Effects of methylprednisolone on hydrogen ion absorption in the canine stomach.

The effect of methylprednisolone (2 mg/kg per day given parenterally for 3 doses, 2 wk or 12 wk) on the permeability of mammalian gastric mucosa to hydrogen ion (H(+)) was examined with denervated fundic pouches in dogs with antrectomies. Transmucosal electric potential difference (PD) and net fluxes of H(+) and Na(+) were determined for luminal [H(+)] from 20 to 160 mM and [Na(+)] from 1 to 140 mM ([H(+)] and [Na(+)] were varied reciprocally). The PD was 50-60 mV lumen negative and was constant over the entire range of Na(+) and H(+) concentration tested. Net H(+) flux varied linearly with [H(+)]. Extrapolation indicated apparent H(+) loss at zero luminal concentration, suggesting a basal HCO(3) (-) secretion. Addition of acetylsalicylic acid (ASA) or taurocholate decreased the PD to 30-40 mV and increased threefold the slope of the relation between net H(+) flux and [H(+)] (k(H)). Calculation of PD-independent permeability constants for H(+) (P(H)) with the Goldman constant field equation indicated that this increase in k(H) could not be attributed solely to the associated decrease in PD. Prednisolone administered for 3 doses had no effect on either the basal mucosal permeability to H(+) or the altered permeability induced by ASA or taurocholate. Chronic administration induced a low rate of basal acid secretion (at 12 wk) but had no effect on either PD or k(H). However, the increase in k(H) and P(H) that developed upon addition of ASA or taurocholate in chronically treated dogs was more than one and a half times that of controls. These data suggest that prolonged treatment with glucocorticoids increases susceptibility of the gastric mucosa to damage by agents that increase permeability to H(+).

Recurrence in the breast following conservative surgery and radiation therapy for early-stage breast cancer.

This report summarizes the experience of the Joint Center for Radiation Therapy (JCRT) in treating patients with clinical stage I and II breast cancer with conservative surgery and radiation therapy. The study population consisted of 1396 patients treated between 1968 and 1985. All patients underwent a gross excision of the tumor and received breast irradiation (with or without nodal irradiation) including a "boost" to bring the primary tumor site to a total dose of at least 60 Gy. The method of treatment evolved over the study-time period. During the interval from 1968 to 1982, patients typically underwent a limited gross excision of the tumor without regard to the microscopic margins of resection. During the period 1983 to 1985, film-screen mammography, inking of specimen margins, and reexcisions for inevaluable or involved margins were more commonly performed. With a median follow-up of 80 months, the 5-year crude rate of failure in the breast (as the first site of failure) was 8% (106/1396) and the crude rate of regional nodal/distant failure (as the first site of failure) was 16% (228/1396). The time-course of failures in the breast was protracted, occurring at a fairly constant rate over the first 7 years after treatment, but still seen beyond that point. Most recurrences in the breast (75%) developed at or near the original tumor site. The most important risk factor for developing a breast recurrence was the presence of an extensive intraductal component in the tumor. The cosmetic results following treatment were excellent or good in the majority of patients (87%) and were most adversely affected by extensive surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathogenetic factors in erosive gastritis.

Under physiologic conditions, luminal acid and pepsin are absolute requirements in the development of erosive gastritis and ulceration. Even the injurious effects of most drugs are potentiated by acid and pepsin. Although the importance of luminal acid has long been recognized, only in the last 10 years has evidence accrued showing the detrimental effects of tissue acidosis in producing injury to the gastric mucosa. It now seems clear that by whatever means it is produced, e.g., through reduced mucosal blood flow, metabolic or respiratory acidosis, or inhibition of acid secretion with subsequent decreased "alkaline tide," tissue acidosis plays a profound role in the pathogenesis of erosive gastritis and ulceration. The gastric mucosal barrier is now recognized as the anatomic integrity of the surface epithelium, rather than as an ethereal physiologic barrier. This barrier is maintained as an intact layer under physiologic conditions by a newly described rapid repair process called restitution.

Time-course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer.

The time-course of local failure following conservative surgery and radiotherapy (S+RT) for early breast cancer is not well established. We therefore examined the time-course and patterns of breast recurrence as a first site of treatment failure in a group of 607 AJCC clinical Stage I or II invasive breast carcinomas treated from 1968-81. Sixty-seven patients had a breast failure (11%), corresponding to 5- and 10-year actuarial rates of 10% and 16%. The hazard rate (i.e., the risk per unit time of a failure) for any breast failure increased over the first 2 years, was fairly constant at about 2.5%/year over the period from 2 to 6 years after treatment, and then decreased to about 1%/year at 8 years. The majority of failures were at or near the primary tumor site (33 true recurrences (TR) and 15 marginal misses (MM). In addition there were 12 failures at sites at least several cm from the boosted volume (E), 6 recurrences in the skin without a parenchymal mass (S), and 1 patient with an unclassifiable failure. Recurrences at or near the primary site (TR/MM) occurred earlier (median 38.5 mo, range 12-87 mo) than recurrences at distant sites in the breast (E) (median 64.5 mo, range 26-90). The hazard rate for TR/MM increased over the first 2-1/2 years to reach approximately 2%/year, remained at that level till about 5 years after treatment, and then decreased to about 0.5%/year at 8 years following RT. By contrast, the hazard rate for E increased slowly with time to approximately 1%/year at 5 years, with little change in the rate after that time. We conclude that the time-course of the development of local recurrence after S+RT is protracted. The majority of failures appear at or near the primary tumor site; these are seen mainly in the first 7 years following RT. Recurrences at distant sites in the breast have an even more protracted time-course. Such recurrences are rare in the first 4 years following RT. Our results emphasize the need to obtain long follow-up in these patients, both to detect these recurrences promptly and to properly evaluate the results of S+RT.

Axillary sampling in the definitive treatment of breast cancer by radiation therapy and lumpectomy.

Between January, 1967 and July, 1980, 176 women who were referred to the Joint Center for Radiation Therapy (JCRT) for definitive breast irradiation underwent low axillary dissection. A typical operative technique is described. The dissection stops short of the axillary vein although the vein is usually visualized. One hundred thirty-two axillae were thought to be N0 or N1a. Forty-six axillae were felt to be N1b. Seventeen percent of the T1 N0 patients had pathologically positive nodes. Twenty-seven percent of the T2 N0 patients had positive nodes. When 5 or less nodes were removed at axillary sampling the incidence of nodal involvement was very low. There were no differences in nodal positivity when comparing upper quadrant to lower or central lesions. Lateral lesions appeared to have higher positivity rates compared with either medial or central lesions. Ninety-four percent of axillae with N1b lesions were pathologically confirmed. The complication rate for this procedure was low. There were 5 transient non-surgical complications and 1 cellulitis resulting in a frozen shoulder, which required corrective surgery. There were no cases of moderate or severe arm edema. Axillary sampling is compared to axillary dissection as a diagnostic procedure. Axillary sampling may underestimate the true pathologic positive rate, but diagnostic accuracy appears excellent if level 1 and 2 nodes are sampled.

Edema of the arm as a function of the extent of axillary surgery in patients with stage I-II carcinoma of the breast treated with primary radiotherapy.

Edema of the arm can be a significant complication following treatment of breast cancer. To determine the risk of arm edema and factors associated with this risk in patients treated with primary radiotherapy, we reviewed the records of 475 women with early breast cancer treated between 1968 and 1980. During this period, the use of axillary surgery prior to radiation gradually increased, and all patients received full axillary irradiation until late in the series. Based on the surgeon's report, the extent of axillary surgery was classified as either a sampling, a lower dissection, or a full dissection. Edema of the arm was scored on clinical grounds and ranged from mild hand swelling to an increased arm circumference of 8 cm. At 6 years, the actuarial risk of developing arm edema was 8% for the entire study population. This risk was 13% for 240 patients who had axillary surgery and 4% for 235 patients not undergoing axillary surgery (p = 0.006). For patients undergoing axillary surgery, the risk of arm edema was 37% with full dissection compared to 5% with sampling (p = 0.0003), and 8% with lower dissection (p = 0.03). The risk of arm edema at 6 years was 28% if more than ten nodes were removed, and 9% if one to ten nodes were removed (p = 0.03). However, the extent of axillary dissection was stronger predictor of subsequent edema than was the number of nodes obtained. The role of axillary irradiation could not be evaluated since 91% of patients received axillary irradiation. The use of chemotherapy, the site or size of the primary tumor, clinical nodal status, patient age and weight, type of suture, the use of a drain, and subsequent local or distant failure did not appear to be significant risk factors. We conclude that the combination of full dissection and full axillary irradiation results in an unacceptably high risk of arm edema.

Surgical pathology of hyperparathyroidism. Usefulness of fat stain and problems in interpretation.

Thirty-six adult patients with classical hyperparathyroidism had parathyroidectomy in which tissue evaluation included oil red O stains. Neutral lipid staining has been reported to distinguish hyperfunctioning parathyroid from suppressed or normal tissue. In normal glands, parathyroid chief cells show abundant coarse and fine intracytoplasmic neutral lipid droplets. In contrast, the cytoplasm of chief cells is essentially free of neutral lipid droplets in adenomatous, hyperplastic, or carcinomatous glands. This study shows that to limit or alter surgical exploration solely on the basis of the findings of the oil red O technique will lead to significant judgmental error (6/36 patients). Such errors are especially likely in the patient who has enlarged parathyroid glands containing a normal distribution of parenchymal to adipose tissue. There was excellent agreement between clinical outcome, surgical-pathological findings, and the oil red O stain in 30 cases of parathyroid adenoma, nodular hyperplasia, and a control group (12 patients) who had biopsies of normal parathyroid tissue during the course of thyroidectomy.

Functional studies of in vitro rat distal colon before and after restitution.

BACKGROUND: Epithelial injury occurs in many acute and chronic diseases of the colon and from simple mechanical and chemical injury in the normal colon. Because epithelial repair is so important, we developed a highly reproducible, entirely in vitro model of restitution in rat distal colon. METHODS: The muscosal surface of colon mounted in Ussing chambers was exposed to 1.5 mol/L NaCl (hypertonic saline, HS) for 10 minutes. Transepithelial potential difference, electrical resistance, and short-circuit current were used to measure return of electrophysiologic characteristics of the tissue during recovery from injury. Recovery of the barrier to transepithelial movement of large molecules was assessed by measuring mannitol and inulin permeability. Na+ and Cl- absorption and forskolin-induced Cl- secretion were used as indicators of functional recovery of the colonic mucosa after HS injury. Morphologic evaluation of tissues was performed by light microscopy and transmission electron microscopy. RESULTS: HS treatment caused marked increases in mannitol and inulin permeability together with exfoliation of colonocytes from the surface and upper crypts, leaving long stretches of denuded basal lamina. Epithelial continuity was morphologically reestablished in 30 to 60 minutes, concomitant with return of permeability to control levels. Potential difference, electrical resistance, and short-circuit current decreased with injury and then gradually recovered, although not to preinjury level. Net Na+ and Cl- absorptions, present in undamaged tissues at approximately equivalent rates, decreased after restitution. Forskolin-stimulated Cl- secretion, present before injury, was abolished after restitution. CONCLUSIONS: These studies describe a highly reproducible in vitro model of injury and restitution of a fully organized epithelium of rat distal colon. Although morphologic continuity and barrier properties recover after extensive superficial mucosal injury, the surface is repopulated by cells displaying transport properties and ultrastructural characteristics distinct from the surface epithelium of undamaged tissues.

Effects of lysolecithin on isolated gastric mucosa.

The effects of lysolecithin, a normal constituent of duodenal juice, on gastric mucosa were measured under isolated conditions. In a relatively low concentration (0.5 mg/ml), lysolecithin, added to the luminal side, caused liberation of organic acids without altering the spontaneous rate of mineral (i.e., HCl) acid secretion by fundic mucosa. The low concentration of lysolecithin also did not appear to affect other active ion transport processes or permeability of either fundic or antral mucosa. However, at a higher concentration (1 mg/ml) lysolecithin inhibited spontaneous mineral acid secretion by fundus, altered active transport of other ions, and increased mucosal permeability of both fundic and antral mucosa. The results suggest that intraluminal lysolecithin in concentrations found in vivo may contribute to gastric mucosal damage.

Effect of bile salts and related compounds on isolated esophageal mucosa.

The effect of several potentially harmful agents in gastric juice and duodenal contents on esophageal mucosa was investigated in the presence or absence of luminal H+ using an in vitro technique. Isolated rabbit esophageal mucosae were incubated in an Ussing chamber, and during exposure to the test agents mucosal integrity was assessed by measurement of mucosal potential difference (PD), tissue electrical resistance (R), and when luminal acid was present, the tissue permeability to H+. At pH 3.5 taurocholate caused a marked decrease in the PD and R and a substantial increase in the rate of luminal H+ loss. This effect was dependent on the presence of luminal H+, since no changes were observed with taurocholate at pH 7.4. In contrast, two of the three deconjugated bile salts tested at pH 7.4, deoxycholate and chenodeoxycholate, caused a profound reduction in the PD and R, similar to that observed with taurocholate in the presence of H+. Pepsin in the presence of H+, lysolecithin to a lesser degree, and trypsin in the absence of H+ also adversely affected isolated esophageal mucosa, but the effects were less pronounced than those caused by bile salts. Our data suggest that different mechanisms are operative in the pathogenesis of acidic and alkaline reflux esophagitis. In the presence of gastric H+, pepsin, and conjugated bile salts are the substances responsible for the greatest injury. In contrast, when acid is absent, trypsin and especially deconjugated bile salts are more crucial pathogenetic factors.

Effect of luminal pH and nutrient bicarbonate concentration on restitution after gastric surface cell injury.

Frog fundic mucosas whose surface layers were severely injured by exposure to 1 M NaCl for 10 minutes in an Ussing chamber uniformly recovered both physiologically and anatomically within 4 to 6 hours. The purpose of the present study was to examine the effects of luminal H+ and nutrient HCO-3 concentrations on this process of reconstitution. With 18 mM HCO-3, return of the transmucosal potential difference, tissue electrical resistance, and short-circuit current toward normal and anatomic recovery occurred at luminal pH of 7.4, 5.0, and 4.0 but not at 3.0. An inhibitor of pepsin did not favorably affect the outcome of luminal pH 3.0, but a nutrient HCO-3 concentration of 47.8 mM completely prevented the adverse effects of luminal pH 3.0. Reconstitution of epithelial integrity did not occur in the absence of HCO-3 at luminal pH 4.0. Thus, low luminal pH inhibits and high nutrient HCO-3 concentration supports the epithelial restitution after mucosal damage caused by hyperosmolar NaCl.

H+ back diffusion stimulating gastric mucosal blood flow in the rabbit fundus.

The effect of barrier breakers on gastric mucosal blood flow (MBF) has been disputed, but the influence of acid back diffusion alone has never been studied. In anesthetized New Zealand white rabbits, intramural pH (pHi) and gastric MBF were measured with an antimony microelectrode and with radioactive microspheres (51Cr, 85Cr, 141Ce), respectively. Innervated fundic pouches were perfused with solutions of varying [H+] at 37 degrees C. In the rabbit, back flux of H+ is linearly dependent on luminal [H+] and in the present studies a direct positive linear correlation was found between luminal [H+] and MBF (r = 0.97 P < 0.001) while pHi remained unchanged up to luminal [H+] of 80 mM. The usual 80% increase in MBF induced by 80 mM HCl was prevented by pretreatment with vasopressin, which decreased pHi and caused gross ulceration. Without vasopressin, [H+] of 120 mM HCl produced gross mucosal ulceration and a decrease in MBF and pHi. Our data suggest that back diffusion of H+ influences MBF in the rabbit. There is an increasing MBF caused by increasing luminal [H+] up to 80 mM, beyond which MBF decreases. When the balance between back diffusion and MBF is disturbed by a vasoconstrictor or a high luminal [H+], pHi decreases and gross ulceration occurs.

The effect of carbenoxolone on changes in canine and human gastric mucosa caused by taurocholate and ethanol.

The effect of carbenoxolone on taurocholate-induced changes in gastric mucosal permeabiity was assessed in three dogs, each of which was prepared with an antrectomy and a vagally denervated gastric pouch. Perfusion of the canine pouches with sodium taurocholate (40 mM) was associated with an increase in hydrogen ion back diffusion. This effect was not diminished by 10 days of carbenoxolone treatment. The effect of carbenoxolone on ethanol-induced changes in gastric mucosal permeability was assessed in six normal human subjects. A significant increase of gastric mucosal permeability was observed in six normal human subjects after instillation of ethanol (20 percent v/v). After 3 weeks of oral ingestion of carbenoxolone, there was inconsistent protection against ethanol-induced increases in gastric mucosal permeability. Basal secretion of hydrogen ion and postethanol hydrogen ion secretion appear to be diminished by carbenoxolone. These studies suggest that carbenoxolone does not protect against taurocholate- and ethanol-induced increases in gastric mucosal permeability in the dog and in man. It seems unlikely that carbenoxolone exerts its beneficial effect on the healing of gastric ulcers in man by an effect on gastric mucosal permeability.

Fine-needle aspiration of normal thyroid tissue may result in the misdiagnosis of microfollicular lesions.

BACKGROUND: Inadvertent sampling of normal thyroid tissue surrounding a nodule may occur when clinically inexperienced personnel perform fine-needle aspiration (FNA) or when a nodule is small. Because the cytologic characteristics of normal thyroid tissue are not well known, we prospectively studied 42 patients undergoing thyroidectomy. METHODS: FNA was performed from the grossly normal contralateral lobe during thyroidectomy. Cytopathologists examined the slides without knowing the source of the tissue. RESULTS: FNA of grossly normal thyroid tissue was adequate for interpretation in 32 of 42 patients, and in nine of 42 cases it was interpreted as unremarkable. However, the remaining specimens were classified as microfollicular lesions (18), mixed macromicrofollicular lesions (three), Hürthle cell lesion (one), and papillary thyroid carcinoma (one). CONCLUSIONS: FNA of grossly normal thyroid tissue suggested a microfollicular lesion in 18 (56%) patients, a result that would raise the possibility of a follicular carcinoma and often lead to the recommendation for operation. When FNA is performed, normal thyroid tissue surrounding a nodule should be avoided, and the possibility of a sampling error should be considered when a microfollicular pattern is obtained in a patient with a small nodule.

Isoperistaltic jejunal interposition for intractable postgastrectomy alkaline reflux gastritis.

BACKGROUND: The Roux-en-Y gastrojejunostomy is a popular method in the operative treatment of alkaline reflux gastritis and other postgastrectomy sequelae, but is associated with a high incidence of the so-called "Roux stasis syndrome." The Henley jejunal interposition has been used occasionally, albeit not widely, as an alternative to the Roux-en-Y reconstruction. STUDY DESIGN: Six patients underwent Henley gastrojejunoduodenostomy to treat severe (Visick grade IV) symptoms following Billroth I and II procedures for peptic ulcer disease. All interposed jejunal segments were 40 cm in length and isoperistaltic in orientation. All patients had follow-up examination and telephone interview (mean 4.3 years, range 2.2 to 7.8 years). RESULTS: All patients noted dramatic improvement after remedial surgery in the first year of follow-up. After the first postoperative year, all patients remained virtually symptom-free (Visick grade I and II) with no complaints of gastrojejunal stasis or bile acid reflux. CONCLUSIONS: This experience suggests that the Henley jejunal interposition is our effective method of treating reflux gastritis and is not associated with the poor emptying frequently associated with the Roux-en-Y reconstruction.

The gastric mucosal barrier and ulceration.

The gastric mucosal barrier is that property which defends against acid and which impedes diffusion of acid from the lumen into the mucosa. The disappearance of luminal H+ is linearly related to luminal (H+) both in the normal stomach and in stomachs exposed to barrier breakers. The latter invaribaly produce anatomic evidence of surface cellular injury. Strong direct evidence for back diffusion of luminal H+ derives from the recent demonstration of a highly significant correlation between the disappearance of luminal H+ and the pH of the lamina propria measured by an implanted microelectrode. The permeabilities of the antrum and fundus to H+ differ from each other in the same species and in different species. Gastric ulceration does not occur in the absence of luminal acid and is not dependent upon the absolute loss of H+ from the luminal solution. Mucosal ischemia induced by hemorrhage reduces tolerance against ulceration as does inhibition of acid secretion, acidification of the tissue caused by absence of nutrient bicarbonate, inhibition of carbonic anhydrase, and blockade of anion exchange by SITS. A tentative schema is proposed by which defense against luminal acid is accomplished in gastric mucosa.

Appendectomy in the pre- and postlaparoscopic eras.

The role of laparoscopic appendectomy remains controversial since many authors have suggested that overall morbidity is primarily a function of the degree of appendicitis rather than the operative approach. We have reviewed our appendectomy experience to determine the advantages and/or disadvantages of the laparoscopic technique in cases of acute appendicitis, and furthermore to ascertain whether the extent of disease should affect the surgical approach used. Data were accumulated for all 1158 patients who underwent appendectomy at a single institution during the following three time periods that span the pre- and postlaparoscopic eras: period I (1987 to 1990), period II (1991 to 1993), and period III (1994 to 1997). Cases were categorized with regard to pathologic findings and operative approach (i.e., open or laparoscopic appendectomy). The percentage of appendectomies performed laparoscopically increased with time (0%, 27%, and 79% for periods I, II, and III, respectively). Overall, the total operating room time was slightly shorter for laparoscopic compared to open appendectomy (99 vs. 102 minutes; P<0.05). Operating room times for open appendectomy remained unchanged, but the times for laparoscopic appendectomy decreased from period II to period III (119 to 94 minutes; P<0.001). In cases of gangrenous/perforated appendicitis, the times for laparoscopic appendectomy were significantly shorter than those for open appendectomy (98/115 vs. 120/125 minutes; P<0.001 for both). Overall, the hospital stay was shorter for patients undergoing laparoscopic appendectomy (1.63 vs. 4.21 days; P<0.001), and the difference was maintained in all three time periods. The differences in length of hospital stay for lap-aroscopic vs. open appendectomy were most dramatic in gangrenous/perforated cases (1.8/3.0 vs. 4.0/9.0 days; P<0.001), whereas there was only a slight difference in cases of simple appendicitis, for example, 1.6 vs. 2.1 days (laparoscopic vs. open appendectomy, period III). There was a significant decrease in the percentage of perforated cases in which surgical treatment had been delayed (>8 hours) (21%, 5%, and 5%) over the three time periods, but the rate of "negative" appendectomies was similar (10%, 8%, and 8%). The complication rates following laparoscopic and open appendectomies during period II were 5.4% and 7.5%, respectively (P>0.05). Laparoscopic appendectomy results in a marked decrease in the length of hospital stay and similar postoperative morbidity compared to open appendectomy. In cases of gangrenous or perforated appendicitis, laparoscopic appendectomy appears to be especially worthwhile in regard to both operating room time and hospital stay.

Interval appendectomy in the laparoscopic era.

In the acute setting, patients with periappendiceal masses generally improve with broad-spectrum antibiotics with or without percutaneous catheter drainage, but whether or not to perform an interval appendectomy remains controversial. We have analyzed our experience over the past decade, comparing results from interval laparoscopic appendectomy (ILA) and interval open appendectomy (IOA). Medical records were reviewed for 56 patients who initially presented with the diagnosis of periappendiceal mass or abscess and who subsequently underwent interval appendectomy. Data were accumulated for both the initial hospitalization and interval appendectomy. Comparisons were made between period 1 (1987 to 1993) and period 2 (1994 to 1997). Follow-up data were obtained via telephone conversations with the patients. Patient characteristics with regard to age, sex, and comorbidities did not differ between the ILA and IOA groups. The number of patients undergoing CAT scan increased from 33% to 55%, whereas the initial hospital stay decreased from 7. 42 to 4.61 days (P<0.001). The percentage of interval appendectomies performed by the laparoscopic method increased from 30% to 85%. The total operating room time did not differ (95 vs. 103 minutes), but the hospital stay was much shorter in the ILA group (0.55 vs. 3.07 days, P<0.001). There were no instances of intra-abdominal or wound infections in either group. In the later time period the mean hospital stay decreased to 0.38 days, with 59% of the operations performed on an outpatient basis. Following ILA, narcotic pain medication was used for an average of 1.3 days and the reported "time to return to full activities" was 2.5 days. ILA is a simple and safe procedure that can usually be performed on an outpatient basis. Given the minimal morbidity of the procedure, we believe that ILA should be considered for most patients who initially present with periappendiceal masses.

Bacterial contamination of the biliary tree after choledochostomy.

Secondary exogenous contamination of bile after choledochostomy could be an important cause of long-term morbidity if infection persists after removal of the T tube. Surprisingly, documentation of the frequency of conversion of sterile to infected bile after choledochostomy has rarely been recorded. Patients undergoing exploration and T-tube drainage of the common bile duct between July 1966 and January 1975, in whom intraoperative and postoperative cultures of bile were available, were studied. Postoperative cultures were obtained from five to forty days after operation. Of ninety-five patients available for study, contamination developed postoperatively in previously sterile bile in 44 per cent. The common duct bile contained bacteria at operation in 42 per cent and remained sterile throughout in 14 per cent. The most common secondary contaminants were klebsiella group and Escherichia coli. The fate of the contaminating organisms in a biliary tree without anatomic abnormalities is unknown. Two cases are presented which suggest that persistent infection may linger in the biliary tree for many years and give rise to pigment calculi. Since bacterial cannot be eradicated so long as a foreign body remains in the common duct and because such bacteria may cause symptoms even in an anatomically normal biliary tree, we suggest that a closed system of biliary drainage be employed and that appropriate antibiotic therapy be instituted for seven to ten days after removal of the T tubes.

Lessons of parathyroid reoperations.

The case histories of the 23 patients in this series demonstrate the importance of a systematic approach to parathyroid surgery. Ligation of the superior thyroid vessels and mobilization of the upper pole of the thyroid are often necessary to find the superior parathyroid glands that are located on the posterior surface of the thyroid. Devascularization of the thyroid gland does not occur with this maneuver because of abundant collateral circulation from the inferior thyroid artery and tracheal vessels. Normal appearing parathyroid glands should not be resected because this procedure does not treat hypercalcemia and may leave the patient with insufficient parathyroid tissue if an adenoma is found at a later date. Bilateral cervical exploration [35,36] is performed before resection of any abnormal appearing parathyroid tissue. Patients may also have supernumerary parathyroid glands [16], especially in the inferior cervical and superior mediastinal areas that are associated with the thymus [37,38].