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• Two varieties of surgical operation are applied to high-lying gastric ulcers. One consists in resecting the ulcer (if it is on the lesser curvature) with all or part of the lesser curvature and a sufficient part of the greater curvature to give a two-thirds resection; this is followed by repair according to either the type 1 or type 2 Billroth operation. The other consists in leaving the ulcer undisturbed, resecting the distal one-half or two-thirds of the stomach, and concluding according to either the Hofmeister or the type 1 Billroth operation; the ulcer heals without trouble in most instances. Both varieties of operation have given excellent long-term results. In either case, specimens of tissue must be obtained and examined for malignancy, which is the greatest problem in the treatment of high-lying gastric ulcers. The unexpected finding of malignancy by microscopic examination is most common in small ulcers. Concomitant gastric and duodenal ulcers are frequent, and among 98 cases of this kind there was marked retention. When obstruction occurs it must be relieved. The temporary insertion of a gastrotomy tube for feeding is to be considered if obstruction is severe, and a posterior gastroenterostomy may be advisable in poor-risk patients.

Surgeons have been reluctant to perform ileostomy for intractable ulcerative colitis in young women because the existence of the ileostomy was believed to militate against pregnancy and subsequent parturition. This belief is unsettled by a study of seven patients with ileostomy and colectomy. In all there were 13 subsequent pregnancies, of which 3 terminated in early spontaneous abortions while 10 went on to term and resulted in live births. In 9 of the 10 term pregnancies the patient was delivered per vaginam, and only one had to be delivered by cesarean section. There was no maternal mortality. In the past, unpredictable exacerbations of ulcerative colitis have been a serious danger in pregnancy. The experiences here recorded show that young women with otherwise intractable colitis can be treated by ileostomy and colectomy without fear of subsequent inability to bear children.

We wish to report on some of the more interesting experiences we have had with the use of the ileocecal-ascending colon type of substitute bladder. The operative technique has been previously described. 1,2 Most of the ureteral implants have been done by a modified Coffey I method. Some anastomoses were made by the combined mucosa-to-mucosa and tunnel technique We are now spatulating the end of the ureter (Fig. 1). Then the end of the ureter is drawn into the new bladder a short distance by two sutures (Fig. 2). The final position of the ureters in the bladder is shown in an open view of the bladder (Fig. 3). The completed anastomosis (on the right side only) is shown in Figure 4, before the left side has been transplanted and before the bladder has been tacked down over the brim of the pelvis. The ureteral transplantation is done as the

• Experience with 189 patients aged 70 years or older undergoing major abdominal surgery is analyzed as to factors affecting the prognosis and safeguards to be recommended. The largest group consisted of 109 patients operated on for diseases of the colon and rectum, and the operation most frequently required in this group was intestinal resection. The commonest cause for emergency surgery in aged patients was massive gastrointestinal hemorrhage necessitating gastric resection. In the 21 patients who died, the most frequent cause of death was pulmonary embolism and the second most frequent was chronic infection. Elderly patients did not tolerate chronic infections, and emergency operations carried a much higher risk than did elective surgery, but in general neither age nor sex, nor coexisting chronic cardiovascular, pulmonary, or renal disease, significantly altered the mortality rate. On the basis of this experience, a list of seven safeguards is stated that have materially reduced the mortality and morbidity rates in the aged patient.