Choledochoduodenostomy (CDD) has been reported as a more effective treatment of CBD stones than T-tube drainage but it is regarded as a last resort or obsolete therapeutic method due to fears of higher mobidity, cholangitis, “sump” syndrome and liver dysfunction. We aimed to assess the aforementioned issues analyzing prospectively our experience from 1976 through Dec.92. Methods: CDD was performed in 89 females and 36 males, aged 60.2±8.7 years, 26 during repeat surgery. Duct stones were the indication in 94, Sphincter of oddi (SO) dysfunction in 23 and obstructive pancreatitis nodule in 8. Peroperative liver biopsies were obtained in 44 patients. The “follow-up” schedule (> 2.5 years in 110) included clinical interview and LFT's on an yearly basis. Ultra sound (USG) was obtained every one or two years. ERC was done in 10 symptomatic patients and in 25 others for protocul purposes. Liver biopsies were taken four to nine years post surgery in 11 patients-five at relaparotomy for non-biliary causes and six percutaneously by fine needle. Ductal mucosa biopsy could safely be performed in one patient 10 years after surgery. The long-term results were classified as excellent, good, fair or poor. Poor meant the need for further invasive therapy (resurgery or EST). Results: There were two operative deaths (1.6%). The long-term results (123 survivors) were considered excellent in 89, good in 22, fair in 9 and poor in three. Three patients died from unrelated causes and eight others ceased the “follow-up” evaluation three to five years post surgery. All of them were considered as having excellent or good results. A widely patent anastomosis of approximately 20 mms without mucosal inflammatory changes was documented in every patient assessed via ERC. food “debris” was detected within the distal duct of four patients yet it was easily flushed through the stoma. Normal tissue patterns were observed in all long-term liver biopsies. Likewise the ductal mucosa biopsy failed to reveal any acute or chronic inflammatory changes. Conclusions: 1) CDD is ahighly effective short and long-term treatment of CBD lithiasis.2) It does not lead to bacterial or “chemical” cholangitis, to “sump” syndrome or to hepatic dysfunction, provided a wide anastomosis is accomplished.3) CDD should only be considered as obsolete after extensive, long-term, prospective, randomized assessments of laparoscopic or combined laparoendoscopic approaches have been shown to be as effective as or superior to CDD.

Malnutrition is a frequently observed complication of total gastrectomy. Does the mode of reconstructing the alimentary tract bear part of the responsibility? We assessed our experience from January 1975 to 1992 to analyze this issue. A series of 64 total gastrectomy patients [40 men, 24 women; aged 59 +/- 11 (SD) years] were considered. Preoperative and periodic follow-up evaluations were prospectively documented: upper gastrointestinal series, endoscopic examination, complete blood count, serum and liver biochemistry profiles, serum proteins, tranferrin, serum iron and calcium, iron-binding capacity, oral glucose tolerance test, ultrasonography or computed tomography, actual and ideal body weight and performance (AJCC/UICC) assessments. Symptoms were classified by means of Cuschieri's scoring system. Esophageal mucosal changes (edema, hyperemia, erosions, ulcerations) were documented on endoscopy. There were 36 of 58 operative survivors who had no evidence of tumor recurrence and were available for long-term evaluation (12-132 months). An RY loop had been constructed in 25 patients, 5 with a Hunt pouch; 9 had an isoperistaltic jejunal interposition (IJI), 4 with a Kock pouch; and 2 had a Braun loop. A 60 to 70 cm long jejunal limb was always utilized. Statistical analyses were obtained by means of the Student t-test and the equality of medians test. Progressive malnutrition was observed in patients with the Braun (omega) loops, both patients displaying persistent esophagitis and dietary restrictions. Both recovered ideal body weight after remedial surgery that transformed the omega loop into an RY loop. Both RY and IJI loops effectively prevented alkaline esophagitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive malnutrition has been reported as a long-term consequence of total gastrectomy (TG), possibly related to the mode of reconstructing the intestine. In reviewing our personal experience (1975-Sept. 91), we attempted to correlate the reconstructive technique used with the subsequent course of the patient. A consecutive series of 62 TGs (59 adenocarcinomas, 3 lymphomas) in 38 males and 24 females 59 +/- 11 (m Mean +/- SD) years old was reviewed. Preoperative and "follow-up" evaluations, including upper gastrointestinal series and/or endoscopic examination, complete blood count, serum and liver biochemistry profiles, serum iron and plasma transferrin, oral GTT, USG or CT scan, actual and ideal body weight (IBW Life Extension Institute of New York), and "performance status" assessments, were prospectively documented. The follow-up symptoms were classified as per Cuschieri's scoring system. The endoscopic esophageal mucosa assessments were documented as well. Among 56 patients surviving operation, 34 were available, without tumor recurrence, for long-term (12-132 months) evaluation. A Roux-en-Y loop reconstruction had been performed in 23, 5 with a Hunt-Lawrence pouch; an isoperistaltic, esophagoduodenal, jejunal interposition (IR) was performed in 9, 4 with a Kock pouch; and an omega loop reconstruction was performed in 2. A 60-70-cm-long jejunal limb was always utilized.(ABSTRACT TRUNCATED AT 250 WORDS)

One-stage subtotal colectomy of an acutely obstructed colon would improve quality of life while shortening the length of hospitalization. Prohibitive surgical risks, though, are commonly ascribed to such an approach. Analyzing the senior author’s experience we compared the one-stage approach versus multistaged resection concerning operative mortality and morbidity rates and the duration of hospital stay. Forty-nine out of 291 (17%) large bowel cancer patients presented with acute left-sided obstruction requiring emergency surgery. Colostomy alone was performed in 18 (37%), multistaged colectomy in 20 (41 %, group A) and one-stage subtotal colectomy in 11 (22%, group B), from January 1973 through September 1990. Both groups were comparable regarding age and sex distribution, TNM staging and ASA classification. Operative mortality and morbidity rates were 10 and 30% in group A and 9 and 18% in group B, respectively. The average length of hospital stay was more than twice the number of days in group A. Whenever an experienced surgical team is available and in the absence of contraindications (local factors precluding a swift dissection, hemodynamic instability, gangrenous bowel) a one-stage subtotal colectomy, taking advantage of a better healing ileo-low-sigmoid anastomosis, carries acceptable mortality and morbidity risks while enhancing the quality of life and shortening the length of hospitalization. It should be considered the procedure of choice, provided selection requirements and technical demands are met.