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Background: When esophagocardiomyotomy (ECM) is performed for achalasia, a complementary antireflux procedure of the surgeon's choice is usually performed to minimize postoperative gastroesophageal reflux. This retrospective analysis describes patients after laparoscopic ECM, most of whom had a modified Dor fundoplication., Methods: Between 1994 and 2001, 81 patients with achalasia of the esophagus had laparoscopic ECM. We have previously described the use of intraoperative endoscopy to verify completion of ECM in a cohort of 48 patients who had either Toupet fundoplication (n = 25) or floppy Dor fundoplication (n = 23). Since then floppy Dor fundoplication has been the preferred antireflux procedure for ease of performance and safety reasons. This article describes the floppy Dor fundoplication as we have performed it since 1997, anchoring the wrap to both crura of the hiatus. In addition, the anterior gastric wall is sutured to the anterior rim of the esophageal hiatus, avoiding creation of the paraesophageal hernia that occurs if the gastric wall abuts the entire the length of a long ECM., Results: During the 1- to 70-month follow up period (mean 45 months), patients who were symptomatic were evaluated by radiographic, manometric, or endoscopic methods; pH studies were not done systematically. The 70% of patients who could be evaluated had postoperative quality of life and symptom assessment interviews that revealed willingness to repeat the operation. Overall satisfaction was high (8.4/10 where 10 is perfect); moderate dysphagia was seen in 11 (16%) 3 to 16 months postoperatively, but patients reverted to a satisfaction score of 8.2 after endoscopic dilation. Occasional heartburn was present in 15 (26%) patients with regular, 5-use proton pump inhibitors (PPI), including 1 with Barrett's esophagus. Others use these medications for gastric disorders. No patient has had cancer of the esophagus develop, but endoscopic surveillance has been inconstant., Conclusions: Swallowing was improved in patients without sigmoid esophagus and overall satisfaction was high. New-onset heartburn is an unpredictable problem that can be treated in most patients. Endoscopic dilatation may be required at intervals after ECM-fundoplication for bridging fibrosis at the cardia, but has not required reoperation, as a rule. Laparoscopic ECM is an attractive operation for achalasia.

Lymphadenectomy including second-echelon lymph nodes (D2 resection) for gastric cancer has not been widely adopted partly as a result of a reported increase in operative morbidity and mortality. In the present study we examined the operative risk of D2 resection in a public teaching hospital. From 1995 to 1998, 57 patients underwent exploratory laparotomy for gastric neoplasm: nine with curative D2 resection (Group I), 17 with curative but less than D2 resection (Group II), 16 with palliative resection (Group III), and 15 with no resection (Group IV). Among the four groups, patients with curative D2 resection (Group I) were older and had increased operative time and estimated blood loss, but their need for blood transfusion, the operative morbidity and mortality, and the mean hospital stay were not increased. In contrast, those patients with palliative resection (Group III) had the highest morbidity among all groups, the only fatality, and prolonged hospital stay. Therefore, curative D2 resection can be performed safely even with significant resident involvement. The advanced patient age or the extensive dissection does not increase its surgical risk. Hence, D2 dissection should be considered whenever curative resection is feasible because it allows accurate staging with the added benefit of possible improvement in patient survival.

Serum amylase and lipase elevation has been observed in trauma patients and patients with traumatic intracranial bleeding. However, the causes of this elevation have not been clearly elucidated. A further question remains as to whether other intracranial events are associated with such enzyme elevation as well. We retrospectively reviewed 75 patients consecutively admitted to Cook County Hospital Neurosurgical Intensive Care Unit over a 3-month period for trauma, infection, tumor, or other space-occupying lesions with an unstable condition or neurological deficit. Eleven patients (15%) had elevated amylase and lipase levels. The patients were divided into two groups: Group I (n = 64) had normal and Group II (n = 11) had raised amylase and lipase levels [amylase 402 +/- 444 U/L with normal < or = 125 U/L and lipase 474 +/- 313 U/L with normal < or = 55 U/L]. All Group II patients suffered an intracranial event. Twenty-four Group I (38%) and 10 Group II (91%) patients required craniotomy (P < 0.01). No patients had clinical or radiographic evidence of pancreatitis. In summary, intracranial events are associated with serum amylase and lipase elevation probably through centrally activated pathways. Because of the lack of diagnostic value, routine pancreatic enzyme monitoring should not be performed in this patient population.

Patients with peptic ulcer occasionally develop complications that require surgical intervention, despite the advances in medical treatment and changes in the natural history of disease. The clinical surgeon must make a decision about performing "selective vagotomy antrectomy versus highly selective vagotomy," based on the information discussed herein. The goals for operative treatment remain safe correction of the presenting problem, avoidance of perioperative morbidity and mortality, and freedom from disabling postoperative side effects. This paper addresses broad aspects of the details of surgical interventions; because most operative procedures are performed in urgent circumstances in patients who often have a variety of conditions, it is not surprising that there is no best operation suited to every complication of ulcer.

The myotomy performed for achalasia of the esophagus should divide all of the constricting, diseased muscular elements that obstruct the esophagogastric junction (EGJ). Whether the disease process includes proximal gastric as well as esophageal components is as yet unclear, but anatomic evidence complemented by clinical data suggest that the disease process does not end at the evanescent and poorly defined EGJ. Clinical reports from enthusiastic proponents of a particular operative approach for achalasia have not been illuminating in this regard, because all patients are improved to some degree post-operatively, and there are no objective parametric standards for the evaluation of swallowing function. This study reports a series of patients in whom endoscopic viewing was used to judge the adequacy of myotomy after 'esophageal' myotomy. The question posed by this study was, 'Does esophageal myotomy remove all constricting elements at the gastroesophageal junction?' Laparoscopic myotomy was performed in 48 patients with a diagnosis of achalasia; these patients are the most recent in a total cohort of 72 patients operated upon for achalasia during the past 20 years. Myotomy was begun on the esophagus, and extended to the esophagogastric junction; anatomic landmarks, including the appearance of submucosal veins, guided the initial dissection. Intraoperative endoscopy was then performed to determine whether there was residual constriction of the channel between the esophagus and stomach; if so, myotomy was extended onto the gastric cardia until visual evidence of obstruction had disappeared. All patients had either Toupet fundoplication or Dor fundoplication after myotomy. There were obvious constricting elements distal to the gastroesophageal junction in 90% of the patients. These patients required extension of the myotomy onto the stomach for an average of 15 mm. All but one patient had improved swallowing post-operatively. Eight patients required 'stretch' of the distal esophagus/cardia within the first year post-operatively; one patient was reoperated for fibrous scar obstruction of the distal esophagus. Esophageal myotomy limited to the esophageal muscle does not remove all constricting elements at the gastroesophageal junction; as a result, the extended myotomy must be complemented by an antireflux procedure during operations for achalasia.

Background: Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial., Methods: Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30)., Results: At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups., Conclusion: Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.

The cause of foregut symptoms is often quite uncertain until a comprehensive evaluation has been performed. The critical elements of this evaluation include historic, radiographic, endoscopic, and physiologic data, and most importantly, the insight of a mature diagnostician. Patients who are not evaluated in a comprehensive way are at risk for serious postoperative problems; surgeons who perform interventions without appropriate diagnostic support may have to deal with these unhappy patients. In the long run, a complete workup provides the guidance for treatment and is cost-effective.

Background: The unexpected intraoperative finding of a cancerous gallbladder has become particularly problematic, because cancer recurs rapidly after laparoscopic cholecystectomy. It would be desirable to identify the patients of greatest risk for gallbladder cancer before operation. After several elderly patients presenting with acute cholecystitis were found to have gallbladder cancer, we performed the following study., Methods: Records of patients (60 years of age or older, 1987 to 1995) with an admitting diagnosis of acute cholecystitis and symptoms including right upper quadrant pain, nausea, vomiting, fever, and leukocytosis were reviewed., Results: Eighty patients were included in the study. Carcinoma involving the gallbladder was found in seven patients; six had primary and one had metastatic carcinoma. The 73 patients without cancer underwent cholecystectomy. The differences between the noncancer and cancer patients included age (68 +/- 7 versus 74 +/- 8 years, p < 0.05), total bilirubin (mg/dl, 1.5 +/- 1.5 versus 3.7 +/- 3.4, p < 0.01), alkaline phosphatase (IU/L, 179 +/- 132 versus 369 +/- 226, p < 0.01), and aspartate aminotransferase (IU/L, 77 +/- 93 versus 158 +/- 157, p < 0.05)., Conclusions: Additional work-up and open cholecystectomy should be considered in elderly patients presenting with apparent acute cholecystitis, especially when liver functions are abnormal.

Cholestasis is a common finding in patients with acquired immunodeficiency syndrome. The underlying causes may be related to intrahepatic processes, cholecystitis, papillary stenosis, or sclerosing cholangitis. Published reports of hepatobiliary diseases in patients with acquired immunodeficiency syndrome are reviewed. The etiological factors are considered, and available therapeutic approaches are discussed. Hepatic causes of cholestasis indicate poor prognosis, and effective treatments are not yet available. Cholecystitis, often acalculous in origin, remains a surgical disease. Endoscopic sphincterotomy appears to give good results in the treatment of papillary stenosis. Although a standard approach to sclerosing cholangitis has not been established, a trial of appropriate antibiotics may be beneficial. Frequently, the cause of cholestasis is multifactorial in these patients; thus, a coherent therapeutic approach is essential for optimal clinical results.

Background: The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of "selective" vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae., Methods: In 1957 the experimental basis for "highly" selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves ("extended" HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers., Results: HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare., Conclusions: HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or life-threatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.

Multicentric adenocarcinomas of the midgut have not been described; even multiple adenocarcinomas limited to the small intestine are extremely uncommon, with only 14 cases reported in the literature. We report a case of multicentric synchronous involvement of the entire midgut with adenocarcinoma in a 52-yr-old Polish woman who had more than 30 lesions extending from duodenum to mid-transverse colon. There was no family history of cancer. Preoperative evaluation and intraoperative exploration were negative for primary malignancy of the lungs, breasts, ovaries, pancreas, and other parts of the gastrointestinal tract. Results of histopathological examination, immunohistochemical staining, and ras mutational analysis of the lesions uniformly support the diagnosis of multicentric poorly differentiated adenocarcinoma. The cause for this unusual presentation is unknown, although sporadic genetic alteration(s) of oncogene(s) might have been the precipitating event.

Background: Gluconeogenic activity is reduced during starvation. However, it is less clear whether the utilization of gluconeogenic substrates is diminished with mild but prolonged diet restriction and, if so, whether there are intrinsic changes in the gluconeogenic pathway. We examined gluconeogenesis in the livers of diet-restricted rats with 13C nuclear magnetic resonance (NMR) spectroscopy., Methods: Fischer 344 rats were given 88% (DR group) of what was consumed by the weight-matched ad libitum-fed normal rats (CL group). At the end of 5 weeks, the removed livers were perfused with [3-13C] alanine while 13C NMR spectroscopy was performed., Results: The final body and liver weights were the same for the two groups. In DR rats, both intrahepatic [3-13C] alanine and metabolites generated via pyruvate and oxaloacetate, including aspartate and carbamoyl aspartate, appeared in significantly reduced amounts. There was also marked diminution in the production of glucose., Conclusions: In the livers of DR rats, alanine uptake through System A transport, the fluxes through pyruvate carboxylase, the biosynthesis of pyrimidine nucleotides, and the production of glucose from alanine were all significantly decreased with mild intake restriction. Attenuated protein synthesis in the liver of diet-restricted animals may be the cause for this decreased utilization of alanine for gluconeogenesis.

Computerized axial manometry (CAM) of the lower esophagus measures squeeze pressure at multiple points in each segment of the lower esophageal sphincter (LES), calculates several unique parameters of LES function, and constructs a 3-D display of the LES. Whether parameters derived from CAM, such as the radial mean pressure (LESrmp), Asymmetry (Asym), and Vector Volume (VV), have relevance to function of the LES remains undefined. This study compares the results of CAM in patients with gastroesophageal reflux disease (GERD) and controls. There were 54 patients with GERD and 21 volunteers; all underwent CAM as part of their evaluation; GERD was defined by clinical and endoscopic examinations, and all patients had abnormal 24-hour pH tests. Statistical evaluation was performed. The LESrmp and the Vector Volume were significantly correlated in both groups of patients and differed significantly in both. Asymmetry of the LES was a significant negative factor in LES strength as shown by VV and LESrmp. Asymmetry alone, however, did not show a strong correlation with reflux. Asymmetry is indirectly correlated with the major determinants of LES strength; in patients with low VV, asymmetry might be a critical factor. When a high VV is present, asymmetry has no particular relevance. CAM provides invaluable measurements of the LES.

Background: Effective surgical treatments for achalasia of the esophagus facilitate swallowing by division of muscles that fail to relax normally during swallowing. If esophagocardiomyotomy is performed, a complementary antireflux procedure is mandatory to prevent postoperative gastroesophageal reflux. We evaluated patients who had undergone a circumferential antireflux procedure after esophagocardiomyotomy to determine the effects of this procedure in patients with an aperistaltic esophagus., Methods: During the past 15 years we treated 94 patients with achalasia by use of pneumatic dilation (66), esophageal myotomy (19), or esophagocardiomyotomy with floppy Nissen fundoplication (24). Achalasia was defined by radiographic and manometric criteria until 1986 when computerized axial manometry of the esophagus was initiated, providing information about the three-dimensional contour and "volume" of the lower esophageal sphincter in addition to the usual manometric data., Results: Dysphagia was effectively relieved in all, and neither postoperative reflux nor esophageal obstruction was observed after esophagocardiomyotomy followed by floppy Nissen fundoplication. The measured lower esophageal sphincter pressures and sphincter volume were markedly reduced., Conclusions: Esophagocardiomyotomy with floppy Nissen fundoplication is an effective treatment for achalasia; clinical evidence of obstruction of the esophagus was not seen, and manometric data were typical of a weakened sphincter.

The evaluation and treatment of patients after operations on the foregut is a challenge for physicians and surgeons. The early postoperative period is an especially important interval because the very survival of the patient as well as the success of the surgical intervention depends on the correct interpretation of the presenting complaints. In all cases, a thoughtful and systematic approach allows physicians and surgeons to identify the causes and best remedies of these challenging problems.

Sixty-five consecutive, locally advanced esophageal cancer patients were treated by the West Side Medical Center Esophageal Service at the Cook County and University of Illinois hospitals. Each patient was prospectively evaluated with multiple endoscopies including esophagogastroduodenoscopy, bronchoscopy, nasopharyngoscopy, and laryngoscopy. Twenty-four patients (37%) had endoscopic findings that significantly altered therapeutic regimens. Patients identified as having an obvious or impending esophageal fistula or poor performance status were treated in a palliative fashion. Forty (61.5%) patients were considered candidates for treatment with multimodal therapy which included radiation, chemotherapy, and surgery. There was a response rate of 82.5% and a 1-year disease-free survival of 88.9% which was statistically significant when compared to the other patient treatment groups. These data illustrate the necessity of multiple endoscopic evaluation of locally advanced esophageal cancer patients for stratification into appropriate treatment groups. Aggressive treatment afforded selected patients excellent relief of presenting symptomatology, as well as an improved, more acceptable, disease-free survival.

We have previously reported that endoscopic sclerosis of the gastric cardia is an effective treatment for experimental gastroesophageal reflux in dogs. The histologic effect of endoscopic sclerosis is limited to the proximal stomach; mucosal deformity provides endoscopic evidence of sclerosis, and the intramural effects are shown by ultrasonographic technique. This report describes histologic and ultrasonographic results in the dogs at the completion of endoscopic sclerosis. This report also describes the endoscopic ultrasound results in the first two patients who have completed endoscopic treatment for reflux by means of endoscopic sclerosis of the gastric cardia. All canine and human subjects had sonodense lesions involving all layers of the proximal stomach at the injection site at the conclusion of treatment. Histologic examination of canine tissues showed dense submucosal and muscularis fibrosis in the stomach; the esophagus was normal. Endoscopic ultrasound demonstrates the effect of endoscopic sclerosis; this technique may be useful in the evaluation of symptomatic responses after this treatment.

Without any further comments we advise the surgeon performing open or laparoscopic vagotomy to know the anatomy and the vagaries of the vagus nerve. In view of the demonstration that the nerves of the greater curvature, identified as a concern in achieving a "complete" PGV, are projected from up to 20% of the nerve cell bodies of the dorsal motor nucleus of the vagus nerve in the brain stem, we believe it is appropriate to adopt the technique of EHSV as a means of avoiding the high recurrence rates reported with conventional highly selective vagotomy or proximal gastric vagotomy. When pyloric stenosis or outlet obstruction is present, anterior hemipylorectomy provides a solution. If surgeons adopt a laparoscopic approach to EHSV, they must be cognizant of all sites of preganglionic innervation, and (ideally) attempt to verify the "completeness" of vagotomy by Congo red testing. We look forward, also, to the work of Andrus and Schneider, who are evaluating alternative methods of achieving complete vagotomy.

Since ablation of afferent nerves prior to stress results in increased severity of acute gastric mucosal lesions, afferent nerves are thought to mediate protective mechanisms in the stomach. These mechanisms are known to include vasodilation of gastric mucosal vessels; vasodilation is thought to allow the gastric mucosa to respond to injurious substances. However, it is not known whether other aspects of mucosal health, independent of those caused by increased blood blow, are affected by afferent blockade. This study compared gastric blood flow and acute gastric mucosal lesions during stress in rats with either chemical sympathectomy or afferent blockade. The purpose of the study was to compare the lesion index and blood flow in each treatment group. The lesion index was highest in rats with afferent blockade and lowest after sympathectomy. Gastric blood flow was partially preserved after sympathectomy, but was not greatly increased, suggesting that some of the effects observed after afferent blockade are unrelated to changes in blood flow.

In previous nerve tracing studies we found evidence that the efferent gastric vagus nerves supplying the anterior gastric wall had a regional organization. The first part of this study aimed to determine whether vagus afferent nerve cells supplying the stomach have a regional organization; an ipsilateral pattern of innervation was found. Next, selective blockade of the afferent nerves was performed and verified by axonal tracing. Animals with afferent blockade were stressed to determine the effect of afferent nerve blockade on the gastric stress response. After selective blockade of afferent vagus nerves to the anterior gastric wall in rats, water-immersion stress was then applied. The part of the gastric wall with afferent nerve blockade had fewer acute gastric lesions than control animals or the contralateral side of the stomach after 24 hr of stress. This study supports the hypothesis that afferent as well as efferent vagus nerves have an ipsilateral arrangement. Afferent nerve blockade of the left vagus nerve protected the anterior wall of the stomach against stress ulceration.

An ideal operation for a benign disease, such as duodenal ulcer, must be effective, relatively free of serious postoperative complications and standardized for effective performance. Highly selective vagotomy, an operation known to have few side effects, has not been adopted by many surgeons because of the concerns about postoperative recurrent ulcers, as well as by concerns about the technical performance of the operation. Recurrent ulcers may be the result of incomplete denervation of the parietal cell mass; based upon the results of intraoperative testing, we suspected that previously unrecognized sites supplied preganglionic vagus nerves to the parietal cell mass. Nerve tracing studies identified four areas in the stomach that are not adequately denervated in the "standard" highly selective vagotomy. Based on these data, we defined and performed "extended highly selective vagotomy" upon 180 patients with ulcers. Herein, the results of follow-up examinations of 113 patients for a mean of at least 4.5 years postoperatively are reported. Recurrent duodenal ulcers occurred in 2.9 percent (two of 69) after extended vagotomy alone, and in none of 44 in whom a drainage procedure was used; the overall recurrence rate was 1.8 percent. Serious postoperative complaints were found in one patient in each group. The use of extended highly selective vagotomy for duodenal ulcer has a rational experimental basis and acceptable clinical results. Pyloroplasty, in conjunction with extended highly selective vagotomy, does not increase the incidence of serious postoperative side effects.

Capsaicin (Sigma Chemical Co.) is a unique chemical agent that causes degeneration of afferent nerve fibers. Previous conclusions about Capsaicin effects on the gastric mucosal response to stress have not precisely defined which afferent nerves were affected. Therefore, the aim of the first portion of this study was to define the origin of afferent vagus nerves to the anterior gastric wall after injections of fluorogold (which is an axonal tracer) into the stomach. The second part of this study was to compare the stress effects on the gastric mucosa in rats with impaired afferent nerve function after Capsaicin treatment.

Gastro-esophageal reflux disease is a common disorder which sometimes requires surgical treatment. Until recently, surgical treatment was the only alternative for severe complications of reflux. During the past 5 years endoscopic treatments for reflux have been reported from several medical centers. These new approaches may herald a new era for the treatment of reflux complications. However, at this time they are purely experimental approaches. Since physiologic antireflux mechanisms involve the muscles of the proximal gastric cardia as well as those of the lower esophageal sphincter, it is not surprising that endoscopic treatments have been directed at these two areas. However, the first endoscopic attempts at reflux control were directed at the lower esophagus sphincter. The most recent efforts at endoscopic control have been aimed at the proximal stomach, based on the concept that scarification beneath the lower end of the esophagus reduces the amount or frequency of reflux. Neither of these latter approaches has been reported in human patients. Since all endoscopic approaches are potentially dangerous, we recommend the adoption of a rigorous protocol for all human application. A possible protocol for this purpose is described herein; the authors will provide data analysis for any cohort of patients receiving endoscopic therapy, and will provide the results of all endoscopic treatments to any serious investigators.

To investigate the viscerotopic distribution of the cells of origin of preganglionic vagus nerve in rats, Fluoro-Gold was injected into various visceral tissues. After injections into the gastroesophageal junction and the gastric corpus, labelled cells were localized in the medial half of the dorsal motor nucleus of the vagus (dmnX). Cells in the nucleus ambiguous (nA) were also labelled after injections into the gastroesophageal junction. After injections into the pancreatic head and the celiac plexus, labelled cells were located bilaterally in the lateral part of the caudal dmnX. In the rostral dmnX, however, the pancreatic head was represented in the medial segment. After injections into the lung, duodenum, liver and ascending colon, no labelling was observed in the brainstem.

Endoscopic studies and treatment are a necessary and vital component of General Surgery practice. Since most of the concepts related to therapeutic endoscopy were conceived and developed in the context of surgical science, it is both appropriate and necessary that surgeons continue their involvement with this modality. Furthermore, within the evolution of surgical science, endoscopic tools will continue to be utilized.

Congenital cysts, sometimes referred to as nonparasitic biliary cysts, are not unusual findings in the liver parenchyma, but they have not been previously described in the common bile duct. This clinical report describes a 41-year-old woman with obstructive jaundice that was caused by congenital cysts. The patient had obstruction of the middle portion of the common bile duct; therefore the major differential diagnostic considerations were cholangiocarcinoma, cancer of the pancreas, or true biliary cysts. Congenital cysts, retention cysts, and neoplastic cysts cannot be differentiated from other true cysts preoperatively. Diagnosis can only be established by microscopic examination after surgical excision.

Over a 3-year period, 156 of 815 patients admitted to a single institution with acute pancreatitis received total parenteral nutrition (TPN) for 2,572 patient days. Seventy had "simple" acute pancreatitis (group I) and 86 (group II) developed local complex disease (pseudocyst, abscess, or necrotic gland). In groups I and II, respectively, days without oral intake (NPO) were 13.6 +/- 1.5 (SEM) and 24.0 +/- 2.1 (p less than 0.005), hospital days were 19.8 +/- 1.7 and 35.8 +/- 3.2 (p less than 0.005), and duration of TPN was 10.9 +/- 1.0 and 21.0 +/- 2.3 days (p less than 0.005). Thirty-three patients in group I and 53 in group II required exogenous insulin. Alteration of standard formulas was necessary in 87 patients, but cessation of therapy was necessary in only one instance. Twenty catheters were removed for suspected sepsis with only 3 confirmed cases. Fat-based formulas were well tolerated in 15% of patients. During TPN, body weight rose from 95.0 +/- 2.4% to 97.4 +/- 4.3% of ideal in group I and remained at 90.5 +/- 1.8% in group II. Albumin rose from 3.36 +/- 0.10 to 3.50 +/- 0.08 g/dl in group I and from 3.01 +/- 0.07 to 3.35 +/- 0.07 g/dl in group II. The entire cohort differed from 10 randomly chosen patients who did not receive TPN in terms of days NPO (2.8 +/- 0.3) and hospital days (5.5 +/- 0.6). Variables associated with prolongation of hospital stay and time NPO were number of prognostic criteria, local complex disease, and underlying chronic pancreatitis only in select groups. We conclude that during acute pancreatitis, TPN can be administered safely but with careful monitoring and we recommend early aggressive therapy in the subgroups noted above and when underlying malnutrition exists. In the borderline patient, TPN may be administered by peripheral vein until the severity of disease is manifest.

Surgical anti-reflux therapy appears to involve the muscles of the proximal gastric cardia and those of the lower esophageal sphincter. In an experimental canine reflux model, we injected sclerosant solution into the submucosa of the proximal gastric cardia, hypothesizing that the subsequent fibrotic reaction might exert an anti-reflux effect. Reflux was induced by atropine infusion, and the amount of reflux was quantitated by pH monitoring. Endoscopic sclerosis was effective in preventing reflux induced by high-dose atropine. Because the length and pressure of the lower esophageal sphincter were unaffected by endoscopic treatment, reflux prevention was possibly related to enhancement of the gastric component of the reflux barrier.

Endoscopic sclerosis of the gastric cardia (ESGC) prevents experimental gastroesophageal reflux (GER) without changes in lower esophageal sphincter (LES) pressure and length. This study was performed to define the histologic appearance of the esophagus and stomach one year after ESGC. Four dogs were studied one year after ESGC with morrhuate sodium; ESGC had been performed at six sites, 1-3 cm distal to the esophagogastric junction. All animals had stable weight and eating habits at sacrifice. Light microscopy of the cardia and LES included morphometry of wall thickness (mm) and assessment of fibrosis (- to ). The esophagus had minimal changes; the gastric cardia had focal fibrosis, maximal on the greater curve, without any change difference in wall thickness. ESGC results in fibrosis of the gastric cardia, without significant changes in the esophagus. These changes prevent GER, possibly by preventing the initiation of a reflux event.

The endoscopic Congo red test allows accurate and rapid evaluation of the completeness of vagotomy and may result in a lower incidence of postoperative incomplete vagotomy. This report describes 44 patients tested during proximal gastric vagotomy. Evidence of incomplete vagotomy was found in over 95% at the conclusion of the conventional operation. Importantly, the test was a guide to further operative maneuvers which abolished the evidence of incomplete vagotomy upon subsequent testing. The endoscopic Congo red test satisfies the requirements for an ideal test for complete vagotomy: it is easily performed, does not require special equipment, and can be repeated several times if necessary to verify that desired effects have been achieved. The wider use of this test, therefore, appears justified.