Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding.

OBJECTIVES: The use of duplex studies for the portal tree has revolutionized the concepts of haemodynamic pathophysiology in the case of portal hypertensive bleeders. The identification of possible haemodynamic patterns in schistosomal bleeders, and the effects of devascularization procedure and distal lienorenal shunts on a selected haemodynamic pattern, are the aim of this work. PATIENTS AND METHODS: Patients (219) with schistosomal hepatic fibrosis and history of bleeding oesophageal varices were studied. The patency, diameter, velocity and flow volume/min in the portal and splenic veins were followed by coloured Duplex. Two matched groups (30 patients each) with the most commonly found haemodynamic pattern (splenic vein flow exceeding portal vein flow) were operated upon. Devascularization procedure was done for the first group (A) and distal splenorenal shunt for the second group (B). RESULTS: Coloured duplex assessment of portal circulation in schistosomal patients identified four haemodynamic patterns. Pattern I (approximately 59%); splenic vein flow exceeds the portal vein flow. Pattern II (approximately 28%); portal vein flow exceeds splenic vein flow. In both patterns, the portal flow was hepatopedal. Patterns III and IV (8% and 5%, respectively) were associated with hepatofugal flow. Splenic vein flow exceeds portal vein flow in pattern III and the reverse in pattern IV. Distal lienorenal shunts done for patients with haemodynamic pattern I was followed by a rebleeding rate of 3.3% while devascularization done for patients with the same pattern was followed by a rebleeding rate of 26.6%. Mild encephalopathy was detected in 10% of patients with distal lienorenal shunts and responded to dietary regulations. CONCLUSIONS: DSRS proved to be ideal for schistosomal patients with hepatopedal flow and splenic vein flow exceeding portal vein flow; since in addition to eliminating the high splenic flow out of portal circulation, it decreased the pressure in the gastroesophageal region. Other patterns with their frequencies and the suggested surgical procedures were also presented.

The use of the 'TRAM' flap in some oncological problems.

The present study was conducted to evaluate the use of the transverse rectus abdominis myocutaneous (TRAM) flap in immediate autologous soft tissue coverage of the large wound defect that results from some oncological problems and would be impossible to close by direct primary sutures. The study included patients with locally advanced breast cancer (LABC) (n = 24), post-mastectomy local recurrence (n = 10), post-mastectomy irradiation ulcer (n = 4), recurrent fibrosarcoma of the chest wall (n = 1), and a huge ulcerating malignant melanoma of the groin region (n = 1). All patients were female except for the patient with melanoma. Their ages ranged between 39-73 years with an average of 56.2 years. The lower TRAM flap was used in 24 patients and the middle in only six. Mesh re-inforcement of the abdominal wall was adopted in 14 patients (35%). The mean operating time was 2.5 h and the average postoperative hospital stay was 9.7 days (range, 7-12 days). Six patients (15%) had partial flap necrosis which healed after debridement and secondary sutures, and eight patients had wound sepsis (20%). No patient suffered from abdominal herniation, although four patients (10%) had an epigastric bulge postoperatively. During the 48.5 month follow-up period (range 36-56 months), three cases of local recurrence and four cases of distant metastases were encountered in the patients with LABC. Three of the latter died at 7, 11 and 12 months postoperatively. Based on these data, it may be concluded that the results of the TRAM flap for immediate coverage of the large post-extirpation defect in different oncological problems have been encouraging. No flaps were lost, no abdominal herniation was encountered, and overall complications were minimal.

Hepatic injuries: management and outcome.

A total of 52 patients with different grades of liver injuries were treated in a 1 year period: 32 patients had penetrating injuries and in 20 patients injuries resulted from blunt trauma. Blunt trauma victims were frequently associated with chest and head injuries and with skeletal fractures. A 4-fold incidence of associated intra-abdominal injuries was encountered in penetrating trauma victims. Blunt and gunshot victims commonly had severe grades of liver injuries (55% and 83.3%, respectively). Stab wounds caused simpler grades of injuries (86.7%). Suture hepatorraphy was the commonest procedure performed (57.7%).The other procedures applied to treat the injured liver were: selective ligation of the injured blood vessels (15.4%); packing (7.7%); and liver resection (3.8%). Two patients died on the operating table before any remedy was applied. The overall morbidity was 40.4%. The liver related complications constituted 17.3%. The total mortality was 13.5% and the liver related mortality was 9.6%.

Effect of gastro-esophageal decongestion on variceal pressure in patients with schistosomal hepatic fibrosis.

This study includes 60 patients having schistosomal hepatic fibrosis and esophageal varices. Splenectomy alone was done for 14 patients having no history of haematemesis and gastroesophageal decongestion with splenectomy was done for the remaining 46 patients with history of haematemesis. Endoscopic variceal pressure measurements were done to all of them peroperatively and 21 days postoperatively. 17 patients, 7 after splenectomy and 10 after gastro-esophageal decongestion, were followed for 18 months post operatively. 21 days postsplenectomy, the variceal pressure dropped insignificantly from 38.09 to 33.27 cm H2O. During the following 18 months, three patients out of seven showed significant increase in variceal pressure. After decongestion with splenectomy, the mean variceal pressure dropped significantly from 42.03 to 29.17 cm H2O. For the 10 patients followed for 18 months, eight of them retained their variceal pressure as low as early postoperative figures. Thus gastro-esophageal decongestion with splenectomy is effective in reducing variceal pressure and in so doing it is better than splenectomy alone.