An old head on new shoulders.

A modified stapling technique for anterior resection is described. A pursestring suture is placed in the proximal colon after resection of the specimen; the head of a stapling gun is detached from the stapler and inserted into the proximal bowel and the pursestring suture is tied. A pursestring suture is placed in the rectal stump. A stapling device head from a previous case is autoclaved and then fitted to the stapling device to allow safe insertion per anum: this head is discarded as soon as the distal pursestring is tied. The anastomosis is then completed in the usual way. This technique has been used successfully in twenty-one cases with minimal morbidity and no mortality.

Tumour necrosis factor alpha secretion in leporine endotoxaemia: role of the liver and effects of hepatic ischaemia.

A leporine model to investigate tumour necrosis factor alpha (TNF alpha) secretion after peripheral vein or mesenteric vein lipopolysaccharide injection was devised. Mesenteric vein injection provoked lower arterial concentrations after 90 minutes (median (range), 2.81, (0.75-11.96) ng/ml) than peripheral vein injection (7.00 (4.27-14.95) ng/ml (p less than 0.05)). Mesenteric vein injection after 10 minutes' warm hepatic ischaemia, which impairs hepatic clearance, provoked higher median arterial TNF alpha values at 90 minutes (7.98 (2.85-21.48) ng/ml) than in normal animals (p less than 0.05). Portal vein endotoxaemia induced less TNF alpha production than systemic endotoxaemia unless hepatic clearance was impaired, thus the major source of TNF alpha in systemic endotoxaemia is probably extrahepatic.

Hepatic transplantation in children using reduced size allografts.

The shortage of paediatric liver donors has led to the use of reduced size hepatic allografts. Between July 1987 and July 1990, 30 reduced size orthotopic liver transplantations were performed in 24 children aged between 3 months and 7 years. All patients were in advanced chronic or acute liver failure and were considered unlikely to survive for long enough for a size-matched donor to become available. The most common indication was biliary atresia. The median intraoperative blood loss was 75 (range 13-1015) ml kg-1. Nine patients have died and seven have undergone retransplantation, four successfully. Seven patients had portal vein hypoplasia with a high graft failure rate due to ischaemic infarction. There was significant morbidity from biliary tract complications, leading to further operations in four cases. The 1-year actuarial survival rate was 62 per cent.