Gastrointestinal bleeding after operation for pancreatic cancer.

Gastrointestinal bleeding after surgery for cancer of the pancreas contributes significantly to patient morbidity and to patient mortality, if the bypass was performed for palliation. Bleeding after resection of the pancreatic tumor appears to be amenable to therapy, and unaltered by the addition of vagotomy at the time of surgery. Patients undergoing palliative surgery who are expected to live beyond the postoperative period may well benefit from measures to reduce the risk of gastrointestinal bleeding.

Gastric outlet obstruction after palliative surgery for cancer of head of pancreas.

Gastroenterostomy as part of the palliation of unresectable cancer of the head of the pancreas, in the absence of gastric outlet obstruction at the time of surgery, has been both rejected, and, more recently, advocated for all such patients. A study of 105 cases yielded four factors that correlated with the subsequent occurrence of gastric outlet obstruction: age, 60 years or younger; hemoglobin level, 11.5 g/dL or less; absence of liver metastases; and survival, three months or longer. A fifth factor, absence of clinical jaundice, may be an indicator of a poor prognosis with a small risk of obstruction. By combining factors, we identified a group with a risk of obstruction of at least 25% (those with two or more factors) and one with negligible risk.

Endoscopic retrograde cholangiopancreatography.

The ERCP report in the patient's chart was compared with findings on common duct exploration or cystic duct cholangiography in 72 patients and found to have a sensitivity of 90.4 percent, a specificity of 98 percent, and an accuracy of 95.8 percent. Factors having the potential to influence the accuracy of ERCP were errors in interpretation by the surgeon and the radiologist and the operative technique of cholecystectomy. Also, the interval between the performance of the procedure and operation was particularly important in the patient with multiple small gallstones or small common duct stones. Small gallstones may spontaneously pass from the gallbladder to the common duct, or small common duct stones may spontaneously pass into the duodenum; therefore, the longer the interval between ERCP and operation, the greater the likelihood of a discrepancy. At operation, gallstones may be squeezed into the common duct during manipulation of the gallbladder unless the cystic duct is obstructed before manipulation of the gallbladder. We found ERCP sufficiently accurate to make cystic duct cholangiography unnecessary in most patients with cholelithiasis having a preoperative ERCP examination.

Vasodilator response in the lower extremity induced by contrast medium. III. Before and after percutaneous transluminal angioplasty.

A standardized test series of contrast medium injections was performed in the iliac and femoral arteries to evaluate the immediate effect of percutaneous transluminal angioplasty. The vasodilator response recorded by video dilution technique was correlated to radiographic anatomy and symptomatology. Discrepancy between anatomic success and clinical relief of symptoms was found in 26 per cent of the dilatations. The severity of disease at the trifurcation was more marked in combination with femoral lesions than with corresponding iliac lesions. Rest pain was a common symptom with femoral lesions and rare with iliac lesions. Resting blood flow increased significantly after femoral dilatation but was unaffected by iliac dilatations. The video dilution technique provided an accurate staging of the severity of obstructive disease, and was an excellent predictor of subsequent symptomatic success or failure of percutaneous transluminal angioplasty.