[Peritoneovenous shunting in intractable ascites of cirrhosis. Results of a prospective study on improving prognostic factors]

A peritoneovenous (LeVeen) shunt was inserted in 39 patients with cirrhosis and intractable ascites. Based on the results of previous experience, the following procedures were performed to improve outcome: 1) intraoperative drainage of most of the ascites; 2) short-term antibiotic prophylaxis by cefotetan; 3) the use of a titanium venous catheter tip. There was no operative mortality. Operative morbidity was minimal. Mean postoperative in-hospital stay was 19 +/- 5 days. Two patients had recurrence of ascites. This resulted from obstruction of the valve in one patient and of occlusion of the venous catheter in the second patient. One-year probability of shunt failure was 5.8 p. 100. Among the long-term complications, variceal bleeding was the most frequent as it occurred in 8 patients and was responsible for death in 6. One-year probability of variceal bleeding was 18.6 p. 100. Overall one-year survival was 68 p. 100, 79 p. 100 in the group of 19 patients with Pugh scores of 8 and less, 58 p. 100 in the group of 20 patients with Pugh scores greater than 8. These results suggest that technically improved peritoneovenous shunting is a low operative risk surgical procedure with high efficiency in the treatment of intractable ascites in cirrhosis.

Segmentectomies in the management of liver tumors

Between 1982 and 1986, liver segmentectomies were performed in 19 patients with liver tumors, including ten hepatocellular carcinomas, six liver metastases, one cholangiocarcinoma, and two benign tumors. During surgery, patients received a mean (+/- 1 SD) of 1050 +/- 150 mL of packed red blood cells and 860 +/- 80 mL of fresh-frozen plasma. There were no operative deaths. The only complication was a prolonged leakage of ascites through the abdominal drain in one patient with cirrhosis. Seven patients with hepatocellular carcinoma were still alive at this writing, with a follow-up ranging from two months to four years. The four patients with metastases from colorectal carcinomas were alive after follow-up times ranging from six to 24 months. These results suggest that liver segmentectomy is a safe procedure and should be considered as the operation of choice for resection of limited liver tumors.

Metabolic fate of a gastric glucose load in unrestrained rats bearing a portal vein catheter

Metabolic and hormonal responses to the administration of a gastric load of glucose (2.4 mg/g body wt) were evaluated after a fast of 6-7 h in unrestrained rats bearing a portal vein catheter. For the purpose of this study, we have designed a new technique for a direct catheterization of the portal vein that allows serial blood sampling in unrestrained Wistar rats. On the 6th postoperative day, food intake, body weight gain, liver function, histology of the liver, pancreas, intestine, and splanchnic blood flows were similar to those of sham-operated control rats. In the basal state glucose turnover was 21.3 +/- 0.9 mg.kg-1.min-1. After glucose ingestion, a portoperipheral gradient of lactate was present, reflecting the production of lactate by the intestine. Insulin secretion was biphasic and peaked at 12 min (344 +/- 46 microU/ml), whereas portal glucagonemia (400-500 pg/ml) remained unchanged. Sixty minutes after gastric glucose administration, 50% of the load was delivered at the periphery, and glucose utilization was increased by 100%. Hepatic glucose production decreased after 20 min and was inhibited by 30% at 60 min. Liver glycogen concentration remained unchanged during the experiment despite a normal capacity for glycogen synthesis.

[Resections of hepatocellular carcinomas in cirrhosis: results of a prospective study of 28 resections]

Twenty-eight liver resections were performed in 24 patients with cirrhosis and hepatocellular carcinoma: 6 major hepatectomies, 13 limited, and 9 atypical liver resections. Postoperative variceal rebleeding was precluded in 5 patients with previous bleeding by preoperative sclerotherapy. Intraoperative bleeding was minimized in 16 patients by clamping the hepatic pedicle. Ascites formation was prevented by reduction of intraoperative and postoperative fluid infusion. There were no operative deaths. Benign postoperative complications occurred in 5 patients (18 p. 100). In one patient, carcinoma was not found in the resected specimen. Nineteen of the 27 others tumors were less than 5 cm in diameter (70 p. 100). Twenty-two tumors were encapsulated (81 p. 100). One and two-year actuarial survival rates were 66 p. 100 and 48 p. 100 in the group of 23 patients after resection of one, or more than one tumor, respectively. In 17 patients with a tumor less than 5 cm in diameter, one and two-year survivals were 76 p 100 and 51 p. 100, respectively. In 16 patients with a free margin of healthy tissue of more than 10 mm, one and two-year survivals were 85 p. 100 and 61 p. 100 respectively. Our results suggest that: 1) the operative risk of liver resection in cirrhosis is low, provided preventive measures are taken to avoid intraoperative bleeding and postoperative variceal bleeding and ascites, and 2) late survival is good in selected groups of patients after resection of hepatocellular carcinoma and cirrhosis.

Titanium catheter tip for peritoneovenous shunts

Early obstruction of the venous tubing is a frequent complication after peritoneovenous (PV) shunting for ascites in cirrhosis and results in a high incidence of shunt failure. A titanium catheter tip, developed because of this material's thromboresistance, was employed in 13 consecutive cirrhotic patients receiving a LeVeen shunt for intractable ascites. While the mean interval before shunt occlusion was 4 +/- 3 months in our previous studies, none of the patients in the present series had venous catheter occlusion during follow-up, which averaged 8 +/- 2 months. The use of titanium in the venous tubing of PV shunts may significantly prolong the patency and function of these devices.

Bleeding from intestinal varices after a Warren shunt

A 62-year-old man with alcoholic cirrhosis presented with massive gastrointestinal bleeding 4 years after a Warren operation. Angiographic examination suggested that the bleeding was due to ruptured jejunal varices. Treatment by propranolol and a side-to-side portacaval shunt failed to prevent further bleeding. An emergency laparotomy for life-threatening gastrointestinal (GI) rebleeding disclosed dense hypervascular adhesions between the second jejunal loop and the retroperitoneum, and a large submucosal varix of the jejunum that had ruptured. Development of intestinal varices after a Warren operation is facilitated by the persistence of a high pressure in the mesenteric territory and by adhesions between the initial part of the intestine and the area of dissection of the renal vein. This case illustrates one of the possible causes of rebleeding after a Warren operation.

Biliary metastases of breast carcinoma. The case for resection

Obstructive jaundice developed in two patients 6 and 8 years after surgery for breast carcinoma. In both patients exploration disclosed a tumor of the hilus which was a biliary metastasis of breast cancer. Surgical resection was performed. Examination of the resected specimen showed infiltration of the duct walls by sheets of metastatic carcinomatous cells from the previous breast cancer. The postoperative course was uneventful in both patients with disappearance of all symptoms due to the biliary obstruction. The first patient died 4 years later from peritoneal deposits and the second was alive at 30 months with a metastasis to the hip. These observations differ from most of those previously reported, by the localization of the tumor at the hilus and the direct infiltration of the duct walls by the tumor. The results of this study suggest that aggressive surgical treatment may be the treatment of choice in patients with extrahepatic biliary metastases of breast carcinoma.

Biliary metastases of breast carcinoma. The case for resection

Obstructive jaundice developed in two patients 6 and 8 years after surgery for breast carcinoma. In both patients exploration disclosed a tumor of the hilus which was a biliary metastasis of breast cancer. Surgical resection was performed. Examination of the resected specimen showed infiltration of the duct walls by sheets of metastatic carcinomatous cells from the previous breast cancer. The postoperative course was uneventful in both patients with disappearance of all symptoms due to the biliary obstruction. The first patient died 4 years later from peritoneal deposits and the second was alive at 30 months with a metastasis to the hip. These observations differ from most of those previously reported, by the localization of the tumor at the hilus and the direct infiltration of the duct walls by the tumor. The results of this study suggest that aggressive surgical treatment may be the treatment of choice in patients with extrahepatic biliary metastases of breast carcinoma.

Surgical treatment of small hepatocellular carcinomas in cirrhosis

Over the last five years a policy of systematic screening for small hepatocellular carcinomas (HCC) in patients at risk has led to an increasing number of resections in patients with cirrhosis. Remarkable progress in the surgery of HCC in cirrhosis has been accomplished through: (a) a better understanding of the surgical anatomy of the liver, (b) the definition of new types of liver resection aimed at reducing the amount of parenchyma removed while still being oncologically satisfactory, (c) the reduction of intraoperative blood loss by various techniques of clamping afferent and efferent vessels, (d) the systematic use of intraoperative ultrasonography, and (e) the prevention of postoperative variceal bleeding and the formation of ascites. Results of resection of small HCC in cirrhosis have been quite impressive in Japanese series, with a low operative mortality and above 50% three-year survivals. Results in the West have been somewhat less good. Differences in the pathology of these tumours and particularly in the rate of encapsulation could account for these differences. Clearly, surgical resection has become an established treatment for small HCC in cirrhosis. More information is needed on the results of surgery in operated patients and this should be compared with the natural history of small HCC in cirrhosis in order to better define the patients who will most benefit from these operations and which tests performed at which intervals, are most reliable in screening patients at risk.

Management of colorectal cancer in patients with cirrhosis and a LeVeen shunt

Two cirrhotic patients with a LeVeen shunt presented with a large bowel cancer. In one patient, the shunt was removed and the venous catheter was ligated prior to the performance of a colon resection. The postoperative course was uneventful. A new valve was inserted and connected to the venous catheter two months later. The second patient had a carcinoma of the rectum. In order to prevent ascites and to ease the colorectal resection he had preliminary construction of a portacaval shunt. Six weeks later, he underwent an anterior resection of the rectum. The postoperative course was uneventful except for a self limiting episode of febrile subacute intestinal obstruction. These two cases demonstrate that it is possible to resect colorectal cancer in patients with cirrhosis, ascites and a peritoneovenous shunt provided measures are taken to avoid specific complications due to the presence of the shunt, ascites or portal hypertension.

Intractable ascites in systemic mastocytosis treated by portal diversion

A 50-year-old male presented with intractable ascites due to systemic mastocytosis. The diagnosis of systemic mastocytosis was established by histology of the bone marrow which showed mast cell infiltration and fibrosis. Ascites was related to portal hypertension which was documented by esophageal varices at endoscopy and by an increase of wedged-free hepatic venous pressure gradient. Liver biopsy disclosed dense fibrosis of hepatic arterial and portal venule walls, resulting in complete obstruction of some portal radicles. Peliosis hepatis and fibrous deposits in the walls of hepatic venules were also present. Because of intractable ascites and significant malnutrition, a portacaval shunt was performed which cleared ascites and dramatically improved the general condition of the patient.

[Sugiura's operation: a Japanese exclusive?]

Fifteen patients with liver cirrhosis (11) or intrahepatic non cirrhotic portal hypertension (4) and previous variceal bleeding were electively treated by Sugiura's operation. There were no operative death. One patient (6.6 p. 100) had recurrent variceal bleeding 58 months postoperatively. One other patient had a self-limited episode of encephalopathy The 5-year actuarial survival rate was 81 p. 100. Four of the cirrhotic patients operated more than 5 years ago were alive at 5 years. The operation resulted in portal vein thrombosis in 2 patients, one of whom died. Results of this small series are quite similar to those of the largest Japanese series. They suggest that Sugiura's procedure has a low operative risk, is very efficient in preventing variceal rebleeding and does not result in encephalopathy.

The use of CA-50 radioimmunoassay inhibition test in the differential diagnosis of benign and malignant liver diseases

The value of a radioimmunoassay (RIA) in the detection of the human carcinoma-associated antigen CA-50 has been assessed in 50 normal subjects, 28 patients with various benign liver diseases and 91 patients with primary and secondary liver carcinomas. Sera from all normal subjects and 25 of 28 (89 per cent) patients with benign liver diseases had a CA-50 level below 17 units/ml. Three patients with sclerosing cholangitis and sixty (66 per cent) patients with primary or secondary liver tumours had CA-50 levels above 17 units/ml. CA-50 may therefore be a useful tumour marker for the diagnosis of liver carcinomas and for the post-treatment monitoring of patients with various liver malignancies.

Recurrent ascites due to central venous thrombosis after peritoneojugular (LeVeen) shunt

Twenty-five patients with cirrhosis with a peritoneojugular (LeVeen) shunt had recurrence of ascites because of obstruction of the venous catheter. They were investigated by direct shuntography and angiography of the superior vena cava (SVC). Shuntograms were suggestive of venous obstruction in all patients and showed either complete blockage at the tip of the venous catheter (87%) or partial obstruction (13%). Cavography disclosed a complete obstruction of the SVC or one of its branches in 65% of the patients, a nonobstructive mural thrombus in 17.5%, and sheathing around the catheter in another 17.5%. Blood clots formed at the tip of the catheter and not at its entrance into the vein. Replacement of the venous tubing or a contralateral shunt was successful in only one of eight patients with incomplete obstruction of the SVC. Failure was always due to recurrent venous obstruction. In patients with complete occlusion of the SVC, portal systemic shunts (12 patients) or peritoneosaphenous shunts (two patients) were always successful. These results suggest: that obstruction of the venous tubing of a LeVeen shunt is chiefly caused by the formation of a clot at the outlet of the tubing and that local procedures are prone to failure. Improvement of the long-term results of peritoneojugular shunting in intractable ascites of cirrhosis is clearly dependent on improvement of the venous tubing to decrease its thrombogenicity.

Pancreatic debridement in acute necrotizing pancreatitis: an obsolete procedure?

Thirty-eight patients treated by pancreatic debridement for acute necrotizing pancreatitis were studied. Group 1 consisted of 12 critically ill patients who underwent early surgery. Group 2 was formed from 15 patients operated upon secondarily for supervening complications and group 3 contained 11 patients operated upon electively for gallstone pancreatitis. The operative mortality was 100, 27 and 0 per cent for groups 1, 2 and 3 respectively. Pancreatic debridement was associated with a high morbidity whether performed for complications (66 per cent) or elective biliary surgery (36 per cent). These data suggest that there is probably only limited indication for pancreatic debridement in patients with acute necrotizing pancreatitis.

Results of portal systemic shunts in Budd-Chiari syndrome

Nine patients with Budd-Chiari syndrome (BCS) were treated by a portal systemic shunt. One had thrombosis of the superior mesenteric vein (SMV) and another had complete obstruction of the retrohepatic inferior vena cava (IVC). All other patients had a marked stenosis of the retrohepatic IVC with caval pressure ranging from 12 to 24 mmHg (mean: 17 mmHg). Seven patients had an interposition mesocaval shunt using an autologous jugular vein. The patient with a thrombosed SMV had a portoatrial shunt. The patient with an obstructed IVC had a cavoatrial shunt after an erroneous portacaval shunt had failed to relieve ascites. There were no operative deaths and no major postoperative complications. One patient died 19 months after operation of acute leukemia complicating polycythemia rubra vera. All other patients were alive and well 8 months to 6 years after operation. None of them had encephalopathy. These results suggest several comments: Portal systemic shunts are a good treatment for BCS and have a low operative risk. The mesocaval shunt is an efficient procedure, even when there is stenosis of the IVC with high caval pressure; shunts to the right atrium should be performed only in the case of complete obstruction or inaccessibility of the IVC. The long-term prognosis is excellent, except in patients with potential malignancies. Therefore, portal systemic shunts should be indicated early in patients with symptomatic BCS.

Portoatrial shunt in Budd-Chiari syndrome

It is now well accepted that mesoatrial bypass is an efficient treatment of Budd-Chiari syndrome and that it is indicated when the inferior vena cava is obstructed. This report presents a patient in whom the superior mesenteric vein was thrombosed after a previous mesocaval shunt. A bypass was constructed between the left side of the portal vein and the right atrium with a 16 mm diameter reinforced polytetrafluoroethylene prosthesis. The prosthesis passed between the left lobe of the liver and the caudate lobe and had a direct trajection. The procedure was simple, the postoperative course was uneventful, and the patient was well 20 months later. This observation suggests that portoatrial shunt is a good alternative to mesoatrial shunts in patients with Budd-Chiari syndrome and unavailable inferior vena cava and superior mesenteric vein.

Surgical resection of segment VIII (anterosuperior subsegment of the right lobe) in patients with liver cirrhosis and hepatocellular carcinoma

A limited liver resection was performed in two patients with cirrhosis and a hepatocellular carcinoma situated in segment VIII (anterosuperior subsegment of the right lobe). One of the patient had previously bled from esophageal varices. Resection of segment VIII was performed following the anatomical planes of section after complete mobilization of the right lobe of the liver. Both patients were alive and free of recurrence 14 and 30 months after surgery. Hepatocellular carcinomas are thus treatable by limited anatomic liver resection even when they are situated in the vicinity of the major hepatic veins and the vena cava.

Increase of oleic acid in erythrocytes associated with malignancies

Total lipid extracts of erythrocyte cell membranes from 60 patients with documented malignancies, 41 patients with various acute and chronic diseases, and 40 healthy subjects were analysed. The results were expressed as ratios of stearic to oleic acid, reflecting the degree of desaturation of stearic acid. The mean ratios for the healthy subjects and controls without cancer were 1.5 (SD 0.27) and 1.45 (0.28), respectively, whereas the ratios for patients with malignancies were consistently lower than the cut off point of 1.0, with a mean of 0.69 (0.15) (p less than 0.001). The desaturation ratio was also significantly lower (p less than 0.001) in the group with recurrent tumours (mean 0.75 (0.04)) compared with those with no evidence of recurrent tumours (mean 1.55 (0.27)). It is suggested that the increased unsaturation (oleic acid) in the circulating erythrocytes may be useful in the diagnosis and postoperative monitoring of patients with cancer.

Reduction in the stearic to oleic acid ratio in the circulating red blood cells: a possible tumour marker in solid human neoplasms

Gas liquid chromatography study of the 18 carbon chain length fatty acids (C18FA) of the human red blood cells (RBCs) was performed on 65 patients with various clinical disorders. It was found that the stearic to oleic acid ratio (SI) of the RBCs was significantly lower (P less than 0.001) in patients with malignant conditions (n = 20, SI = 0.62 +/- 0.16) compared with pathological non-malignant diseases (n = 10, SI = 1.19 +/- 0.2) and the normal control group (n = 35, SI = 1.57 +/- 0.5). Our early results suggest that the increased unsaturation (oleic acid) in the circulating RBCs could be used as a chemical marker in various solid neoplasms.

[Histochemical changes of the intestinal mucus in benign and malignant lesions of the colon and rectum]

The purpose of this work was to assess the presence of an abnormal production of sialomucins in different pathological conditions using high iron diamine-Alcian-blue staining. Sixty patients with a colorectal tumor and 95 subjects with either a normal colonic mucosa or suffering from non-malignant colorectal disease were studied. An increased production of sialomucins was searched in the first group on the mucosa of the tumor, on the transitional mucosa and on the surgical resection margins respectively and in the second group, on the colonic mucosa. A retrospective study was also performed on 48 patients who underwent curative resection for colorectal tumor. Twenty-four of those patients subsequently developed local tumor recurrence whereas the 24 other patients remained free of recurrence. The prospective study showed the presence of a constantly increased production of sialomucins in the neoplastic mucosa. These abnormalities were found in: 85 p. 100 of cases in the transitional mucosa, in 42 p. 100 and 25 p. 100 of the proximal and distal resection margins respectively, and in 73 p. 100 of patients with dysplasia. The retrospective study showed that 83 p. 100 of patients suffering from local recurrent tumors had an increased production of sialomucins whereas only 8 p. 100 of patients free of local recurrence presented such an abnormal production. This study confirms the presence of an increased production of sialomucins in various pathological colorectal conditions. It suggests that it is possible to individualize a high risk group of patients who might justify a closer follow-up with appropriate therapy.

The LeVeen shunt in the elective treatment of intractable ascites in cirrhosis. A prospective study on 140 patients

One hundred and forty patients with an intractable ascites complicating a chronic liver disease received a peritoneovenous shunt (PVS) using the LeVeen valve. Operative mortality was ten per cent but was 25% in patients with severe liver failure. Intraoperative drainage of ascites sharply decreased postoperative complications and mortality. One-year actuarial survival rate was 81.4%, respectively 77.7%, 61.3%, and 24.7% in patients with good liver function and moderate or severe liver failure. Variceal hemorrhage occurred in 11 patients and late infection in another 11 patients. Thirty-eight patients (30.5%) had recurrence of ascites. This was mostly due to an obstruction on the venous side of the shunt. An elective portacaval shunt had to be done in 23 patients for recurrence of ascites or variceal bleeding. Among the 57 patients still alive at time of writing, 51 were free of ascites. These results suggest that PVS is an efficient operation. This procedure may be largely indicated in the selected and small group of cirrhotic patients with true intractable ascites and moderate or no liver insufficiency.

[Encephalopathy following portal shunting in nodular regenerative hyperplasia of the liver]

Two patients with nodular hyperplasia of the liver developed a chronic disabling encephalopathy after an interposition mesocaval shunt. Both had a low total hepatic blood flow-rate postoperatively. Encephalopathy disappeared following surgical occlusion of the shunt. These observations emphasize the risk of postshunt encephalopathy in patients with non-cirrhotic intrahepatic portal hypertension.

[Acute necrotic pancreatitis: toward restriction of surgical indications]

Fifty-two patients operated for acute necrotising pancreatitis are reported. All severely-ill patients, operated early in order to perform a necrosectomy, died subsequently. Patients without severe illness were operated either for a complication of their pancreatic necrosis or electively for biliary lithiasis. The postoperative mortality was 29 p. 100 and 0 p. 100 respectively. Pancreatic necrosectomies were associated with a high morbidity whether performed for complications (64 p. 100) or during elective biliary surgery (33 p. 100). From this study, it appears that there is no indication for early necrosectomy in the severe forms of acute necrotising pancreatitis. However, pancreatic abscess remains a formal indication for drainage. It seems also justified to perform elective surgery without necrosectomy for biliary lithiasis complicated by acute necrotising pancreatitis.

[Brain-death unit and renal transplantation. Evaluation of 5 years' experience]

From 1977 to 1982, 170 potential organ donors were referred to "a brain-death unit". A vast majority of these patients were provided by intensive care units of district general hospitals from Ile-de-France. This fact confirms the dispersion of potential organ donors and the usefulness of an organ-procurement structure based in an University Hospital. Its effectiveness is demonstrated by an harvesting rate of 58%, largely over the already published reports in case of absence of such a center. It is concluded that the adoption of this system by other hospitals would significantly increase the number of cadaver kidney grafts available for transplantation whereas actually the number of kidney grafts remains dramatically low in France.

Idiopathic localized bile duct strictures: relationship to primary sclerosing cholangitis

Two patients have been described who presented with localized hilar bile duct strictures initially diagnosed as cholangiocarcinoma. Resection of the strictures showed benign disease. The subsequent development of further independent benign strictures was consistent with sclerosing cholangitis. Problems in diagnosis and management of this form of primary sclerosing cholangitis have been discussed.

Carcinoma in choledochal cysts. Age-related incidence

We examined a case of malignant degeneration that occurred as a long-term complication of a choledochal cyst. Analysis of the literature shows the incidence of carcinoma varies with age at the initial appearance of symptoms. The child with a choledochal cyst that appears before 10 years of age carries a minimum risk (0.7%) of subsequent malignant degeneration compared with the patient in the second decade (6.8%) and older (14.3%). Data suggest that carcinoma may be readily overlooked at the time of choledochal cyst exploration. In light of the findings, an age-adjusted strategy for management should be used.

Delayed hepatic resection for major liver injury

Seven patients with major liver injury initially assessed and managed elsewhere, and then referred to the Hepatobiliary Unit at Hammersmith Hospital, London, are reported. Six of the 7 patients had been operated upon and 4 had undergone two laparotomies before referral. All were seriously ill as a result of bleeding or liver necrosis and infection. Further laparotomy was carried out for the control bleeding, débridement of dead tissue and drainage of infected material. Hepatic resection was performed in all patients and 3 of the 7 died in the postoperative period. Liver resection is necessary for the control of bleeding and removal of dead tissue in severe shattering injuries. Should temporary packing be instituted in order to obtain control, then early referral for definitive treatment is necessary. Delay is dangerous and extension of necrosis with secondary infection is inevitable.

[Unusual sequelae of a cranial injury]

A 13 year old child who had an apparently mild head injury presented with psychiatric sequelae. The main feature was a variable level of consciousness. The only explanation for the symptoms lay within the family environment. A hysterical converion symptom was possible but the start of a psychosis could not be excluded.