Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents.

PURPOSE: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). METHODS: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. RESULTS: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. CONCLUSIONS: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

Two-clamp method to avoid portal anastomotic stenosis in liver transplantation.

We developed a two-clamp technique to avoid stenoses in portal anastomoses during liver transplantation. A portal anastomosis is created with a continuous polypropylene suture. A second vascular clamp is placed on the donor portal vein before release of the recipient vein clamp. After release of the proximal clamp, the vein is allowed to distend to its maximal diameter, and the suture is gently tied. This technique was used in both portal and arterial anastomoses in 43 consecutive liver transplant recipients. No cases of postoperative stenosis or thrombosis were observed.

Long esophagoplasty: functional study.

The functional results of different types of plasty were evaluated in 46 patients who had undergone esophageal replacement for different pathologies. The patients were classified into three groups according to the type of plasty: I) 19 ileocecocolonoplasties (ICC), II) 11 left colonoplasties (LC), III) 16 gastroplasties (GP). The postoperative studies made were: a) clinical evaluation, b) radiological barium contrast study, c) isotopic transit of semisolid food marked with 99m-Tc colloidal sulfur and d) manometry. The clinical evaluation disclosed no significant differences between the three groups. Isotopic scans revealed more rapid emptying of the ICC, with elimination by the ileal segment in the first minute of 76.3 +/- 3.3% of the isotope, and by the entire plasty of 79.4 +/- 4.2% in 15 minutes (p less than 0.001). The manometric study showed non-response by the GP. The motor activity of the terminal ileoplasty was greater than that of the other plasties studied, and that of the right colonoplasty was greater than that of the left (p less than 0.01). Likewise, the clearance of acid (HCl 0.1N) by the ICC was more rapid than that of the LC (p less than 0.01). It is concluded that, functionally, the ICC is a better long esophagoplasty than the other procedures studied.

Manometric evaluation of the feline esophagus.

Fifteen healthy mongrel cats were manometrically evaluated to quantitate esophageal function and to establish the feline esophagus as an appropriate model for investigations relevant to human physiology and pathology. Detailed findings are presented in the paper. Characteristics of the upper and lower esophageal high-pressure zones and of esophageal body motility were found to be similar to human values. Response to bethanechol stimulation was also similar to that seen in humans. This study establishes normal manometric values for the feline esophagus and validates it as an appropriate model for investigations of esophageal physiology and pathophysiology.

Effect of incomplete obstruction on feline esophageal function with a clinical correlation.

This study was performed because of the observation of unexplained esophageal dysfunction in patients with incomplete esophageal obstruction. A Gore-Tex band, measuring 110% of resting esophageal circumference, was placed about the esophagus at the gastroesophageal junction of 17 cats to produce incomplete obstruction by limiting the normal distention that occurs with swallowing. Esophageal manometry was performed before surgery and at 1 and 4 weeks after surgery. Lower esophageal high-pressure zone pressure was not influenced, but sphincter relaxation was impaired. Evaluation of esophageal body contractions showed that simultaneous contractions increased from 0% before surgery to 68% at 1 week and 85% at 4 weeks after surgery (p less than 0.001 versus preoperative for both comparisons). The incidence of repetitive contractions increased from 3.1% before surgery to 10.5% at 1 week and 10.9% at 4 weeks after surgery (p = NS). The average contraction pressure decreased from 22.5 mm Hg before surgery to 13.9 mm Hg at 4 weeks after surgery (p less than 0.05). Barium swallows showed esophageal dilatation, that was confirmed on gross examination. Histologic examination was remarkable only for retention esophagitis. Sham surgery in three cats with identical mobilization of the gastroesophageal junction did not affect motility. Motility returned to normal after the band was removed in three cats. Manometric evaluation of 15 patients with distal esophageal peptic strictures and 17 patients with excessively tight antireflux repairs showed a significantly increased (p less than 0.001) frequency of simultaneous contractions, 35% and 34%, compared with the 2.1% of 25 normal subjects. The following conclusions can be drawn: Partial obstruction alters feline esophageal body function and these achalasia-like changes are reversible on relief of the obstruction and similar motility aberrations occur in patients because of mechanical or functional distal obstruction; this suggests that dysmotility can synergistically contribute to dysphagia.