Thomas R. Kelly

Carcinoma of the gallbladder

One hundred ten cases of primary carcinoma of the gallbladder occurring over a 25 year period were reviewed. Except for anemia and weight loss, the signs, symptoms, laboratory, and roentgenographic studies were of little value in the preoperative diagnosis of the disease. Most patients presented with advanced disease with extension to the liver and metastases to the common bile duct nodes. In nine patients the tumor was not clinically apparent at the time of cholecystectomy, the diagnosis being made postoperatively by the pathologist. By the end of the first postoperative year, 85 percent of the patients had died. Only two patients survived more than 5 years, for an overall 5 year survival rate of 2 percent. Usually the only survivors are patients with lesions resected early that were not apparent to the operating surgeon and without deep invasion of the gallbladder wall. The best hope for reducing the mortality from this disease lies in earlier cholecystectomy in patients with benign gallbladder disease and in extending the limits of resection when small, and presumably early, lesions are encountered.

Gallstone pancreatitis. Local predisposing factors.

Local predisposing anatomic and stone factors were studied in ISO patients with gallstones in order to analyze why some patients with cholelithiasis acquire gallstone pancreatitis and others do not. Number and size of gallstones in the gallbladder and common bile duct, presence of pancreatic duct reflux, diameter of the cystic duct, and size of the duodenal orifice and ampulla of Vater were all studied in 75 patients with gallstone pancreatitis (Group I), 75 patients with cholelithiasis (Group II), and by dissections in 50 autopsy specimens. Stones 5 mm or less in diameter were present in 51 (70%) of Group I gallbladders as compared to 30 (41%) of Group II patients (p < 0.001). Impacted common bile duct stones were found in 21 (29%) of the Group I patients and only four (5%) of the patients in Group II (p < 0.001). The mean size of the stones that impacted at the ampulla of Vater in the Group I patients were 3.10 mm, whereas in the Group II patients the mean size of the stones was 7.50 mm (p < 0.001). The Group I cystic ducts were larger (3.80 mm) than the ducts in the Group II patients (2.36 mm) (p < 0.001). On operative cholangiography, 50 (67%) showed reflux of contrast material into the pancreatic duct compared to only 14 (18%) in the control Group II (p < 0.001). These data indicate that small gallbladder stones, enlarged cystic ducts, properly sized impacted stones, and a functioning common channel are predisposing local etiologic factors in the development of gallstone pancreatitis.

Thoracic outlet syndrome: current concepts of treatment.

This current concept of treatment of the Thoracic Outlet Syndrome based on a personal experience with 304 patients, resulted in complete (85%) or partial (7%) relief of symptoms in 92% of operated patients. The diagnosis centers upon a thorough history and the exclusion of other causes of arm and shoulder pain utilizing a strict flow pattern of differential diagnosis. Angiography and electromyography are of limited value and are only performed in selected cases. Operation should be reserved for the thoroughly evaluated patient who continues to have pain despite adequate conservative therapy. Transaxillary removal of the first rib, fibromuscular bands and cervical rib, when present, is the operation of choice. SummaryThe current concepts of treatment of 304 patients with TOS are reviewed. The diagnosis can be made with a high degree of accuracy by utilizing the combination of a detailed history, simple tests of physical examination and appropriate neurological and orthopedic consultations. If patients are highly selected through a thorough evaluation program surgery will result in gratifying relief of symptoms in over 90% of cases. The treatment of choice is meticulous resection of the first rib through a transaxillary approach.

Thoracic outlet syndrome

The diagnosis and treatment of thoracic outlet syndrome based on a personal experience with 473 patients resulted in relief of symptoms in over 90 percent of patients treated operatively. The diagnosis centers on a thorough history and the exclusion of other causes of arm and shoulder pain, utilizing a strict flow pattern of differential diagnosis. Angiography and electromyography are of limited value and should only be performed in selected cases. Operation should be reserved for the thoroughly evaluated patient who continues to have pain despite adequate conservative therapy. Transaxillary removal of the first rib, fibromuscular bands, and cervical rib, when present, is the operation of choice.

Primary hyperparathyroidism: Hyperparathyroid crisis

Hyperparathyroid crisis is a rare disease but should be suspected in acutely ill patients complaining of weakness, lethargy, nausea, vomiting, confusion and abdominal pain. Despite the variety of clinical manifestations, the syndrome forms a distinctive pattern which, in the presence of a serum calcium level greater than 16 mg/100 ml, should be recognized. The most difficult problem in diagnosis is the differentiation of hyperparathyroid crisis from ectopic parathyroid hormone-producing tumors. The disease is an endocrine emergency which requires prompt surgery after rapid correction of dehydration and hypercalcemia. The best results are achieved by removing offending parathyroid tissue within 72 hours after the onset of symptoms.

Primary hyperparathyroidism: A personal experience with 242 cases

Two hundred forty-two patients with primary hyperparathyroidism operated on at Akron City Hospital are reviewed. The importance of the association of peptic ulcer and pancreatitis with primary hyperparathyroidism is stressed. Nineteen percent of the patients had associated peptic ulcer or pancreatitis. The mechanisms involved in the production of these diseases in patients with primary hyperparathyroidism are emphasized. The two deaths occurred in the small but challenging group of patients with acute parathyroid crisis and carcinoma. The decision concerning the extent of parathyroidectomy should be made by the surgeon for each patient, based on the number, location and gross appearance of the identified glands. Removal of a single enlarged gland, if the other three glands are normal, is all that needs to be done in most cases. A recurrence rate of 1 percent and an appreciable decrease in postoperative tetany support this conservative approach. Subtotal parathyroidectomy should be reserved for patients with diffuse hyperplasia.

Acute arthritis: A complication of surgically induced hypoparathyroidism

Abstract In two patients with hyperparathyroidism acute arthritis of the right knee developed after the surgical correction of the hyperparathyroidism. The onset of arthritis with joint effusion became evident at the same time that the blood phosphorus level was greater than 3.5 mEq./L. A mechanism of simultaneous hyperphosphatemia and hyperuricemia resulting in a classic case of gout of the right knee was postulated. Other possibilities included rheumatoid arthritis, infectious arthritis, pseudogout, and chondrocalcinosis, although all have been ruled out with the clinical and laboratory evidence at hand.