimes a jejunostcmy with a silicon catheter as 0.3 cm in diameter was made for preparing postoperative enteric nutrition. Two abdominal drains were placed under the first and the second anastcmosis respectively for 8-9 days after operation. By using the above procedure, there re no pancreatic fistula and biliary fistula in our series. The authors believe that this surgical technique could successfully prevent the dreaded lication of pancreatic fistula in pancreaticoduodenectcmy by invaginating the pancreatic stump into the len of jejunum well.