Arterialization of the portal vein for control of variceal bleeding. Clinical and angiographic follow-up.

Angiographic and clinical findings in 33 patients who underwent arterialization of the portal vein and end-to-side portacaval shunt over a seven-year period are reviewed. Both encephalopathy and postoperative bleeding were less frequent than in previous series. Major angiographic findings included stenosis or closure of the gastroepiploic artery-portal vein shunt, narrowing of the intrahepatic portal vein, aneurysm formation in the saphenous vein graft, shunt narrowing or thrombosis, and development of portosystemic collaterals. The authors conclude that as long as the shunt remains patent, a more physiological state is maintained.

Influence of cadaver donor age on the success of kidney transplants.

To investigate the impact of donor age on the outcome of renal transplants, a retrospective analysis of 440 consecutive cadaver donor kidney transplants were performed by dividing the transplants into six groups, according to the decade of donor age. These groups were comparable with regard to recipient age, sex, race, and HLA matching grade, while the pediatric group received kidneys preferentially from the first and second decade donors. Although cadaver donor age, between 11 and 50 years, did not appear to influence the result of kidney transplants, the kidneys retrieved from the first and sixth or higher decades of donors fared significantly worse. Improved criteria for the evaluation, selection, and management of cadaver donors of extreme ages is needed to achieve a satisfactory result.

Evaluation of anterior extravesical ureteroneocystostomy in kidney transplantation.

We evaluated the anterior extravesical ureteroneocystostomy technique in 184 consecutive renal transplants done in 2 consecutive calendar years. Complications included 5 cases of ureteral and 1 of pelvic necrosis, and 2 of ureteral obstruction, with a ureteral complication rate of less than 4 per cent. All cases of pelvic or ureteral necrosis except 1 were seen in cadaver donor kidneys that were imported from other centers. No bladder complications were seen. Pelvioureteral obstruction, presumably of congenital origin in the cadaver donor, was discovered in the kidney after transplantation in 2 cases and was corrected successfully by pyeloureterostomy to the native ureter. The extraordinary simplicity of this technique, coupled with improvement in the complication rate, makes it our procedure of choice.

Arterialization of the portal vein in cirrhosis: the findings at celiac arteriography.

An angiographic study of a new operation for portal hypertension involving arterialization of the portal vein in combination with an end-to-side portacaval shunt is described. The angiographic appearances differ from those of end-to-side shunts alone. With the new operation there is, in particular, no significant change in the wedge pressure or in the hepatic artery size from preoperative to postoperative studies, and in the majority of patients, the liver size is also unchanged. The incidence of porto-systemic shunting from the portal vein to the low pressure caval system (66%) is lower than for end-to-side shunts alone. Changes are seen in the distal portal bed in the majority of cases.

Arterialization of the portal vein in cirrhosis: the findings at wedge hepatic venography.

A new operation for the treatment of cirrhosis and portal hypertension has recently been described involving arterialization of the portal vein in combination with an end-to-side portacaval shunt. We present, for the first time, the appearances at wedge hepatic venography. No significant change is seen in the wedge hapatic pressure as a result of this technique, and the sinusoidal pattern is preserved. Filling of the portosplanchnic collaterals is not as frequent as after end-to-side shunts alone, and the appearances seem to reflect improved sinusoidal perfusion. The clinical results have been encouraging.

Distribution of water between extracellular and intracellular compartments of incised wounds of rabbits.

The distribution of water between the extracellular and intracellular compartments in incised wounds of skin, muscle and stomach has been studied in healthy rabbits and the progress of healing monitored by the determination of tensile strength for 120 days. It has been shown that, after wounding, there is an immediate expansion of the extracellular space. The increase is most marked during the first 24 hours and is maximal by this time in wounds of the skin and the muscle. During the first 30 days of healing, all incised tissues contain similar amounts of extracellular water which constitute approximately one-half of the total tissue mass, irrespective of the size of the extracellular space prior to wounding. There is an inverse relationship between the increase in the amount of extracellular water and the size of the extracellular space prior to wounding. All incised tissues maintain an elevated, and similar, concentration of extracellular water for more than 120 days. The period of maximal gain in tensile strength corresponds to the period of maximal expansion of the extracellular space which signifies a particularly active phase in the wound healing process. The intracellular space in wounds of muscle and stomach is reduced for more than 120 days, but no significant changes are seen in the intracellular water of wounds of skin. It has been concluded that expansion of the extracellular space is essential for wound healing, and it can, therefore, serve as a sensitive indicator of tissue injury.

Prognostic significance of portal pressure in patients with bleeding esophageal varices.

Portal pressure was determined in 76 patients during acute bleeding varices, and the degree of portal hypertension was related to the cessation or noncessation of hemorrhage with nonoperative management. A direct relationship between the severity of hemorrhage and the degree of portal hypertension was established. It is suggested that portal pressure be determined as soon as feasible when bleeding varices are suspected and that other causes of hemorrhage be carefully excluded. The obtained data are of great prognostic significance and might be helpful in planning the course of therapy in these individuals.

Arterialization of the liver in combination with a portacaval shunt in the dog.

A dog preparation has been developed combining an end-to-side portacaval shunt with arterialization of the hepatic portion of the portal vein through an anastomosis between the inferior branch of the splenic artery and the stump of the portal vein. In this dog preparation, total hepatic blood flow, perfusion of the intrahepatic portal vein, and sinusoidal pressure remained within the preoperative range in the majority of the dogs. The data presented indicate that arterialization of the liver, under those conditions, resulted in no histologic damage or atrophy of the parenchyma of the liver and was effective in achieving significant prolongation of life and prevention of most of the adverse metabolic sequelae that follow a portacaval shunt in dogs. The indocyanine green extraction was restored to normal. The extraction of ammonia was impaired in all dogs with shunts; however, a significantly better ammonia extraction was seen in dogs with arterialization of the liver. It is being postulated that the dual perfusion of the liver through the hepatic artery and the portal vein is essential for the maintenance of the normal morphologic and functional states of the liver in dogs. The avoidance of hyperfusion of the sinusoidal bed with arterial blood is the most critical factor in preventing morphologic damage of the liver if arterialization of the portal vein is used.