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.

Operative cholangiography. Review of 7,529 operations on the biliary tree in a community hospital.

Primary operation for cholelithiasis ranks third in frequency among general surgical procedures performed in this country each year [16]. The mortality and morbidity associated with retained common duct stones are apparent to all biliary surgeons. Although operative cholangiography is a standard procedure in many centers, some still use this adjunct to biliary surgery infrequently, as shown by the 51 percent performance rate in the present study. However, the literature is replete with evidence supporting the routine use of cholangiography. In the present report positive findings on common duct exploration almost doubled when operative cholangiography was added to the clinical and operative criteria for common duct exploration. Our experience indicates that common duct exploration is not always required when the patient has jaundice if normal operative cholangiograms support the patient's history and other laboratory findings. Cholangiography was also found to be accurate in the five cases in which a secondary biliary procedure had to be performed.

Pilonidal cyst: an operative approach.

An operative technic is presented which has been used on fifty-four patients with pilonidal cyst. This technic has resulted in primary union and complete healing within six weeks in 89 per cent of cases. The use of an incision that crosses the vertical gluteal fold at an angle and eliminates the suture line in the gluteal fold has been beneficial in all patients on whom it was used.

Thyroid cancer. Twenty-three years' experience at Baptist and St. Thomas Hospitals.

One hundred fifty-six patients with thyroid cancer were diagnosed and treated at Baptist and St. Thomas Hospitals from 1952 through 1955. Papillary carcinoma, representing 65 to 70 per cent of the total, occurs in all age groups and is the most readily curable of all carcinomas. Slightly more than 50 per cent of our series presented with multinodular goiters. When a male patient has nontoxic nodular goiter, it is three times more likely that he will have cancer of the thyroid than a female patient with a similar goiter. Definitive thyroid surgery was performed by over fifty different surgeons in 143 patients and simultaneous neck dissection in twenty-five. The histologic types ranged from papillary (9 per cent mortality) to anaplastic carcinoma (nearly 100 per cent mortality). Age and sex were shown in our series to affect survival. The female survival figures were better than the male, and older patients fared far worse then younger ones. Survival rates are much improved in patients with cervical node metastases when radical neck dissection is done. Patients reoperated for enlarged nodes located lateral to posterior triangle were found not to have metastatic cancer. Hyperthyroidism was confirmed in 0.25 per cent.