Atom Bombs and Radiation Injuries

Commentary I feel that the brief reports of these eight cases offer their own lessons, but would like to summarize shortly my own opinions. In a case of obstructive jaundice in which there is some doubt as to the cause at laparotomy: i. When the gall bladder is collapsed a careful dissection in the porta hepatis may reveal a growth. UTsually little can be done but f would suggest that by opening the duct below and dilating the malignant stricture, palliation may be achieved with temporary clearance of the jaundice. 2. When the gall bladder is distended the duodenum and head of pancreas should be freely mobilized and the bile duct brought under direct vision. If there is a growth and it is absolutely confined to the bile duct a local resection is advised. If it appears to have spread outside the confines of the duct and involved the pancreatic head, a pancreatico-duodenectomy should be performed. 3. Where a lesion of the ampulla is suspected and there is the slightest doubt as to its nature, a transduodenal inspection should be made after mobilizing the duodenum. If doubt still exists, and facilities for frozen sections are available, a diathermy excision should be performed and the treatiueoit -,ill bc depend(lent on the patlhological repor.. Having performed a resection of one sort or another, the bile duct should be anastomosed to the jejunum, and this is much easier to perform over a soft rubber tube. The portion of jejunum should always be defunctioned (Figs. 5 and 6) to obviate the danger of ascending cholangitis. I have found that ligation of the proximal end of the duct and usage of the gall bladder to re-establish biliary continuity is unsatisfactory, the danger being that the bile duct will slough and the patient succumb to a biliary peritonitis. The decision to perform a oneor two-stage operation depends upon the age and general condition of the patient. A one-stage operation is preferable but when the liver function is demonstrably poor a two-stage procedure is necessary. We have found that the most useful liver function tests are serum protein, thymol turbidity and alkaline phosphatase estimations. fn conclusion I would like to say that although these are relatively rare tumours they are as common as carcinoma of the gall bladder and as carcinoma of the pancreas (Willis, 1948). Their identification may often mean the saving of life by a relatively simple surgical procedure. I am grateful to Mr. Norman C. Tanner for giving me access to his notes, and to Mrs. Mace and Miss Mason of the photographic department of St. James's Hospital.