Preoperative liver biopsy and survival after portasystemic shunting

The value of preoperative liver biopsy in predicting the outcome of portasystemic shunting was investigated. Using coded slides, the authors examined liver biopsy specimens from 41 patients with alcoholic cirrhosis who underwent portasystemic shunting. The degree of fatty change, alcoholic hyalin, alcoholic hepatitis, central hyalin sclerosis and the activity and severity of the cirrhosis were assessed and possible correlations were noted with the preoperative Child's classification, postoperative encephalopathy and with early and late mortality. A correlation was found between the presence of alcoholic hyalin in more than 10% of hepatocytes and early mortality; all of the six patients who died within 30 days of operation had this finding in the liver biopsy specimen. Early mortality correlated better with alcoholic hyalin than with the Child's classification. There was some correlation between late mortality and the degree of hyalin sclerosis and with the activity and severity of cirrhosis. The authors conclude that the findings of a liver biopsy done preoperatively are valuable in indicating prognosis and operative mortality in alcoholic cirrhosis.

The acute effects of sustained volume expansion on the renin-aldosterone system and renal function in human hepatic ascites

To investigate the acute effect of sustained volume expansion in patients with chronic hepatic ascites, renal and hemodynamic studies were performed on six patients receiving the peritoneovenous shunt. Within 1 hr of shunt insertion, the cardiac output rose by 20% to 60% above the preoperative level and the renal blood flow by 70% to 300%. At the same time both the plasma renin activity and serum aldosterone levels fell to a mean of 34% of the preoperative levels. The urine output increased from fourfold to 38-fold, but the sodium excretion increased in only two of the six patients. The data show that the acute effect of sustained volume expansion is predominantly on water rather than on sodium excretion. This manoeuver acutely suppressed circulating renin and aldosterone levels; however, the blunted natriuretic response suggests that other factors are involved in the sodium retention in these patients.

Urinary excretion of N-acetyl-beta-D-glucosaminidase and alanine aminopeptidase in patients receiving amikacin or cis-platinum

Urinary excretion of alanine aminopeptidase (EC 3.4.11.2) and N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30) was determined for 25-70 days in five patients receiving cis-platinum and for 8-53 days in six patients receiving amikacin. This study was performed to investigate if the excretion of urinary enzymes represents a sensitive parameter for the early detection of toxic kidney damage. The determination of N-acetyl-beta-D-glucosaminidase was carried out by the method of Knoll et al. [13]. The procedure of Mondorf et al. [14] for the estimation of alanine aminopeptidase activity was adapted to the Gemsaec Fast-Analyzer. In both patient groups an increase in the excretion of the two enzyme activities could be demonstrated. In patients receiving amikacin, the excretion of alanine aminopeptidase was always higher than that of N-acetyl-beta-D-glucosaminidase, whereas in three patients receiving cis-platinum it was the opposite. In two cis-platinum patients the excretion of both enzymes was of the same size. The changes during amikacin therapy seem to be reversible, whereas in four cis-platinum patients these changes seemed to be partly irreversible. Serum creatinine concentration was less sensitive than the urinary enzyme excretion for detection of kidney damage.

Early re-entry procedure. Part II. A five year histologic evaluation

The following study was carried out to assess the histologic integrity of a bone graft which had appeared clinically successful at early re-entry some 5 years previously. The tooth required extraction due to a labial root fracture and was subsequently extracted in modified block section, demineralized, sectioned, stained and evaluated histologically. Histologic evaluation revealed the presence of a functional periodontal membrane apparatus in active stages of both bone and cemental remodeling. Necrotic bone spicules within the areas of otherwise viable periodontium suggested residue from prior graft material. Histologic evaluation presented here supports the previous clinical impression that early re-entry of autogenous grafts for evaluation and physiologic recontouring, where indicated, appears justified without apparent adverse effects on local periodontal regeneration.

Studies into the mechanism of reversal of experimental acute hepatic failure by hepatocyte transplantation. 1

The authors reported previously that single cell suspensions of syngeneic, allogeneic and xenogeneic hepatocytes can significantly improve survival in a rat model of acute hepatic failure induced by D-galactosamine. This report explores the mechanism by which hepatocyte transplantation reverses the toxin-induced hepatic necrosis. Radioautographic studies indicated that intraperitoneally administered hepatocytes labelled with tritiated thymidine did not repopulate the injured recipient liver. Hepatocytes irradiated with 10 000 rad (i.e., the cells were nonreplicating) also resulted in a significant (P less than 0.001) increase in animal survival when given to rats treated with D-galactosamine. Experiments with subcellular fractions of hepatocytes demonstrated that an intact cell was not required and that a heat stable "factor" (or factors) present in the cytosol fraction, which is not insulin or glucagon, is responsible for the increase in survival observed. This factor appears to increase the rate of endogenous regeneration of the injured recipient liver.

Renal and hemodynamic effects of the peritoneovenous shunt. II. Long-term effects

The long-term renal and hemodynamic effects of the peritoneovenous shunt for intractable ascites were studied in 11 patients to elucidate the mechanism of its persistent beneficial effect. Sodium balance studies were performed in 7 patients. All had patent shunts and no clinically detectable ascites. On a 20-mEq sodium diet, the mean sodium excretion was 17.2 +/- 5.3 mEq/day which was increased over the preoperative mean of 2.4 +/- 0.4 (p < 0.025) on the same diet. There was a 100% increase in creatinine clearance over the preoperative level (p < 0.0005). The mean plasma renin activity and serum aldosterone levels were within normal limits in most patients, and the sodium excretion correlated inversely with the levels of each. During 100-mEq sodium challenge diet, the sodium excretion ranged from 4 to 130 mEq/day with a mean of 56.1 +/- 16.5 and with 6 of the 7 patients displaying sodium retention. On this diet the mean creatinine clearance was 104.3 +/- 6.4 ml/min, and the mean plasma renin activity and serum aldosterone levels had decreased physiologically with the higher sodium intake. Again the sodium excretion correlated inversely with the serum aldosterone on the 100-mEq sodium diet. In 8 patients, the portal pressure, as reflected by the wedge hepatic vein pressure, had decreased by a mean of 37% (p < 0.0005). But, despite this, 2 of the 8 patients had major variceal hemorrhages postoperatively. There was a significant inverse correlation between the increase in sodium excretion and the fall in portal pressure in 4 patients. Thus, sodium retention in cirrhosis is multifactorial with the reninaldosterone system and, possibly, portal hypertension per se both playing a role. Peritoneovenous shunting in carefully selected patients partially reverses the sodium retention and renders patients more manageable over the long term.

Allogeneic and xenogeneic hepatocyte transplantation in experimental hepatic failure

Previous studies have demonstrated the efficacy of syngeneic hepatocyte transplantation in the treatment of D-galactosamine-induced acute hepatic failure in Lewis strain rats. This report describes the efficacy and immunological consequences of allogeneic and xenogeneic hepatocyte transplantation in the same model. The i.p. administration of allogeneic (minor and major histoincompatibility) hepatocytes or xenogeneic (rabbit or porcine) hepatocytes at a dose of 4 x 10(7) cells/rat given at 48 hr after toxin all resulted in significant improvement in survival compared to that of controls, and also comparable to the results obtained with syngeneic hepatocyte transplantation. Sensitization to i.p. allogeneic (WF) hepatocyte administration was demonstrated by in vivo 51Cr release, indirect immunofluorescent technique, and accelerated skin allograft rejection. Similarly, the in vivo 51Cr release assay was able to detect sensitization to porcine hepatocytes. Despite evidence of immunogenicity, redosing with either WF or porcine hepatocytes resulted in no overt toxicity. Furthermore, presensitization by either WF hepatocytes or skin allografts did not adversely affect survival after WF hepatocyte treatment in D-galactosamine-induced hepatic failure in Lewis strain rats. These data demonstrate that histocompatibility is not a constraint to successful hepatocyte transplantation and that repeated treatments are potentially safe and efficacious despite sensitization.

Cellular transplantation in the treatment of experimental hepatic failure

The survival of Lewis rats with D-galactosamine-induced fulminant hepatic failure was prolonged if they were given intraperitoneal injections of single-cell suspensions of liver or bone marrow cells from normal rats. Suspensions of liver cells were also effective in prolonging the survival of rats with ischemia-induced hepatic necrosis. The liver cells did not act by repopulating the recipient liver.

The subepithelial connective tissue graft

A technique has been described which can augment concavities and irregularities in edentulous ridges where cosmetics are important. Using the combination of temporary acrylic resin restorations and connective tissue autografts, unattractive con-cavities and ridge irregularities can be corrected.

Reversal of toxic and anoxic induced hepatic failure by syngeneic, allogeneic, and xenogeneic hepatocyte transplantation

This report describes the efficacy of syngeneic hepatocyte transplantation in an anoxic model and of xenogeneic (rabbit and porcine) hepatocyte transplantation in a toxic model of fulminant hepatic failure in the rat. Lewis strain rats that received 4 X 10(7) hepatocytes intraperitoneally at 48 hours after hepatic artery ligation had a significantly improved survival rate (79%, n = 14) when compared with control animals (38%, n = 21, P less than 0.05). Xenogeneic hepatocytes (4 X 10(7) cells/rat) given intraperitoneally to D-galactosamine-poisoned Lewis rats at 48 hours after toxin administration were able to significantly improve survival rate as compared with controls (71% versus 14%, n = 14, P less than 0.01 for rabbit; and 75%, n = 14 versus 12.5%, n = 16, P less than 0.001 for porcine). Although an increase in in vivo cytotoxicity could be demonstrated after procine hepatocyte transplantation, no adverse clinical effects were observed. The methodology for the harvest and storage of large numbers of hepatocytes from a large animal liver has been developed, and it is now feasible to proceed to the clinical application of hepatocyte transplantation for human fulminant hepatic failure.

Therapy for thrombotic occlusion of long-term intravenous alimentation catheters

Thrombosis and infection are closely related complications of implanted silastic catheters. A procedure, by which the thrombi are dispersed with urokinase while the catheter remains in situ, was uniformly successful in clearing the line in 20 patients, although in 5 the infusion had to be repeated 24 hr later. Catheter-associated infections are rendered susceptible to antibiotics as the infected thrombotic nidus is lysed and the organisms exposed. In 7 patients, 4 of whom were taking antibiotics, fever and blood cultures became negative. The procedure results in no detectable systemic fibrinolysis or other complications.

Percutaneous fine-needle aspiration biopsy. I. Its value to clinical practice

From the experiences in dealing with 2591 cases of transthoracic and transabdominal fine-needle aspiration biopsies (1967-1978), we present our views on the value of this relatively new diagnostic method to clinical practice. Virtually any accessible localized lesion in any organ of the body can be investigated by fine-needle aspiration biopsy, which is considered most useful in patients with suspected malignant disease. Transthoracic and transabdominal fine-needle aspiration biopsy may provide information otherwise obtainable only by thoracotomy or laparotomy. It is an inexpensive and safe method with high accuracy for obtaining a pathologic diagnosis, and can impart some practical significance to clinical practice, especially in clinical management. The pitfalls in cytomorphologic interpretation, which often cause unsuccessful attempts, can be readily avoided with increased practical experience, as indicated by the increase in detection rate of lung cancer by fine-needle aspiration method from 82.8% in 1967-1968 to 93.4% in 1976 at the Toronto General Hospital. The accuracy of cytologic diagnosis plays a major role in spreading this still relatively unfamiliar but excellent diagnostic method. We believe that the method deserves widespread clinical application and when this happens, it will bring about great savings in health care resources.

Percutaneous fine-needle aspiration biopsy. I. Its value to clinical practice

From the experiences in dealing with 2591 cases of transthoracic and transabdominal fine-needle aspiration biopsies (1967-1978), we present our views on the value of this relatively new diagnostic method to clinical practice. Virtually any accessible localized lesion in any organ of the body can be investigated by fine-needle aspiration biopsy, which is considered most useful in patients with suspected malignant disease. Transthoracic and transabdominal fine-needle aspiration biopsy may provide information otherwise obtainable only by thoracotomy or laparotomy. It is an inexpensive and safe method with high accuracy for obtaining a pathologic diagnosis, and can impart some practical significance to clinical practice, especially in clinical management. The pitfalls in cytomorphologic interpretation, which often cause unsuccessful attempts, can be readily avoided with increased practical experience, as indicated by the increase in detection rate of lung cancer by fine-needle aspiration method from 82.8% in 1967-1968 to 93.4% in 1976 at the Toronto General Hospital. The accuracy of cytologic diagnosis plays a major role in spreading this still relatively unfamiliar but excellent diagnostic method. We believe that the method deserves widespread clinical application and when this happens, it will bring about great savings in health care resources.

Orthodontic procedures that improve the periodontal prognosis

Osseous defects not amenable to conventional resective or regenerative osseous surgery alone may respond to a combination of orthodontic and periodontal techniques. Two orthodontic procedures-correction of mesially tipped teeth and forced eruption-have been described that may enhance the periodontal prognosis. Each procedure is accomplished with use of sectional orthodontic appliances and each requires a short time for treatment. Beneficial results include improvement of the crown-to-root ratio, reception of the forces of occlusion in the long axis of the tooth, and reduction or elimination of infrabony defects.

A prospective randomized trial of the selective distal splenorenal shunt

Distal splenorenal shunt has been compared in a prospective randomized way with end-to-side portacaval shunt in patients who have survived a major hemorrhage from esophageal varices. The operative mortality was higher after the elective shunt than after the portacaval shunt. However, most of these deaths occurred in the early phases of the study. Postoperative encephalopathy was significantly lower after the selective shunt than after the portacaval shunt. Follow-up studies to date show no significant difference in late survival.

Complications after peritoneovenous shunting for ascites

The results and complications in our first 23 consecutive patients receiving the peritoneovenous shunt for intractiable hepatic ascites are presented. A good initial diuretic effect was obtained in 20 of the 23 patients, with reversal of hepatorenal failure in 3 of 5 patients. The postoperative complication rate was high (74 percent). Infection, coagulopathy and complication of the underlying liver disease contributed to a mortality rate of 26 percent. Late complications were related to the primary liver disease. The 6 month survival rate was 58 percent and the 1 hear survival rate 52 percent with five patients followed up for more than 2 years. Because of the significant morbidity and mortality associated with the peritoneovenous shunt, we recommend it only for patients with massive intractable hepatic ascites whose condition is refractory to maximal medical therapy.

Thrombosis of the portal vein following distal splenorenal shunt

Portal vein thrombosis with a patent shunt is a distinct clinical entity which can follow selective distal splenorenal shunt and should be looked for in patients in whom ascites and abdominal pain develop postoperatively. Possible mechanisms include an increase in blood viscosity and a decrease in portal flow which may be aggravated by inadequate devascularization.

Elective management of the patient who has bled from esophageal varices

Variceal hemorrhage can be controlled by nonsurgical means in over 50% of patients. As a result, their general hepatic status can often be improved by preoperative preparation for the elective procedure. The major problem following elective end-to-side portacaval shunting is encephalopathy; it occurs in up to one half of patients who undergo this shunting procedure. Mesocaval shunting has been proposed as a better operation because of lower frequency of encephalopathy; however, the authors' experience has not confirmed this. Distal splenorenal shunting, as shown by the results of a prospective controlled trial, does have a lower frequency of encephalopathy, but the initial morbidity and mortality are higher and an improvement in the duration of survival is not yet evident.

Methods of altering crestal levels. Clinical case reports

Selected cases have been presented using different techniques to alter crestal levels. Self Regeneration or Autogenous bone grafts have been most successful in cases of three-wall and two-wall infrabony lesions. When a hemiseptal lesion occurs on the mesial of a tooth an uprighting procedure can be accomplished. When there is an adjacent tooth a forced eruption technique using orthodontic forces can be used. A surgical elevation technique has been presented which also has shown positive changes in bony topography.

The renal and hemodynamic effects of the peritoneovenous shunt for intractable hepatic ascites

Fifteen patients with chronic liver disease having a peritoneovenous shunt for chronic intractable ascites were studied prospectively for renal function and hemodynamic changes during balance studies, pre-, peri-, and postoperatively. Shunt insertion caused a rapid redistribution of ascites into the intravascular compartment with hemodilution and significant rises in cardiac output (9 patients) (P less than 0.025) renal blood flow (3 patients) (P less than 0.025), and creatinine clearance (15 patients) (P less than 0.005), and decreases in plasma renin activity (10 patients) and serum aldosterone levels (9 patients) (P less than 0.025). Despite these changes, small repeated doses of furosemide were required to start and maintain a diuresis and natriuresis with sodium excretion rising from 7.2 +/- 4.1 to 174 +/- 44 meq/day (P less than 0.0005) in the 15 patients. At 2 wk postoperatively, the 15 patients had lost a mean of 7.5 kg in weight associated with a persistent improvement in creatinine clearance and a continued natriuresis, 15.9 +/- 7 mEq/day (P less than 0.005), despite no statistically significant change in cardiac output (7 patients) or renal blood flow (4 patients) compared with preoperative levels. This operation is an effective therapy for refractive ascites, but the incidence of potentially fatal complications makes us hesitate to recommend it except for patients resistant to normal conservative measures.

Use of a glucose controlled insulin infusion system (artificial beta cell) to control diabetes during surgery

An artificial beta cell has been used to achieve and maintain a preset plasma glucose concentration in five diabetic patients undergoing surgery. These subjects were compared to control groups of normal subjects receiving either saline or glucose, and diabetics receiving glucose intraoperatively. Hyperglycaemia during surgery was seen in normals (mean plasma glucose +/- SEM: 185 +/- 16 mg/dl) and, to a greater degree, diabetics (247 +/- 36 mg/dl) receiving glucose. Insulin and C-peptide levels did not increase during 2 hours of operation in any of the control groups, suggesting beta cell suppression during surgery. As C-peptide levels declined similarly in normal subjects whether they received saline or glucose, the hyperglycaemia seems to be due to an inability to use exogenous glucose. This is confirmed by a correlation of maximal plasma glucose to glucose infusion rate (r = 0.78, p less than 0.01). The artificial beta cell was able to achieve the same plasma glucose after 2 hours of operation (128 +/- 21 mg/dl) as normal subjects receiving saline (110 +/- 7 mg/dl). The artificial beta cell proved to be a safe, convenient and effective way of monitoring and controlling the hyperglycaemia seen in diabetic patients undergoing surgery.

Periampullary tumours: advances in diagnosis and surgical treatment

Forty-five carcinomas of the region of the ampulla of Vater were resected at the Toronto General Hospital during a 16-year period. In 26 the presenting symptom was pain and in 32 it was jaundice. The most useful means of investigation was endoscopic retrograde cholangiopancreatography. Angiography was of value in determining resectability prior to operation, and percutaneous aspiration biopsy allowed a preoperative diagnosis in the case of large pancreatic tumours. In 39 patients who had a Whipple procedure the operative mortality was 8%. Total pancreatectomy performed in two patients and local excision of ampullary carcinoma in four patients were attended by no operative deaths. Long-term survival was best in patients with ampullary carcinomas and worst in those with pancreatic cancer.

The alteration of lingual mucosa with free gingival grafts. Protection of a denture bearing surface

A technique has been described which has altered the form of denture bearing alveolar mucosa. Free gingival palatal grafts were used to create an attached gingival environment upon which removal denture prosthesis may rest.

Management of carcinoma of the extrahepatic bile ducts

The records of 80 cases of carcinoma of the extrahepatic bile ducts were studied. The median duration of survival, in months, of patients who were treated by curative surgery, palliative surgery and radiation, palliative surgery alone and biopsy alone was 21.7, 9.3, 5.5 and 1, respectively. The best results were obtained by excision of the tumour, but only 10% of tumours were considered resectable. A more aggressive surgical approach to tumours still confined to the bile ducts might be expected to increase the resectability rate and improve survival. The use of a U tube is recommended because it ensures greater comfort even though survival is no longer than when a T tube is used. The roles of adjuvant radiotherapy and chemotherapy need further study. Because of some encouraging responses with the use of radiotherapy and the infusion of 5-fluorouracil the authors are currently evaluating these two methods of treatment.

Fine needle aspiration biopsy of malignant lesions in and around the pancreas

A simple method of percutaneous fine needle aspiration biopsy of malignant lesions in and around the pancreas following radiological localization is described. Biopsy was performed in 28 patients. Twenty-three were eventually considered to have malignant disease and biopsy was positive in 19 of these (83%), including 16 of 18 patients with carcinoma of the pancreas (89%). One patient developed an exacerbation of pancreatitis following the procedure. Surgery became unnecessary in 5 of the 18 patients with positive biopsies. From these results and from a review of the literature on percutaneous fine needle aspiration biopsy, we believe that this is a simple, relatively painless, reasonably safe and reliable method of obtaining a preoperative diagnosis and advocate the procedure as desirable in all patients in whom malignant disease is suspected and can be localized radiologically.

Insulinoma resection facilitated by the artificial endocrine pancreas

The artificial endocrine pancreas was adapted to assist with the intraoperative localization of an insulin-secreting islet cell adenoma in a 23-year-old patient with a five-month history of hypoglycemic attacks. Glycemia was monitored in continuously withdrawn whole blood, and dextrose was infused to maintain euglycemia by an artificial endocrine pancreas with a closed loop that excluded its usual insulin delivery capability. The dextrose infusion rate was established in accordance with a control algorithm whose parameters were chosen to amplify changes in dextrose delivery rate for small alterations in the measured baseline glucose concentration. The dextrose infusion rate preoperatively was 155 mg. per minute and decreased to 100 mg. per minute with initiation of surgery. An area in the tail of the pancreas suspected of containing the insulinoma was excluded from the circulation by a noncrushing clamp. After 14 minutes the dextrose infusion progressively decreased to 27 mg. per minute reflecting a glycemic rise of 15 mg. per deciliter. These changes were taken to represent a fall in ambient insulin activity. This was subsequently confirmed directly by the demonstration of reduction in immunoreactive insulin and progressive increase in both plasma free fatty acid levels and postoperative glucose intolerance. Exclusion of the insulinoma from the circulation resulted also in a rapid decrease of circulating proinsulin concentration giving an estimated half-life of 25 minutes.

Fine needle aspiration biopsy of malignant lesions in and around the pancreas

A simple method of percutaneous fine needle aspiration biopsy of malignant lesions in and around the pancreas following radiological localization is described. Biopsy was performed in 28 patients. Twenty-three were eventually considered to have malignant disease and biopsy was positive in 19 of these (83%), including 16 of 18 patients with carcinoma of the pancreas (89%). One patient developed an exacerbation of pancreatitis following the procedure. Surgery became unnecessary in 5 of the 18 patients with positive biopsies. From these results and from a review of the literature on percutaneous fine needle aspiration biopsy, we believe that this is a simple, relatively painless, reasonably safe and reliable method of obtaining a preoperative diagnosis and advocate the procedure as desirable in all patients in whom malignant disease is suspected and can be localized radiologically.

Selection of operation in patients with bleeding esophageal varices

The results of surgical treatment of bleeding esophageal varices over an 8-year period in 155 patients are reviewed. Primary treatment of bleeding was conservative, with intravenous administration of vasopressin and balloon tamponade. Emergency operations were carried out after 48 hours in persons with persistent bleeding who were surgical candidates. Operative mortality was higher in this group (40%) than in those undergoing elective or urgent operations (each 10%). Postoperative encephalopathy occurred in 35% of patients and was correlated closely to late death after establishment of a shunt. The mesocaval shunt is no better than the portacaval but appears to be a good alternative in an emergency. In a controlled trial the distal splenorenal shunt was found to be associated with a lower rate of postoperative encephalopathy than the portacaval shunt, but thus far the long-term survival rates have not differed.

Twenty-five years of experience with radical surgical treatment of carcinoma of the extraperitoneal rectum

Between the years 1950 and 1975, 1,100 patients with carcinoma of the rectum were seen at the Toronto General Hospital. Of these, 519 had tumors below the peritoneal reflection. The resection rate in this latter group of patients was 94%. One hundred and thirty-three patients were treated by low anterior resection (LAR) and 316 by combined abdominoperineal resection (APR). Although the incidence of postoperative complications was high (LAR 41%, APR 53%), the operative mortality was low (LAR 2.2%, APR 2.9%). Recurrent tumor appeared more frequently in the pelvis (24%) than at distant sites (18%), was more common in more advanced disease, and correlated with the incidence of late death. The overall (actuarial) survival figures were 50% at 5 years and 37% at 10 years, with no significant difference between LAR and APR. For curative resections, the 5- and 10-year survival figures were 59% and 44%, respectively. Clinical staging (Dukes) influenced survival greatly, both at 5 years (Dukes A 77%, B 65%, C 33%, D 3%) and at 10 years (Dukes A 55%, B 53%, C 20%, D 0%). The level of the lesion did not influence either recurrence rate or survival.

The early reentry procedure

A technique and rationale for the early reentry of autogenous bone grafts has been described. Rather than wait 1 to 2 years for reentry as has been previously suggested, a 3-month interval was chosen. Results of the study showed: (1) Healing of osseous grafts starts very quickly and we do not have to wait long periods of time to ascertain whether the graft is successful. (2) That all grafts do not fill the defect completely and that there may be an alteration in contour. (3) That it is often important therefore that a reentry procedure be done to contour the bone. (4) Healing after reentry procedure occurred rapidly and uneventfully and minimum sulcular depth was obtained. (5) Reentry of autogenous osseous grafts for evaluation and physiologic recontouring is possible at 3 months without adversely affecting the ultimate clinical maturation and success of the graft.

Randomized trial of chemoimmunotherapy for resectable and non-resectable gastrointestinal cancer

Two trials were carried out in order to compare, in two similar groups of patients, the efficacity of 5-fluorouracil (5FU) with or without BCG. The first trial comprised 159 patients with different forms of carcinoma. The differences in survival rate between the 77 patients treated with 5FU and the 82 patients who had received 5FU and BCG seem to be in favour of the combined treatment, but are not statistically significant. The second trial (20 cases treated with 5FU and 23 cases treated with 5FU and BCG) concerned patients with Dukes' Stage B and C colorectal cancer; the results of the combined treatment are clearly more favourable.

Combined treatment with BCG and chemotherapy for metastatic gastrointestinal cancer

The survival of patients who have cancers of the gastrointestinal tract is poor even after surgical resection of all gross disease. In an initial consecutive series of patients with metastatic or recurrent cancers, an attempt to improve survival with combined nonspecific immunostimulation by the intraperitoneal administration of BCG followed by oral BCG cycled with chemotherapy was studied. The results suggested that a population of patients with gastric and colonic cancers showed improved survival with this treatment. A randomized trial of combined chemoimmunotherapy versus chemotherapy alone was begun on November 1, 1974, for all cancers of the stomach and pancreas and all colorectal cancers beyond stage C by Dukes' classification. The initial results with patients entered by December 31, 1975, and followed until March 1, 1976, are reported.

Adjuvant immunostimulation in malignant melanoma with oral Bacille Calmette-Guérin

Results of the administration of oral bacille Calmette-Guérin (BCG) as an adjunct to standard treatment in 62 patients with malignant melanoma indicate that this drug is of value in preventing distant spread of the disease when it is limited to one region and in its early stages. BCG increases survival in patients with visceral metastases. In those in whom these metastases are surgically resectable, it inhibits the development of further metastases. Oral BCG treatment does not affect the course of the disease in patients with massive hepatic or intracranial metastases.