Survival after distal splenorenal shunt.

These data support the conclusions that the distal splenorenal shunt is attended by the highest post-shunt survival as yet reported for patients with non-alcoholic cirrhosis, portal hypertension and bleeding varices; the procedure is safe, and in this series, the mortality has been nil for 66 consecutive operations. An analysis of the causes of death suggests that continued alcohol abuse plays an important part in the late mortality among those in the post-shunt alcoholic cirrhosis group.     

Management of stenosis of distal splenorenal shunt by balloon dilation

Stenosis of a distal splenorenal shunt may lead to inadequate variceal decompression with the risk of rebleeding. We report this complication in three patients at five, 16 and 17 months after DSRS, with successful management by balloon dilation. One patient had rebled from varices and the other two showed roentgenologic evidence of inadequate variceal decompression. All of the shunts were patent but showed a mean pressure gradient of 15 millimeters of mercury which was reduced to a mean of 7 millimeters of mercury by dilation. Angiography at 15 months showed no restenosis and sustained reduction of the pressure gradient in one patient. The other two patients await long term follow-up observation. Rebleeding or reappearance of varices are indications for repeat angiography after DSRS to determine the cause. The risk of dilating a venous anastomosis must be weighed against the risk of rebleeding; the results of this report demonstrate that this can be done with a satisfactory outcome.     

Thrombosis of the portal vein following distal splenorenal shunt.

Portal vein thrombosis with a patent shunt is a distinct clinical entity which can follow selective distal splenorenal shunt and should be looked for in patients in whom ascites and abdominal pain develop postoperatively. Possible mechanisms include an increase in blood viscosity and a decrease in portal flow which may be aggravated by inadequate devascularization.     

The jugular vein as an interposition graft in the distal splenorenal shunt

The selective distal splenorenal shunt is the preferred portal decompression procedure for patients with refractory bleeding esophageal varices. An autogenous jugular vein interposition graft in the distal splenorenal position obviates the tedious struggle associated with mobilizing the splenic vein from the pancreatic substance, thereby lessening blood loss, avoiding postoperative pancreatitis and shortening operative time. An autogenous jugular vein interposition distal splenorenal shunt can, therefore, be performed with less morbidity while affording the same physiologic benefits as the standard distal splenorenal shunt.     

Fatal disruption of a splenorenal shunt after multiple pregnancies

A 39-year-old woman underwent a distal splenorenal shunt operation for bleeding esophageal varices due to liver cirrhosis. Following the operation she had 7 pregnancies at almost yearly intervals. At the term of the last pregnancy a disruption of the anastomotic site caused a fatal hemorrhage. The outcome of postshunt pregnancies as reviewed in the literature is usually favorable, but numerous pregnancies in these circumstances may carry a considerable risk.     

Distal splenorenal shunt in treatment of bleeding esophageal varices in renal transplant recipients

We conclude from this study that bleeding esophageal varices may occur as a late complication of liver disease associated with chronic renal failure and renal transplantation. In two of the three patients reported upon, the liver disease was probably determined on the basis of cirrhosis, secondary to chronic, active hepatitis from non-A, non-B hepatitis, while the third patient had hepatic fibrosis. Such bleeding is best controlled by selective variceal decompression with a DSRS. Finally, it is technically feasible to perform a DSRS upon some patients following a left nephrectomy, and the renal vein is of adequate caliber even in the presence of nonfunctioning kidneys.     

Distal splenorenal shunt for decompression of portal hypertension in children with cystic fibrosis.

Apart from the sound physiologic basis for the distal splenorenal shunt as compared with the portacaval shunt and the conventional central splenorenal shunt, there are two important reasons why we think the use of this type of shunt is especially advantageous in children with portal hypertension secondary to cystic fibrosis. Firstly, the thick, fibrotic retroperitoneal area in the porta hepatis, where a portacaval shunt has to be constructed, can be avoided, which makes the distal splenorenal shunt the easier operation. Secondly, notwithstanding the relatively small-sized vessels, a wide anastomosis can be constructed with a high flow rate and, therefore, a minimal chance of shunt thrombosis.     

The successful management of portal vein thrombosis after hepatic transplantation with a splenorenal shunt

Portal vein thrombosis is an infrequent complication after hepatic transplantation, but is quite dramatic when it occurs. It is usually managed by retransplantation with a significant mortality rate. We present a patient in whom portal vein thrombosis after hepatic transplantation was ultimately managed by a splenorenal shunt. The portal vein thrombosis was manifested by bleeding esophageal varices and, yet, normal hepatic function obviated the need for a new graft (one was not readily available). To the best of our knowledge, this is the first presentation of a patient with a transplant of the liver with acute portal vein occlusion and maintained hepatic function who has been successfully managed by a portosystemic shunt.     

Early experience with the selective splenocaval shunt for variceal bleeding

Selective variceal decompression is the operative method of choice in the definitive management of recurrent hemorrhage from gastroesophageal varices. The distal splenorenal shunt is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, in patients with an anatomically aberrant relationship between the splenic and left renal veins and in patients with preoperative visceral angiographic findings suggesting that they are at risk for development of the postoperative syndrome of renal vein hypertension. In these clinical situations, selective variceal decompression can be obtained with a splenocaval shunt, constructed by directly anastomosing the splenic vein to the infrarenal vena cava. Seven patients who have undergone the selective splenocaval shunt are reviewed in this report. Early experience with these patients demonstrates the use of the selective splenocaval shunt when an alternative to the distal splenorenal shunt is needed.     

A segmental approach to computerized tomographic portography for hepatic resection

Surgical treatment has proved to be of benefit to patients with primary and metastatic tumors of the liver. However, the ability to localize tumors preoperatively to particular segments within the liver has not been emphasized. The large size of this organ and its complex vascular structure have not allowed the surgeon either to determine accurately the hepatic segment occupied by the tumor or to identify major vascular structures adjacent to the tumor. We have expanded the use of a new roentgenologic technique to determine preoperatively with more clear definition the segmental anatomy of the liver. Computerized tomographic portography (CT-P) images hepatic veins and the segmental branches of portal vein and identifies the anatomic location of tumor nodules. To read the roentgenograms, one first identifies the middle CT-P slice that will cut the transverse scissura. Slices cephalad to the transverse scissura are through segments 7, 8, 4a and 2 in a clockwise order; slices caudad to the transverse scissura are through 6, 5, 4b and 3. Selected CT-P cuts from a series of patients show the typical CT-P configuration of the hepatic vasculature anatomy and the structures that can be identified roentgenologically. The CT-P provides valuable information not previously available preoperatively to the surgeon operating upon the liver.     

Intraoperative intra-arterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis

Acute arterial embolic or thrombotic occlusion of the runoff vessels is associated with an incomplete operative thromboembolectomy and an unacceptably high rate of amputation. This report presents a six year analysis of the use of intraoperative intra-arterial thrombolytic therapy, evaluating 38 patients who presented with impending loss of limb because of an acute occlusion of the runoff vessels. All of the patients had extensive thrombosis of a distal vessel and a complete distal thromboembolectomy was not possible. Fourteen patients received infusion of streptokinase, maximum dose of 50,000 units; 26 received urokinase (UK), maximum dose of 150,000 units, and two underwent an isolated limb perfusion technique using one million units of UK. Thirty-four lower and four upper extremities were treated. Twenty-eight of 38 patients had successful revascularization procedures that resulted in salvage of the limbs, and ten of the 38 underwent an extensive amputation. In 18 of the 28 who were successfully revascularized, lysis was clearly obtained, which contributed to the ultimate success; in ten of the 28, it was unclear whether or not lysis significantly contributed to salvage of the limbs. Although four of the 38 died within 30 days postoperatively and one patient had a hemorrhagic complication, neither the deaths nor the complication could be attributed to a lytic agent. There was no evidence of systemic thrombolysis in these patients. Intraoperative intra-arterial thrombolytic therapy administered by the slow bolus injection technique is safe. It can be an important adjunct to mechanical thromboembolectomy and bypass procedures in patients with limb-threatening ischemia caused by thrombosis of the distal part of the vessel. The isolated limb perfusion technique using high dose UK is particularly valuable in acute, small vessel, multiarterial occlusion. Intraoperative intra-arterial infusion of thrombolytic agents may make the difference between salvage or amputation of the limb without causing additional risk for the patient.     

Gay men seeking surrogacy to achieve parenthood

Assisted reproduction technologies have developed at an extraordinary rate in recent years. This, combined with the changing landscape of legal, technical and social possibilities, enables gay men to consider their options for fatherhood as new opportunities emerge for them to create families. Media coverage of gay celebrities embracing surrogacy as a way of having a family and high-profile legal cases have raised awareness of surrogacy across the world. However, gay fatherhood achieved through assisted reproduction is a highly under-researched area, both in the UK and internationally. The research that currently exists on gay fatherhood is largely related to gay men who become parents through processes such as adoption and fostering and children conceived through previous heterosexual relationships. Much of this evidence has centred on parenting experiences, the outcomes for children or the legal perspectives. This paper outlines the different types of surrogacy and the legal issues facing gay men who choose this route to parenthood, summarizes the limited research on gay men and surrogacy and discusses gaps in the current knowledge base.Assisted reproduction technologies have developed at an extraordinary rate in recent years. This, combined with recent legal, technical, and social changes has produced new possibilities and opportunities for gay men to become fathers and create their families. Media coverage of gay celebrities embracing surrogacy as a way of having a family and high-profile legal cases have raised awareness of surrogacy across the world. However, gay fatherhood achieved through assisted reproduction is a highly under-researched area in both the UK and internationally. The research that currently exists on gay fatherhood is largely related to gay men who become parents through processes such as adoption and fostering and children conceived through previous heterosexual relationships. Much of this evidence has centred on parenting experiences, the outcomes for children or the legal perspectives. This paper outlines the different types of surrogacy and the legal issues facing gay men who choose this route to parenthood, summarizes the limited research on gay men and surrogacy and discusses gaps in the current knowledge base.     

Evaluation and treatment of early hemorrhage of the alimentary tract after selective shunt procedures

The cause and treatment of early variceal bleeding in 15 patients who had undergone distal splenorenal shunt were reviewed. Eight of these patients were taken from a group of 91 who underwent selective shunts from July 1983 through June 1985 and had extensive preoperative and postoperative evaluation of shunt patency and pressure gradient. Seven patients operated upon before July 1983 were reviewed because they illustrate the cause, diagnosis, successful and unsuccessful management of bleeding after selective shunt. Urgent selective arteriography combined with shunt catheterization is the key diagnostic and therapeutic maneuver. Thrombosis of the shunt can be successfully managed by revising the anastomosis. Stenosis of the shunt can be successfully treated with balloon dilation or operative revision of the anastomosis. When renal vein hypertension (RVH) occurs, there might be inadequate decompression of the varices. A gradient of 10 millimeters of mercury or greater from left renal vein to vena cava is diagnostic. Measurements of 30 patients who had no bleeding and one patient with documented RVH show the gradient decreases over time. Treatment should be supportive until this adaptation occurs. Hemorrhage can also occur in patients with a patient shunt but without a significant pressure gradient. Inadequate decompression of the varices through the short gastric veins leading to the spleen has been proposed as one cause. Termed short gastric hypertension, this syndrome could be expected to parallel RVH because the venous collaterals will enlarge and eventually decompress the varices. Treatment should be aimed toward supporting the patient until this adaptation occurs. A small number of patients continue to bleed despite these therapeutic interventions but can sometimes be salvaged with a total shunt.     

Promoting equity to achieve maternal and child health

Maternal and child mortality rates, the targets for two of the eight Millennium Development Goals, remain unacceptably high in many countries. Some countries have made significant advances in reducing deaths in pregnancy, childbirth, and childhood at the national level. However, on a sub-national basis most countries show wide disparities in health indices which are not necessarily reflected in national figures. This is a sign of inequitable access to and provision of health services. Yet there has been little attention to health equity in relation to the Millennium Development Goals. Instead, countries have focused on achieving national targets. This has led to an emphasis on utilitarian, as opposed to universalist, approaches to public health, which we discuss here. We recommend a policy of "proportionate universalism". In this approach, universal health care and a universal social policy are the ultimate goal, but in the interim actions are carried out with intensities proportionate to disadvantage. We also briefly describe an initiative that aims to promote evidence-based policy and interventions that will reduce inequity in access to maternal and child health care in China, India, Indonesia and Viet Nam.     

Timing intercourse to achieve pregnancy: current evidence

Physicians who counsel women for preconception concerns are in an excellent position to give advice to couples regarding the optimal timing of intercourse to achieve pregnancy. The currently available evidence suggests that methods that prospectively identify the window of fertility are likely to be more effective for optimally timing intercourse than calendar calculations or basal body temperature. There are several promising methods with good scientific bases to identify the fertile window prospectively. These include fertility charting of vaginal discharge and a commercially available fertility monitor. These methods identify the occurrence of ovulation clinically and also identify a longer window of fertility than urinary luteinizing hormone kits. Prospectively identifying the full window of fertility may lead to higher rates of conception. Proper information given early in the course of trying to achieve pregnancy is likely to reduce time to conception for many couples, and also to reduce unnecessary intervention and cost.     

A double ballooned inflatable and collapsible T tube for selective proximal or distal cholangiography

A double ballooned T tube for common bile duct occlusion and optional collapse of the intra-balloon tube segments was used for improved roentgenologic delineation of the biliary tree intraoperatively and postoperatively. This silicone T tube is effective for intraoperative and completion cholangiograms, and avoids resuturing of the choledocotomy. Furthermore, with increased inflation, each balloon is capable of occluding the proximal or distal, or both, intraductal horizontal limbs. These features have been exploited for optimal imaging and therapeutic purposes. The tube with its deflated balloons is left in the common duct for drainage and further selective proximal or distal cholangiograms. Several extensions of its use can be envisaged.