An aggressive surgical approach to bile duct cancer.

Fifty-five patients with bile duct carcinoma have been treated at the Vanderbilt University, Metropolitan Nashville General, and Baptist Hospitals since 1957. Thirty-eight per cent (21) of the patients had tumors arising in the upper third of the bile duct; eight (15%) were in the middle third, and ten (18%) were in the lower third. In 12 instances, the malignant process involved both the middle and lower thirds of the bile duct, and in four cases, the extent of the tumor was too great to determine its origin. Most patients (49) presented with jaundice. Thirty (54%) also had pain, and 43 (24%) had experienced some weight loss. Fifteen had hepatomegaly, but only eight were found to have an enlarged gallbladder upon physical exam. Four patients (7%) had a positive history for hepatitis. Resection of the tumor was possible in 19 patients (35%). Decompressive procedures and biopsies were done in 25 of the others. Decompression was not possible in 11 patients. Survival for the 11 patients whose tumors were only biopsied averaged 4.6 months. Of the 25 patients who had palliative decompression, average survival has been 7.7 months. The 19 patients who had resection of their tumors survived an average of 2.08 years. Six of these patients are alive from 1-9 years post-diagnosis. Recently, a more aggressive surgical approach to bile duct carcinoma has been successful and has affected possible cure in ten patients of 19 in whom resection was possible and offered prolonged palliation to many of the other patients.

Penetrating injuries to the neck. Selective management.

The management of penetrating neck trauma remains a controversial subject. Two distinct approaches have been advocated: "mandatory" versus "selective" exploration of all neck wounds. Surgical intervention in our institution is based upon the latter, a selective principle of individualization of the patient and his injury. Obvious early exploration is indicated for patients with evidence of major vascular injury, visceral injury, or with progressive neurologic deficit. In the absence of such signs of injury, the authors used a diagnostic protocol which includes esophagram and arteriography. This retrospective reviews and assesses the results of this selectively conservative policy.

Carcinoma of the gallbladder and bile ducts. A retrospective review.

In retrospective review, 31 patients with carcinoma of the gallbladder and 39 patients with carcinoma of the extrahepatic bile ducts (excluding ampullary tumors) were identified. Case records and operative reports of patients seen between 1955 and 1980 were reviewed for the purpose of evaluating clinical features, preoperative studies, and operative treatment of these two disease processes. Similarities and differences between the two malignancies are highlighted. Demographic features of these patients supported findings of previous studies. Preoperative symptoms were typical of calculus disease often with the stigmata of malignancy superimposed. Laboratory findings provided a rather nonspecific confirmation of cholestasis. Roentgenogram examinations proved to be of little value in differentiating either disease process. A variety of surgical procedures was used by several surgeons to attempt cure or palliation in these tumors. Cholecystectomy was the most frequent procedure performed for patients with gallbladder carcinoma (18 cases). Curative cholecystectomy yielded an average 17.8 month survival. More radical procedures produced higher survival rates although the study size is of questionable statistical significance. Biliary-enteric bypass (choledochojejunostomy) was performed most often for patients with bile duct carcinoma (12 cases). The magnitude of the operation failed to affect the duration of patient survival except in patients with carcinomas of the distal common bile duct. Three Whipple procedures were performed for distal bile duct lesions yielding the one five-year survivor of this study but with an associated 30 per cent operative mortality. Operative strategy and options are discussed. The current literature dealing with these two malignancies is reviewed.