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Obstructed jaundice due to calcified lymph nodes around the common bile duct
374
American Journal of Surgery
Section
of Surgery
be made to see whether there is any invcIvement there that may uItimateIy give symptoms. DR. JOHN A. MCCREERY: I think that Dr. Cave was fortunate to fmd a IocaIized cyst that couId be compIeteIy extirpated. At BeIIevue HospitaI, where perhaps haIf a dozen cases are seen in a year, it is very rareIy that this can be done, the tumors usuaIIy being muItiIocuIar and too extensive for compIete remova1. DR. JOSEPH E. J. KING: I had a patient in 1924 who had never had any symptoms unti1 he sustained a faII in an eIevator, was badIy shaken and vomited. Symptoms became acute. At operation an echinococcus cyst was found in the Iower Iobe of the Iiver between the gaI1 bIadder and the round Iigament. It was 3 to 4 inches in diameter and projected sIightIy from the margin of the Iiver. I was abIe to enucIeate it compIeteIy, but it was so Iarge I couId not bring the parts together so I approximated the Iower and upper surfaces as cIoseIy as possibIe and inserted a smaI1 drain. The wound heaIed and the patient went home in three weeks and has had no further troubIe. That is the first case I ever saw in which the cyst couId be entireIy enucIeated. I think Dr. Cave is to be congratuIated on aIso having been abIe to accompIish this in his case. DR. CAVE (cIosing). Of course my patient may get other cysts in the Iiver, but the sharp Iine of demarcation was striking and the entire cyst couId be removed without any diffIcuIty. At first I decided against drainage, but it seemed such a Iarge area that I put in gauze. OBSTRUCTED JAUNDICE DUE TO CALCIFIED LYMPH NODES AROUND THE COMMON BILE DUCT HENRY W. CAVE, M.D. This patient, a man aged fifty-four years, was admitted to the RooseveIt HospitaI on August g, 1926, compIaining of weakness and jaundice. FamiIy and persona1 history were irreIevant. Present iIIness began about five weeks before with sIight stiffness of a11 of his joints, genera1 weakness and indefinite distress after the intake of food. His iIIness, however, took no definite form unti1 three weeks before admission when he became jaundiced, and had cIaycoIored stooIs and dark biIe-stained urine. He had Iost 20 pounds in the preceding five weeks. There had been no pain and no vomiting. Physical examination showed a fairIy weIIdeveIoped and under-nourished man who
appeared to be iI1. His skin and scIerae showed definite jaundice with a sIight greenish tint. The abdomen appeared to be moderateIy fuI1; no masses paIpabIe; the edge of the Iiver was paIpabIe 148 inches beIow the costa1 margin. SIight tenderness was eIicited to the right of the midIine in the epigastrium. A provisiona diagnosis was carcinoma of the pancreas. CIotting time was three minutes; bIood pressure I 18/78; bIood count normaI. Operation, August IO. Upper right rectus incision. The Iiver was found to be somewhat enIarged; approximateIy three fingers’ breadth beIow the costa margin. It was norma in appearance and in consistency. The gaI1 bIadder was not distended appreciabIy, thin waIIed, bIuish and did not empty readiIy on pressure. Numerous Iarge hard masses about the size of haze1 nuts were feIt, which were first taken to be stones within the Iumen of the common bile duct. These numerous calcified nodes running aIong the duct were dissected out and found to have the appearance of smaI1 bunches of grapes, a11 caIcified. The entire Iymph node seemed to be dispIaced by caIcified smaI1 seedlike masses. To be quite sure that there were no stones within the Iumen of the duct it was opened and a probe was passed quite easiIy into the hepatic ducts but with some sIight diffIcuIty toward the duodena1 end of the duct. However, it was feIt that the common duct, which was not distended or thickened, was entireIy free from any stones. A smaI1 rubber catheter was inserted into the common biIe duct through the opening aIready made and cIosure of the rent in the duct was made about the tube. A wrapped tube drain was pIaced down to Morrison’s pouch. Head of the pancreas, stomach and duodenum were normaI. Nothing was done to the gaI1 bIadder. Pathological Report. Specimen consists of seven pieces of tissue ranging in size from I cm. by 134 cm. to $5 cm. by I cm. They are composed of a smaI1 amount of fibrous and puIpy brown materia1, infiItrated with yeIIowish-white seed-Iike masses of stony hardness. On microscopical examination they showed the Iymph foIIicIes containing germina1 centers, the gIands infiItrated with weII-organized strands of fibroid tissue which breaks the foIIicIes up into patchy groups of foIIicIe ceIIs. PathoIogicaI diagnosis was chronic Iymphadenitis with caIcareous degeneration. Postoperative Course. The postoperative course was entirely uneventfu1. The catheter
Section
of Surgery-
American Journal of Surgery
3’3
Right mid-rectus incision. The large intestine as we11 as numerous Ioops of the smaI1 intestine were found markedIy diIated. There was an increased amount of peritonea1 fhrid. A Iarge, hard, granulated growth was discovered in the sigmoid, which was fairIy fixed, with marked edema and dilatation of the bouei above the growth. A few enIarged gIands couId be feIt in the mesentery of the sigmoid. The Iiver was found to be negative for any metastatic invoIvement. On account of the patient’s poor condition it was deemed advisabIe to do simpIy a cecostomy. At the end of the operation the patient’s pulse was very rapid and her condition not good. However, after an infusion she seemed to improve. Cecostomy opening worked perfectIy. Second operation, June 28, 1926, nineteen days after first operation. The first stage of a CARCINOMA OF THE SIGMOID Mikulicz operation was done through a Iower IN A YOUNG WOMAN Ieft rectus incision. The annuIar growth in the HENRY W. CAVE, M.D. sigmoid seemed to have diminished in size since previous operation. The waI1 of the bowe1 A patient, aged twenty-five years, was admitted to the RooseveIt HospitaI on June g, above the growth did not seem to be so thick1926, complaining of inabiIity of howeIs to ened or edematous. The peritoneum at the move, and distended abdomen. FamiIy history outer side of the sigmoid was incised and the was negative. Nothing in her persona1 history entire sigmoid deIivered up into the wound. was of any importance. Present iIIness began A Iarge segment of the mesentery just beneath four months ago, when she noticed that her the growth, where enIarged nodes were feIt, boweIs wouId move onIy with great diffrcuIty was excised and the Ieaves of the cut mesentery and a considerabIe amount of Iaxatives. brought together with interrupted catgut sutures. The entire growth was brought we11 Previous to this time her genera1 heaIth had been excehent. At about the same time that she up on the anterior abdomina1 waI1 and after noticed an increasing constipation she had carefu1 suture of both Iimbs of the bowe1, inIIuenza and during this iIIness vomited quite wound was sutured. On JuIy IS, the second often and had a great dea1 of pain in her abdostage was done with excision of the growth. A men not IocaIizecI at any particuIar point. few days Iater a cIamp was applied to the Ioops In March she consulted her famiIy physician in order to cut down the spur. HeaIing then who made a diagnosis of “inflammation of took pIace satisfactoriIy up to the point where, the womb” for which she was given turpentine on August 21, a cIosure of the Ieft coIostomy enemas. At times since the onset of the iIIness was made. Seven days Iater a closure of the she had feIt feverish without chiIIs. Appetite cecostomy was carried out. had been good unti1 a week prior to admission. Pathological report was adenocarcinoma of She has Iost considerabIe weight. Seven days the sigmoid; metastatic adenocarcinoma of prior to admission she found that her bowels the mesentery lymph nodes. \vouId not move, there was increasing distenPostoperative Course. The patient made an tion of the abdomen and increased tenderness uneventfu1 recovery. She has been seen from and for the Iast two days she had been vomiting. time to time since and has gained in weight. Pb,ysical Examination. Patient was a sickHer howeIs have been moving reguIarIv and she looking young woman with a distended abdoseems to be in good condition. The case is men. Pulse rate was 104; temperature 100.2’~. ; presented for the reason that growths of the white bIood ceIIs 10,000, poIymorphonucIears Iarge bowe1 in young aduIts are infrequent 70 per cent; bIood pressure I IO 430. Preoperaand aIso to demonstrate how vaIuabIe is a tive diagnosis \vas intestinal obstruction, properly functioning cecostom?; in the hancause undetermined. dIing of growths dista1 in the Iarge bowel. Operation, June o, two hours after admission : (No discussion)
in the common duct was easily withdrawn on the sixteenth day and bile drainage persisted for about three davs Ionger. The patient was discharged cured with wound healed on August 3 I, twenty-two days after operation. Occlusion of the common bile duct from calcified Igmph nodes surrounding it is uncommon. In this patient there was no cause that could be found for the chronic adenitis with c&&cation of Iymph nodes. There was delinitely no pnncreatitis nor any demonstrabre disease of the gaI1 bIadder and, except for the rnlargement of the Iiver, there seemed nothing in this organ that couId have contributed to the adenitis. The appendix was not disturbed. (No discussion)
American Journal of Surgery
Section
of Surgery
be made to see whether there is any invcIvement there that may uItimateIy give symptoms. DR. JOHN A. MCCREERY: I think that Dr. Cave was fortunate to fmd a IocaIized cyst that couId be compIeteIy extirpated. At BeIIevue HospitaI, where perhaps haIf a dozen cases are seen in a year, it is very rareIy that this can be done, the tumors usuaIIy being muItiIocuIar and too extensive for compIete remova1. DR. JOSEPH E. J. KING: I had a patient in 1924 who had never had any symptoms unti1 he sustained a faII in an eIevator, was badIy shaken and vomited. Symptoms became acute. At operation an echinococcus cyst was found in the Iower Iobe of the Iiver between the gaI1 bIadder and the round Iigament. It was 3 to 4 inches in diameter and projected sIightIy from the margin of the Iiver. I was abIe to enucIeate it compIeteIy, but it was so Iarge I couId not bring the parts together so I approximated the Iower and upper surfaces as cIoseIy as possibIe and inserted a smaI1 drain. The wound heaIed and the patient went home in three weeks and has had no further troubIe. That is the first case I ever saw in which the cyst couId be entireIy enucIeated. I think Dr. Cave is to be congratuIated on aIso having been abIe to accompIish this in his case. DR. CAVE (cIosing). Of course my patient may get other cysts in the Iiver, but the sharp Iine of demarcation was striking and the entire cyst couId be removed without any diffIcuIty. At first I decided against drainage, but it seemed such a Iarge area that I put in gauze. OBSTRUCTED JAUNDICE DUE TO CALCIFIED LYMPH NODES AROUND THE COMMON BILE DUCT HENRY W. CAVE, M.D. This patient, a man aged fifty-four years, was admitted to the RooseveIt HospitaI on August g, 1926, compIaining of weakness and jaundice. FamiIy and persona1 history were irreIevant. Present iIIness began about five weeks before with sIight stiffness of a11 of his joints, genera1 weakness and indefinite distress after the intake of food. His iIIness, however, took no definite form unti1 three weeks before admission when he became jaundiced, and had cIaycoIored stooIs and dark biIe-stained urine. He had Iost 20 pounds in the preceding five weeks. There had been no pain and no vomiting. Physical examination showed a fairIy weIIdeveIoped and under-nourished man who
appeared to be iI1. His skin and scIerae showed definite jaundice with a sIight greenish tint. The abdomen appeared to be moderateIy fuI1; no masses paIpabIe; the edge of the Iiver was paIpabIe 148 inches beIow the costa1 margin. SIight tenderness was eIicited to the right of the midIine in the epigastrium. A provisiona diagnosis was carcinoma of the pancreas. CIotting time was three minutes; bIood pressure I 18/78; bIood count normaI. Operation, August IO. Upper right rectus incision. The Iiver was found to be somewhat enIarged; approximateIy three fingers’ breadth beIow the costa margin. It was norma in appearance and in consistency. The gaI1 bIadder was not distended appreciabIy, thin waIIed, bIuish and did not empty readiIy on pressure. Numerous Iarge hard masses about the size of haze1 nuts were feIt, which were first taken to be stones within the Iumen of the common bile duct. These numerous calcified nodes running aIong the duct were dissected out and found to have the appearance of smaI1 bunches of grapes, a11 caIcified. The entire Iymph node seemed to be dispIaced by caIcified smaI1 seedlike masses. To be quite sure that there were no stones within the Iumen of the duct it was opened and a probe was passed quite easiIy into the hepatic ducts but with some sIight diffIcuIty toward the duodena1 end of the duct. However, it was feIt that the common duct, which was not distended or thickened, was entireIy free from any stones. A smaI1 rubber catheter was inserted into the common biIe duct through the opening aIready made and cIosure of the rent in the duct was made about the tube. A wrapped tube drain was pIaced down to Morrison’s pouch. Head of the pancreas, stomach and duodenum were normaI. Nothing was done to the gaI1 bIadder. Pathological Report. Specimen consists of seven pieces of tissue ranging in size from I cm. by 134 cm. to $5 cm. by I cm. They are composed of a smaI1 amount of fibrous and puIpy brown materia1, infiItrated with yeIIowish-white seed-Iike masses of stony hardness. On microscopical examination they showed the Iymph foIIicIes containing germina1 centers, the gIands infiItrated with weII-organized strands of fibroid tissue which breaks the foIIicIes up into patchy groups of foIIicIe ceIIs. PathoIogicaI diagnosis was chronic Iymphadenitis with caIcareous degeneration. Postoperative Course. The postoperative course was entirely uneventfu1. The catheter
Section
of Surgery-
American Journal of Surgery
3’3
Right mid-rectus incision. The large intestine as we11 as numerous Ioops of the smaI1 intestine were found markedIy diIated. There was an increased amount of peritonea1 fhrid. A Iarge, hard, granulated growth was discovered in the sigmoid, which was fairIy fixed, with marked edema and dilatation of the bouei above the growth. A few enIarged gIands couId be feIt in the mesentery of the sigmoid. The Iiver was found to be negative for any metastatic invoIvement. On account of the patient’s poor condition it was deemed advisabIe to do simpIy a cecostomy. At the end of the operation the patient’s pulse was very rapid and her condition not good. However, after an infusion she seemed to improve. Cecostomy opening worked perfectIy. Second operation, June 28, 1926, nineteen days after first operation. The first stage of a CARCINOMA OF THE SIGMOID Mikulicz operation was done through a Iower IN A YOUNG WOMAN Ieft rectus incision. The annuIar growth in the HENRY W. CAVE, M.D. sigmoid seemed to have diminished in size since previous operation. The waI1 of the bowe1 A patient, aged twenty-five years, was admitted to the RooseveIt HospitaI on June g, above the growth did not seem to be so thick1926, complaining of inabiIity of howeIs to ened or edematous. The peritoneum at the move, and distended abdomen. FamiIy history outer side of the sigmoid was incised and the was negative. Nothing in her persona1 history entire sigmoid deIivered up into the wound. was of any importance. Present iIIness began A Iarge segment of the mesentery just beneath four months ago, when she noticed that her the growth, where enIarged nodes were feIt, boweIs wouId move onIy with great diffrcuIty was excised and the Ieaves of the cut mesentery and a considerabIe amount of Iaxatives. brought together with interrupted catgut sutures. The entire growth was brought we11 Previous to this time her genera1 heaIth had been excehent. At about the same time that she up on the anterior abdomina1 waI1 and after noticed an increasing constipation she had carefu1 suture of both Iimbs of the bowe1, inIIuenza and during this iIIness vomited quite wound was sutured. On JuIy IS, the second often and had a great dea1 of pain in her abdostage was done with excision of the growth. A men not IocaIizecI at any particuIar point. few days Iater a cIamp was applied to the Ioops In March she consulted her famiIy physician in order to cut down the spur. HeaIing then who made a diagnosis of “inflammation of took pIace satisfactoriIy up to the point where, the womb” for which she was given turpentine on August 21, a cIosure of the Ieft coIostomy enemas. At times since the onset of the iIIness was made. Seven days Iater a closure of the she had feIt feverish without chiIIs. Appetite cecostomy was carried out. had been good unti1 a week prior to admission. Pathological report was adenocarcinoma of She has Iost considerabIe weight. Seven days the sigmoid; metastatic adenocarcinoma of prior to admission she found that her bowels the mesentery lymph nodes. \vouId not move, there was increasing distenPostoperative Course. The patient made an tion of the abdomen and increased tenderness uneventfu1 recovery. She has been seen from and for the Iast two days she had been vomiting. time to time since and has gained in weight. Pb,ysical Examination. Patient was a sickHer howeIs have been moving reguIarIv and she looking young woman with a distended abdoseems to be in good condition. The case is men. Pulse rate was 104; temperature 100.2’~. ; presented for the reason that growths of the white bIood ceIIs 10,000, poIymorphonucIears Iarge bowe1 in young aduIts are infrequent 70 per cent; bIood pressure I IO 430. Preoperaand aIso to demonstrate how vaIuabIe is a tive diagnosis \vas intestinal obstruction, properly functioning cecostom?; in the hancause undetermined. dIing of growths dista1 in the Iarge bowel. Operation, June o, two hours after admission : (No discussion)
in the common duct was easily withdrawn on the sixteenth day and bile drainage persisted for about three davs Ionger. The patient was discharged cured with wound healed on August 3 I, twenty-two days after operation. Occlusion of the common bile duct from calcified Igmph nodes surrounding it is uncommon. In this patient there was no cause that could be found for the chronic adenitis with c&&cation of Iymph nodes. There was delinitely no pnncreatitis nor any demonstrabre disease of the gaI1 bIadder and, except for the rnlargement of the Iiver, there seemed nothing in this organ that couId have contributed to the adenitis. The appendix was not disturbed. (No discussion)