Selection of operation in patients with bleeding esophageal varices.

The results of surgical treatment of bleeding esophageal varices over an 8-year period in 155 patients are reviewed. Primary treatment of bleeding was conservative, with intravenous administration of vasopressin and balloon tamponade. Emergency operations were carried out after 48 hours in persons with persistent bleeding who were surgical candidates. Operative mortality was higher in this group (40%) than in those undergoing elective or urgent operations (each 10%). Postoperative encephalopathy occurred in 35% of patients and was correlated closely to late death after establishment of a shunt. The mesocaval shunt is no better than the portacaval but appears to be a good alternative in an emergency. In a controlled trial the distal splenorenal shunt was found to be associated with a lower rate of postoperative encephalopathy than the portacaval shunt, but thus far the long-term survival rates have not differed.     

Clinical Problems: Elective Splenorenal Anastomosis

Thirty-six patients underwent splenorenal anastomosis for haemorrhage from oesophageal varices. Twenty-nine patients were cirrhotics and seven had extrahepatic blocks or congenital hepatic fibrosis. The patients have been followed from 16 years to 6 months. The operative mortality was 11%. Recurrent haemorrhage occurred in two patients (6%) and neurological manifestations in 38% of the patients at risk. It is concluded that splenorenal anastomosis is associated with a high degree of shunt patency.     

Bleeding varices: 2. Elective management.

Patients who have previously bled from esophageal varices should have their hepatic function, neurologic status and nutritional status evaluated and should be examined for ascites before elective variceal decompression is done to prevent recurrent variceal hemorrhage. The two most important procedures used for this evaluation are liver biopsy and visceral angiography. If the liver biopsy reveals little or no necroinflammatory activity, shunt surgery is indicated. For patients with moderate or severe necroinflammatory activity, surgery is delayed until the inflammation subsides. The central aim of visceral angiography is to determine whether the patient has hepatopetal or hepatofugal portal venous flow. Patients with hepatopetal flow are treated with a selective distal splenorenal shunt. Those with hepatofugal flow are managed with a total shunt, such as an interposition H-graft portacaval or mesocaval shunt.     

SPLENOPORTAGRAPHY IN PORTAL HYPERTENSION—Its Value in Selecting the Operative Procedure of Choice

Splenoportagraphy has become an almost indispensable adjunct to the surgical management of portal hypertension. In many instances it will provide the basis for the selection of the operative procedure. Certain instances of intrahepatic portal hypertension due to cirrhosis that might better be managed by splenorenal shunt rather than by the generally preferred method of direct end-to-side portacaval shunt may be determined by this procedure. The procedure finds its greatest application in the accurate delineation of the three major types of extrahepatic portal hypertension, each of which demands a different surgical approach.     

Splenoportagraphy in portal hypertension; its value in selecting the operative procedure of choice

Splenoportagraphy has become an almost indispensable adjunct to the surgical management of portal hypertension. In many instances it will provide the basis for the selection of the operative procedure. Certain instances of intrahepatic portal hypertension due to cirrhosis that might better be managed by splenorenal shunt rather than by the generally preferred method of direct end-to-side portacaval shunt may be determined by this procedure. The procedure finds its greatest application in the accurate delineation of the three major types of extrahepatic portal hypertension, each of which demands a different surgical approach.     

THE SURGICAL TREATMENT OF PORTAL HYPERTENSION

Portacaval shunt operations were done in 15 of 18 patients who were treated surgically for portal hypertension. In eight cases the shunt was established by splenorenal anastomosis; in seven by anastomosis of the portal vein to the side of the inferior vena cava. Of the eight patients with splenorenal shunt, two are well, four are considered improved, and two have died. Of the seven in whom the portal vein was joined to the vena cava, two are improved, one is unimproved, and four have died.     

Effects of Dietary Amino Acids on Brain Amino Acids and Transmitter Amines in Rats with a Portacaval Shunt

The etiologic relationship between disturbances in metabolism of amino acids and amines and hepatic coma was investigated by examining the effects of diets containing various mixtures of amino acids on brain amine metabolism in rats with a portacaval shunt, using a method for simultaneous analysis of amino acids and amines. Rats with a portacaval shunt were fed on four different amino acid compositions with increased amounts of various amino acids suspected to be etiologically related to hepatic coma, such as methionine, phenylalanine, tyrosine, and tryptophan. The animals were killed 4 weeks after operation. During the experimental period, these animals did not become comatose, but exhibited various behavioral abnormalities. Marked increase in the plasma and brain levels of the augmented amino acids, especially methionine and tyrosine, were observed in rats with a portacaval shunt. Brain noradrenaline, dopamine, and serotonin levels were significantly decreased when the brain tyrosine level was increased. These results indicate that in rats with a portacaval shunt the dietary levels of amino acids greatly influence the brain levels of both amino acids and transmitter amines.     

TIPS and splenorenal shunt for complications of portal hypertension in chronic hepatosplenic schistosomiasis–A case series and review of the literature

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) and shunt surgery are established treatment options for portal hypertension, but have not been systematically evaluated in patients with portal hypertension due to hepatosplenic schistosomiasis (HSS), one of the neglected tropical diseases with major impact on morbidity and mortality in endemic areas.MethodsIn this retrospective case study, patients with chronic portal hypertension due to schistosomiasis treated with those therapeutic approaches in four tertiary referral hospitals in Germany and Italy between 2012 and 2020 were included. We have summarized pre-interventional clinical data, indication, technical aspects of the interventions and clinical outcome.FindingsOverall, 13 patients with confirmed HSS were included. 11 patients received TIPS for primary or secondary prophylaxis of variceal bleeding due to advanced portal hypertension and failure of conservative management. In two patients with contraindications for TIPS or technically unsuccessful TIPS procedure, proximal splenorenal shunt surgery in combination with splenectomy was conducted. During follow-up (mean follow-up 23 months, cumulative follow-up time 31 patient years) no bleeding events were documented. In five patients, moderate and transient episodes of overt hepatic encephalopathy were observed. In one patient each, liver failure, portal vein thrombosis and catheter associated sepsis occurred after TIPS insertion. All complications were well manageable and had favorable outcomes.ConclusionsTIPS implantation and shunt surgery are safe and effective treatment options for patients with advanced HSS and sequelae of portal hypertension in experienced centers, but require careful patient selection.     

Uptake of Amino Acids by Brain Microvessels Isolated from Rats after Portacaval Anastomosis

Abstract: The uptake of amino acids by microvessels isolated from brains of rats was studied. Previous studies have demonstrated alterations in blood-brain amino acid transport after portacaval shunt in rats. In order to elucidate whether such changes in the blood-brain barrier were located in the microvessels, brain microvessels were isolated from both rats with portacaval shunt and controls. Brain microvessels from rats 2 weeks after shunt operations took up significantly greater amounts of ¹⁴C-labeled neutral amino acids, but not of glutamic acid. lysine, or α-methylaminoisobutyric acid than microvessels from sham-operated controls. Measurement of uptake kinetics showed a higher V _max for phenylalanine and leucine uptake and a lower V _max for lysine uptake in microvessels from shunted rats compared with control, whereas the respective K _m's of uptake were similar in both preparations. The results suggest that changes in brain microvessel transport activity account for altered brain neutral amino acid concentrations after portacaval shunt and that such changes can be studied in vitro in isolated microvessels.     

Total Intracardiac Repair of the Adult Cyanotic Tetralogy of Fallot: Clinical Experience and Late Follow-up

Twenty-seven adult patients with the cyanotic type of tetralogy of Fallot had total intracardiac repair during the past five years at the Toronto General Hospital. Twenty-one of 27 patients (77%) had had a previous shunting operation performed five to 21 years prior to the total intracardiac repair. Seventeen of 21 (81%) of these anastomoses were patent at the time of the total intracardiac repair. The hospital mortality was 11% and was attributable to hemorrhage - a well-recognized problem in adult tetralogy, due to excessive collateral circulation. All 24 surviving patients followéd up from six months to five years showed marked clinical improvement, with disappearance of the cyanosis and reduction in acne and clubbing. Permanent heart block has not occurred. Late hemodynamic studies showed a significant persisting shunt in two out of 16 or 12%.     

Lack of effect of portacaval shunt on ornithine decarboxylase activity in regenerating rat liver.

The influence of the end to side portacaval shunt on the level of activity of the enzyme ornithine decarboxylase following partial hepatectomy was investigated. A sharp rise in the enzyme level was found in both the shunted animals and in the normal controls. The chronology of the increase in enzymic activity was somewhat altered in the portacaval shunted animals, but both groups had similar peak values. The rate of cell division was also found to be unaffected. This report finds no evidence of support for the reported inhibition by the portacaval shunt of the increase in ornithine decarboxylase following partial hepatectomy.     

Portacaval shunt and measurement of canine bile acid enterohepatic circulation: effects of cholecystectomy

Studies were made of the usefulness of serial serum bile acid determinations in dogs with end-to-side portacaval shunt for determining relative rates of bile acid enterohepatic circulation (EHC). Studies in intact and cholecystectomized dogs with shunt showed that bile acid EHC in fasting cholecystectomized animals was about three times faster than in intacts. As expected, feeding greatly increased EHC in intacts, but caused smaller but definite increases in cholecystectomized animals. Cholecystokinin (Kinevac) administration caused transient increases in intact dog bile acid EHC, but had no effect in cholecystectomized animals. These results confirm most previous studies and demonstrate that the method is sensitive and useful for comparing rates of bile acid enterohepatic circulation under different circumstances.     

Low density and high density lipoprotein turnover following portacaval shunt in swine.

Turnover of 125I-low density lipoprotein (LDL) and of 131I-high density lipoprotein (HDL) was determined before and after end-to-side portacaval shunt in eight swine. LDL (d 1.019-1.063) and HDL (d.1.09-1.21) were isolated by ultracentrifugation and iodinated by the iodine monochloride technique. Immediately postoperatively there was no consistent change in the fractional catabolic rate (FCR) of LDL compared to preoperative control values, while in all animals FCR of HDL was significantly increased (by as much as 300%). After recovery from surgery, neither LDL nor HDL catabolic rates were significantly elevated above control values in four swine. However, plasma levels of LDL and HDL protein, and of LDL and HDL cholesterol were significantly reduced 10-12 weeks after the portacaval shunt. The reduced levels of LDL and HDL associated with normal fractional clearance rates imply a reduction in synthesis of LDL and HDL following portal diversion.     

Combined Internal Mammary Artery Implantation and Free Omental Graft Operation: A Highly Effective Revascularization Procedure: (A Study of 17 Cases)

One hundred and forty patients with coronary artery disease treated by internal mammary artery implantation were followed up from six months to 13 years. The mortality rate was 3%; improvement was obtained in 70%. Occlusive disease of all three major coronary arteries, however, requires more blood than can be supplied by the implant procedure, and the free omental graft operation was developed for the management of selected patients with this condition. Normally in animals triple coronary artery ameroid constriction results in 100% mortality. When the free omental graft operation, with or without internal mammary artery implantation, was performed, 80% of such animals survived. The free omental graft forms capillary anastomoses in three days and arteriolar vessels in eight days, which leave the base of the aorta, enter the omentum, thence to the myocardium. A combined internal mammary artery implantation and free omental graft operation was performed in 17 patients with triple coronary artery disease as shown by cine coronary arteriography. There was no operative mortality, and 12 of the patients are free of pain and have returned to work.     

Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension

ObjectiveThe aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni.LocationThe University of São Paulo Medical School, Brazil; Public Practice.MethodsHemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15).ResultsThe cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05).ConclusionsThe late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.     

Improving surgical outcome following the Norwood procedure

Background

The Norwood procedure consists of three palliative operations, performed in neonates with hypoplastic left heart syndrome. Especially the first stage (Norwood I) is associated with the highest mortality rates in paediatric cardiac surgery (up to 25%). During surgery, the aorta is reconstructed and a systemic-to-pulmonary shunt is applied. Originally the modified Blalock-Taussig shunt was used, but recently the right-ventricle-to-pulmonary-artery shunt is increasingly being employed. We reviewed the results of our operative strategy, where an individualised choice of shunt is made. Furthermore, attempts to reduce interstage mortality (between Norwood I and II) were assessed.

Methods

All neonates who underwent Norwood stage I palliation from August 2004 until November 2010 were included in this retrospective analysis. Mortality rates and management strategies were compared.

Results

Thirty-six patients were available for analysis. Overall 30-day mortality was 5.6% (2 patients) and interstage mortality after discharge was 14% (5 patients). In 2006, a novel clinical protocol was introduced, aimed at reduction of mortality during the interstage period. This resulted in reduction of interstage mortality from 23% to 9% (3 of 13 infants, versus 2 of 23), with a cumulative survival of 82% (maximum follow-up 4 years).

Conclusion

Early surgical results following the Norwood procedure using an individualised shunt choice are favourable.     

The effect of portacaval shunt on plasma lipids and lipoproteins in swine.

Plasma lipids and lipoprotein composition and distribution were studied in fasted miniature swine prior to and at 5 and 19 weeks following portacaval shunt surgery or a sham operation. Plasma triacylglycerol and cholesterol levels were significantly reduced in the portacaval shunt swine at 5 weeks. These reductions were accompanied by significant decreases in the plasma very low density lipoprotein (d less than 1.006), low density lipoprotein (d = 1.02-1.07) and high density lipoprotein (d = 1.09-1.21) levels. The very low density lipoprotein were shown depleted in lipids and the low density lipoprotein was a cholesterol-depleted, triacylglycerol-enriched particle. No changes in the composition of the high density lipoprotein were observed. These reductions and changes in composition were maintained until killing at 19 weeks post-surgery.     

Canine bile acid enterohepatic circulation

The enterohepatic circulation (EHC) of bile acids has been studied in fasting dogs with portacaval shunt maintained in the steady state. In such animals the rate of EHC is proportional to systemic blood bile acid concentration. Bile acid EHC was irregular (20 to 100% variation) when measured at 15 minute or hourly intervals. Studies showed that the variations persisted in cholecystectomized and sphincterectomized animals. The irregularities were enhanced by bethanechol chloride which increases intestinal peristalsis and suppressed by diphenoxylate HCl which slows peristalsis. The variations appear to arise from irregular patterns of intestinal peristalsis. This phenomenon may explain some variations in blood bile acid concentration observed in patients with liver disease.     

The Injured Liver Induces Hyperimmunoglobulinemia by Failing to Dispose of Antigens and Endotoxins in the Portal System

Hyperimmunoglobulinemia is frequently observed in patients with chronic liver diseases. However, the exact mechanism underlying the high level of antibody formation is not fully understood. In our study, we provide evidence for the functional role of the liver and the stimulation of plasma cell proliferation in hyperimmunoglobulinemia. We collected sera from patients with chronic liver diseases, and the level of serum immunoglobulins in patients was examined; this was also investigated in animal models of liver cirrhosis and hepatocellular carcinoma. An end-to-side microsurgical portacaval shunt was used to mimic liver dysfunction in rats. We used portal vein serum and inferior vena cava serum to immunize healthy rats and mice in order to confirm the function of the healthy liver in disposing of antigens and endotoxins from the gut. For the analysis of the state of plasma cell activation, plasma cells from mice were stained with PE-conjugated anti-CD138 and FITC-conjugated anti-BrdU for flow cytometry analysis. Hyperimmunoglobulinemia was observed both in patients with chronic liver diseases and in related animal models, and high plasma LPS levels were also observed. There was a significant increase in the activation and proliferation of plasma cell in mice immunized with antigens or LPS-positive serum compared with controls that were immunized with antigens and LPS-negative serum. We confirmed that the healthy liver plays an important role in disposing of antigens and endotoxins derived from the gut. Hyperimmunoglobulinemia in chronic liver diseases mainly arises due to the collateral circulation secondary to portal hypertension, gut antigens and endotoxins that bypass the liver and reach the antibody-producing cells.     

Elective End-to-side Portacaval Shunt: Results in 64 Cases

In a series of 64 cases of elective end-to-side portacaval shunts performed for liver disease the success rate—in that the patient survived with a patent shunt, free of subsequent haemorrhage and severe encephalopathy—was 48%.The early postoperative death rate was 12·5% and the five-year survival 65%. Bleeding from oesophagogastric varices after blockage of the shunt was responsible for at least half of the early postoperative deaths, and most late deaths were due to liver failure. A decreased chance of late survival was associated with age over 40 years, active chronic hepatitis, and with a preoperative history of hepatocellular jaundice.Shunt blockage occurred in 16% of patients, and all bled again from oesophagogastric varices. Shunt block is more likely if the portal vein is calcified or thrombosed, and may be more likely if the portal vein diameter, as shown by splenic venography, is 1·5 cm or less.In survivors with a patent shunt the most serious late complication was chronic, severe portal-systemic encephalopathy, which occurred in 38%. Severe encephalopathy was associated with age over 40 years, a preoperative history of any degree of encephalopathy, diabetes mellitus, and with continued drinking in the alcoholic. Most patients who had portal-systemic encephalopathy in the first year postoperatively developed chronic disabling encephalopathy.A preoperative history of transient mild or moderate ascites did not seem adversely to influence the outcome.