The present status of biliary tract surgery.

The techniques now routinely available for modern biliary tract diagnosis and treatment have allowed today's biliary surgeon to make a diagnosis more rapidly and with greater delineation of the pathology than a decade ago. As well, the extension of these diagnostic techniques has allowed interventional procedures to be carried out by both the radiologist and the endoscopist such that certain palliative procedures may now be done without laparotomy, and reoperations may be avoided by percutaneous or endoscopic approaches. Operative surgery in this area has not had the same spectacular advances. Rather there have been refinements and additions to previously used techniques that have standardized the procedures. Moreover, surgery has benefited from the technologies that have allowed the better preparation of the patient by the percutaneous or endoscopic relief of jaundice before an operation, the disimpaction of stones in cholangitis, and papillotomy in acute pancreatitis. The availability to the surgeon of the extremely slim flexible endoscope has made biliary endoscopy at operation simpler as well as providing a tool for percutaneous biliary endoscopy and stone extraction. In the same era, tests that were among the most common for diagnoses such as the oral cholecystogram and intravenous cholangiogram have become infrequent and perhaps obsolete. It has become obvious that the complete biliary surgeon must now have available isotopic, sonographic, and radiologic imaging, endoscopy, and other equipment not even imagined by those who pioneered biliary surgery.

Acute acalculous cholecystitis.

Sixty-eight patients with acute acalculous cholecystitis were reviewed. The results of history and physical examinations were usually nondiagnostic. IDA cholescintigraphy (93 per cent accuracy rate) was the only reliable diagnostic modality. The results of oral cholecystography, intravenous cholangiography and ultrasonography were considerably less reliable. One-half of the patients had gangrenous cholecystitis. Cholecystectomy was the preferred operation with an over-all mortality of 9 per cent. IDA cholescintigraphy is an important new modality for the diagnosis of acute acalculous cholecystitis which, in the past, has often been difficult to diagnose.

Stapling in intestinal surgery.

Although stapling technology was introduced to surgical procedures early in this century, its accelerated use has taken place since 1968. Several methods of restoring interrupted continuity of the large and small bowel are available to the surgeon. The method used is influenced by the level involved, especially as it relates to the availability of the two ends to be joined. The degree of cleansing of the bowel lumen also affects the method chosen, especially in colorectal anastomosis. The surgeon should avail himself of the appropriate training in the operation and use of stapling instruments because the principles of stapling technology differ from those of conventional suturing technics.

Evaluation of the postoperative patient with 99mTc-IDA cholescintigraphy.

In order to assess the role of 99mTc-iminodiacetic acid (IDA) cholescintigraphy in evaluating postoperative patients, a total of 213 studies were performed in 189 patients over a 3-year time period. Of these, 130 studies were obtained in 125 cases with signs and/or symptoms suggesting postcholecystectomy syndrome. A normal sized duct that emptied within an hour ruled out significant pathology with a high degree of accuracy (97%). A less reliable finding of normalcy was the combination of ductal dilatation with functional patency in that three of 20 patients (15%) who exhibited this pattern were proven to have nonobstructing calculi in their common bile duct. AZ spectrum of abnormal findings was encountered. Ductal dilatation was a most significant indicator of partial or intermittent ductal obstruction when it was associated with altered time-activity dynamics in the ducts and secondarily, delayed biliary-to-bowel transit time of the radiotracer. Patterns indicating complete common duct obstruction, cystic duct remnants, and bile leaks also proved to be very sensitive. Seventy-three studies in 56 patients very accurately evaluated the integrity of biliary-enteric bypass anastomosis. Complete and partial obstructive patterns were similar in appearance to those encountered in postcholecystectomy syndrome. Several leaks were also detected in this patient population. Ten studies were performed in eight patients who underwent Billroth II gastroenterostomies primarily to see if afferent loop obstruction was present. Three of these patients did demonstrate dilated A-loops with stasis, thereby making a positive diagnosis possible.

Total fecal diversion by the temporary skin-level loop transverse colostomy.

The temporary skin-level loop transverse colostomy has been described. Proof of its ability to divert the fecal stream totally is illustrated by complete diversion in 25 patients ingesting a postcolostomy barium meal. There was no postoperative complication.

The dilemma of Crohn's disease: ileoduodenal fistula complicating Crohn's disease.

Nine cases of duodenal fistula complicating Crohn's disease are reported. All nine patients were male. Four patients had Crohn's disease of the ileum and five had ileocolitis. No patient had primary duodenal Crohn's disease. Because attempt at primary closure of the duodenal defect may fail, our treatment of choice has been formal cross cut two-layered duodenojejunal anastomostis with extensive drainage of the area postoperatively. This treatment has been associated with no mortality and little morbidity, and no late recurrence of duodenal fistula.

Internal bile diversion--a new model for the study of cholesterol metabolism.

Biliary diversion in different ways has been studied as a prevention against induced hypercholesterolemia in experimental animals. A new model for the study of cholesterol metabolism is described in dogs in this paper. The technique consists in ligation and division of the common bile duct and interposition of an isoperistaltic loop of jejunum between the gallbladder and urinary bladder. This technique is free of complications such as diarrhea, infection, and peptic ulceration that are seen in other biliary diversion models, and it is tolerated well by the animals. This requires further study for its effectiveness in the prevention of experimental hypercholesterolemia and subsequent development of arteriosclerosis.

The role of the peritoneum in the healing of abdominal incisions.

These results support the assumption that careful approximation of the gascial edges is one key in the repair of abdominal incisions. It is difficult to say how pertinent these observations are to the clinical situation in which nonabsorbable sutures are generally used. However, we believe that some of these factors are germane in both situations and that concentration on maintaining a meticulous, accurate and strong fascial approximation will result in a safer, faster and equally strong and less frustrating closure of the abdominal incision.

Prevention of induced atherosclerosis by diversion of bile or blockade of intestinal lymphatics in dogs.

The prevention of induced hypercholesterolemia and atherosclerosis was studied by means of intestinal lymphatic blockade and of bile diversion in the dog. Hypercholesterolemia and atherosclerosis were produced by high cholesterol feeding after induction of hypothyroidism with radio-iodine plus thiouracil. Complete diversion of bile, by shunting all bile into the urinary bladder, effectively prevented hypercholesterolemia and atherosclerosis; in contrast, blockade of the intestinal lymphatics failed to prevent the consequences of the atherogenic regimen, because of the development of collateral lymphatic channels.

Failure of intestinal lymphatic block to prevent experimental hypercholesterolemia.

Intestinal lymphatic blockade was produced in dogs by ligating the individual lymphatics and then obturating them with an acrylic solution. Despite meticulous technique a complete and lasting lymphatic block could not be produced. Extensive collateral channels developed via the omental, the colonic, the renal and the retroperitoneal lymphatics. Some of the vessels recanalized. Absorptions studied using C-14 octanoic and H-3 oleic acid suggested that although the lymphatic blockade was partially successful in lowering the content of oleic and octanoic acid in the lymph, direct lymphovenous transport compensated for the lymphatics' obstruction. The cholesterol values of the lymph blocked dogs were not lower than those of the controls. Intestinal lymphatic obstructions does not appear to be a practical approach to the prevention or treatment of hypercholesterolemia.