Comparison of somatostatin and vasopressin in bleeding esophageal varices

Somatostatin (ST) and vasopressin (VP) infusions were compared in the treatment of actively bleeding esophageal varices. Fifty-four patients with liver cirrhosis were included in the study. Thirty-two were given ST 4.2 micrograms/min, and 22 patients were given VP 0.4 IU/min for 72 h after endoscopic diagnosis. The role of alcoholic cirrhosis was similar in both groups. Initial control of bleeding was achieved significantly more often (p = 0.0281) when ST was used (84.4%) than during VP treatment (57.1%). Rebleeding occurred in 18.8% and 4.8%, respectively. Side effects of treatment were significantly more common when VP was used than during ST treatment (p = 0.0021). Overall mortality was high in both groups, being 34% in the ST group and 36% in the VP group. ST infusion seems to be more effective and safer than VP in the treatment of acute variceal bleeding. However, the high frequency of rebleeding during ST treatment means that, after primary hemostasis with ST infusion, other methods, such as surgery or sclerotherapy, are needed to prevent the serious complications of rebleeding.

Renal allograft immunosuppression. I. Early inflammatory and rejection episodes in triple drug treatment compared to double drug combinations or cyclosporin monotherapy

We have investigated the impact of triple drug immunosuppression on the occurrence of early inflammatory episodes, as detected by fine needle aspiration biopsy, and of episodes of clinical rejection during the immediate postoperative period. The prospective component of this study includes 128 consecutive first cadaveric renal transplant recipients receiving triple drug treatment consisting of azathioprine (Aza), cyclosporin (CyA) and methylprednisolone (MP). For controls we have used three historical groups: one immunosuppressed with Aza and MP (group A), another with CyA monotherapy (group B), and the third with CyA together with MP (group C) in equivalent drug dosages. On the average, 0.8 episodes of inflammation per patient were recorded during the immediate postoperative period of 30 days with triple drug treatment. This was significantly less than the 1.3 episodes in patients receiving Aza and MP (P less than 0.01), the 1.7 episodes in patients on CyA monotherapy (P less than 0.001), or the 1.6 episodes in patients receiving CyA together with MP (P less than 0.001). Although the first episode of inflammation commenced concurrently in each group and the peak intensity of inflammation was the same, the mean duration of inflammation was significantly shorter--2.7 days--under triple drug treatment than the 7.8-11.7 days for controls (P less than 0.001). The frequency of rejection episodes under triple treatment was also significantly lower--0.2 per patient--than the 0.8 per patient in controls (P less than 0.001). The first rejection episode occurred later in the triple drug treatment group--on the average, on day 15.2--than in the historical controls (on days 7.7-11.7).(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term high-dose corticosteroids and gastroduodenal mucosa. A prospective clinical study on renal transplant recipients

In order to evaluate the effect of a short-term high-dose corticosteroid therapy on the gastric and duodenal mucosa, 30 consecutive renal transplant recipients (mean age 39.1 years, 10 women and 20 men) underwent an endoscopic examination of gastroduodenal mucosa 12 and 30 days after renal transplantation. In addition to the postoperative immunosuppressive medication (methylprednisolone and azathioprine), antacids and H2-receptor antagonists were given. Seventeen patients showed no signs of acute rejection, whereas 11 patients experienced one episode and 2 patients two episodes of rejection during endoscopic follow-up. Each rejection episode was treated with a high-dose regimen of methylprednisolone. The two groups of patients studied, i.e., those who did and those who did not experience rejection, were matched for age, sex, period of preoperative dialysis treatment, period of postoperative time elapsed from transplantation, serum creatinine level, and dose of methylprednisolone or azathioprine at the beginning of the endoscopic follow-up, as well as for ulcer prophylactic medication during follow-up. The gastroduodenal mucosa was similar in the two patient groups, both endoscopically and histologically, at the start of the study. During the observation period of 2 weeks, erosive antral gastritis increased significantly in patients who did not experience rejection, whereas in patients with acute rejection and concomitant high-dose corticosteroid therapy, the antral mucosa remained nearly unchanged. Also, the gastric corpus and the duodenum remained unaltered in both groups during follow-up. No ulcer complications occurred in the series.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of intravesically applied antibiotic solution in the prophylaxis of infectious complications of renal transplantation

The effect of intravesically applied antibiotic solution in the prevention of infectious complications of renal transplantation was evaluated in a prospective, randomized study. The bladder was filled preoperatively with saline solution containing cephalotin in the test group, and with saline solution only in the controls. Both groups of patients received IV doses of cephamandole during, and once after, surgery. Two hundred consecutive patients were randomly allocated to the study groups. The overall incidence of urinary tract infection was 10.4% during the first 4 postoperative weeks; that of wound infections was 1.6% and of septicemia 3.3%. The addition of cephalotin to the bladder irrigation fluid did not have any effect on the overall incidence of infectious complications.

Intraoperative ultrasound as an aid to surgical strategy in liver tumor

Ultrasonography of the liver was performed on 27 patients during laparotomy for liver lesions--11 primary and 13 metastatic mainly colon/rectum malignancies, and three benign conditions. Supplementary information on the liver parenchyma was provided in 11 cases (41%) in which the surgical strategy was decided simply by inspection and palpation of the liver. Ultrasound was most valuable for visualizing the vascular anatomy of the liver, giving clarification in 18 cases (66%), especially the relationship of tumor to portal and hepatic veins. This was decisive for the surgical strategy in four cases, enabling resection in two and modifying planned procedure in two. In a case of polycystic liver, ultrasonography imaged deep-lying cysts and aided the fenestration procedure. Liver resection was performed in 16 cases without operative mortality. Hepatic ultrasonography is useful for determining tumor spread, but of even greater value for the determination of strategy by clarifying tumor/vascular anatomic relationships.

Survival after liver transplantation of patients with primary biliary cirrhosis in the Nordic countries. Comparison with expected survival in another series of transplantations and in an international trial of medical treatment

Until December 1988, 38 patients with primary biliary cirrhosis (PBC) had been transplanted in the Nordic countries. The observed survival probability in accordance with Kaplan-Meier analysis was around 75% 2-3 months after surgery, with few deaths during the next 3 years. The observed survival curve was compared with the expected survival calculated from the experience of a recent English PBC transplant series; the patterns are very similar. Secondly, the observed survival was compared with the expected survival curve, calculated from the survival experience of an international trial of medical treatment--that is, the expected survival had the patients not been transplanted; after the first 2-3 months the observed survival stayed better than the expected survival. Finally, the merits of transplantation for each particular patient was evaluated by means of the ratio of probability of survival when transplanted to probability of survival when medically treated 3, 6, and 8 months after surgery. The ratio increased with time, indicating a relative increase in the benefit of transplantation with time after surgery.

Superior mesenteric artery syndrome. A follow-up study of 16 operated patients

A series of 18 patients underwent surgery for upper abdominal symptoms and signs of superior mesenteric artery syndrome (SMAS). The diagnosis was made by simultaneous arteriography and barium meal. Findings at operation confirmed SMAS in every patient, and a duodenojejunostomy was performed. Duodenal and jejunal wall biopsy from 13 patients revealed normal myenteric and submucous plexuses. A follow-up study of 16 patients was performed after 7 years. At follow-up, the weight loss seen preoperatively had been corrected. However, symptoms were essentially similar to those found at the original examination. Only the frequency of the most distressing symptom, vomiting, was significantly decreased (p less than 0.05). The most striking features in the production of the "pincher mechanism" of the duodenum were found to be a short aortomesenteric distance together with sagittal parallelism between aorta and superior mesenteric artery. In conclusion, we recommend a conservative attitude in the treatment of SMAS. Surgical treatment with duodenojejunostomy may be indicated only if vomiting is a predominant symptom and proper conservative treatment has failed.