June 1984, Volume 34, Issue 6

Case Reports

Selected Abstracts

The Treatment of Refractory Ascites by Le Veen Shunt (Letraitement de Pascite refractaire par le shunt de LeVeen). J.J. Gonvers, P. Loup, H.R. Brunner and other. Sehweiz. Med. Wochenschr., 1981, 111: 220.
SEVEN PATIENTS with refractory or recurrent ascites secondary to cirrhosis were treated operati­vely with a• LeVeen shunt. All patients were severely ill and were in the hospital four to six weeks before operation with intractable ascites. Six patients had alcoholic cirrhosis while one had postnecrotic cirrhosis. The shunts were all initially successful and the patients realized an average 11.2 kgni. weight loss. An ongoing diuresis could be documented ten days after operation with an associated natriuria. The plasma renin fell from 20.71 ± 1.72 ngm/nil./hr. to 6.85± 3.45 ngm./ mi/hr. The plasma aldosterone level fell from 91.16 ± 17.21 ngm/dl. to 2035 ± 7.95 ngm./ dl. The decline in both values was significant at p L 0.05. There were no early operative complications and no evidence of diffuse intravascular coagulopathy was reported.
However, the long term results of shunting these seriously ill patients was not encouraging. Five of seven patients have died. In three of these fatalities, thrombotic or septic complications directly related to the shunt were cited. It was suggested that LeVeen shunt was cited. It was also suggested that LeVeen shunt should be reserved for only patients with intractable ascites or hepatorenal syndrome because the late hazards of the shunt are substantial.
-Ronald C. Merrel

The Central Splenorenal Shunt for Portal Hyper­tension in Children; Experience with Eight Consecutive Patent Anastomoses. Arnold G Coran, John R. Wesley and William H. Weintraub J.Pediatr. Surg., 1980, 15: 827.
EIGHT CHILDREN with symptomatic portal hypertension underwent central splenorenal shunts over a period of five years from 1974 to 1979. The cause of the portal hypertension was extrahepatic obstruction in five patients, extrahepatic obstruction plus congenital hepatic fibrosis in one patient, postnecrotic cirrhosis in one patient and cirrhosis secondary to alpha-l-antytrypsin defici ency in one patient. Severe hypertension was present in all patients as well as massive splenornegaly.
The surgical procedure consisted of mobilization of the splenic vein out of its bed in the pan­creas up to its junction with the inferior mesentery vein, splenectomy, dissection of the left kidney vein from the kidney hilus to its entrance underneath the abdominal aorta. The splenic vein is then approximated to the kidney vein in such a fashion that in the completed shunt, the splenic vein remnant will have a gentle curve. The diameter of the constructed anastomosis ranged from 4 to 20 mm.
There was one patient with an immediate postoperative complication. The follow-up period ranged from one to five years. There were no further episodes of spontaneous bleeding and the hyperspienism improved in the patient. Seven• of eight patients had postoperative shunt studies and all of the shunts were patent. The preoperative esophageal varices that were present in all patients disappeared in five and were markedly reduced in the other three patients.
Postoperatively, all of the patients were treated with pneumovax vaccine immediately and were placed on prophylactic antibiotics. There were no significant septic problems. There were also no episodes of hepatic encephalopathy in the follow-up period. In conclusion, it is believed that central splenorenal shunts are effective in the management of portal hypertension and that anastomosis as small as 4 mm. in diameter can remain patent.
-Roland S. Philip

Carcinoma of the Gallbladder, a Review and an Appraisal of its Surgical Treatment. Virgiio S.
Durban, Jr., and Crisostomo A. Arcilla. Southeast Asian .J Surg., 1981,4:51.
THIRTEEN patients with carcinoma of the gallbladder are presented. The patient records from four hospitals over a ten year period in Quezon City, the Philippines were reviewed. The 13 patients constituted about 0.1 per cent of all malignancies and 1 per cent of gastrointestinal carcinoma.
Carcinoma was seen in one of 72 patients who had cholecystectomies. Presenting symptoms were those generally expected in patients with acute or chronic cholecvstitis. Nine of the Patients had adenocarcinomas. Three were located in the fundus, one in the neck, four in the body and neck and the remaining five were diffuse. The smallest lesion was 0.3 centimeters. Involvement of the liver occurred in six patients. Lymph node spread was noted in four patients and extension to the common intestinal duct in five. Two patients had extensive involvement of the omentum and colon. Eight of 13 patients had coexisting evidence of cholecystitis and cholelithiasis.
Cliolecystectomy was performed in eight patients and in five of these eight the presence of carcinoma was unsuspected during the operation. The remainder had more widespread disease. Two had cholecystectomy with T-tube drainage of the common duct. The remainder of the patients had other palliative procedures or biopsy only. Two patients died within two weeks. Both had extensive disease. Of the eight who were available for follow-up examination, two are still alive one year after operation-one patient survived 3.5 years, postoperatively.
Cholecystectomy, wedge resection of the liver and removal of the regional lymph ‘nodes in suitable candidates was recommended. Hepatic trisegmentectomy was also recommended if local conditions suggest there might be a chance for cure. Further, removal of the gallbladder in pa. tients who are asymptomatic as a means of prophylaxis was endorsed.
-ThomasJ. Tarnay

A Comparative Study of Choledochoduodenostomy and Sphincterotomy (Choledoco-duodenostomie et papilo-sphineterotomie; Etude cornpartive). A. Ahuaii. Lyon Chir., 1981, 77:10.
IN FIVE YEARS, 1, 227 biiary operations were performed. Those included 83 sphincterotomies and 44 choledochoduodenostomies. Sphincterotomy was done in 33 patients with duct stones, 26 patients with stones m the papila and 15 patients with papillitis. Choledochoduodenos. torny was performed in 12 patients with carcinoma ot ttie heau of the pancreas, tive patients with chronic stenosis pancreatitis, and three patients with carcinoma of the common bile duct.
Four patients died after sphincterotomy, due to acute pancreatitis, two, duodenal fistula, one, and hemorrhage and kidney failure, one. Non-lethal complications included two temporary duodenal fistulas, two acute pancreatitis controlled medically and two hemorrhages. Results were excellent in 33 patients, 58 per cent, good in 18, 11 per cent, satisfactory in seven and unsatisfactory in one patient.
One patient died of fulminant cholangitis following choledochoduodenostomy. One patient had a tempoiary biliary fistula and two patients had attacks of cholangitis. Twenty patients, 71 per cent, had excellent results, five patients had good results, 17 per cent and three patients had satisfactory results. Some guidelines about the relative indications of the two operations are given. It is pointed out that each patient has to be individualized and that the surgeon’s personal preference for one or the other technique plays a crucial role.
-Ranes C. Chakravorty

Liver Abscess at the Hadassah University Hospital During the Years 1967-77. M. Shapiro, D. Rachmilewitz, I. Avinoah and others. 1st. J. Med. Sci., 1980. 16: 761.
A RETROSPECTWE review of 36 patients who were diagnosed to have abscess of the liver was
done at the Hadassah University Hospital between the years 1967 and 1977. There were 22 men, 75 per cent, and nine women, 25 per cent, with a range in age of two months to 80 years.
The diagnosis was made without operation in 21 patients, with emergency operation in nine and in six patients, 17 per cent, at autopsy. The cause of the abscess was amebic in 15 patients 42 per cent and pyogenic in 21 patients 58 per cent. The patients had either one or more large abscesses, 5 to 15 cm. in diameter, which were usually amebic in cause; and there were multiple small abscessses, less than 2 cm. in diameter, which were pyogenic in origin.
There were multiple presenting symptoms in patients, with the most frequent being fever, abdominal pain, weakness and anorexia. Ten patients had fever as the only symptom. The duration of symptoms ranged from three days to 13 months. scans of the liver were helpful in making the diagnosis:
The mortality rate in patients with amebic liver abscesses was 20 per cent and 52 per cent in patients with pyogenic liver abscesses. The treatment of pyogenic liver abscesses is surgical drainage while amebic abscesses frequently respond to treatment with metranidazole or other antiamebic medications. Early diagnosis and treatment favorably alter an otherwise poor diagnosis.
-Roland S. Philip

Survival and Quality of Life After Selective Portasystemic Shunts. Hector Orozoo, Luis Guevara, Misael Uribe and others. Am. J. Surg., 1981, 141: 183.
A FIVE YEAR experience of patients with cirrhosis who underwent selective portasystemic shunts was reviewed. Fiftyfive patients were observed for a minimum of one year. Thirty were men with a mean age of 38. All patients bled from esophageal or gastric varices and 40 had more than four episodes of bleeding.
The cirrhosis was caused by alcoholism in 29 patients. According to Child’s criteria, 31 were in class A; 18 in class B; and 6 in class C. Eighteen patients underwent distal splenorenal shunts. Twenty-seven had construction of a selective end-to-end renosplenic shunt and 10 had a splenocaval shunt performed using prosthetic material.
The operative mortality was 16 per cent. Two patients at Child’s class A died. The remaining seven patients who died were at Child’s class B and C Causes of death were gastrointestinal bleeding, 4 patients; hepatic coma, 2, patients; hepatorenal syndrome, 3 patients. The longer the operative procedure, the greater the mortality in patients. The over-all five year life table of survival was 59 per cent.. In the Child’s class subgroup, the five year survival was 83.4 per cent while those in the B and C groups had only a 36 per cent five year life expectancy. Although patients who were not alcoholics fared better, the difference was not statistically significant. Selective portasystemic shunting procedures were recommended for patients at Child’s class A and for patients in groups B and C as long as they could be improved in the hospital before hand.
-Thomas J. Tarnay

The Importance of Postoperative Choledochoscopy for Management of Retained Biiary Tract Stones. Tatsuo Yamakawa, Komaki and Jun. ichi shikata.Jpn. .L Surg., 1980, 10:302.
A SERIES OF 292 patients who underwent postoperative choledochoscopy at the Teikyo University Hospital is presented. Of this group, there were 104 patients with retained bifiary tract stones and complete extraction of these stones was successfully carried out in 101 patients using a choledochofiberscope.
Methods used to extract and mobilize the stones varied depending upon the location of the stone and these are individually described. Basically a balloon tipped catheter was used to manipulate the stone into an accessible area where it was grasped with a basket forceps or crushed with a crushing forceps, or both. The use of a large T.tube, number 18 or greater, is stressed and dilation of the sinus tract when narrow or tortuous was discussed. The diagnostic and therapeutic value of this method of stone extraction is unquestionable and as this safe and reliable procedure becomes routine, therapeutic results will be improved significantly.
-David P. Connolly

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