Pancreatic cystic neoplasms are uncommon, but it is important to differentiate them from pseudocysts and ductal adenocarcinoma. A retrospective review was performed to determine distinguishing characteristics and optimal treatment. In 51 patients operated on between 1981 and 1994 at a referral center, the following cystic neoplasms were found: 20 serous cystadenomas, 10 mucinous cystadenomas, 11 mucinous cystadenocarcinomas, five cases of mucinous ducal ectasia, and five papillary cystic neoplasms. Both mucinous ductal ectasia and papillary cystic neoplasms had distinguishing features when compared to other cystic neoplasms. Mucinous ductal ectasia was seen only in men, presented with typical symptoms, and had distinctive features on endoscopic retrograde cholangiopancreatography. Papillary cystic neoplasms occurred in young women (mean age 31 years) and were larger (mean 10.3 cm). Mucinous tumors were always symptomatic, whereas 55% of serous tumors were asymptomatic (P <0.001). The overall rate of resectability was 80%, and there was one operative death (2 %). Intraoperative biopsy was diagnostic in 18 (78%) of 23 cases. An actuarial 5-year survival of 52% was found for resected mucinous cystadenocysticneoplasms.

Bile duct injuries are a serious complication of cholecystectomy Laparoscopic cholecystectomies (LC) were originally associated with an increased incidence of injuries Patients referred to a tertiary center were reviewed to assess the trends in the number, presentation, and management Seventy-three patients were referred over a 6-year period with a maximum of 17 patients referred in 1992, but the number has not declined substantially over time The persistent number of referrals is a consequence of ongoing injuries One third of injuries were diagnosed at LC, and the use of cholangiography has not mcreased The number of cystic duct leaks has not decreased and they represent 25% of all cases The level of injury has remained unchanged with Bismuth types I and II in 3 7% and types III and IV in 38% Excluding patients with cystic duct leaks, 58% were referred after a failed ductal repair Definitive treatment with biliary stenting was successful in 37%, and 34 patients (47%) required a bihary-entenc anastomosis Complications occurred in 18 patients (25%) including seven with postoperative stricture or cholangins No biliary reoperations have been performed at a mean follow-up of 36 months

An accurate serologic measure of hepatic function would be clinically useful in selecting donors for liver transplantation. An experimental model that incorporates varying lengths of total hepatic warm ischemia with reperfusion injury was utilized to compare serologic parameters and mitochondrial performance of oxidative phosphorylation in predicting hepatocellular injury. Monoethylglycinexylidide (MEGX) formation following bolus intravenous lidocaine injection was found to be significantly decreased (P < 0.0001) at all periods of ischemia when compared to that in nonischemic controls. A serum MEGX level of <50 μg/liter suggested severe hepatic damage. No correlation was found between MEGX level and liver viability as measured by animal survival. Serum transaminase (AST and ALT) levels demonstrated progressive, nonsignificant elevations with increasing length of ischemia (P = 0.0779 at the maximum ischemic time). Polarographic measurements of mitochondrial oxidative phosphorylation did not reveal a significant alteration in subcellular metabolism with prolonged ischemic time. These data highlight the comparative sensitivity of MEGX formation as an early quantitative measurement of hepatocellular injury during warm ischemia, although it was not predictive of organ viability.

Background. This retrospective study compared psychosocial adjustment, body image, and sexual function in women who had either breast conservation or reconstruction for early stage disease. Methods. Questionnaires were completed at a mean of 4 years after surgery by 72 women who had partial mastectomy and 146 women who had immediate breast reconstruction after mastectomy. Results. In general, fewer than 20% of women reported poor adjustment on the domains measured. The two groups did not differ in overall psychosocial adjustment to illness, body image, or satisfaction with relationships or sexual life. There was a specific advantage of partial mastectomy over breast reconstruction in terms of maintaining pleasure and frequency of breast caressing during sexual activity. Women who had undergone chemotherapy had more sexual dysfunction, poorer body image, and more psychological distress. Hormonal therapy and radiation therapy, however, did not measurably affect quality of life. Factors predictive of greater psychosocial distress included a troubled marriage, a poor body image, sexual dissatisfaction, less education, and treatment with chemotherapy. Conclusions. The choice of local treatment had little psychosexual impact, whereas chemotherapy was associated with long term impairments.

This five-volume third edition ofShackelford's Surgery of the Alimentary Tracthas again been edited by George D. Zuidema, MD, with the help of coeditors Mark B. Orringer, MD, Wallace P. Ritchie, Jr, MD, PhD, Jeremiah G. Turcotte, MD, Robert E. Condon, MD, and Lloyd M. Nyhus, MD. They have splendidly updated this classic work. Under Zuidema's general editorship, each of the coeditors was responsible for one of the five volumes, and they have outstanding surgeons to write the various chapters within each volume. This is truly a monumental work, running to 2660 pages. The volumes are attractively bound and handsomely produced on quality paper. The text is clear throughout, well organized, and replete with photographs, line drawings, roentgenographic reproductions, tables, and excellent black-and-white illustrations. Photographs and figures are in their appropriate places in the text and are nicely distributed. The illustrations are clear and very well done. Each volume

(1991) PMN-Elastase in comparison with CRP, antiproteas and LDH as indicators of necrosis in human acute pancreatitis. Pancreatogastrostomy: A safe drainage procedure after pancreatoduodenectomy. The purpose of this study was to evaluate the role of pancreaticogastrostomy as an alternative method of restoring pancreaticointestinal continuity after pancreatico-duodenectomy. Since 1975, 45 patients have undergone pancreaticogastrostomy after pancreaticoduodenectomy at our institution. Pancreaticoduodenectomy was performed for pancreatic carcinoma (24 patients), ampullary carcinoma (8 patients), duodenal carcinoma (4 patients), common bile duct carcinoma (4 patients), pancreatic islet cell carcinoma (1 patient), trauma (1 patient), extensive colon carcinoma (1 patient), chronic pancreatitis (1 patient), and gastroduodenal artery aneurysm (1 patient). There was one operative death, for an overall operative mortality rate of 2%, and seven patients had major postoperative complications, for an overall morbidity rate of 15%. No pancreatic anastomotic leaks or other complications related to the pancreaticogastrostomy occurred. Twenty-four patients have died of recurrent carcinoma, with a mean survival of 25 months (range, 5 to 66 months), and 20 patients are alive and well, with a mean follow-up of 27 months (range, 2 to 106 months). Eight of these patients are alive 2 or more years after operation and four do not have exocrine pancreatic insufficiency. This experience confirms that pancreaticogastrostomy is a safe method of pancreatic drainage after pancreaticoduodenectomy and suggests that it may have technical advantages and therefore merits more widespread application.

Gastric emptying of solids is abnormally slow after vagotomy. To determine whether it was possible to accelerate emptying by electrical stimulation either of the gastric wall directly or of a "foreign" nerve brought in to reinnervate the stomach, eight dogs underwent truncal vagotomy (TV); five of the dogs received intercostal nerve muscle pedicle (NMP) implants. Gastric atony was demonstrated postoperatively in all animals up to 4 months later by means of radiological contrast studies. After allowing time for neurotization to occur (mean 78 days), the cervical vagi were stimulated to confirm that TV was complete. Gastric peristalsis, intraluminal pressures, and emptying were assessed during stimulation of the NMPs and of the gastric wall, followed by sacrifice for histologic study. Neither reinnervation alone nor stimulation of the NMPs improved emptying. Although viable somatic nerve was found in the gastric wall, nerve sprouting was not. By contrast, stimulation of the gastric wall with trains of pulses (20 Hz, 2-10 ms, 2-5 mA) evoked peristalsis in all animals. We conclude that somatic nerve tissue cannot produce functional reinnervation of a visceral organ; however, direct muscular stimulation can accelerate gastric emptying after TV.

When a striated muscle becomes paralyzed, not only its motor function, but its sensory innervation may be Impaired. Methods of rehabilitation have previously focused only on motor innervation, although striated muscles are submitted to self‐regulation of length and tension. Indeed, reinnervated muscle may not contract appropriately unless sensory information is available, nor is it known whether sensory receptors are included in the reinnervation process. We hypothesized that the myotatic reflex (MR) would be absent in the event these sensory organs are not reinnervated, and that an artificial myotatic reflex (AMR) would be useful in reestablishing fine motor control. The strap muscles were exposed in six anesthetized rabbits. The MR was verified by stretching an intact sternohyoid muscle. Next, loss of the reflex was documented after the ipsllateral ansa hypoglossl was divided, and a crossover nerve‐muscle pedicle (NMP) was brought In from the opposite sternothyroid. After 3 months, the MR was still absent; however, stretch of the contralateral sternohyoid produced a reflex response on the reinnervated side. A strain gauge sutured to the reinnervated muscle was linked to an electronic modulator so that stretch induced electric stimulation of the NMP and contraction (the AMR). We conclude that (1) proprioception is not reestablished in the reinnervated muscle; (2) by contrast, sensory Information from the muscle of origin of the NMP Is conveyed to the reinnervated side; and (3) the AMR offers promise toward more sophisticated control of paralyzed (I.e., facial, laryngeal) musculature.

Carcinoma of the periampullary region continues to be a challenging problem. The incidence of these tumours, especially adenocarcinoma of the pancreas, has increased steadily over the last 20 years. In spite of better diagnostic techniques, the long-term survival for patients with these tumours has remained relatively unchanged. Total pancreatectomy and regional pancreatectomy have not demonstrated a survival advantage superior to that of pancreatoduodenectomy. Especially for pancreatic carcinoma, earlier diagnosis and effective adjuvant therapy are necessary. Finally, local excision of small ampullary carcinomas in high-risk surgical patients offers survival rates comparable to those of a major resection.

Records of 32 patients with 34 villous and tubulovillous adenomas of the duodenum, treated at the Cleveland Clinic over the past 21 years, were reviewed. Twenty-two patients (69%) had complete resection of the adenoma; the incidence of malignancy was 47%. Five patients underwent a Whipple procedure; 4 patients had segmental resection of the duodenum; 12 had wide local excision of the adenoma; 1 had both a segmental resection and a local excision for two separate adenomas; and 5 patients had endoscopic excision alone. The remaining five patients underwent exploratory laparotomy alone or with palliative bypass procedures. A 28% recurrence rate was observed, all of these after segmental resection, local excision, or endoscopic excision. The highest recurrence rate was associated with local excision. The 2− and 5-year survival rates for patients with adenomas containing invasive cancer were 22% and 0%, respectively, compared to 87% and 87%, respectively, for benign adenomas (including those with carcinoma in situ). Twenty-two per cent of patients had intestinal polyposis syndromes. Duodenal adenomas were diagnosed a mean of 17 years after colectomy for polyposis, indicating the need for continued surveillance in these patients.

This book is written by three surgeons from the Moscow Medical Institute and has been translated from Russian into English. The book presents an encyclopedic review of the subject of benign strictures of the bile ducts. The writing throughout is somewhat wordy and nonobjective. The book begins in a rather unsophisticated way with a review of the terminology and classification of various types of bile duct strictures. These have been classified by the authors according to their etiology and by the level of the ductal lesion, degree of narrowing, extent of the stricture, and clinical course of the patient. Benign posttraumatic strictures, strictures of previous biliary anastomoses, secondary inflammatory strictures from other lesions, and primary sclerosing cholangitis are all covered. Several chapters are devoted to the causes of strictures, their clinical manifestations, methods of diagnosis, preparing the patient for surgery, principles of surgery for bile duct strictures, operative techniques of

Prophylactic cholecystectomy has been recommended in patients who have diabetes and silent gallstones because of the reports of increased mortality resulting from acute cholecystitis in such patients. To assess recent mortality rates, we reviewed the course of acute cholecystitis in patients hospitalized between 1960 and 1981 at one hospital. Death occurred in 3 of 46 patients with diabetes and in 7 of 263 patients without the disease (p = 0.55). The age-adjusted estimate of the relative risk for death was 2.2 (95% confidence interval, 0.5 to 9.4) for diabetic compared with nondiabetic patients. All 3 diabetic patients who died had been diagnosed as having diabetes within 5 years of death, and only one had been taking insulin. Patients who had elevated blood urea nitrogen levels (greater than 20 mg/dL) were found to have an increased mortality rate when compared with patients with normal levels (27% compared with 2%; p less than 0.001). Results were similar for the outcome of serious complications. These results suggest the need for reconsideration of the recommendation for prophylactic cholecystectomy in diabetic patients with silent gallstones.

This atlas focuses on a selected group of "complicated and difficult general surgical procedures," each one described by a surgeon who has either perfected the operation or who is noted for his experience in its performance. Each author introduces the operation with several brief paragraphs on its indications, utilization, or both, describes the technique of the operative procedure in a stepwise fashion, discusses the complications and alternatives to the operation described, and adds final comments as to its success or its role in the surgical armamentarium. The atlas has been prepared and edited by Dr Martin Litwin who has contributed one procedure to it, pancreaticoduodenectomy (Whipple's operation). The atlas contains 36 operative procedures, 15 of which relate to the esophagus and stomach; seven to the liver, biliary tract, and spleen; six to the pancreas; three to the small intestine; and five to the colon. The book is large, the illustrations