Broadened Allocation of Pancreas Transplants Across Compatible ABO Blood Types.

BACKGROUND: Current Organ Procurement and Transplantation Network (OPTN) policy restricts certain blood type-compatible simultaneous pancreas and kidney (SPK) transplants. Using the Kidney Pancreas Simulated Allocation Model, we examined the effects of 5 alternative allocation sequences that allowed all clinically compatible ABO transplants. METHODS: The study cohort included kidney (KI), SPK, and pancreas alone (PA) candidates waiting for transplant for at least 1 day between January 1, 2010, and December 31, 2010 (full cohort), and kidneys and pancreata recovered for transplant during the same period. Additionally, because the waiting list has shrunk since 2010, the study population was reduced by random sampling to match the volume of the 2015 waiting list (reduced cohort). RESULTS: Compared with the current allocation sequence, R4 and R5 both showed an increase in SPK transplants, a nearly corresponding decrease in KI transplants, and virtually no change in PA transplants. Life-years from transplant and median years of benefit also increased. The distribution of transplants by blood type changed, with more ABO:A, B, and AB transplants performed, and fewer ABO:O across all transplant types (KI, SPK, PA), with the relative percent changes largest for SPK. DISCUSSION: Broadened ABO compatibility allowances primarily benefitted SPK ABO:A and AB candidates. ABO:O candidates saw potentially reduced access to transplant. The simulation results suggest that modifying the current allocation sequence to incorporate broadened ABO compatibility can result in an increase in annual SPK transplants.

Pharmacokinetics and dosage reduction of cis-diammine(1,1-cyclobutanedicarboxylato)platinum in patients with impaired renal function.

cis-Diammine(1,1-cyclobutanedicarboxylato)platinum (CBDCA) is a nonnephrotoxic but myelosuppressive analogue of cisplatin (DDP) with greatly reduced protein binding and greatly increased renal excretion. Thus, CBDCA might produce undue toxicity in patients with decreased renal function. Twenty-two patients [14 females and 8 males; median age, 66 (range, 35 to 83); median Karnofsky performance status, 70 (range, 40 to 90)] with refractory tumors and renal dysfunction [creatinine clearance (CCr) 6 to 83 ml/min] were treated with 31 courses of i.v. bolus CBDCA every 4 to 5 weeks. Dosages were determined by pretreatment CCr. Patients with CCr greater than or equal to 40 ml/min received 400 mg/sq m; patients with CCr 20 to 39 ml/min received 250 mg/sq m; and patients with CCr 0 to 19 ml/min received 150 mg/sq m. Toxicities were assessed by weekly clinical and laboratory assessment. Responses were assessed in patients with measurable disease. Plasma pharmacokinetics and urinary excretion of total and ultrafilterable platinum were measured with flameless atomic absorption spectrometry. Observed toxicities were similar to those in patients with normal renal function. Myelosuppression, especially thrombocytopenia, was the major toxicity. Nausea and vomiting were mild to moderate. There was no ototoxicity, neurotoxicity, or nephrotoxicity or reduction in CCr due to CBDCA. Total body clearance of ultrafilterable platinum correlated highly with CCr. The percentage of reduction in platelet count correlated highly and linearly with the area under the curve (AUC) of plasma-ultrafilterable platinum. However, for any AUC, there was 17% greater platelet reduction in patients who had previously received extensive myelosuppressive chemotherapy than in nonpretreated patients. Since total body clearance is proportional to CCr, platelet reduction is proportional to AUC, and total body clearance = dosage/AUC, we have derived an equation to calculate a dosage that will produce a desired reduction in platelet count. Calculations for theoretical patients (both pretreated and nonpretreated) with CCr of 100 ml/min produce dosages very close to maximum tolerated dosages derived in actual Phase I trials. The actual clinical utility of these predictive equations must await validation in prospective studies with larger numbers of patients.

The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia.

OBJECTIVES: We sought to determine the prognostic value of the admission electrocardiogram (ECG) in patients with unstable angina and non-Q wave myocardial infarction (MI). BACKGROUND: Although the ECG is the most widely used test for evaluating patients with unstable angina and non-Q wave MI, little prospective information is available on its value in predicting outcome in the current era of aggressive medical and interventional therapy. METHODS: ECGs with the qualifying episode of pain were analyzed in patients enrolled in the Thrombolysis in Myocardial Ischemia (TIMI) III Registry, a prospective study of patients admitted to the hospital with unstable angina or non-Q wave MI. RESULTS: New ST segment deviation > or = 1 mm was present in 14.3% of 1,416 enrolled patients, isolated T wave inversion in 21.9% and left bundle branch block (LBBB) in 9.0%. By 1-year follow-up, death or MI occurred in 11% of patients with > or = 1 mm ST segment deviation compared with 6.8% of patients with new, isolated T wave inversion and 8.2% of those with no ECG changes (p < 0.001 when comparing ST with no ST segment deviation). Two other high risk groups were identified: those with only 0.5-mm ST segment deviation and those with LBBB, whose rates of death or MI by 1 year were 16.3% and 22.9%, respectively. On multivariate analysis, ST segment deviation of either > or = 1 mm or > or = 0.5 mm remained independent predictors of death or MI by 1 year. CONCLUSIONS: The admission ECG is very useful in risk stratifying patients with non-Q wave MI. The new criteria of not only > or = 1-mm ST segment deviation but also > or = 0.5-mm ST segment deviation or LBBB identify high risk patients, whereas T wave inversion does not add to the clinical history in predicting outcome.

A double beta-lactam combination versus an aminoglycoside-containing regimen as empiric antibiotic therapy for febrile granulocytopenic cancer patients.

The double beta-lactam combination of moxalactam plus piperacillin was compared with the aminoglycoside-containing regimen of moxalactam plus amikacin in a prospective, randomized trial of empiric therapy for 302 febrile episodes in granulocytopenic cancer patients. The moxalactam/piperacillin regimen was found to be as effective as the moxalactam/amikacin regimen (70 percent overall responses); responses with moxalactam/piperacillin and moxalactam/amikacin were similar for microbiologically documented infections (24 of 37, 65 percent, versus 20 of 35, 57 percent), for the subgroup with bacteremias (19 of 32 versus 14 of 28), and for clinically documented infections (41 of 58, 71 percent, versus 40 of 48, 83 percent). Responses were similar also for bacteremia in patients with persistent, profound (less than 100/microliter) granulocytopenia. Among profoundly (less than 100/microliter) granulocytopenic patients with gram-negative bacteremia, an increase in the granulocyte count to more than 100/microliter during therapy and a peak bactericidal activity of 1:16 or more (the latter noted in seven of nine moxalactam/piperacillin trials and six of nine moxalactam/amikacin trials) correlated with a favorable clinical response in 85 percent (p less than or equal to 0.00003) and 92 percent (p less than or equal to 0.044), respectively. Although serious side effects were minimal with either regimen, the double beta-lactam combination was associated with significantly less frequent nephrotoxicity (two of 145 versus 12 of 130; p less than or equal to 0.003) and ototoxicity (none of 34 versus seven of 34; p less than or equal to 0.006). The double beta-lactam combination of moxalactam plus piperacillin was found to be as effective as moxalactam plus amikacin but to have significantly less nephro- and ototoxicity.

Hemorrhagic events during therapy with recombinant tissue plasminogen activator, heparin, and aspirin for unstable angina (Thrombolysis in Myocardial Ischemia, phase IIIB trial).

This study assesses the effects of invasive procedures, hemostatic and clinical variables, and doses of recombinant tissue plasminogen activator (t-PA) on hemorrhagic events in the thrombolysis in myocardial ischemia (TIMI), phase 1B clinical trial (n = 1,425). Patients seen within 24 hours of the onset of ischemic chest pain at rest were randomized using a 2 x 2 factorial design for comparison of: (1) t-PA versus placebo as initial therapy, and (2) an early invasive (coronary arteriography with percutaneous angioplasty, if feasible) versus an early conservative strategy (coronary arteriography followed by revascularization if initial medical therapy failed). All patients received conventional medication for acute ischemic syndromes, including heparin, aspirin, beta blockers, nitrates, and calcium antagonists. The total dose of t-PA or placebo was 0.8 mg/kg, up to a maximum dose of 80 mg. In patients treated with t-PA, major and minor hemorrhagic events were more common than among those assigned to placebo (p < 0.001). Patients assigned to the invasive strategy arm had a higher hemorrhagic event rate than the noninvasive strategy, although the difference was not significant (p = 0.026). Patients > 75 years of age had higher intracranial hemorrhage rates than those < 75 years of age (6.7% vs 0.2%, respectively, p = 0.01). Major hemorrhagic events were more common in patients with higher heparin levels (p < 0.001), higher peak D-dimer levels (p = 0.007), and lower nadir fibrinogen levels (p = 0.005). Thus, increased morbidity due to hemorrhagic complications is associated with the use of t-PA, increased age, and selected hemostatic measures. Comparison to TIMI II demonstrates a significant association between the dose of t-PA and hemorrhagic complications.

Nuclear cardiac ejection fraction and cardiac index in abdominal aortic surgery.

Since atherosclerotic heart disease results in more than half of the perioperative deaths that follow abdominal aortic surgery, a prospective protocol was designed for preoperative evaluation and intraoperative hemodynamic monitoring. Twenty men who were prepared to undergo elective operation for aortoiliac occlusive disease (12 patients) and abdominal aortic aneurysm (eight patients) were evaluated with a cardiac scan and right heart catheterization. The night prior to operation, each patient received volume loading with crystalloid based upon ventricular performance curves. At the time of the operation, all patients were anesthetized with narcotics and nitrous oxide, and hemodynamic parameters were recorded throughout the operation. Aortic crossclamping resulted in a marked depression in CI in all patients. CI remained depressed P less than 0.05 after unclamping in the majority of patients. There were two perioperative deaths, both from myocardial infarction or failure. Both patients had ejection fractions less than 30% and initial CIs less than 2 L/M2, while the survivors' mean ejection fraction was 63% +/- 1 and their mean CI was 3.2 L/M2 +/- 0.6. We conclude that preoperative evaluation of ejection fraction can select those patients at a high risk of cardiac death from abdominal aortic operation. These patients should receive intensive preoperative monitoring with enhancement of ventricular performance.

Activated clotting time monitoring of intraoperative heparinization: our experience and comparison of two techniques.

The activated clotting time (ACT) has been used clinically for 41/2 years to monitor the adequacy of intraoperative heparinization in both cardiopulmonary bypass (CPBP) and peripheral vascular surgery (PVS) patients. Since January, 1976, we have operated on 440 PVS patients in our institutions, of whom 255 had intraoperative monitoring of heparinization by means of the ACT test; an additional 185 patients received heparin according to an empiric protocol. An automated machine for determining the ACT (Hemochron) had been used on the last 28 patients in the ACT group. We conclude that: (1) the ACT is an acurate method of monitoring anticoagulation during PVS, (2) the Hemochron is a simple and effective machine to perform the ACT, (3) values obtained by the Hemochron generally exceed those of the ACT done by hand by approximately 20 seconds at lower levels of heparin and are equal at higher levels of heparin, (4) supplemental heparin was required in 22% of our patients to maintain their ACT values at twice control values, (5) the response to heparin is twofold: an initial sensitivity or resistance followed by an independent and variable rate of consumption, and (6) the ACT is a useful method for predicting inadequate heparin reversal or heparin rebound at the conclusion of the operation.

Parathyroid autotransplantation.

Autotransplantation of the parathyroid to the forearm has been performed in eight patients following total or subtotal parathyroidectomy. The mass of gland implanted was approximately one half that used in other series. Bilateral simultaneous parathormone levels drawn at three months after autografting several higher levels in the autografted arm in every patient examined. Replacement calcium and vitamin D therapy were withdrawn from two patients within eight months after transplant, and it is anticipated that all patients will be off maintenance at 12 months. Electron and light microscopy of grafted tissue has revealed viable glands with intracellular secretory granules, many mitochondria, and little fat. Indications for autotransplantation include patients with refractory renal osteodystrophy, reoperations for primary hyperparathyroidism, and extensive extirpative cancer surgery of the head and neck.

Identification of heparin resistance during cardiac and vascular surgery.

An investigation of the response of the activated clotting time to systemic heparinization during cardiopulmonary bypass and peripheral vascular surgery was prompted by the death from clotting of a patient with endocarditis while undergoing valve replacement. The activated clotting time during cardiopulmonary bypass was thereafter maintained at 300 to 400 seconds. Consumption of heparin sodium, derived from an individual dose-response curve, was 0.01 to 3.86 units/kg/min. There was no correlation between initial heparin resistance and the subsequent rate of consumption. Some patients undergoing peripheral vascular surgery required additional heparin after an initial standard dose of 8,000 units so as to maintain their activated clotting time at twice the control values. These data are discussed in relation to previous articles, and recommendations are made for adequate intraoperative heparinization.

Infected prosthetic grafts.

An experience with 20 infected prosthetic grafts in a series of 652 prosthetic arterial reconstructions has been reviewed. There was 13 aortofemoral, one straight aortic, three femoropopliteal, one carotid subclavian, one axilloaxillary, and an axillocarotid graft. The most common site of infection was the groin. All patients had received preoperative and postoperative broad-spectrum antibiotic coverage, perhaps contributing to a high incidence of Gram-negative bacterial cultures. Early procrastination contributed to morbidity and mortality. Attempts at local wound management with drainage and irrigation generally failed, especially if the suture line was involved. Graft excision without revascularization resulted in a number of amputations and a high mortality. Excision of the entire aortofemoral graft combined with extra-anatomical revascularization was uniformly fatal. Our experience suggests that the first objective should be to establish operatively the extent of the infection. If very localized, antibiotic irrigation may cure. Involvement of one side can be treated in one stage by extra-anatomical bypass using the obturator foramen coupled with excision of the infected portion. If the entire graft is involved, we recommend extra-anatomical bypass as the initial procedure. High-dose antibiotic for systemic effect are then administered and two to three days later the infected graft is removed.

Bronchial adenoma: a review of 51 patients.

The cases of 51 patients with bronchial adenomas were reviewed. There were 43 bronchial carcinoids, 5 adenoid cystic carcinomas, 2 mixed tumors, and 1 mucoepidermoid carcinoma. The carcinoid group was divided into typical (31, 72%) and atypical (12, 28%) subgroups. Nine carcinoids (20%) were categorized as metastasizing adenomas; in this group, 7 lesions were atypical and 2 were typical. Thirty-two lobectomies, 7 bilobectomies, 8 pneumonectomies, 2 sleeve resections, and 2 tracheal resections were performed. Ten-year survival was 88% for patients with typical carcinoids and 59% for those with atypical carcinoids. In the group with adenoid cystic carcinoma, 1 patient died postoperatively, 1 had recurrence of the tumor, 2 were alive and free from disease 16 and 23 years later, and 1 died of heart disease at 11 years. The patient with mucoepidermoid carcinoma was alive without recurrence 15 years after operation. In conclusion, bronchial adenomas of the carcinoid type are potentially malignant. Their prognosis depends on the histology of the tumor, and on the presence of metastasis to the regional lymph nodes and distant organs.

Gastric outlet obstruction after omentopexy for perforated "acute" and "chronic" duodenal ulceration.

One hundred and eighty-seven men, aged twenty to eighty years with an average of forty-eight years, underwent surgery for perforated duodenal ulcer. Seventeen received an immediate definitive procedure; none died. Nine (5 per cent) of the remaining 170 who had omentopexy died one to fifteen days postoperatively. They were older and waited longer. One hundred and twenty-one patients (76 per cent) were adequately followed. Thirty-nine (32 per cent) had "acute" perforation and eighty-two had "chronic" perforation. Twenty-four (30 per cent) of the latter underwent definitive operation within three months without mortality. Overall, 25 per cent of the ninety-nine patients followed after omentopexy required reoperation within twelve months. However, only three (8 per cent) of the thirty-nine with "acute" perforation required operation as compared with twenty-one (37 per cent) of the fifty-eight with "chronic" perforation. The main reason for early operation in the "chronic" group was obstruction; 21 per cent failed to empty their stomach immediately or soon after omentopexy and half as many either had pain or bled severely within twelve months and also required reoperation. The "acute" and "chronic" groups continued to differ in their need for further operation. Overall, 57 per cent of the ninety-seven patients required a definitive operation one to twenty-four years later. However, only ten of the thirty-nine patients (26 per cent) in the "acute" group required definitive operation as compared with forty-five of the fifty-eight patients (77 per cent) in the "chronic" group. Outlet obstruction of the stomach was the main indication for definitive surgery in twenty-six of the fifty-five (47 per cent) reoperations. This high incidence of gastric obstruction after omentopexy was not peculiar to our institution since, over the past six years, eighteen patients having omentopexy elsewhere had to be operated on for this complication. We recommend that patients with "chronic" perforation should not undergo omentopexy but rather immediate vagotomy and a drainage procedure.

Long-term randomized prospective comparison of Finney and Heineke-Mikulicz pylorplasty in patients having vagotomy for peptic ulceration.

Two hundred patients undergoing vagotomy for duodenal ulceration over a period of forty-three months were randomly given Heineke-Mikulicz or Finney pyloroplasty. One died of a myocardial infarction twenty-four fhours after operation, six-teen died within seven years from conditions unrelated to surgery, nine were lost to follow-up study, and 174 were followed up an average of 5.2 years. These patients were evaluated for signs and symptoms of recurrent ulceration or complications of their operation. A majority underwent postoperative secretoay and gastric emptying studies. The proved rate of ulcer recurrence was higher in patients with Heineke-Mikulicz pyloroplasty (4 per cent versus 2 per cent); however, over-all recurrence (proved, probable, and possible) was 13 per cent in each category. The dumping syndrome, seen in 14.4 per cent with Heineke-Mikulicz and 10.7 per cent with Finney pyloroplasty, was the most common complication...

Interposition grafting for portal hypertension.

During the past six years, thirty-seven patients underwent interposition graft shunting for thirty-three instances of bleeding from varices and five instances of intractable ascites, either electively (twenty-seven instances) or as an emergency (eleven instances). Autogenous jugular vein was used in twenty-five instances, homologous vena cava in nine, and Dacron in four. Portacaval and mesocaval anastomoses were done in equal numbers (nineteen). Using Childs' method of clinical evaluation, thirty-three patients were Class C and four Class B. There were five (13.2 per cent) early deaths with one (3.5 per cent) in the elective and four (36 per cent) in the emergency group. Twelve grafts were open at autopsy, fifteen at splenoportography, and seven assumed patent because patients were asymptomatic. Two Dacron grafts and two homografts thrombosed. There were ten late deaths, only one related to graft failure. Apparently, the operation controls ascites, with autogenous jugular vein being the ideal material. Interposition grafting is a simple, safe procedure that can be used for portal decompression in patients with bleeding varices.

Total infrarenal aortic occlusion.

Our experience from 1960 to 1976 with total infrarenal aortic thrombosis (Leriche syndrome) was reviewed. Sixteen heavy smokers (14 men and 2 women) with an average age of fifty-four years underwent thrombectomy with aortoiliac (12 patients) or aortofemoral (4) Dacron bypasses. The last ten patients were hydrated for 12 hours preoperatively with 3,000 ml of Ringer's solution containing supplemental potassium. Mannitol (25 g), furosemide (20 mg), and heparin (120 u/kg) were given intraoperatively. Thrombectomy was accomplished by transection of the aorta, with proximal manual control of the aorta after the renal arteries were occluded. With this technic there were no deaths or renal complications, whereas previously, three of the six patients developed renal complications and one died. Ninety-two per cent of the grafts have remained open. We recommend that the direct transabdominal approach be continued rather than the extraanatomic bypass (axillobilateral-femoral), since further propagation of the aortic thrombosis may then lead to infarction of the kidneys or other viscera.

Activated clotting time (ACT) monitoring of intraoperative heparinization in peripheral vascular surgery.

We conclude that (1) the activated clotting time (ACT) is an accurate method of monitoring anti-coagulation during peripheral vascular surgery and can easily be performed by a technician in the operating room or at the bedside; (2) an initial heparinizing dose of 120 to 130 units/kg is adequate in 95 per cent of the patients; (3) the ACT should be maintained at greater than twice the control values (180 to 200 seconds), which required supplementation within 2 hours in 21 per cent; (4) the response to heparin is twofold: an initial sensitivity or resistance followed by an independent and variable rate of consumption; (5) the patient's heparin dose-response curve should be used to calculate the amount of supplemental heparin needed to maintain the ACT at a safe level; (6) protamine should be given if the ACT at the conclusion of the operation is greater than 150 seconds (50 per cent of our patients); and (7) a final ACT 15 to 30 minutes postoperatively should be obtained to ensure adequate reversal or to detect heparin rebound or depletion of clotting factors.

Treatment of postoperative reactive hypoglycemia by a reversed intestinal segment.

Eleven men with disabling reactive hypoglycemia, in a range of 12 to 50 mg per 100 ml, were treated an average of seven years after gastric surgery with a 10 cm reversed jejunal segment. The reversal was placed at the gastric outlet in six patients and just below the ligament of Treitz in five. The former technic produced a somewhat better correction of hypoglycemia than did the latter. A good result was obtained in all eleven and none has had recurrence of seizures or fainting. Whereas the average minimal blood sugar before reversal was 34 mg per 100 ml, after reversal it was increased to 64 mg per 100 ml. The most severe hypoglycemia was noted in a patient after vagotomy and pyloroplasty. We recommend that all patients with dumping syndrome undergo glucose tolerance tests and plasma insulin determinations to ascertain whether they have reactive hypoglycemia. It is our conclusion that introduction of a reversed jejunal segment can control refractory reactive hypoglycemia resulting from previous gastric surgery.

The role of profundaplasty in revascularization of the lower extremity.

Profundaplasty has been performed on 112 limbs (88 primary and 24 secondary) in eighty-five men. Seventy-six limbs had incapacitating claudication, twenty-three rest pain, and thirteen either gangrene or ischemic ulceration. In thirty-six limbs treated by profundaplasty alone there were no deaths but five subsequently had amputation for ischemic pain. In the seventy-six limbs treated by profundaplasty plus other operative augmentation there were three operative deaths and one late death; three required further operative surgery and in four amputation was necessary. Oblique arteriographic films of the femoral area are essential for evaluation of the profunda femoris artery. Both radionuclide and Doppler pressure studies confirmed physical and arteriographic findings. The latter would appear superior because of ease of availability and cost. After profundaplasty alone and aortofemoral bypass there was a moderate increase in calf blood flow, but in only those with a patent superficial femoral artery did blood flow and pressure studies return to within normal limits. Profundaplasty is an important addition to the armamentarium of the vascular surgeon in dealing with arteriosclerotic insufficiency of the lower extremities.

Acute perforations of the sigmoid colon secondary to diverticulitis.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.

Age and morbidity of vagotomy with antrectomy or pyloroplasty.

Seven hundred ninety-three vagotomies with either pyloroplasty (645 patients) or antrectomy (148 patients) were reviewed between 1970 and 1981. Mortality was lowest with elective pyloroplasty (0.4 percent) followed by elective antrectomy (0.7 percent), and emergency pyloroplasty (5.1 percent). The risk of death was significantly higher (p less than 0.05) for the older half of the population (older than 55 years of age). Major morbidity was lowest after elective pyloroplasty (6.3 percent) when compared with elective antrectomy (10.6 percent), and greatest after emergency pyloroplasty (18.1 percent). Proved ulcer recurrence was most frequently seen after pyloroplasty (4.5 percent) and least frequently seen after antrectomy of age) had a significantly decreased risk of ulcer recurrence (p less than 0.001). Disabling sequelae occurred in 3.6 percent of those who underwent pyloroplasty, in 5.6 percent of those who underwent antrectomy with Billroth I reconstruction, and in 8.5 percent of those who underwent antrectomy with Billroth II reconstruction. Significantly more patients who underwent antrectomy with Billroth II reconstruction required reoperation (p less than 0.01) than did those who underwent either pyloroplasty or antrectomy with Billroth I reconstruction. Although antrectomy has become a popular operation, vagotomy combined with pyloroplasty is still the procedure of choice in patients over the age of 55 years. In those requiring emergency operations for duodenal ulcer, and in those in whom antrectomy is technically difficult because of a badly scarred duodenum. Billroth II reconstruction should be avoided after vagotomy and antrectomy.