Duodenal Obseruction;
Congenital Duodenal Obstruction; a Review of 65 Cases.
Frankin J. Harberg, Willam J. Pokorny and Herbert Hahn. Am. J. Surg., 1979, 138:825.
Sixty-five patients with congenital duodenal obstruction seen over a 20 year period are reported. Intrinsic defects consisting of doudenal atresia, stenosis and diaphragm occurred in 36. The remainder had extrinsic defects, such as malrotation, annular pancreas and isolated peritoneal band.
Those with intrinsic defects were admitted at an average age of seven days, while those with extrinsic defects were older. Intrinsic defects were also commonly associated with low-birth weight, trisomy 21 syndrome and other serious malformations.
The most common operations performed were duodenojejunostomy for intrinsic lesions and annular pancereas and Ladd\'s operation for malrotation. There were five deaths occurring in babies with low birth weight and other congenital anomalies. The authors conclude that modern surgical and supportive therapy give good results for operations for these malfoimations.
William G. Annan.

Subphrenic Absess
Subphrenic Abscess (Les abces sous-phreni-ques) M.P. Many Bord. Med., 1979, 12:1633.
Among thirty-eight intraabdominal abscesses operated upon in a seven year period, 21 were subphrenic abscesses directly below and in connection with the diaphragm. On six occasions the abscesses were multiple. Four left subphrenic abscesses were associated with retrogastric or intermesenteric abscesses, and two right subphrenic abscesses were associated with subhepatic abscesses. The causes were as follows: six subphrenic were associated with biliary tract operations, three right subphrenic abscesses followed trauma to the liver. Splenectomy and acute panereatitis each accounted for two left subphrenic abscesses. Hemipanereatectomy and a perforated peptic ulcer each accounted for one left subphrenic abscess. Two abscesses on the right side and one on the left followed acute appendicitis. One on each side followed intestinal resections and one left subphrenic abscess followed a caesarean section complicated by peritonitis.
Diagnosis was established in five patients by fistulography into the site of a drain tract. Needle aspiration was used in two patients as a diagnostic method, as well as for the injection of antibiotics. The most valuable diagnostic methods were echograms and Gallium 67 scans. Liver and lung scans were sometimes useful in demonstrating a space occupying lesion under the right diaphragm.
Treatment consisted of transthoracic drainage using the most direct approach to the lesion. Of 11 right subphrenic abscesses, four were drained through the bed of the 11th rib, six through the bed of the tenth rib, and one drained spontaneously. Of the ten surgically drained right subphrenic abscesses, eight had extrapleural drainage and two transpleural drainage. Of ten left subphrenic abscesses, six were drained through the bed of the tenth rib and four through the bed of the 11th rib. Five were drained extrapleurally and five transpleurally.
Fredenck W. Preston.

Breast Cancer
Early Detection of Ductal Breast Cancer; the Diagnostic Procedure for Pathological Discharge from the Nipple. Gunther Kindermann, Eberhard Pathor, Junus Weishaar and others. Tumori, 1979, 65:555.
Other than a lump, skin retraction or pain in the breast nipple discharge is the most common complaint of patients with breast problems. Serosanguinous, watery and bloody discharges in nonpregnant patients may be caused by carcinoma. The color of the discharge is of little value for the diagnosis. Cytologic speicmens may be valuable but are not toally reliable. The method of choice is galactography-ductography, contrast-mammography. Experience with this method since 1964 is reported.
When the pathologic discharge from the nipple is the only symptom of an early stage of carcinoma, glaactography is the diagnostic method of choice to locate intraductal, nonpalpable lesions. The technique of galactography, the adequate surgical approach of pathologic galactographs, milk-duct segment resection and the appropriate histologic work-up study of the surgical specimen are demonstrated. One thousand, nine hundred and eighteen galactographies in 1,363 women with pathologic discharge are discussed. In only 427, 31.4 per cent, patients was a milk ductsegment resection necessary. In 8.5 per cent of the patients, they found invasive intraductal carcinoma and in 2.9 per cent, ductal carcinoma in situ. Only one patient with carcinoma of the breast had axillary metastases. Extensive intraductal solid, papillary or adenomatous proliferations were found in 11.9 per cent of the patients with excision. In 46.7 per cent of the patients, papillomas were excised, a definitive treatment for this process. The requirement for success in the early diagnosis of carcinoma is close teamwork among the radiologic surgical and pathologic-services; the diagnostic result depends upon this. The authors attribute their yield of exact diagnosis to a very sophisticated histologic work-up study.
Donald M. Clough.

Operative Cholangiography
Operative Cholangiography; Review of 7,529 Operations on the Biliary Tree in a Community Hospital.
H. Joseph Honday, Join L. Farringer, Jr. Richard B. Terry and Dawid R. Pickens, Jr. Am. f. Surg., 1980, 139:379.
This report is a retrospective analysis of 7,529 patients who underwent operations on the biliary tract. Five thousand and ninety-five cholecystectomies were performed during the years 1958 through 1967. Only 179 patients,  3 per cent, had pre-exploratory cholangiography,  and 88 per cent of these were satisfactory in quality. In comparison with operative findings, there was a false-negative of 1.4 per cent and false-positive of 22 per cent in the cholangio-graphy interpretation. During the period 1968 through 1976, 51.7 per cent of patients who underwent cholecystectomy had pre-exploratory cholangiography, of which 96 per cent were satisfactory in quality. The accuracy of cholangio- graphy was 85 per cent and the false-negative results were 1.9 per cent. In the second period of study, when 284 patients with both common bile duct exploration and pre-exploratory chol-angiography were anlyzed, the cholangiography interpretation was accurate in 82 per cent of the patients. Routine use of operative cholangiography in conjunction with clinical and operative criteria is recommended.
Stephen C. Lau.

Contraceptives and Tumours
Oral-Contraceptive-Associated Liver Tumours; Occurrence of Malignancy and Difficulties in Diagnosis.
James Neuberger, B. Portmann. Heather B. Nunneriey and others. Lancet, 1980, 2:273.
This is a report of ten oral contraceptive associated hepatic neoplasms treated at the Liver Unit of King College Hospital, London, Seven of the neoplasms were malignant and three, benign adenomas.
Diagnosis was found to be often delayed with symptoms initially interpreted as being caused by cholecystitits, peptic ulcer or angina pectoris. Examination at the time of adminision to the liver unit found an enlarged liver in most patients. Laboratory investigations disclosed elevated erythrocyte sedimentation rate, markedly elevated alkaline phosphatase and normal alpha-fetopro-tein. Tehcnetium sulphur colloid scans disclosed a filling defect in all patients with malignant growths. In the benigns group, two of three scans failed to disclose a filling defect.
Treatment was by partial hepatectomy, hepatic artery ligation or embolization, resection, transplanation and cytotoxic drug therapy. All patients with benign adenomas did well. Four of the seven with carcinoma died of their disease. Two patients, who continued to take oral con­traceptives after resection, developed recurrences in the remaining blobe of the liver.
William G. Annan.

Bile Duct Repair
Experimental Experiences in Common Bile Duct Repair, Using Five Different Materials.
R. Kirchner. II. Hartung, A. Oswald and others. Chr. Gastroenterol, 1979, 13:73.
The aim of this investigation was to find a method to treat benign strictures of the common bile duct while preserving the function of the sphincter of Oddi. In dogs, the following materials were used in patchplasty: knitted Teflon polytetrafluoroethylene; woven Teflon and Dac-ron, polyester; modified bovine arterial hetero-graft, and human umbilical cord. In patch widening plasty with knitted Teflon, pore size of 3Cu, the graft was covered with a bile duct epithelium within four weeks after replacement without any shrinking or occlusion over a period of two years. Using the other four materials mentioned above, no epithelialization could be observed and occlusion of the common bile duct following, precipitation of bile salts was frequent.
E. Theodore Palm.