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The incidence of DRF in the regraft study group was most commonly seen in patients with a historic high level of HLA sensitization. Primary NF was an immune mediated event seen in 63% of third regrafts. Delayed use of CyA with ALG induction coverage provides good graft survival with either double or triple maintenance therapy. Stricter patient selection for third transplants and aggressive clinical monitoring of the regrafted patient has provided a 1-year actuarial graft survival result of 88% at our transplant center.

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A controlled trial was carried out in 209 primary cadaveric renal transplants to compare the effects of cyclosporine and steroids (double therapy) with those of cyclosporine in lower initial dose, azathioprine, and steroids (triple therapy). Patients have been followed 1-36 months since transplantation. Actuarial two-year graft survival (double 74%, triple 76%) and two-year patient survival (double 90%, triple 93%) were similar for both groups. Further analysis of particular risk factors including age, diabetes, HLA matching, acute renal failure, and use of sequential Minnesota antilymphocyte globulin in patients with delayed graft function also showed similar outcomes with both immunosuppressive regimens. Initial hospitalization time, rate of rejection, incidence of serious infection, and rate of rehospitalization were not different. Mean CsA doses and mean trough whole-blood levels were higher in double-therapy patients at hospital discharge but not by three months posttransplant. There were no differences between the two groups in iothalamate clearance at any time. Hypertension was more frequent six months posttransplant in the triple-therapy group (p less than 0.05). Thus, similar results were obtained with both regimens, and except for hypertension no regimen appeared to have increased side effects up to three years posttransplant.

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Twenty-two patients with Zollinger-Ellison syndrome were managed by a combined medical and surgical approach. Patients were treated initially with cimetidine or ranitidine. A laparotomy was performed to remove easily resectable tumors and to carry out a proximal gastric vagotomy. Tumors were found in 9 patients (41%) and all visible tumors were removed from 6 of the 9 patients. Fasting serum gastrin concentrations and serum gastrin responses to intravenous secretin were normal 6 wk after surgery in each of the patients from whom all visible tumors were resected and are normal in 4 patients, 6 wk to 5 yr after surgery. Acid secretion was reduced after vagotomy in each patient, even when tumors were not found or completely resected. Thus, vagotomy decreased the acid secretory response to endogenous hypergastrinemia. In addition, vagotomy augmented the inhibitory effect of H2-receptor antagonists on acid secretion. Follow-up has ranged from 6 wk to 6 yr (median, 2 yr). Dosages of cimetidine or ranitidine have been reduced, compared with preoperative amounts, in all but 1 patient. Two patients are taking no antisecretory drugs. Only 3 patients have had occasional symptoms of ulcer disease. Complications such as bleeding, perforation, or obstruction have not occurred in any patient. Endoscopy was performed in all patients to estimate the point prevalence of active ulcers and an ulcer was found in 1 patient. Based on these results, it is our opinion that this combined medical and surgical approach is an effective treatment for patients with Zollinger-Ellison syndrome.

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Of 505 consecutive renal transplants urologic complications occurred in 4.1 per cent of cadaver, 2.6 per cent of living related, 1.9 per cent of diabetic and 3.8 per cent of nondiabetic allografts. Over-all, patient survival and graft salvage rates were 94 and 83 per cent, respectively. Principles of prevention, diagnosis and management of these complications are discussed. In contrast to prior standards the bladder catheter was removed within 36 hours postoperatively in nearly all cases without any increase in morbidity.

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There were 49 insulin-dependent diabetics who received 52 renal allografts: 13 from living related and 39 from cadaveric donors. The mean age and time on dialysis were similar for both recipient groups. Patient survival at 1 and 2 years was 100 per cent for living related donor recipients, and 76 and 56 per cent at 1 and 2 years for cadaveric recipients. Renal allograft survival was 92 and 85 per cent at 1 and 2 years for living related donor recipients. Cadaveric allograft survival was 49 and 41 per cent at 1 and 2 years. The cumulative mortality rate was 39 per cent and the over-all surgical morbidity was low. Renal transplantation in diabetic patients is worthwhile from the standpoint of patient and allograft survival.

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The substantial morbidity and mortality associated with severe acute pancreatitis has led to a variety of therapeutic approaches. We reviewed the records of 40 patients who had undergone the "triple-tube" procedure (gastrostomy, cholecystostomy, and jejunostomy) with drainage of the lesser sac and retroperitoneum. Cardiovascular, respiratory, renal, and hepatic dysfunction were common, and reoperation was required in 35% (14) of the cases. Gastrostomies and jejunostomies were associated with numerous complications, and cholecystostomies were rarely of benefit except when biliary tract disease was present. Debridement and drainage of necrotic pancreatic and retroperitoneal tissue afforded a higher survival rate in the small population in which they were employed. The overall mortality was 55% (22), reflecting and severity of the disease at the time of surgery. Early recognition and limited surgical debridement may be beneficial in this high-risk group.

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The preoperative resuscitation and operative management of hepatic trauma has vastly improved over the past 50 years. The majority of patients can be handled with simple techniques, with close attention to local hemostasis and adequate drainage. When major liver trauma does occur, exsanguination remains the leading cause of death. An integrated effort of physicians, nurses, and ancillary hospital support staff is needed to care for these severely injured patients.

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The incidence of renovascular hypertension in the transplanted kidney is reported to range between 5 and 15%. A review of 391 consecutive renal transplant patients revealed 16 patients (5.4%) with hypertension secondary to partial obstruction of renal arterial blood flow. The clinical course of this group of patients was marked by early normotension followed by progressive diastolic pressure elevation, with improving renal function and loss of accumulated excess volume. Five etiologic factors are responsible for impaired arterial flow in this group of patients. Indication for operation was based on hypertension and/or impaired renal function. Patch angioplasty using saphenous veins was the procedure of choice in most instances. The average blood pressure was 185 mmHg; systolic/125 mmHg; diastolic preoperatively, compared with 140 mmHg; systolic/90 mmHg: diastolic postoperatively. Twelve of 16 patients had good results, and improvement in renal function was observed in eight patients. Serum renin levels did not correlate well with the operative findings. The use of meticulous technique, combined with maximum use of autogenous tissue, is emphasized.

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Six of seven patients with acute pancreatitis who were intractable to prolonged medical therapy underwent successful endoscopic retrograde cholangiopancreatography (ERCP) followed by immediate operative therapy. All of these patients had surgically correctable lesions consistent with chronic pancreatitis. There was one associated mortality and no morbidity. The conditions of the surviving six patients were significantly improved in the immediate postoperative period, and long-term follow-up has been encouraging. Pancreaticojejunostomy and conservative resection appeared to have good results. The timing of the operation immediately after ERCP in patients with acute pancreatic pathology eliminated problems with exacerbation or sepsis. Patients whose clinical conditions do not improve with aggressive medical therapy for acute pancreatitis may have both chronic and acute disease that is amenable to operative therapy.

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We evaluated the effect of vagotomy on gastric acid secretion and the clinical course in 3 patients with Zollinger-Ellison syndrome. Basal acid hypersecretion was reduced by 49, 86, and 96%, and peak acid output in response to pentagastrin was reduced by 36, 39, and 71% in the 3 patients. In one patient, 300 mg cimetidine reduced basal acid secretion from 65 to 20 meq/hr before vagotomy; whereas after vagotomy basal acid secretion was reduced from 36 to 0.6 meq/hr by the same dose of cimetidine. One patient has required no antisecretory therapy for 14 yr, whereas 2 patients have also been treated with cimetidine with excellent results. We conclude that vagotomy facilitates control of acid secretion in Zollinger-Ellison syndrome, and we recommend vagotomy and cimetidine rather than total gastrectomy or cimetidine alone for the management of these patients. This combined surgical and medical approach should also allow discovery and removal of isolated tumors in about 10% of patients.

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