Intrahepatic vascular shunting for portal hypertension: early experience with the transjugular intrahepatic porto-systemic shunt.

The treatment of patients with portal hypertension and hemorrhaging varices remains an enigma within the surgeon's world. Many procedures have been described, which suggests that no general consensus exists regarding the proper care for these individuals. Also, these procedures usually lead to massive blood use and exposure to patients who have had multiple blood transfusions, thus posing an extreme infectious risk to the surgical team. Eight patients refractory to repeated esophageal sclerotherapy with advanced portal hypertension underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure. One other patient with altered anatomy underwent transjugular porto-caval shunt (TPCS) procedure via the caudate lobe of the liver. All procedures were successful in stopping esophageal hemorrhage within 6 hours of shunting. The portal-hepatic vein pressure gradient pre-shunt averaged 20 mm Hg, and post-shunt averaged 11 mm Hg. Two patients developed encephalopathy, which was controlled with medication and/or diet modifications. Three patients classified as Child's C-plus died within 1 week of their shunting procedure, and one patient, who had received greater than 60 units of blood, within 10 days pre-shunt, died 45 days post-shunt of multi-system organ failure. Four of the original nine patients are now classified as Child's A with active lives, eligible for transplantation without altered abdominal anatomy. The follow-up period is from 5 to 11 months. TIPS and TPCS are methods that should be considered the front-line invasive management techniques for patients with portal hypertension who have failed esophageal sclerotherapy.

The efficacy of palliative and definitive percutaneous versus surgical drainage of pancreatic abscesses and pseudocysts: a prospective study of 85 patients.

We compared the efficacy of percutaneous to surgical drainage in a prospective study in 85 patients with pancreatic abscesses and pseudocysts. Percutaneous drainage of pancreatic abscesses in 18 patients cured three and palliated 12 who were eventually cured by elective surgical ablation; three patients died. This compares well to our 15 surgical patients, of whom four were cured by surgery alone and six were palliated. All were subsequently cured by additional computerized tomography-guided or ultrasound-guided percutaneous drainage and medical management or surgery. Five of the 15 died. Percutaneous drainage cured 11 of 14 infected pseudocysts and palliated two, which were subsequently cured by surgery; one was palliated but the patient was lost to follow-up. Surgical drainage cured six of 12 infected pseudocysts and palliated the other six, of which four were cured by further surgery and the other two were cured by secondary percutaneous drainage. Nine of 12 noninfected pseudocysts were cured by percutaneous aspiration, and two were palliated and later cured. In one patient, disease progressed, and he was ultimately lost to follow-up. Thirteen of 14 noninfected pseudocysts were cured by surgical drainage. The other patient died of pulmonary embolus. In patients treated by percutaneous techniques, there were four major complications. Our study established distinct advantages of percutaneous drainage under computerized tomographic and ultrasonic guidance: (1) the procedures can be carried out under ultrasonic guidance in an intensive care unit on critically ill patients, (2) the technique proved highly effective for initial palliation, with defervescence and stabilization occurring in most critically ill patients within 48 hours, (3) findings from fine needle aspiration provided valuable information as to microorganisms and antibiotic sensitivities and differed in 29 of 85 patients from those of concomitant blood cultures, and (4) definitive eradication of the process (surgical ablation of residual necrotic material) can be elected after the patient's clinical condition stabilizes.

Lesöes dos ductos biliares e da vascularizaçäo intra-hepática na correçäo cirúrgica de traumatismos e do fígado: relato de dois casos / Bile duct injuries and intrahepatic vascularization in the surgical repair of liver injuries: report of 2 cases

Com a incidência progressivamente crescente de traumatismos hepáticos, surgem novas complicaçöes que säo detectadas em funçäo da utilizaçäo, cada vez maior, da radiologia especializada. Säo relatados dois casos de traumatismos hepáticos graves, tratados com ressecçöes e que tiveram lesöes biliares, as quais necessitaram procedimentos corretivos ulteriores. Em um dos pacientes havia, concomitantemente, lesäo arterial hepática, cujas implicaçöes säo discutidas

Ablation of tumor and inflammatory tissue with absolute ethanol.

Absolute ethanol was used to ablate tumors, inflammatory lesions, and end-stage nephrosclerotic kidneys in 38 patients. Thirty patients had various types of renal tumors, and 3 had chronic end-stage renal failure with malignant hypertension. One patient had a fibrosarcoma of the right leg and one had a metastasis in the humerus from a renal carcinoma. A large adrenal carcinoma was treated with absolute ethanol in a patient who had liver metastases that were ablated one year after the first procedure. An additional patient had metastatic liver disease from a non-functioning adrenal carcinoma. The remaining patient had an extensive hypervascular inflammatory lesion (tuberculosis and aspergilloma) of the right upper pulmonary lobe. In addition to ethanol, coils were introduced in one patient and Gelfoam in another. The amount of ethanol used ranged from 5 to 50 ml. Twenty-two patients suffered from considerable transient pain during ethanol injection, but sedation was necessary in only 3 of them. Skin necrosis appeared in 2 patients requiring plastic reconstruction in one of them. Two patients died within 5 days of the procedure unrelated to the ablation. Two patients presented upper gastrointestinal bleeding within 2 days of the ethanol injection and one of these died in acute renal failure. One patient suffered from left colonic infarction after left renal tumor ablation, but survived for several months. Absolute ethanol was a useful and efficient sclerosing agent causing extensive tumor destruction and marked reduction of the vascularity in tumor and inflammatory lesions, but caused an 18 per cent complication rate.

Percutaneous biliary drainage in neoplastic jaundice. Statistical data from a computerized multicenter investigation.

Technical and clinical data concerning 731 controlled patients submitted to nonsurgical percutaneous biliary drainage (PBD) for preoperative or palliative purposes were collected from eight institutions. Using a computerized analysis program, general and special statistics were obtained, with special attention given to 536 neoplastic cases. Technical success, type, level and nature of the lesions, purpose of drainage, surgery performed, complications, and other clinical and technical information were considered and compared with the clinical results. Statistically significant data were obtained comparing, respectively, bilirubin levels with duration of drainage, survival with type of treatment (PBD alone or followed by radical or palliative surgery), operative with post PBD mortality, survival with type of PBD (external catheter, internal catheter, and endoprosthesis), and complications with type of PBD used.

Management of traumatic hematuria by selective renal artery embolization.

Angiography and selective renal arterial embolization were performed in 17 patients with traumatic lesions of the kidney and hematuria. Of the patients 8 had retroperitoneal extravasation of contrast medium owing to rupture, 6 had traumatic arteriovenous fistulas and 5 had pseudoaneurysms. Immediate control of hemorrhage was achieved in 16 patients (94.1 per cent), while delayed control was obtained in 1. Hematuria recurred in 4 of the 17 patients (23.5 per cent) and resulted in total nephrectomy in 3 (17.6 per cent) despite repeated embolization in 2. Embolization alone was successful in 14 patients (82.4 per cent). According to the followup preservation of renal function and viable parenchyma was excellent in all embolized patients. Our results indicate that transcatheter embolization should be performed in patients with renal trauma and uncontrollable hematuria before any surgical attempt is made.

Angioplastia transluminal percutanea da arteria renal. Resultados tardios no tratamento da hipertensao arterial renovascular. / Percutaneous transluminal angioplasty of renal arteries.Late results in the treatment of renovascular arterial hypertension

Os autores apresentam os resultados da angioplastia transluminal percutanea da arteria renal (ATPAR) para tratamento da hipertensao arterial num seguimento de mais de dois anos, em 19 pacientes com 21 estenoses da arteria renal. A etiologia da estenose era displasia fibromuscular em 15 pacientes e ateroscleroses em quatro. A pressao arterial (PA) normalizou-se em 100% dos pacientes com hiperplasia fibromuscular e em 50% daqueles com lesao aterosclerotica. Em 25% dos pacientes com lesao aterosclerotica a PA se manteve inalterada e em 25% houve melhora do controle ambulatorial de hipertensao

Colangiocarcinomas. Avaliacao pela ultra-sonografia e correlacao com a colangiografia transparieto-hepatica. / Cholangiocarcinomas. Evaluation by ultrasound and correlation with transparietohepatic cholangiography

Os autores estudaram pela ultra-sonografia e pela colangiografia transparieto-hepatica 21 casos de colangiocarcinomas. Estes dois metodos possuem grande importancia no diagnostico da ictericia obstrutiva e de suas causas. A utilizacao combinada destes dois metodos estabelece com precisao o diagnostico, o grau de envolvimento da arvore biliar fornecendo informacoes importantes com relacao a ressecabilidade cirurgica do tumor. E proposta uma classificacao sonografica destas lesoes tumorais estabelecendo-se correlacao com o prognostico cirurgico. Os colangiocarcinomas devem ser incluidos no diagnostico diferencial das ictericias obstrutivas sendo de grande importancia sua identificacao precoce em razao de seu prognostico favoravel nestes casos

Embolizacao de tumores renais. / Embolization of renal tumors

Os autores apresentam a sua experiencia em 76 pacientes portadores de tumor renal submetidos a embolizacao. Em 62 pacientes usou-se gelfoan e em 14 alcool absoluto.Apresentam os resultados obtidos, os efeitos colaterais observados e as vantagens do metodo

Percutaneous transluminal angioplasty of renal artery stenosis.

Percutaneous transluminal angioplasty was performed in 7 patients with hypertension and renal artery stenosis, caused by atherosclerosis in 3 patients and fibromuscular disease in 4. The balloon dilatation was successful in all patients. In 6 patients the blood pressure was normalized within 5 days after the procedure, and remained so in 5 on follow up 3 to 10 months later.

Linfoma histiocitico renal (reticulossarcoma). Apresentacao de caso. / Renal histiocytic lymphoma (reticulosarcoma). Case report

Os autores apresentam um caso de infiltracao renal por linfoma histiocitico primitivo do baco, salientando os aspectos clinicos, radiograficos e angiograficos

Varicocele: the value of reflux in the spermatic vein.

Three groups of patients were studied: varicocele with altered spermogram (24 patients), varicocele with normal spermogram (12 patients), and 12 normal individuals. All underwent selective spermatic venography by the Seldinger technique. No statistically significant differences were found as to the presence of spermatic vein reflux in three groups, nor between varicocele patients and controls. It was concluded that reflux per se cannot explain the alterations of spermatogenesis, nor does it have prognostic value in varicocele.