The TIRADS has allowed us to improve patient management and cost-effectiveness, avoiding unnecessary FNAB. In addition, we have established standard codes to be used both for radiologists and endocrinologists.

Eighty-seven patients with neoplasm (57 cases), pancreatitis (28 cases), or benign biliary obstruction (2 cases) were treated with pyloric preserving pancreatectomy with two postoperative deaths, neither due to abdominal complications. About 50% of patients had delay in recovery of gastrointestinal function. Six and seven patients had clinically significant biliary and pancreatic fistulas, respectively, with some patients having both. Complications required 16 reoperations. Marginal ulcer was suggested by endoscopy or barium study in five patients, three of whom were successfully managed by a medical regimen. In the other two patients, exploration failed to demonstrate an ulcer or jejunitis. In most patients, long-term gastrointestinal function was judged to be excellent based on weight gain and lack of digestive symptoms. Pyloric function and gastric motility were evaluated by abdominal scanning using indium 111 and technetium 99m. Gastric emptying of liquids and solids was normal. Estimations of enterogastric reflux showed a moderate difference between normal subjects and pancreatectomy patients. Cancer-free survival was comparable to that after the standard Whipple procedure.

From 1961 to 1980 at the Lahey Clinic, 309 patients had initial surgical therapy for differentiated thyroid carcinoma. Review of this experience in comparison with previous decades revealed a progressive increase in the incidence of the disease in men, an increase in less extensive forms of the disease, an increase in use of bilateral subtotal thyroidectomy (77 % of patients), the discontinuation of use of prophylactic nodal dissection, and the progressive replacement of radical neck dissections by modified and limited neck dissections. In this series, with a median follow-up period of 13 years, 11% of patients had recurrence, and 7% died of disease. Determinants of outcome were shown to be risk groups as defined by age and sex, extent of disease (size of tumor and extent of extraglandular involvement), capsular invasion, blood vessel invasion, ability to remove all tumor at operation, and, to a lesser extent, pathologic type. Presence of nodes affected recurrence rate but did not have any deleterious effects on survival. Multifocal involvement did not appear to be an adverse prognostic factor. Treatment was successful in 73% of patients with nodal recurrences, in 53% with local recurrences, and in 27% with distant recurrences. Recurrences more often were treated successfully in low.risk patients than in high-risk patients. None of the deaths from local recurrence could have been prevented by initial total thyroidectomy. Recurrent nerve paralysis and hypoparathyroidism each occurred in only 1 patient (0.4%) who underwent bilateral subtotal or near-total thyroidectomy. We conclude that a selective approach using lesser opera-

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Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Although several studies have shown a low incidence of bile duct injuries during laparoscopic cholecystectomy, concerns remain because of the sustained increase in the number of referrals for biliary reconstruction after the procedure. Twenty-one patients have been referred to our institution because of major bile duct injuries after laparoscopic cholecystectomy. The injury was recognized during the laparoscopic procedure in only 6 of the 21 (29%). Nineteen patients underwent hepaticojejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcation was required in 10 patients (50%), at the bifurcation in 3, and below the bifurcation in 7. Nine of the eleven patients in whom the initial repair was performed at the local hospital presented with early stricture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps during laparoscopic cholecystectomy to avoid bile duct injuries are described. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.