Common bile duct obstruction by free floating tumor.

UNLABELLED: Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion [1] and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. CONCLUSION: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

Management of transpelvic gunshot wounds.

The records of 98 patients with transpelvic gunshot wounds from 1983 to 1988 were reviewed: 22 patients were admitted in shock and required aggressive resuscitation and immediate exploration, and 76 patients were normotensive and were evaluated with diagnostic peritoneal lavage, angiography, cystography, proctoscopy, CT scan, and contrast-enhanced CT enema in various combinations as indicated. Using this approach, 40 stable patients were observed without operation and discharged without complications. Fifty-eight patients were explored: 20 had both arterial and hollow viscus injuries. Thirty-nine major vascular injuries were evaluated: 27 were ligated and 12 repaired. Other injuries were colon, 27; including seven rectal perforations, multiple small bowel perforations, five bladder, one ovarian, four ureteral, three caval, three renal, and two distal aortic injuries. Colon injuries associated with vascular injuries were treated with colostomy and ligation of the vessel with extra-anatomic bypass when revascularization was required. Overall 12 patients died as a result of their injuries, a mortality of 12.2%. However, 50% of the patients who were admitted in shock died. Two external iliac artery injuries and two ureteral injuries were missed at initial operation. Penetrating trauma to the pelvis presents a serious challenge because of the complex anatomy of the region. Patients in shock have a high incidence of vascular injury and subsequent exsanguination, and associated visceral injuries may complicate their management. However, stable patients may be managed without operation, when appropriate diagnostic techniques fail to demonstrate an injury. Arterial ligation and extra-anatomic bypass should be considered for vascular injury with gross fecal contamination.