We report a case of spontaneous rupture of the spleen due to invasion from a pancreatic tumour. We are
unaware of any similar case having been reported in the literature.

S. Chung

K. Park

A. K. C. Li

A Pancreatic Tumour Presenting as a Ruptured Spleen

A patient is presented with multiple vascular anomalies in the branches of the celiac axis as well as inthe portal vein and its branches. Apparently, unique in the literature is the presence of a large arteriovenousfistula between the hepatic artery and one of the hepatic veins. The anomalies are presumedto be congenital in origin.

John M. Howard

M.  Malafa

Robert J. Coombs

Anthony M. Iannone

Arteriovenous Fistula Between the Hepatic Artery and the Hepatic Vein

Injection sclerotherapy is widely used in the treatment of oesophageal varices. However, few studieshave compared the local toxicity of sclerosant agents which may be important if serious local complicationsare to be avoided.In this study the depth of injury caused by submucosal injection of increasing concentrations ofsodium tetradecyl sulphate, polidocanol, 5&#37; ethanolamine oleate and 5&#37; varicosid in rabbits stomach,has been compared by histopathological examination.Macroscopic ulceration was seen in 14.6&#37; of injection sites. Increasing concentrations of sodiumtetradecyl sulphate and polidocanol produced increasingly extensive microscopic inflammation. Fivepercent varicosid caused more inflammation than 5&#37; ethanolamine and only 3&#37; polidocanol and 5&#37;varicosid caused full thickness inflammation. Only 5&#37; ethanolamine produced inflammation consistentlyconfined to the mucosa and submucosa.On the basis of this study we feel that 5&#37; ethanolamine is the most suitable agent for injectionsclerotherapy.

C. S. Robertson

C.  Womack

K.  Robson

D. L. Morris

A Study of The Local Toxicity of Agents Used for Variceal Injection Sclerotherapy

A prolonged ascitic leak through abdominal drains is a source of postoperative complications and of
prolonged postoperative hospital stay after liver resection for hepatocellular carcinoma (HCC) in
cirrhotic patients. Therefore we elected to abstain from routine abdominal drainage in the last 14
resections in cirrhotic livers. A significantly smaller number of patients had postoperative complications
following liver resections without drainage (7%) than historical controls with abdominal drainage (59%,
p &lt; 0.01). The number of complications related to ascites was significantly greater in patients with
abdominal drainage (76%) than without (0%, p &lt; 0.001). Postoperative hospital stay was also significantly
longer following resections with abdominal drainage (19 ± 4 days) than in patients without (12 ± 1 days, p &lt; 0.01). The long postoperative hospital stay in patients with abdominal drainage was
related to ascitic discharge for a mean period of 13 ± 10 days. No clinically significant accumulation
of ascites was noted in patients without drainage. A more frequent utilization of hepatic vascular inflow
occlusion did not account for the better results in the group of patients without drainage. These results
suggest that routine abdominal drainage should not be used following liver resection for HCC in
cirrhotic patients. This appears to be another of the technical details improving postoperative results
in these patients.

C. Smadja

L. Berthoux

J. L. Meakins

D. Franco

Patterns of Improvement in Resection of Hepatocellular Carcinoma in Cirrhotic Patients: Results of a Non Drainage Policy

Seventy patients in whom sphincteroplasty was performed by an original technique are presented. In
65 cases the indication was stenosis of the sphincter of oddi, associated or not with cholelithiasis or
hepatic hydatid disease. There were relative indications in another 5 patients. Sphincteroplasty was
achieved with the aid of an original probe, and average length of the incision of the ampullary area
was 28 mm.In the immediate postoperative period there was one case of acute postoperative pancreatitis, one
duodenal fistula and an upper digestive haemorrhage; also a residual stone was detected. All these
complications have responded favourably to conservative treatment. There was a single death in an old
patient with bronchopneumonia.The late results were very good or good with the exception of two cases: one which presented with
cholangitis episodes maintained by duodenal stasis, and one female patient, who after one year from
sphincteroplasty had to be reoperated on for an hepatic abscess.

S. Duca

Sphincteroplasty of the Sphincter of Oddi in the Treatment of Benign Distal Obstructions of the Bile Duct

Our experience of 90 hepatectomies (HE) and examinations of 64 cadaver livers resulted in the elaborationof a simplified technique for the exposure of hepatic pedicles (HP) and the rapid selective ligationwithout significant normothermal ischemia of the retained parts of the liver. The method comprises 4consecutive steps: 1) a superficial T-shaped incision of Glisson&#39;s capsule at the site of HP projectionon the liver&#39;s inferior surface, 2) introduction of the surgeon&#39;s forefinger into the liver parenchyma,controlled by clamping the hepatoduodenal ligament, the fingertip finding a tubular structure well distinguishedby its smooth elastic surface from the friable parenchyma and bending the finger to hookthe pedicle, 3) drawing the hooked pedicle downwards through the slit in the capsule and temporarilyclamping it, while releasing the hepatoduodenal ligament so as to restore blood supply to the retainedparts of the liver, 4) checking for correct ligature position on the HP before its final ligation by matchingthe actual ischemic area with the intended line of resection and moving the clamp proximally or distallyalong the exposed pedicle for the release or clamping of lateral branches as necessary. Whereuponresection can be performed by any of the known methods.This method has been used in 8 major HE, allowing to reduce intraoperative blood loss from2200&#177;247 ml to 1000&#177;225 ml and reducing general liver ischemia from 10 minutes and more to 2&#8211;3minutes.

E. I. Galperin

S. R. Karagiulian

A new Simplified Method of Selective Exposure of Hepatic Pedicles for Controlled Hepatectomies

Despite the best conservative measures available for the control of major variceal hemorrhage, somepatients either continue to bleed, or rebleed early, and require emergency surgery. One hundred patientswith cirrhosis and uncontrolled bleeding were treated with emergency portasystemic shunts between 1968and 1983. Fifty eight patients had end-to-side portacaval shunts and 42 had Dacron interposition mesocavalshunts. Both groups were comparable with respect to age, sex and prevalence of alcoholism. There was anincreased severity of liver disease as assessed by Child&#39;s class in the mesocaval group of patients.Overall in-hospital mortality was 31&#37; with no significant difference demonstrated between themesocaval group (28&#37;) and the portacaval group (33&#37;), nor between alcoholic cirrhotics (34&#37;) and non-alcoholiccirrhotics (21&#37;). Mortality rates based on severity of liver disease were: Child&#39;s A (1/6) 17&#37;,Child&#39;s B (9/48) 19&#37;, and Child’s C (21/46) 46&#37;. There was a statistically significant difference betweenChild&#39;s A &#38; B and Child&#39;s C (p &#60; 0.01). Four patients were lost to follow-up. No significant differenceswere found in 5 year survival by life table analysis comparing portacaval (39&#37;) vs. mesocaval (28&#37;) groupsor alcoholic cirrhotics (36&#37;) vs. non-alcoholic cirrhotics (29&#37;). Encephalopathy in survivors was absent in46&#37;, mild in 28&#37; and severe in 26&#37; of patients. There was no significant difference in encephalopathyrates following portacaval or mesocaval shunting.Neither operation was clearly superior and choice of operation can be made on the basis of technical andanatomical factors and surgeon experience. Emergency shunting remains a useful option for patients withvariceal bleeding refractory to other more conservative therapy, and is associated with acceptable earlymortality and long term survival rates.

 D. I. Soutter

B.  Langer

B. R. Taylor

P.  Greig

Emergency Portasystemic Shunting in Cirrhotics With Bleeding Varices &#8212; A Comparison of Portacaval and Mesocaval Shunts

Hemihepatectomy along with portal vein or hepatic artery replacement in dogs was well tolerated, butcombined with replacement of both vessels it was lethal because of outflow block and shock. Total liverblood flow should be kept as high as possible during such procedures in man.

Egge J. Boerma

Herman H. M. de Boer

M. Niels van der Heyde

Urbain  J. G. M. van Haelst

Hemihepatectomy and Replacement of The Afferent Hepatic Blood Supply in The Dog

A series of plasma globulin studies was carried out on 108 patients who were operated on for splenictrauma during the last 3 years. The reasons for splenectomy or spleen salvage were; gunshot woundsin 22 patients (20.3&#37;); stab injuries in 10 patients (9.2&#37;) and blunt abdominal trauma in 76 patients(70.3&#37;). Plasma gamma globulin determinations were made on the 8th postoperative day and at 3months. In the splenectomy group; plasma gamma globulin determinations demonstrated a significantreduction in serum IgM levels (p &#60; 0.001) but no significant changes in IgA and IgG levels (p &#62; 0.05).No changes were detected in IgA, IgG and IgM levels in the spleen salvage group (p &#62; 0.05).We believe that the preservation of the traumatized spleen should be the prime aim of surgeons.

Yesilkaya  Yasar

Yilmaz  Zeki

Erkilic  Ahmet

Sen  Metin

Kilic  H&#252;seyin

Plasma Gamma Globulin Levels After Splenectomy and Spleen Salvage

Recent reviews of the management of hilar biliary cancer suggest that radical resection is the preferred
treatment option. It seems true that most of the long term survivors are treated this way, but it is equally
true that most patients receive palliative rather than curative treatment. Before we go too far in our
advocacy of radical treatment, we need to develop methods for quantifying palliation because that is in
truth what we usually achieve. A method of quantifying palliation is described. Surgeons are encouraged
to use methods of this kind in order to allow valid comparison of the results of different methods of
treatment.

J. M. Little

Hilar Biliary Cancer – Are We Getting It Right?

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