Fifty patients with massive lower gastrointestinal bleeding were initially managed with emergency angiography. The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units. Thirty-six patients (72%) had bleeding site located; bleeding sites were distributed throughout the colon. Etiologies of bleeding included diverticular disease (19 patients) and arteriovenous malformations (15 patients). Twenty of 22 (91%) patients receiving selective intra-arterial vasopressin stopped bleeding; however, 50% rebled on cessation of vasopressin. Thirty-five of 50 (70%) patients underwent surgery, with 57% operated on electively after vasopressin therapy. Seventeen patients had segmental colectomy, with no rebleeding. Nine of the 17 patients had diverticular disease in the remaining colon. Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency subtotal colectomy without angiography (8.6% vs. 37%) (p less than 0.02). Emergency angiography successfully locates the bleeding site, allowing for segmental colectomy. Vasopressin infusion transiently halts bleeding, permitting elective surgery in many instances.

Marjolin's ulcers have a grave prognosis, especially when regional nodes are involved. Recent studies suggest such cancers are in an immunologically privileges sites due to the dense scar tissue. The prognosis has been shown to be much worse for tumors not having a round cell infiltrate prior to surgery, as in Marjolin's ulcers. The use of topical 5-fluorouracil (5-FU) induces a round cell infiltrate. Three case reports of large Marjolin's ulcers are presented which were first treated with topical 5-FU. Radical ablative surgery was avoided in these patients with a successful outcome.

Since 1980, the authors have managed 19 patients with operative injuries to their biliary tracts. Eleven patients (58%) incurred their injuries during cholecystectomies for acute cholecystitis (average age--56 years); seven patients (37%) received their injuries during elective cholecystectomies (average age--24 years); and in one patient (5%) the injury occurred during gastrectomy. In group I were eight patients in whom injuries were recognized and repaired intraoperatively during their initial operations. Seven of these patients (88%) had primary duct reanastomoses, and one patient had a choledochoduodenostomy. All healed without further surgery, and none later had cholangitis develop. In group II were 11 patients diagnosed and reoperated later after surgery (mean time until diagnosis, 12 days). Seven of these patients (64%) were managed with Roux-en-Y hepaticojejunostomies or choledochojejunostomies. Four patients had cholangitis develop after surgery: two had demonstrable anastomic stenosis and two had no stenosis. Three of these four patients (75%) who had cholangitis develop did not have stents used in their repairs. The overall mortality rate in this series of 19 patients was 11%. The major risk factors for biliary tract injury were the presence of acute cholecystitis and of anatomically small biliary ducts. For this latter reason, younger patients who had elective cholecystectomies were particularly at risk. In delayed repair, the use of internal stents appeared to be useful in preventing the later development of stenosis and/or cholangitis; however, recurrent cholangitis developed in two patients who did not have demonstrable anastomotic stenoses.

The placenta, normally confined to the decidual lining of the uterine cavity, can in some circumstances invade the muscular wall of the uterus, a condition known as placenta accreta. Less common is placenta increta, in which placental cotyledons become intertwined with the muscular stroma of the uterus. Placenta percreta, in which the trophoblastic tissues penetrate the serosa of the uterus and may extend directly to adjacent structures, is even more rare and is potentially life-threatening. There have been only 10 reports of direct invasion of placenta percreta into the urinary bladder. We review these cases and report 3 recent patients, one of whom was diagnosed pre-operatively by ultrasonography.

Three patients with biopsy-proven lentigo maligna were treated with topical 5-fluorouracil. Treatment consisted of twice daily application of 5% 5-fluorouracil cream for 13, 6, and 9 weeks, respectively. Two patients demonstrated presence of invasive melanoma; in one the melanoma was evident before chemotherapy, and in the other the lesion became evident after chemotherapy. In both the lentigo was treated topically and the melanoma excised locally. Posttreatment followup times through April 1, 1974 have been 42, 24, and 22 months, respectively. There has been no evidence of metastases in any patient. Topical chemotherapy with 5-fluorouracil cream appears to offer an encouraging alternative method of therapy for lentigo maligna of the face.