Nutrition and immunity after peritoneovenous drainage of intractable ascites in cirrhotic patients

Severe malnutrition and related impaired cell-mediated immunity are commonly found in cirrhotic patients with intractable ascites and may be responsible for the poor prognosis of these patients. The effects of LeVeen peritoneovenous shunting of ascites on protein reserves and cell-mediated immunity were studied in 31 cirrhotic patients with intractable ascites over a period of 1 year following operation. Arm-muscle circumference, serum albumin, and transferrin levels markedly increased and became close to the normal values. In the same period, delayed hypersensitivity improved. Although the lymphocyte count and the absolute T cell concentration in peripheral blood remained low after peritoneovenous shunting, the in vitro lymphoblastic transformation in response to phytohemagglutinin was augmented. An increased capacity to eat normal meals and the resumption of a good appetite due to the discontinuation of a salt-restricted diet seemed to be the most important factors in the dramatic improvement in the nutritional status of these patients. Restriction from heavy alcohol use may have also contributed, although the patients had already stopped drinking for several months before operation. Improvement in cell-mediated immunity might have been secondary to the increase in protein reserves.

[Treatment of intractable ascites in cirrhotic patients by portal shunt]

Forty one patients with chronic liver disease and intractable ascites were treated by a portal-systemic shunt. Operative mortality was 4.8 p. 100. Ascites was definitely cleared in 97 p. 100 of the 39 survivors. Fourteen patients later developed encephalopathy which was severe in 6 (15.3 p. 100). One-year survival rate was 72 p. 100. Late deaths were mainly due to complications of liver disease. These results suggest that portal diversion is an efficient and permanent treatment of intractable ascites in cirrhotic patients. Operative mortality and overall survival rates are similar to those observed after peritoneo-venous shunting. The peritoneo-venous shunt is preferable as the first-choice treatment of intractable ascites in cirrhotics because of the risk of encephalopathy. Portal diversion should be proposed for patients with previous variceal hemorrhage and for those in whom peritoneo-venous shunt has failed.

Treatment of postshunt encephalopathy with secondary arterialization: an experimental study in the rat

Secondary arterialization of the hepatic stump of the portal vein has been performed in rats 7 days after portacaval anastomosis (PCA) at a date when the electrocorticographic changes of postshunt encephalopathy were evident. A complete regression of encephalopathy ensued. This correlated with an increase in the weight of the liver and estimated hepatic blood flow. These results confirm the efficiency of liver arterialization, primary or secondary, in the treatment of postshunt encephalopathy. In the groups of rats studied in this experiment a significant correlation was always found among encephalopathy, liver weight: body weight ratio, and hepatic blood flow. This reinforces the hypothesis that a decrease in hepatic blood flow is the main factor in the generation of liver atrophy, decrease of hepatic function, and encephalopathy following portacaval shunt. Primary arterialization of the liver in humans has not gained much favor because of technical difficulties, a high mortality rate, and the absence of clear-cut evidence of its efficiency. Our results suggest that arterialization of the liver might better be kept as a secondary procedure for those cases in which encephalopathy develops after PCA.

Liver atrophy and encephalopathy after portacaval shunt in the rat

The effect of various types of portal diversion (portacaval, mesocaval and pancreatico-splenocaval anastomoses, portacaval transposition and arterialization) on liver atrophy and post-shunt encephalopathy was studied in the rat. Among all diversions, only portacaval anastomosis produced dramatic liver atrophy and encephalopathy. Moreover, portacaval anastomosis was also the only portal diversion which induced low body weight gain. There was no correlation between blood ammonia levels and encephalopathy. Liver atrophy was always correlated to a decrease of hepatic blood flow. Diminution of liver blood flow was only slight following partial (either mesenteric or pancreatico-splenic) diversion of portal blood and nil after portacaval transposition or anastomosis. These results suggest that: (1) pancreatic (insulin-rich) blood is not essential for maintenance of liver trophicity. Hemodynamic factors seem to be predominant in the pathogenesis of post-shunt liver atrophy. (2) Post-shunt encephalopathy arises only when total diversion of the portal blood and liver atrophy are associated.

Enhancement of Aflatoxin B1 induced liver carcinogenesis by portal diversion in the rat

Conflicting results have been reported on the influence of portacaval anastomosis on liver carcinogenesis. The purpose of this investigation was to study the effect of portal diversion on liver carcinogenesis induced in the rat by a potent chemical liver carcinogen, Aflatoxin B1 (AFB1). Liver tumors appeared earlier and were significantly bigger in rats with shunts than in sham-operated controls. Portal diversion also induced in rats fed AFB1 a splenic atrophy with nearly complete disappearance of Malpighian corpuscles suggesting a profound immunodepression. This might be responsible for the enhancement of liver cancer by portacaval anastomosis in the rats fed AFB1. Thus, the influence of portal diversion on liver cancers appears to be multifactorial.

[Study of venous distensibility using plethysmography with venous occlusion in post-phlebitic syndromes]

Venous distensibility has been studied in the cases of twelve patients presenting a post-phlebitic syndrome, compared with five patients with primary varicose veins. In the post-phlebitic syndromes we note far fewer symptoms of venous distensibility, whereas in the cases of varicose veins there is an increase of venous distensibility. Statistics of the delta V max. 50 and the symptoms of distensibility are given in a recapitulatory table, and a diagram.

Portal diversion for portal hypertension in children. The first ninety patients

Ninety children with portal hypertension were treated by portal diversion. Fifty-two had cavernous transformation of the portal vein and 38 had an intrahepatic block from various causes. There were 59 central splenorenal shunts, 19 mesocaval, 11 portacaval and one distal splenorenal. In 61 peripheral shunts the veins used for the anastomosis were less than 10 mm in diameter. There was no operative mortality in children with extrahepatic block. One child with cystic fibrosis died postoperatively. Thrombosis of the shunt occurred in five children (5.6 per cent) and was responsible for recurrent bleeding in two. Four children with a thrombosed shunt underwent succesful reoperation and one is awaiting another anastomosis. No late complications occurred in the 52 children with extrahepatic block, while encephalopathy developed in four children with intrahepatic block. These figures confirm our earlier results in the management of portal hypertension in childhood and suggest that portal diversion is the treatment of choice. Several precautions have permitted lowering of the rate of thrombosis whichever shunt is performed. Portal diversion should be indicated following the first episode of hemorrhage in children with extrahepatic block. In patients with intrahepatic block, congenital hepatic fibrosis and cystic fibrosis are good indications as are in general the hepatic diseases with no or mild activity.

Criteria for hepatic transplantation in cirrhosis

Among the patients considered for hepatic transplantation, cirrhosis should be theoretically the best indication. Results so far are disappointing because the patients who have undergone a transplantation had end stage liver disease. When gastrointestinal bleeding, renal failure, coagulopathy and encephalopathy are used as criteria, one can accurately select patients who will die from cirrhosis within one month. Our results for those who had a liver graft in this group are poor. Criteria were then selected to identify a less dramatically ill group of patients with cirrhosis. These patients have residual poor liver function after surviving acute severe complications and have a spontaneous survival of less than one year. The results of liver transplantation in two patients in this group are encouraging.

Heterotopic liver transplantation in end-stage HBsAg-positive cirrhosis

A patient with end-stage cirrhosis complicating HBsAg-positive chronic active hepatitis given a heterotopic liver transplant is alive and well 28 months after transplantation; liver function is normal, and there are no hepatitis-B related lesions on the liver graft despite positivity of HBsAg in the serum. This observation confirms that a heterotopic liver graft can offer long-term survival in man and suggests that this technique may be a more suitable procedure than orthotopic transplantation in end-stage cirrhotics.

Emergency hepatic arterial embolization for secondary hypercalcemia in hepatocellular carcinoma

Two successive hepatic arterial embolizations were performed in a patient with hypercalcemia secondary to hepatocellular carcinoma. The first procedure was performed on an emergency basis due to a cardiovascular episode and was immediately beneficial. The second procedure, performed five months later for a recurrence, was effective in 3 days; 13 months later, there had been no recurrence.

Portal hypertension after bile duct obstruction: effect of bile diversion on portal pressure in the rat

Biliary obstruction of 14 and 28 days induced in the rat an increase of portal pressure (PP) and wedge hepatic vein pressure (WHVP); the higher these were, the longer was the obstruction. Occurrence of portal hypertension seemed related to portal and periportal fibrosis. Relief of obstruction after 14 days by bilioduodenal anastomosis brought back to normal PP and WHVP. In rats with longer obstruction periods, bilioduodenal anastomosis failed to lower PP and WHPV although biological signs of cholestasis returned to normal levels. These results suggest that portal hypertension may arise very shortly after biliary obstruction in rats and that it may persist in animals with a prolonged biliary obstruction despite an efficient bile drainage. In clinical conditions, such results would favor early treatment of lesions that usually cause prolonged bile duct obstruction, such as postoperative bile duct stenosis.