Combined liver and whole pancreas procurement in donors with a replaced right hepatic artery.

Aberrant donor arterial anatomy, such as a replaced right hepatic artery, is often considered a contraindication to combined liver and whole pancreas procurement for transplantation. With the increasing interest in transplantation of the pancreas and the demand for cadaver organs, methods for simultaneous procurement despite aberrant donor anatomy are essential. We describe the surgical techniques used successfully in six instances of combined liver and whole pancreas procurement in donors with a replaced right hepatic artery and suggest that a replaced right hepatic artery should not preclude simultaneous procurement in otherwise suitable donors.     

Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.     

Pancreaticoduodenal transplantation in humans

Whole cadaveric pancreata were transplanted to the pelvic extraperitoneal location in four patients with diabetes who previously had undergone successful cadaveric renal transplantation. One graft was lost within a few hours from venous thrombosis but with patient survival. The other three are providing normal endocrine function after two and a half, 11 and 12 months. The exocrine pancreatic secretions were drained into the recipient jejunum through enteric anastomoses. Because mucosal slough of the graft duodenum and jejunum in two patients caused a protein losing enteropathy and necessitated reoperations, we now do the pancreatic transplantation with only a blister of graft duodenum large enough for side-to-side enteroenterostomy. The spleen has been transplanted with the pancreas mainly for technical reasons, and this technique should have further trials in spite of the fact that delayed graft splenectomy became necessary in two recipients to treat graft induced hematologic complications.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

Surgical importance of oblique projection in arteriography for carcinoma of the pancreas.

Oblique projections in celiac and superior mesenteric angiography have been of value in patients with carcinoma arising in various parts of the pancreas. Oblique views allow better perception of the slight and uncertain changes in the pancreatic vessels, which are not discernible on anteroposterior projections because of overlapping with the extrapancreatic vessels and the spine. Anteroposterior and oblique views of both celiac and superior mesenteric arteries are the first, and, therefore, the most essential, step in angiography of lesions of the pancreas.     

Revised method of orthotopic hepatic transplantation in canines

Experimental transplantation of the liver is a complex procedure, and technical considerations can often complicate the interpretation of results from studies of hepatic preservation. Improvement in experimental transplantation techniques will decrease adverse effects of the procedure on laboratory animals and assist in the development of improved preservation techniques. The procedure should be designed to mimic the clinical situation. The technique described herein differs from previously described techniques in the operation upon the donor. The bile duct is preserved for anastomosis to the recipient bile duct. The liver is isolated on vascular pedicles, with a new approach to the infrahepatic inferior vena cava, which decreases blood loss. Subdiaphragmatic transection of the suprahepatic inferior vena cava ensures a short segment that cannot twist or telescope into the transplanted liver. The hepatic artery is dissected to the level of the aorta, in contrast with the aorta being used as a conduit. Nonheparinized blood is collected from the hepatic donor. During the operation upon the recipient, the approach to the infrahepatic vena cava minimizes blood loss. A new method of hepaticohepatic arterial anastomosis with preservation of the duodenal blood supply is described. A passive shunt for mesenteric blood flow is used. The bile duct is preserved and choledochocholedochal anastomosis is performed over a stent. The operating time of both harvesting and transplanting was considerably shorter compared with that of reports in the literature and with previous methods used in our laboratory. No dissection of the cold organ was done. There was no incidence of venous outflow obstruction, as previously described. With this technique, blood transfusion of only 1 unit (425 milliliters) resulted in an elevated hemoglobin concentration postoperatively. In 20 consecutive transplants, no failure occurred as a result of technical reasons. This new method appears to simplify the procedure, reduce operating time, is less stressful to the dogs and has produced results superior to those from our previous methods. This method would appear to be easily adaptable to other laboratories interested in hepatic transplantation.     

Hemodynamic study of occlusion of the splenic vein caused by carcinoma of the pancreas

The most common cause of occlusion of the splenic vein is pancreatic disease, such as pancreatitis or carcinoma of the pancreas. As compared with benign causes, carcinoma of the pancreatic body or tail may readily involve not only the splenic vein, but also, eventually, the splenic artery. Therefore, the clinical features of occlusion of the splenic vein may be profoundly altered according to the nature of the underlying causes. In an attempt to clarify the pathophysiologic findings and hemodynamic mechanism of occlusion of the splenic vein associated with carcinoma of the pancreas, three patient reports were selected from our past experience. Upon analyzing the clinical course of these patients, three consecutive phases may be distinguished. Phase 1 is the insidious or latent phase represented by Patient No. 1. The splenic vein is partially occluded and gastric varices or splenomegaly has not developed. Phase 2, the collateral developing phase, is represented by Patient No. 2. The splenic vein is completely occluded while the splenic artery is patent, resulting in marked gastric varices and splenomegaly. Phase 3 is the vanishing phase and is represented by Patient No. 3. The occlusion of the splenic artery is superimposed on the occlusion of the splenic vein, causing gastric varices to vanish and the enlarged spleen to shrink.     

Progress in reconstruction after resection of the head of the pancreas

Fistulas of the pancreas due to dehiscence of pancreaticojejunostomy after partial pancreaticoduodenectomy caused severe postoperative complications. Whereas various methods with and without anastomosis of the pancreas are recommended to deal with the pancreatic stump, mortality rates of 20 to 75 per cent have been reported. These different results prompted us to start a prospective, nonrandomized study in which three methods of reconstructing the remnant of the pancreas involving anastomosis were compared with pancreaticocutaneous drainage without anastomosis. One hundred and thirty-one patients with partial pancreaticoduodenectomy entered this trial, 54 female and 77 male patients with an average age of 55.9 years. The indications included: 42 instances of chronic pancreatitis, 44 instances of carcinoma of the pancreas and 45, periampullary carcinoma. We performed 33 end to side pancreaticojejunostomy procedures (four fistulas of the pancreas, a mortality rate of 15.0 per cent), 31 end to end anastomoses (three fistulas of the pancreas, a mortality rate of 6.5 per cent) and 48 double loops with anastomoses of the pancreatic and hepatic duct to separate jejunal loops (nine fistulas of the pancreas, a mortality rate of 2 per cent). Nineteen patients were operated upon using external drainage of the pancreatic stump by means of Penrose drains (five fistulas of the pancreas, a mortality rate of zero per cent). To reduce the fatal risks caused by combined fistulas of the pancreas and biliary tract, the use of separate intestinal loops for anastomoses of the pancreas and biliary tract offers the best solution, since no fatal complications of the pancreaticojejunostomy were observed. In contrast, pancreaticocutaneous drainage was performed upon patients with endangered pancreatic anastomoses due to local morphologic conditions, such as tender pancreatic parenchyma or thin pancreatic ducts. The total loss of exocrine function and the high morbidity rate of 37 per cent is justified in spite of the mortality rate of zero per cent. Total pancreaticoduodenectomy, for technical reasons, represents no acceptable alternative in view of higher mortality rates.     

A new technique for arterialization of the hepatic graft

We believe that the new technique described herein for reconstructing the hepatic artery is the method of choice for arterialization of hepatic grafts. This technique is easily performed, even during retransplantation and even if the recipient or donor has double arteries. Since submission of this article, an additional 20 transplantations of the liver have been performed without graft loss using this technique. This includes five infant livers with donors as small as two days old and weighing 3.2 kilograms.     

Application of streptokinase in peripheral vascular thromboembolism

To assess the efficacy of and the complications associated with streptokinase in clinical use, we administered this drug prospectively to 9 patients with thromboembolism of the peripheral vessels from August 1984 to January 1987. The involved vessels included the renal artery, superior mesenteric artery and vessels of the lower extremities. During the course of treatment, thrombin time (TT), prothrombin time (PT), and partial thromboplastin time (PTT) were monitored regularly. Complications such as fever, chills, liver function abnormalities and hematuria were managed effectively. One patient experienced anaphylactic shock and required immediate discontinuation of streptokinase. Good results were obtained in all other patients. According to the results of our study, streptokinase offers the advantages of rapid lysis and complete resolution of clots in peripheral thromboembolic disease. The complications can be minimized if clinical and laboratory responses are monitored appropriately and patients are carefully selected.     

Embolization for hemorrhage of liver metastases from choriocarcinoma

BACKGROUND: Because gestational trophoblastic disease (GTD) is highly sensitive to chemotherapy, life-threatening hemorrhage from metastases can occur especially early after starting therapy. CASES: Two cases of post-term choriocarcinoma with liver metastases complicated by profuse life-threatening hemorrhage are reported. Emergency treatment with transcatheter angiographic embolization of the hepatic artery was performed to control bleeding. DISCUSSION: Although embolization of the iliac vessels for gynecologic malignancies, including GTD, have been described, this is the first time that embolization of the hepatic artery to control bleeding from liver metastases in GTD is reported. The use and indications for embolization are expanding, and also in acute hemorrhagic complications in GTD, this intervention should be considered.     

Prenatally diagnosed portocaval shunt and postnatal outcome: a case report

Congenital absence of the portal vein (CAPV) is a rare anomaly in the form of a portocaval shunt, whereby the intestinal and splenic venous drainage bypasses the liver and drains directly into the systemic circulation. We report a case of CAPV diagnosed prenatally after the recognition of a dilated umbilical vein draining directly into a large inferior vena cava (IVC). The IVC then drained into the right atrium of a dilated, hyperdynamic heart. The ductus venosus could not be identified. Repeated postnatal scans showed a gradual disappearance of venous lakes in the region of the porta hepatis and a clear drainage of the splenic vein to the left renal vein and the superior mesenteric vein to the IVC. From birth up to twelve months follow-up there was no evidence of liver dysfunction, encephalopathy or liver lesions.     

Nonobstructive dilatation of the fetal bowel in twin gestations. A possible sonographic marker for fetal compromise

OBJECTIVE: To assess the possible association of in-utero bowel dilatation and circulatory changes with fetal compromise. METHODS: A retrospective survey of all ultrasound examinations was performed at the Chaim Sheba Medical Center (n approximately 10,000) between 1995 and 1999. Cases with ultrasonographic evidence of bowel dilatation, but without evidence of obstruction, were recruited. In utero Doppler studies of umbilical, splenic, superior mesenteric arteries, and middle cerebral artery (MCA) were performed: systolic/diastolic ratio (S/D), pulsatility index (PI) and resistance index (RI) were calculated in the above arteries and compared with those of normal fetuses. Nonstress test and cord blood pH were also assessed. Neonatal medical records were procured. RESULTS: Four fetuses, all of who were products of twin gestations, showed bowel dilatation without evidence for obstruction. Three of the four fetuses were small-for-gestation-age (SGA) and of bichorionic gestation, while one was of monochorionic twin gestation, with twin transfusion syndrome. In all three SGA fetuses, Doppler studies revealed increased peripheral resistance in the umbilical artery and adaptive peripheral vasodilatation in the fetal midcerebral, splenic and superior mesenteric arteries. In all cases, an abnormal nonstress test led to prompt delivery. CONCLUSIONS: Acute fetal bowel dilatation in a twin gestation is associated with abnormal splanchnic and gut perfusion that may lead to fetal compromise.     

Orthotopic liver transplantation for complicated HELLP Syndrome

A case of hepatic complication in a pregnant woman suffering from HELLP syndrome resulting in the need for transplantation is reported, and an algorithm for those instances is suggested. According to the literature, this is the 5th report of hepatic complications in HELLP syndrome necessitating liver transplantation. Since all but one of the transplanted patients survived (as opposed to a high mortality in non-transplanted patients), it is concluded, that a timely decision for transplantation is a safe option in this high risk group.     

An anatomic investigation of radical resection of tumor in the hepatic duct confluence

The fetal umbilical vein in the ligamentum teres can be reopened to provide a 10 centimeter long vein, as wide as the left portal vein or the central splenic vein, that gives access to the left portal vein in the umbilical fissure of the liver. By cutting the ligamentum teres, this potential autologous venous graft is lost and, therefore, the ligamentum teres should never be sacrificed without reason. The umbilical side of the reopened umbilical vein can be anastomosed with the splenic vein to form a portal vein bypassing conduit that enters the liver in the umbilical fissure and take over function of the portal vein. From the results of this postmortem investigation, it can be concluded that radical block resection of the area consisting of the hepatic duct confluence, classic right hepatic lobe and complete hepatoduodenal ligament, preceded by construction of a complete separate afferent blood supply of the classic left hepatic lobe, is possible both anatomically and technically. There is no indication denying the supposition that the result of such a procedure is functionally analogous to standard extended right lobectomy with bilioenteric reconstruction.     

Splenic Artery Aneurysm in Pregnancy

EDITORIAL COMMENT: We accepted this rather detailed case report for publication because of the special relationship of rupture of splenic artery aneurysms with pregnancy. It is wise for obstetricians to know that this condition is an important uncommon cause of abdominal pain and collapse during pregnancy, labour or the puerperium.
Summary: Rupture of a splenic artery aneurysm during pregnancy or delivery is a rare event. Only 99 cases have been reported. There is significant risk to mother and fetus. This paper describes a splenic artery aneurysm rupture with a concomitant unruptured hepatic artery aneurysm and coincidental partial placental abruption with fetal death at 22 weeks' gestation. Splenectomy was performed to achieve haemostasis. Nonsurgical treatment by embolization of the hepatic artery aneurysm was performed after a routine postoperative computed tomogram (CT) and angiogram revealed the lesion. CT screening of high-risk patients and ultrasound/pulsed Doppler screening of pregnant women with unexplained abdominal pain might be an important precaution in the avoidance of obstetric catastrophies.     

Results of resection and proposed guidelines for patient selection in instances of non-colorectal hepatic metastases

Resection of hepatic metastases from carcinomas of the colon and rectum appears to extend the survival time in appropriately selected patients. Selection criteria have been widely published. Similar data for patients with hepatic metastases from primary sites other than the colon and rectum are lacking. To determine which, if any, patients in the latter category benefit from resections, we reviewed ten such instances treated at our institution plus 141 instances of resection for noncolorectal hepatic metastases previously reported. The over-all five year survival rate after resection of noncolorectal hepatic metastases is 20 per cent. When Wilms' tumor is excluded, the five year survival rate is 15 per cent. Approximately four of ten patients with metastases to the liver from Wilms' tumor or carcinoid survived five years after resection. Similar benefit is rarely obtained after resection of hepatic metastases of the breast, kidney, adrenal gland and carcinomas of the stomach; malignant melanoma, and leiomyosarcoma. No extension of survival is apparent for resection of hepatic metastases of gynecologic malignancies or carcinoma of the pancreas. Specific guidelines for selection are discussed in view of the limited prognosis when tumors other than carcinomas of the colon and rectum metastasize to the liver. Careful patient selection and minimization of complications are required.     

Acute pseudo-obstruction of the colon following partial splenic artery embolization: report of a case.

This is a case of a 45-year-old woman suffering from liver cirrhosis with hypersplenism who received a partial splenic artery embolization with gelfoam pieces. Thrombocytopenia and leukopenia improved immediately after treatment. Marked abdominal distention, metallic bowel sounds and combined small and large bowel distension with air-fluid levels as shown on a plain abdominal X ray were noted on the fifth day after the embolization procedure. Laparotomy was performed. No mechanical obstruction was found during surgery. Acute pseudo-obstruction of the colon (Ogilvie's syndrome) was diagnosed. This condition was considered to be a complication of the partial splenic artery embolization and has not hitherto been reported.     

Observations during treatment of acute necrotizing pancreatitis with surgical ablation.

Seven patients with acute necrotizing pancreatitis were treated by surgical ablation. Immediate improvement was seen in six patients. Two patients died during the course of postoperative complications requiring reoperations. At operation, strikingly conforming lesions were found in the shape of a sharply limited necrotic portion of the gland. The body and tail of the pancreas constituted this necrotic portion in all patients. In a certain group of patients, the vascular anatomy infers a total infarction of the body and tail of the pancreas if a thrombosis of the transverse pancreatic artery occurs. In view of these observations, more interest should be directed toward the possibility of a vascular occlusion as a cause of pancreatic necrosis.