Congenital absence of the intrahepatic portion of the portal vein in an adult male resected for hepatocellular carcinoma.

We report a case of congenital absence of the portal vein (CAPV) in an adult male who underwent resection for hepatocellular carcinoma. CAPV is a rare anomaly; only 29 cases, mostly in children, have been presented to date. An association between CAPV and cardiac abnormalities, polysplenia syndrome, skeletal abnormalities and liver tumors has been seen in children. To the best of our knowledge this is the first case of CAPV in an adult male resected for hepatocellular carcinoma. However, since CAPV can be without symptoms, the number of undiagnosed cases is not known.

Thoracoscopic surgery of palmar hyperhidrosis.

New thoracoscopic methods have been reported to minimise the operative trauma after surgical treatment of primary hyperhidrosis of the palms. We therefore began with this minimally invasive technique for sympathetic ablation in 1990. Our first 81 patients presented here confirm earlier results of excellent effects, few complications and mild side-effects when treating palmar hyperhidrosis with thoracoscopic sympathectomy.

Degeneration activity: a transient effect following sympathectomy for hyperhidrosis.

The degeneration activity of effector organs is due to a period of transmitter release from degenerating sympathetic post-ganglionic nerve endings. This is the theoretical explanation for a period of sweating some days following sympathectomy for hyperhidrosis seen in some patients operated on with the thoracoscopic technique in Jönköping, Sweden. The reasons for degeneration activity, well documented in animal experiments, are discussed in this paper.

Primary Roux-Y gastrojejunostomy versus gastroduodenostomy after antrectomy and selective vagotomy.

One hundred twenty-one patients with prepyloric ulcer disease entered a randomized clinical trial comparing gastroduodenostomy with Roux-Y gastrojejunostomy after antrectomy and selective gastric vagotomy. The postoperative course and morbidity were quite similar in the two study groups, as was the postoperative infectious complication rate. Forty-four of the patients with a Billroth I reconstruction and 52 of those with a Roux-Y reconstruction were followed up with a clinical assessment at least 6 months after the operation. The postgastrectomy symptoms were quite frequent, but did not differ between the two study groups. Seventy-five percent of the patients with a Billroth I gastroduodenostomy had symptoms corresponding to Visick grades 1 and 2, compared with 81% of those with Roux-Y reconstruction. Although the latter procedure was very effective in preventing bile reflux to the gastric remnant, no difference was observed in the gastric emptying rate after the two operations.

Thromboxane A2-receptor blockade and prostacyclin in porcine Escherichia coli shock.

Septic shock was induced by intravenous infusion of live Escherichia coli in pigs to investigate the influences on central hemodynamic, coagulation, and fibrinolytic reactions by a thromboxane A2 (TxA2)-receptor blocker (BM 13.177; n = 6) and a prostacyclin analogue (iloprost or ZK 36,374; n = 7). The early pulmonary vasoconstriction following E coli infusion was attenuated, but not abolished, by BM 13.177. Only minor effects were seen after pretreatment with iloprost. Neither drug had any major effect on the coagulation and fibrinolytic activation. These results confirm that TxA2 is an important, but not the only, mediator of early pulmonary vascular response in porcine septicemia and that neither TxA2 nor prostacyclin is of major importance for the hemostatic reactions in this shock model.

Influence of aprotinin, a protease inhibitor, on porcine E. coli shock. Studies on coagulation, fibrinolytic and hemodynamic response.

The effect of a protease inhibitor, aprotinin, on hemostasis (a2M, a2AP, AT III, prothrombin-convertin activity, fibrinogen, fibrinogen monomers and fibrinolytic activity on fibrin plates) was investigated in pigs with septic shock. Anesthetized pigs were given live Escherichia coli i.v. (n = 7), or aprotinin (1,000,000 KIE i.v.) 15 min before live E. coli (n = 6), or Ringer's solution only (sham controls, n = 8). Septic shock developed in all E. coli-infused pigs. Pulmonary vascular resistance increased, platelet and leukocyte counts fell and signs of systemic activation of the coagulation and fibrinolytic systems appeared in the E. coli groups, but aprotinin attenuated the effects on these systems and also on the pulmonary circulation. Five of the six aprotinin-pretreated pigs survived, but none of the seven with septic shock and no pretreatment. Thus the shock induced by infusion of live E. coli and the resultant changes in the coagulation and fibrinolytic systems and in cardiopulmonary hemodynamics were diminished by aprotinin pretreatment.

Influence of prostanoids on gastrointestinal mucosal injury in experimental septic shock.

Capillary stasis and mucosal injury in the stomach and small intestine were studied in septic shocked pigs. Septicemia was induced by live E. coli i.v. in 28 animals. Additionally, five animals were infused with Ringer's solution and served as sham controls. The 28 E. coli-infused animals were pretreated with either a cyclooxygenase inhibitor--indomethacin, n = 6, a thromboxane (TxA2)-synthetase inhibitor--UK 38,485 alone, n = 6, or combined with a serotonin-antagonist--ketanserin, n = 9. Seven E. coli-infused animals were left untreated and served as septic controls. The sham controls were hemodynamically stable and had normal histological findings. All bacteria-infused animals exhibited signs of septic shock with pronounced hemodynamic reactions. Attenuation of the bacteria-induced increase in pulmonary arterial blood pressure was found in all pretreated animals but most pronounced in the indomethacin-pretreated group which also showed protection against gastric mucosal injury and capillary stasis. TxA2-inhibited animals had aggravated capillary stasis and mucosal injuries. It is concluded that gastric mucosal damage could be modified by drugs influencing the prostanoid system. The "cytoprotective" effect of prostaglandins seem to be of minor importance for the prevention of the gastro-intestinal mucosal injury seen in some series.

Arachidonic acid cascade metabolites in porcine E. coli shock. Coagulation, fibrinolytic and hemodynamic response.

Cardiopulmonary hemodynamics and changes in various hemostatic factors (alpha 2M, alpha 2AP, AT III, prothrombin-proconvertin activity, fibrinogen concentration, ethanol gelation test and fibrinolytic activity on fibrin plates) were investigated in pigs during shock induced with live Escherichia coli. Anesthetized pigs were treated with indomethacin or with the combined cyclooxygenase/lipoxygenase inhibitor BW755C before the E. coli infusion or were left untreated as septic controls. Septic shock developed in all of these animals. Pretreatment attenuated the early deterioration of pulmonary circulation but did not modify the coagulation/fibrinolytic activation or the disturbed cardiopulmonary hemodynamics seen in the delayed phase of shock. The arachidonic acid cascade metabolites thus seems to mediate the early, but not the delayed cardiopulmonary reaction and to have minor importance for activation of coagulation and fibrinolysis in E. coli-shocked pigs.

Total gastrectomy in the elderly patient.

Postoperative morbidity and mortality were studied in 72 patients who consecutively underwent total gastrectomy for primary gastric malignancy. Patients aged greater than or equal to 70 years (n = 32) were compared with younger patients (n = 40). Two patients in both groups died postoperatively, making the surgical mortality 6.3% and 5%, respectively. Major surgical complications arose postoperatively in 12 cases. Conservative measures (balloon dilation of anastomotic stricture, protracted drainage, and puncture and drainage of intraabdominal abscess) sufficed in five cases, while reoperation was required in seven. One of these seven patients died. The remaining three deaths were due to myocardial infarction, cerebral vascular insult and exudative pericarditis, respectively. The median postoperative hospital stay was 14 days in the younger and 15 days in the older patient group. Approximately half of the patients in both groups were alive 2 years postoperatively. Total gastrectomy is a meaningful and reasonably safe operation for primary gastric malignancy also in elderly patients.

Coagulation and fibrinolytic reactions in experimental porcine septic shock: pretreatment with different antiplatelet factors.

The aim of this study was to investigate the influence on various hemostatic factors (alpha 2-macroglobulin, antiplasmin, antithrombin III, prothrombin-proconvertin activity, fibrinogen concentration, ethanol gelation test, and fibrinolytic activity on fibrin plates) of bacteremic shock in swine and the influence on these factors of drugs interfering with platelet function. Anesthetized pigs were given live Escherichia coli intravenously (n = 49) or Ringer's solution (n = 7) and were monitored for 3 hours. Pretreatment was given with indomethacin (n = 6), the TxA2 inhibitor UK 38 485 (n = 7), the prostacyclin analogue ZK 36 374 (n = 7), the 5HT antagonist ketanserin (n = 6), or ketanserin combined with UK 38 485 (n = 9) or dipyridamole (n = 8). Septic shock developed in all E. coli animals. There were decreased levels of platelets and leukocytes and activation of the coagulation/fibrinolytic systems by E. coli. Except for a slight attenuating effect on the antithrombin III (ketanserin and dipyridamole) and alpha 2-macroglobulin (ketanserin) decreases, there were no significant effects of the drugs. It is concluded that live E. coli induced several changes within the coagulation and fibrinolytic systems. Only minor effects were seen when different drugs influencing platelet function were given.

Pulmonary vascular response to live Escherichia coli: influences of different antiplatelet substances.

The aim of this study was to investigate whether pretreatment with drugs that interfere with platelet functions in different ways could modify the pulmonary vascular response in a porcine septic shock model. Septic shock was induced by i.v. infusion of live Escherichia coli bacteria. Bacteriemic animals were divided into five groups: untreated or pretreated with a thromboxane-A2 synthetase inhibitor (UK 38 485), a serotonin-receptor antagonist (ketanserin), a combination of these two drugs, or a platelet antiaggregating drug (dipyridamole). E. coli induced significant pulmonary hemodynamic and respiratory changes. The pulmonary responses to E. coli infusion were attenuated after pretreatment with UK 38 485 but unaffected by prior administration of ketanserin or dipyridamole. The combined pretreatment did not attenuate the pulmonary hypertension or other pulmonary responses to E. coli more than UK 38 485 alone. Dipyridamole did not alter the pulmonary circulation after bacterial infusion. It was concluded that thromboxane-A2 is an important, but not the only, mediator of the pulmonary vascular response in septic-shocked pigs and that factors such as serotonin and platelet aggregability seem to be of minor, if any, importance for the hemodynamic response.

Splenic resection for benign cyst. A case report and technical comments.

A case of post-traumatic splenic cyst is presented. Reasons for splenic preservation and technical aspects of conservative surgery of the spleen are discussed.

Diagnosis and treatment of gallstone ileus. Report of 83 cases.

83 patients with gallstone ileus treated at 6 hospitals in Sweden during 1960-1979 are presented. Overall mortality was 26.5%. The high age (mean 75 years) and poor general condition of many patients seem to be the main reason for the high mortality rate. 76 patients (92%) were laparotomized and in 63 (76%) the operative procedure was limited to enterolihotomy. Three of these patients had later a second attack of gallstone ileus; other late complications of the gallbladder disease were rare and less serious. In three patients a cholecystectomy was added to enterolithotomy. The postoperative period for these patients was uneventful while postoperative mortality was high (60%) in 5 patients operated with enterolithotomy and small intestinal resection.

Gastrocolic fistula: a rare complication of benign gastric ulcer.

Gastrocolic fistula secondary to a benign gastric ulcer is an extreme rarity. We recently treated a 81-year-old female with an en-bloc resection of the fistula tract combined with truncal vagotomi and pyloroplasty. The symptoms typical of a gastrocolic fistula, the diagnostic procedures and treatment are discussed.