The widely differing mortality rates of severe gastroduodenal hemorrhage reported in the literature (10-30%), are due to very inhomogeneous patient groups. The purpose of this study was therefore to rank various clinical and endoscopical factors by giving them points from 0 to 6, both to establish comparable groups and to use them as prognostic parameters for a potential fatality rate. One hundred and ninety-three patients with severe gastroduodenal bleeding, verified at emergency gastroscopy immediately after admission, were admitted to this prospective study. The statistical assessment of the prognosis for these 8 factors revealed a linear correlation between increasing score and mortality rate for the following risk factors: patient age, activity and intensity of hemorrhage, type and number of associated illnesses, various therapeutic procedures. Only the type of the source and the site of the hemorrhage did not correlate well. By adding up the points of all risk factors for every patient we calculated the overall score and established a correlation to the mortality rate: A definite statistical correlation was demonstrated between increasing score and fatal outcome. If a patient with a score of less than 20 points did survive in 100%, the mortality rate increased linearly to 83.3% in patients with a score of 40 points. Using this scoring system it is possible to establish comparable groups of patients - which seems indispensable for a critical examination of various therapeutic procedures. Furthermore, this score can serve as a predictor of the probability of a fatal outcome shortly after patient admission.

The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment to be employed.

This project was undertaken to evaluate in a prospective fashion the effects of selective preoperative endoscopic-retrograde cholangiography and stone extraction (ERCP-ST EXTR) on the results of biliary tract surgery. Over a 6-year period, 728 patients with primary or secondary biliary tract disease were admitted to the First Surgical Department, landeskrankenanstalten, Salzburg, Austria. If, based on preoperative screening, the possibility of common bile duct stones (CBDS) existed, the patients were subjected to ERCP-ST EXTR. Two to 4 days later, these patients underwent a simple cholecystectomy with intraoperative cholangiogram and functional manometry. Evaluation criteria for this study were morbidity, mortality, and retained stone (RST) rates. The overall complication rate for the entire series was 6%. In patients who underwent operative common duct stone removal (n = 78), the complication rate amounted to 21.8%. The rate was reduced to 2.1% by ERCP-ST EXTR. The RST rate was likewise reduced from 2.2% to 0.5% by ERCP-ST EXTR. Mortality in patients with CBDS fell from 3.8% to 1% through the use of this method. In those patients with secondary stones who were treated by ERCP-ST EXTR only, morbidity was 2%, the RST rate was 0%, and mortality was 0%. It is concluded that selective ERCP-ST EXTR, followed by simple cholecystectomy, is a suitable treatment protocol and that this approach may reduce complication and mortality rates.

Histamine release was shown in the course of seven orthotopic homologous liver transplantations in the young Landrace pig. Elevated plasma histamine levels in the right atrium of the donor and recipient were found after introduction of anaesthesia, after exposure of the liver and its vessels, and following revascularization. The histamine release following revascularization is so massive that it can explain the hypotensive reactions observed in this phase of the operation. The increase of the plasma histamine concentration in the other phases of transplantation is so small that it is very probably without effect on the blood pressure. In the portal plasma, high plasma histamine levels were measured during the exposure of the liver, especially in the donor, but to a lesser degree also in the recipient. However, the liver completely took up this released histamine, and no increase of plasma histamine level could be demonstrated in the right atrium. Various possibilities exist to explain the development of hypotension following revascularization: anoxia, acidosis, elevated serum potassium levels, endotoxins, VDM, kinins, prostaglandins and the decrease of the circulating blood volume due to sequestration of blood in the transplanted liver. From the results of our experiments, however, it was concluded that histamine release plays an important role in the development of hypotension following revascularization.

We report a case of a doubled gallbladder missed in preoperative ultrasound and laparoscopic cholecystectomy but demonstrated by endoscopic retrograde cholangiography (ERC) postoperatively.