Prognostic Significance of Hepatic Vein Waveform by Doppler Ultrasonography in Cirrhotic Patients with Portal Hypertension

Objective: We prospectively evaluated the prognostic value of the flat hepatic vein waveform, measured by Doppler ultrasound, in cirrhotic patients with portal hypertension.
Methods: The Doppler pattern of right and left hepatic veins in a series of 120 consecutive cirrhotic patients with portal hypertension but without hepatocellular carcinoma was examined, together with clinical and biochemical parameters.
Results: Flat waveform of the right hepatic vein was recognized in nine patients and that of the left hepatic vein was seen in 13. After a mean follow-up of 13.6 ± 9.7 months, 17 patients died, all from liver failure. In the univariate analysis, variables significantly associated with the duration of survival were age, etiology of the liver cirrhosis, upper gastrointestinal bleeding after start of the study, Child-Pugh score, ascites, encephalopathy, prothrombin index, bilirubin, albumin, and flat Doppler waveform in the right and left hepatic veins. Multivariate analysis showed that flat Doppler waveform in the right hepatic vein, bilirubin, and prothrombin index were independently related to survival.
Conclusions: The prognostic accuracy in cases of cirrhosis with portal hypertension is significantly improved with acquistion of information obtained from hepatic vein waveform by Doppler ultrasound.     

New therapeutic strategy of open pelvic fracture associated with rectal injury in 43 patients over 60 years of age

BACKGROUND/AIMS: A diversion of the fecal stream is generally regarded as an integral component of minimizing both the infectious morbidity and mortality associated with an open pelvic fracture. However, the efficacy of the fecal diversion in elderly has yet to be clearly elucidated. We performed a formal retrospective comparison between the elderly patients who underwent diversion and those who did not. METHODOLOGY: Forty-three consecutive patients who were over 60 years of age and suffered a pelvic fracture associated with rectal injury. The use of fecal diversion was used to delineate the comparison groups: group 1, underwent diversion; group 2, did not undergo diversion. The 2 groups were compared based on the outcome variables and patient demographics. RESULTS: The diverted patients were more severely injured as demonstrated by a higher ISS (p < 0.05). The length of hospital stay was also significantly greater for the diverted patients than for the non-diverted patients (p < 0.05). The number of abdominal injuries (p < 0.05) and the number of total diagnoses (p < 0.05) were also significantly greater for the diverted patients than for the non-diverted patients. There was a significant difference in the distribution of intraabdominal fecal contamination (p < 0.05). No significant difference was observed in the distribution of fracture stability, fracture patterns, wound location, or wound severity between the diverted and non-diverted groups. On the other hand, the chi 2 test for trend (Mantel-Haenszel) for fecal diversion and the Gustilo grade produced a P value of 0.04. A primary repair with end-colostomy was performed in 7 of 23 patients and a resection with an end-colostomy was performed in 16 of 23 patients in group 1. On the other hand, a primary repair was performed in 3 of 20 patients and a resection with anastomosis was performed in 17 of 20 patients in group 2. By the third postoperative month, no significant difference was seen in the survival rate: 61% in group I versus 65% in group 2 (P = 0.40). By the first postoperative month, the survival rate was significantly lower in group 1 than in group 2 (P = 0.04). CONCLUSIONS: Diversion should not be regarded as an absolutely safe intervention for open pelvic fracture associated with rectal injury. However, if a failure of the primary repair or resection with anastomosis once occurs, then the patient's condition could change suddenly or worsen. Elderly patients especially have a poor physiological reserve, and thus a failure to perform a primary repair or resection with anastomosis can quickly lead to patient mortality. There may be some bias when selecting fecal diversion or not based on each surgeon's subjective judgment. In our cases, diversions tended to be done in severe cases. If surgeons encounter a pelvic fracture with severe rectal injury, then aggressive fecal diversion may thus be the procedure of choice in emergency elderly cases.     

Estimation of right ventricular volume with two dimensional echocardiography

To evaluate the applicability of two dimensional echocardiography to right ventricular volume determination, a study was made of 33 consecutive patients separated into three groups (control, right ventricular volume overload and right ventricular pressure overload). Biplane two dimensional echocardiograms that were perpendicular to each other were obtained from the apical approach. The echocardiographic right ventricular volume, calculated by applying Simpson's rule, was considered to be right ventricular body volume without right ventricular outflow tract volume. The echocardiographic dimensions of the right ventricular long, short and maximal short axes were also measured in each view. These volumes and dimensions were compared with both the angiographic right ventricular body volumes calculated by applying Simpson's rule and with the values in each group. Correlation between the echocardiographic and the angiographic right ventricular body volumes (r = 0.94 at end-diastole, r = 0.84 at end-systole) was good and much better than that between echocardiographic right ventricular dimensions and angiographic right ventricular body volumes. Echocardiographic calculation of right ventricular body volume was useful in distinguishing the control group from the group with right ventricular volume overload (p < 0.005).

The correlation between the echocardiographic dimensions of the right ventricular long axis and angiographic right ventricular volumes was poor, whereas that between the echocardiographic dimensions of the right ventricular short or maximal short axis and the angiographic right ventricular volumes was fairly good. It was therefore suspected that during right ventricular enlargement, the increase in size is more extensive in the direction of the short than in the direction of the long axis. It is concluded that estimation of right ventricular volume and morphology with two dimensional echocardiography may be of value in clinical practice.     

Gastrointestinal cancer and herpes zoster in adults

BACKGROUND/AIMS: Herpes zoster is associated with immunosuppression, and also has an increased risk of malignancy. The aim of this study is to determine whether patients with Herpes zoster are at a higher risk of occult malignancy and gastrointestinal diseases. METHODOLOGY: We examined 131 of 201 Japanese patients who showed evidence of Herpes zoster in the gastrointestinal tract including the large intestine using gastrointestinal endoscopy, total colonoscopy and CT scanning. RESULTS: Six of 131 patients (4.6%) with Herpes zoster, who had undergone all three examinations, had malignancies. This rate is significantly higher than the predicted rate (P < 0.05). Five of six patients had gastrointestinal or colon cancer. Previously, 17 of the 201 patients has been surgically treated for cancers (17/201 = 8.5%, predictable rate = 8.9%), eleven of these 17 patients had surgery for gastric cancer, or for colon cancer etc. We also diagnosed three patients to have cancers after an episode of Herpes zoster, out of the 140 patients who we examined as study prospects (3/140 = 2.1%, relative risks = 1.75). No significant increases in the malignant rates were observed before or after the onset of Herpes zoster. CONCLUSIONS: These findings are considered to support the policy to investigate patients with Herpes zoster for the presence of occult malignancies, though the rate of malignancy in such patients before or after episodes of Herpes zoster was not significantly different from that of the predictable rate.     

New approaches to hepatocellular carcinoma and concomitant esophageal varices prolong survival

A retrospective study was done on 226 patients with hepatocellular carcinoma and coexisting esophageal varices treated at our institute between 1974 and 1988. The patients were divided into two groups: Group A containing patients treated between 1974 and 1982 (n = 92), and Group B comprising those treated between 1983 and 1988 (n = 134). Surgical treatments were applied to 64 patients (69.6%) and 37 patients (27.6%) in groups A and B, respectively (p less than 0.001). Ninety out of 134 patients (67.2%) in group B were prescribed regional chemotherapy. Forty-nine patients (53.3%) in group A, and 96 (71.6%) in group B had esophageal varices that were about to rupture as indicated endoscopically. Nineteen patients (38.8%) in group A, and 10 (10.4%) in group B were treated surgically (p less than 0.005). The varices in 76 out of 96 patients (79.2%) in group B were treated by endoscopic sclerotherapy. Survival rates during the first 5 years in groups A and B were 28% and 65%, 16% and 43%, 5% and 27%, 4% and 18%, and 4% and 6%, respectively. It would appear that appropriate conservative treatment of the poor surgical candidates will, in general, lead to good clinical results.     

Advances in the treatment of hepatocellular carcinoma and concomitant esophageal varices

Twenty-four patients with hepatocellular carcinoma (HCC) concomitant with esophageal and/or cardial varices concurrently underwent hepatic resection for HCC and various treatments for varices. All patients had cirrhosis of the liver, and had either blue or white varices with "red color signs" endoscopically. These patients were assigned to two groups. Group A patients simultaneously underwent partial hepatectomy and selective shunt or direct interruption procedures (n = 13). Group B patients underwent hepatic resection and devascularization of the upper half of the stomach and/or preoperative or postoperative endoscopic injection sclerotherapy (n = 11). Seven patients in Group A had a tumor recurrence 4 to 58 months postoperatively, while in Group B, one of 11 patients had a tumor recurrence in the remnant liver. There was one patient in Group A with postoperative rebleeding from esophageal varices, and there was neither variceal bleeding nor variceal recurrence after treatment in Group B. Liver failure was the immediate cause of death in five, including three in-hospital deaths in Group A. Survival rates during the first 5 years in Group A were 75%, 67%, 31%, 21% and 10%, while the four-year survival rate in group B was 100%. In the light of this evidence, the treatment given to Group B is to be preferred.     

Glucocorticoid-induced osteoporosis and anabolic effect of PTH on bone

Glucocorticoid-induced osteoporosis(GIO)is the major cause of secondary osteoporosis, and prevention of GIO is thought to be essential to avoid bone fracture. Direct inhibitory effect of glucocorticoid on bone formation is considered as the main mechanism of GIO. Clinical guidelines have recommended that bisphosphonate is the first choice for the treatment of GIO. Bone mineral density in patients with GIO has recently been reported to be increased by the treatment with parathyroid hormone(PTH)at a low dose and by intermittent administration.     

The principles and practices of intramedullary nailing for fracture fixation

Intramedullary nailing is fracture fixation for long bone fractures. The fixation system is stabilization at fracture site, using a metal rod, from the inside of medullary cavity of long tubular bone. This principle of fracture fixation is intramedullary splinting. The procedures of fixation are reduction at fracture site, decision of entry point, reaming, insertion of nail and interlocking screw fixation, additionally controlling of dynamization for acceleration of fracture healing. The development of intremadullary nailing has sequentially addressed the design of nail, fixation system and technical exploitation, and expanding of indication. This paper introduces the concept and recent development of intramedullary nailing.     

Laparoscopic splenectomy for portal hypertension

BACKGROUND/AIMS: Laparoscopic splenectomy is now increasingly being performed. However, controversy remains regarding the effectiveness of a laparoscopic splenectomy for patients with portal hypertension. METHODOLOGY: Seventy-three patients with portal hypertension who underwent a laparoscopic splenectomy from February 1992 until October 2000 were reviewed and the effectiveness of the procedures for portal hypertension was evaluated. Forty-two patients had esophagogastric varices and twenty had a concomitant hepatocellular carcinoma. The indications for surgery were bleeding tendency due to thrombocytopenia (n = 40), difficulty in receiving treatment for hepatocellular carcinoma due to thrombocytopenia (n = 18), and sclerotherapy-resistant esophagogastric varices (n = 15). RESULTS: A laparoscopic splenectomy was successfully performed in all the patients. The rate of conversion to conventional open surgery was 9.6% (7/73). The mean operative time was 210.1 +/- 101.9 minutes, and the estimated blood loss was 374.7 +/- 352.4 mL. There were no cases of mortality, and morbidity was encountered in 11.0% of patients. The increase in the platelet count correlated significantly to the spleen weight (P < 0.001). The platelet count had been maintained at over 10 x 10(4)/mm3 for over three years. Eighteen patients with hepatocellular carcinoma successfully underwent treatment for hepatocellular carcinoma after surgery and no recurrence of esophagogastric varices was encountered. CONCLUSIONS: A laparoscopic splenectomy resulted in the successful secondary treatment of hepatocellular carcinoma and esophagogastric varices. Portal hypertension was not a contraindication. A laparoscopic approach is therefore the procedure of choice for a splenectomy in portal hypertension.