Percutaneous vascular intervention after surgical shunting for portal hypertension

Twenty percutaneous transluminal angioplasty (PTA) procedures and 13 percutaneous venous embolization (PVE) procedures were performed in 23 patients who either had or were at risk for the development of recurrent bleeding, hepatic encephalopathy, or both after surgical shunt placement for portal hypertension. PTA, performed in 12 patients with significant shunt stenoses, resulted in reduction or elimination of gradients in all patients; rebleeding has occurred in only one patient. Complications consisted of one fatal rupture of a mesocaval interposition vein graft and one balloon rupture requiring surgical removal. PVE, performed in 11 patients, resulted in measurable improvement in four of seven encephalopathic patients and temporary control in the two patients with intractable bleeding. Three patients underwent PVE prophylactically. PTA of graft strictures is a valuable treatment modality. Embolization may be helpful in selected cases of hepatic encephalopathy.     

Evolutionary aspects of a stress reaction

Interconnections between the integrative systems, such as nervous, endocrine, and immune ones, are clearly seen during a stress response. The sources of such a cooperation should be sought at the earliest stages of evolution of multicellular organisms. The paper deals with the main points of the formation of a stress response and the development of the systems involved in this process. Based on the data available in the literature and their own findings, the authors conclude that just primitive multicellular organisms, such as coelenterates, have hemolymph cells (chemocytes) that combines the properties of all regulatory systems of more highly organized species. However, the need for such cells no longer arises afterwards. Glucocorticoids, one of the major stress hormones, show up during the development of a stress response relatively late--in fish. While in fish, the production of ACTH and glucocorticoids in the pituitary cells is under urotensin control, this function belongs to corticotropin-releasing hormone of pituitary origin in more advanced animals. The predominant value of corticotropin-releasing hormone simultaneously occurs with the development of the pituitary portal vascular system. Such transformations lead to the formation of the hierarchically arranged neuroendocrine axes that are responsible for showing a stress response, on the one hand, and to the development of qualitatively new interactions between the nervous, endocrine, and immune systems, on the other.     

SUBTOTAL THYROIDECTOMY IN THE MANAGEMENT OF GRAVE'S DISEASE

Treatment options for Grave''s disease include radio-iodine ablation, which is the standard treatment in the USA, antithyroid drug therapy, which is popular in Japan, and surgery, which is commonly employed in Europe and India. There are very few reports about the outcome of surgery in Grave''s disease in the Indian setting. Surgery for Grave''s disease is an attractive option in under developed countries to cut short prolonged drug treatment, costly follow up and avoid the need for radio-isotope facilities for 1311 ablation. Aim of the present study was to assess the result of subtotal thyroidectomy in 32 cases of Grave''s Disease referred for surgery by the endocrinologist in a teaching hospital. Patients were prepared for surgery with Lugol''s iodine and propranalol. Subtotal thyroidectomy was performed by a standard technique, which included dissection and exposure of recurrent laryngeal nerves and parathyroid glands. Actual estimation of weight of the remnant gland was not part of the study. Duration of follow up ranged from 6 months to 4 years. 13 of 32 cases were males. Age ranged from 20 to 57 years. There was 1 death in the immediate post-operative period. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve palsy. 1 patient developed temporary hypoparathyroidism. 1 patient developed recurrence of hyperthyroidism and 3 cases developed hypothyroidism all within 2 years of surgery. The study has demonstrated the safety and effectiveness of surgery for Grave''s Disease in comparison to the reported high incidence of hypothyroidism following radio-iodine therapy and high recurrence rate after anti thyroid drug therapy.Key Words: Grave''s Disease, Thyroidectomy