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Fifty consecutive patients who underwent 52 formal hepatic resections (excluding isolated wedge resections) for metastatic colorectal cancer were analyzed to determine whether DNA content was of prognostic significance. The Dukes' stages of the colorectal primaries were: A (10%), B (20%), C (40%), D (28%), and unknown in 2%. Four patients whose liver metastases were discovered at the time of resection of the primary bowel cancer underwent concomitant liver resection, and the remaining patients underwent delayed resections. The hepatic resections performed were right lobectomy (50%), extended right lobectomy (19%), left lobectomy (13%), left lateral segmentectomy (6%), left lobectomy and right wedge (6%), extended left lobectomy (4%), and right lobectomy and left wedge (2%). The overall morbidity rate was 29%. The in-hospital mortality rate was 9%. As of November 1991, 36 patients have recurred. The 5-year actuarial survival was 28%. Flow cytometry could be performed on 37 archival specimens, 15 of which were found to be diploid whereas 22 were aneuploid. All metastases from Dukes A colorectal primaries demonstrated a diploid DNA content. In addition, there was no difference in actuarial survival between diploid and aneuploid tumors. These data suggest that in selected patients, formal hepatic resection of colorectal liver metastases can be performed with an acceptable morbidity rate, mortality rate, and survival, but ploidy of the resected tumor is not of prognostic significance.

• New rules for quality assurance provoked a comparison of effects of two approaches used concurrently for 14 years. In an incidental approach, a multidisciplinary conference reviewed all postoperative complications as they occurred and attributed each to one of six causes. Remedies were instituted and data were filed. In a statistical approach, death and complication rates were computed annually and compared with previous years' rates and with rates reported to Congress as national norms. Statistics suggested acceptable quality in each specialty but calculations were tedious and differences achieved significance too rarely or too slowly to identify problems, protect patients, and improve care. The incidental approach was popular and produced immediate improvements in patient care. Conferees attributed one half of complications to errors. Frequent acknowledgment of susceptibility to error may contribute to the safety and quality shown by our statistics. ( Arch Surg . 1992;127:733-738)

Four hundred patients with resectable colon and rectal cancers were operated on by 37 surgeons at 31 institutions. Patients were monitored with carcinoembryonic antigen (CEA) level determinations and clinical examinations. One hundred thirty patients had recurrences, and 75 were reoperated on, with 43 reoperations CEA-directed and 32 clinically directed. Two of 75 died within 1 month after the second operation. Twenty-two second-look patients remain free of disease 5 years after their second operaton. The highest resectability of recurrent cancer occurred in patients with a CEA level below 11 ng/ml in whom the CEA level was determined at intervals of 1 to 2 months. Cancer 55:1284-1290, 1985.

An analysis of twenty-six cases of epidermoid carcinoma of the anus from the University of Virginia Medical Center and 1,060 cases from the surgical literature has been presented. We believe this review justifies the following conclusions. 1. (1)Considerable delay in diagnosis frequently occurs, adversely affecting the prognosis of patients with this disease. 2. (2)Abdominoperineal resection remains the treatment of choice. Wide local excision is inadequate for most lesions, and should be reserved for lesions of the anal verge less than 2 cm in diameter with favorable histology, that is, low grade of malignancy. 3. (3)Large lesions and those with a high grade of malignancy are associated with a poor prognosis, but even these patients may sometimes be cured with aggressive surgical excision. 4. (4)Synchronous inguinal node metastases are associated with a poor prognosis, but an occasional patient may be cured by iliofemoral node dissection. 5. (5)Iliofemoral node dissection is indicated for metachronous inguinal node metastases in the absence of distant spread. 6. (6)Iliofemoral node dissection should not be performed if these nodes are not clinically involved with metastases. Approximately 70 per cent of these patients will not need this procedure and would therefore have this resection and its attendant morbidity unnecessarily.

Over an 8-year period, among 41 patients with obstructive jaundice caused by metastases to the liver or lymph nodes adjacent to the porta hepatis, palliative biliary decompression was established surgically in 11, by percutaneous transhepatic biliary drainage (PTBD) in 25, and by both methods in 2. Three patients had no drainage procedure performed. Early mortality after drainage occurred in 6 of 38 patients, and the median survivals (actuarial) for the remaining 32 patients were 4.5 months for the surgical group (range 2 to 21 months) and 4 months for the PTBD group (range 2 to 14 months). Although there were trends toward more frequent hospital readmissions and episodes of cholangitis in the PTBD group, the only statistically significant difference was in the number of catheter manipulations required. We concluded that when patients develop obstructive jaundice as a manifestation of metastatic cancer, useful palliation can be achieved by either surgical or percutaneous decompression.

The clinicopathologic features of a malignant fibrous histiocytoma arising in a female breast are presented. Seven cases have been previously reported. These may be divided into three subgroups based on history and pathologic findings. Three of the seven occurred in women without a history of other tumors or previous irradiation. One appeared with a cystosarcoma phyllodes, and three arose following radiation for carcinoma of the breast. The patient in this study had received no radiation. Treatment has been based on surgical resection; the roles of chemotherapy and radiation are uncertain. Although resection alone in the first subgroup has lead to no reported mortality, the small number of cases and the relatively short follow-up does not allow a meaningful assessment of the prognosis in this disease.

Medical adrenalectomy, consisting of aminoglutethimide plus either dexamethasone or hydrocortisone, was administered to 53 women with advanced breast cancer. Sixteen (30%) patients had an objective response, five patients had stabilization of disease, 26 patients demonstrated progression of disease, two patients did not adhere to protocol, and four patients had severe toxicity necessitating discontinuation of the drugs. Medical adrenalectomy accurately predicted response to subsequent surgical adrenalectomy in 23 patients. Estrogen receptor (ER) data accurately predicted response (eight of nine (89%) ER-positive patients responded) or failure (only two of 14 (14%) ER-negative patients responded) to medical adrenalectomy. Thirty (of 51 women adhering to protocol) had no toxicity. Therefore, it appears that medical adrenalectomy is safe, usually well tolerated, and can accurately predict response to surgical adrenalectomy. Its use should be limited to ER-positive patients, and it may totally supplant surgical adrenalectomy in the management of advanced breast cancer.

The patient whose case is reported, Miss L. Y., aged 37 years, stenographer, first consulted me on April 13, 1928. Her family history was negative for malignancy. The patient's general health had been good except for two fairly severe attacks of influenza, and paratyphoid about 1924. She had been extremely nervous and had had three or four “nervous breakdowns.” She had gained weight during the past year. Wassermann tests were consistently negative, and other laboratory examinations were negative. She had noticed a tumor at the lower end of the right radius for at least two years before I first saw her (Figs. 1, 2, and 3). The growth had been treated with X-rays and finally was operated upon elsewhere about the first of April, 1927, the growth being thoroughly curetted. Roentgenologic examination on October 21, 1927, seemed to show a recurrence (Fig. 4). When I saw her there was a tumor of the lower end of the right radius, appearing chiefly on the palmar surface (Figs. 5 and 6). The skin over it was stret...

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• An adjuvant program of fluorouracil for patients undergoing "curative" resection for adenocarcinoma of the colon and rectum was initiated as a randomized clinical trial in January 1968. Patients were randomly assigned to an intraluminal fluorouracil or intraluminal control (saline) group and were so treated at the time of surgical resection if findings at operation indicated that all gross neoplastic disease could be resected. Those patients receiving intraluminal fluorouracil (30 mg/kg) received intravenous fluorouracil (10 mg/kg) on each of the first two postoperative days and five subsequent postoperative courses of oral fluorouracil (90 mg/kg) in each 18-day course over a one-year period. By July 1,1975, there were 203 patients undergoing curative resection entered into the study. Survival and disease-free data, as of Dec 31, 1976, revealed no benefit from this adjuvant course of fluorouracil. These data support the need for continued randomized clinical trials of new and innovative adjuvant therapy compared with an untreated control group. ( Arch Surg 113:164-168, 1978)

At the present time there are few indications for the repair or replacement of venous defects. As the scope of surgery grows, however, reconstitution of the vena cava and other major veins will require the availability of suitable graft material. There is, at present, no definitive answer as to which type of replacement is most desirable for venous reconstruction. Indications for venous reconstruction presumably will include circumstances in which the superior vena cava, the inferior vena cava above the renal veins, the superior mesenteric veins, the portal vein, or one or both renal veins are involved by tumor, trauma, thrombosis or postinflammatory obliteration. Other indications might include instances in which major venous shunts are required, as in the surgery of congenital anomalies of the heart and great vessels, or in portal to systemic shunting procedures. The present study was undertaken first to compare autogenous with homologous vein grafts, and secondly

The ease with which blood transfusion by the citrate method may be carried out has, during the last ten years, resulted in its use, almost to the exclusion of direct methods. It has popularized transfusion in various diseases, and has, without doubt, in the aggregate been most beneficial. More patients requiring transfusion have been transfused than before the development of the indirect method, and there can be no question that a large number of lives have been saved by its employment. The general statistical results are good. It is in a consideration of the results in individual cases that certain dangers in citrate transfusion become apparent. REACTIONS FOLLOWING CITRATE TRANSFUSION Considerable literature has accumulated during the last few months concerning the types of reaction following citrate transfusion, and the causes therefor. P. W. Clough and M. C. Clough 1 have given an excellent summary of the three types of reaction

J. W. M., a farmer, white, aged 67, was admitted to the hospital on Dec. 14, 1927, complaining of great pain in the abdomen, constipation and vomiting. Two days before admission, after eating a big dinner, he was suddenly seized with cramplike pains in the lower part of the abdomen. The pain was severe, and the lower part of the abdomen became somewhat distended. He took enemas and purgatives. There were fair results from the enemas, but the purgatives accentuated the pain and did not produce results. He then began to vomit and soon vomited large quantities of brown, fecal smelling material. A diagnosis of intestinal obstruction was made. The patient had had a somewhat similar but much milder attack about ten years before admission, but soon recovered. He had been fairly healthy most of his life, but for many years had had chronic constipation which had been much worse

It cannot be too often emphasized that surgery should be more a science than an art. A surgeon who is a dexterous operator and who skilfully amputates a leg that with patience and scientific application could be saved is merely a good artisan, and is distinctly inferior to the surgeon who could save the leg even though he should be a bungling operator. The ideal is to be thoroughly imbued with the principles of the biologic sciences, thoughtfully to apply these principles, and at the same time to be mechanically skilful. The science of anatomy is essential to the mechanics of surgery. He would be a poor locomotive mechanic who did not understand the construction of his engine; and in operations on the neck, for instance, a surgeon who is ignorant of anatomy would be like the proverbial bull in a china shop. A knowledge of anatomy is essential to

The method of suturing blood-vessels which I described recently inThe Journal1consists in the use of a new instrument together with the application of a continuous mattress suture. The mattress suture apposes the intima more satisfactorily than the overhand stitch. I have found, however, that it is sometimes difficult to prevent leakage with the continuous mattress stitch, as the points between the sutures have but little compression by the suture and no raw surface, For this reason, if a leakage occurs, it is sometimes difficult to stop. This is particularly true when suturing vessels of different caliber, as in transplanting a segment of vein between the cut ends of an artery, and has been the chief objection to this method. In order to overcome this objection, I have recently used adoublemattress stitch, or cobbler's stitch, which has been so successfully employed by Dr. Crile in intestinal