Herniorrhaphy and concomitant peritoneovenous shunting in cirrhotic patients with umbilical hernia

From 1981 to 1987, a total of 40 cirrhotic patients with umbilical hernia were treated either by conventional herniorrhaphy (26) or by herniorrhaphy and concomitant insertion of a peritoneovenous (PV) shunt (14). The aim of concomitant PV shunt insertion was to reduce postoperative complications of herniorrhaphy in those patients with intractable ascites, or in whom difficulty to control postoperative ascites was contemplated. In the group of patients with PV shunt, 8 were class B and 6 were class C according to Child's classification; 7 patients had complicated hernia including 2 patients with skin ulceration, 4 with rupture, and 1 with incarceration. In the group with standard herniorrhaphy, 5 patients were class A and 21 were class B; 13 patients were operated on electively for uncomplicated hernia without ascites, 6 had incarceration, and 7 had skin ulceration. The technical procedure of concomitant PV shunting and hernia repair included: insertion of the valve, surgical repair of the hernia, and insertion of the venous tube. In that order, in-hospital mortality was nil. Postoperative complications included sepsis in 2 patients who had concomitant insertion of a PV shunt, and massive ascitic fluid production in 5 patients treated by conventional herniorrhaphy, resulting in ascitic leak from the surgical wound in 1 case. Recurrence of the hernia was observed in 6 patients treated by conventional herniorrhaphy, and in none who had a patent PV shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

[X-ray computed tomography and percutaneous drainage change the indications for reoperation after digestive surgery]

In order to assess the major clinical biological and radiological signs of an intra-abdominal abscess following digestive surgery as well as the place of automatic reoperation, this retrospective study analysed 79 patients requiring intensive therapy for such a complication since 1982. Surgery consisted in oesophagectomy (n = 38), hepatectomy or cholecystectomy (n = 12), pancreatic surgery (n = 17) and colectomy (n = 12). A postoperative abdominal abscess was recognized in 75 patients consisting in intrathoracic or intra-abdominal oesophageal fistulas (n = 31), pancreatic abscesses and fistulas (n = 17), peri- or intrahepatic abscesses (n = 11), colonic fistulas (n = 12) and acalculous cholecystitis. With regard to the intensity of symptomatology the patients have been allocated into 2 groups. In group I, including 12 patients, the infectious syndrome occurred early (3 first postoperative days), was severe and associated with positive blood cultures in 60% of cases. The patients were reoperated without previous CT-scanography. Four died postoperatively. In group II, including 67 patients, the symptomatology was more discrete. CT-scanography was highly beneficial, with discovery of an abscess in 90% of cases. In 20 patients, the abscess has been punctured and drained successfully by percutaneous route. In 6 patients with negative CT-scanography, an automatic reoperation resulted in the discovery of an abscess in 2 cases. Five out of 6 of these patients died postoperatively. It is concluded that in case of intraabdominal complication following digestive surgery: a) in case of early and severe symptomatology, a rapid reoperation is mandatory; b) CT-scanography has a high diagnostic value for abscess recognition in patients with discrete and delayed symptomatology; c) nearly one third of the abscesses can be treated successfully by percutaneous drainage; d) the value of automatic reoperations remains unsubstantiated.

[Ultrasonographic and x-ray computed tomographic aspects of Mirizzi's syndrome]

The Mirizzi syndrome is due to common hepatic duct obstruction secondary to the impaction of a large gallstone in the neck of the gallbladder or the cystic duct. The sonographic and computed tomography features in 3 cases of Mirizzi syndrome are described and compared with percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography findings. The Mirizzi syndrome was diagnosed preoperatively on sonography in 2 out of 3 cases and on plain computed tomography scans in all 3 cases. However pre or intraoperative visualization of the biliary tract is mandatory in suspected Mirizzi syndrome to detect the presence or absence of cholecystobiliary fistula, in order to adapt the operative strategy.

[Recent advances in surgical therapy of hepatocarcinomas. 5 questions on the exeresis of carcinomas of the cirrhotic liver]

The surgical treatment of cancers in cirrhotic liver has two main objectives: 1) to remove the cancer with low mortality and mobility rate; 2) to carry out a radical operation with a survival index of 50% three years after the operation. For this purpose, five queries may contribute to programming the most suitable surgery. 1) What patients can be operated? a) those without abdominal ascitic effusion; b) anicteric patients; c) those with fairly well preserved liver function. 2) What liver cancers can be resected? Mainly those with a single localisation. 3) What investigations offer a picture of the extent of tumoral invasion? a) ultrasonography; b) arteriography with simultaneous injection of Lipiodol and later echography; c) intraoperative echography. 4) What surgical operation should be carried out? Liver resection as "economical" as possible (cirrhotic liver) but at the same time as "radical" as possible (hepatocarcinoma). 5) What results can be expected? a) 5% mortality; b) 30% survival 3 years after operation. As the prognosis of liver cancers in cirrhotic livers is better the more limited are the dimensions of the tumour at the time of operation, only systematic screening of cirrhotic patients by repeated ultrasonography permits their treatment at an earlier stage.

Sensitivity and specificity of microscopic examination of gallbladder bile for gallstone recognition and identification

During cholecystectomy, gallbladder bile and gallstones were obtained from 77 patients and gallbladder bile was obtained from 39 patients free of stones (11 patients had biliary stenosis). According to their chemical composition, gallstones were classified as cholesterol (n = 46) or pigment (n = 31) stones. In patients with gallstones (a) cholesterol crystals better helped to identify cholesterol gallstones (sensitivity, 87%; specificity, 97%; positive predictive value, 97%) than did an abnormal cholesterol saturation index of bile (sensitivity, 93%; specificity, 48%; positive predictive value, 73%); (b) the presence of cholesterol crystals was significantly related to the cholesterol content of gallstones and the bile cholesterol saturation index; and (c) bilirubinate crystals, when present alone (without cholesterol crystals), were good predictors of pigment gallstones (sensitivity, 71%; specificity, 93%; positive predictive value, 88%). In the absence of stones, bilirubinate crystals were present in 9 of 28 patients without biliary stenosis (4 with alcoholic cirrhosis and 2 with alcoholic pancreatitis) and 8 of 11 patients with biliary stenosis. In the absence of stones, cholesterol crystals were present in 2 of 28 patients without biliary stenosis and in 4 of 11 patients with biliary stenosis, suggesting that bile stasis can induce cholesterol crystal formation.

Acute Budd-Chiari syndrome as first manifestation of adrenocortical carcinoma

We report the case of a young woman in whom investigations for acute Budd-Chiari syndrome disclosed an hormone-secreting but clinically nonfunctioning adrenocortical carcinoma. We supply a very brief review of the literature.

[Nutritional status of patients with digestive system cancer: preoperative prognostic significance]

We have attempted to establish a prognostic nutritional index prospectively in 633 patients with digestive carcinoma making it possible to predict tumor resectability and occurrence of postoperative complications. The following factors were studied prior to surgery: age, sex, weight loss index, triceps skinfold thickness, midarm circumference, lymphocyte count, plasma albumin, transferrin and prealbumin levels, delayed hypersensitivity as investigated by 8 skin tests. The prognostic nutritional index was calculated using Mullen's formula. Unidimensional and multidimensional studies (linear discriminant and logistic discriminant analyses with partial correlations) were used for the statistical analysis. Mortality was 6,7 p. 100 while 16,2 p. 100 of patients presented a postoperative complication. The following variables showed a significant correlation with the resectability of the tumour: weight loss (p less than 0.0001), triceps skinfold thickness (p less than 0.01), midarm circumference (p less than 0.01), total lymphocyte count (p less than 0.01), plasma transferrin (p less than 0.01), delayed hypersensitivity (p less than 0.05). In the occurrence of postoperative complications there was a statistically significant value only to weight loss (p less than 0.001) and delayed hypersensitivity (p less than 0.05). Logistic discriminant analysis gave a linear model predicting tumor resectability in 78 p. 100 of patients and postoperative complications in 86 p. 100 of patients in which weight loss and delayed hypersensitivity were statistically significant. No prognostic value of Mullen's index was found. This study shows that assessment of the preoperative nutritional status of patients with gastrointestinal cancer makes it possible to predict tumor resectability and postoperative complications.

[Early treatment of biliary lithiasis in biliary pancreatitis]

Since 1982, 38 consecutive patients with biliary pancreatitis were treated prospectively in order to prevent recurrent migration of gallstones. Removal of the stones was achieved by "early surgery" i. e. within the first week after admission or by endoscopic sphincterotomy in patients with severe pancreatitis. Gallstones were visualized by ultrasonography in 31 patients (82 p. 100). Microlithiasis was present in 14 (37 p. 100) and was missed at ultrasonography in 7 patients. According to Ranson's prognostic signs, only 4 patients had 4 or more signs. These 4 patients and 2 additional patients aged more than 85 underwent urgent retrograde cholangiography and endoscopic sphincterotomy. No complications could be attributed to this technique. Among the 4 patients with severe pancreatitis, 3 developed an abscess which required delayed surgery without further complications. The 32 other patients underwent a biliary operation within the first week after admission. Common bile duct calculi were present in 14 patients being discovered by cholangioscopy in 6. One patient died after operation and one was reoperated on for a pseudocyst on day 40. No recurrent attack of pancreatitis was observed in either group. Our study suggests that slightly delayed biliary operation with cholangioscopy during the same hospitalization can be performed safety in patients with mild pancreatitis. In patients with severe attack and/or poor general condition, endoscopic sphincterotomy is a safe technique and deserves wider consideration in the management of severe acute pancreatitis for which delayed drainage of pancreatic necrosis may occasionally be required.

Anorexia in oesophageal carcinoma

The influence of anorexia on nutritional status and tumour resectability was prospectively assessed in 50 patients with oesophageal carcinoma and severe dysphagia. Among the 21 patients in whom anorexia was present, objective measurement of clinical status demonstrated that malnutrition was present in 13 (62%) and resection of the tumour was possible only in five (24%). On the contrary, among the 29 patients without anorexia, malnutrition was only present in five (17%) and resection of the tumour was possible in 24 (82%). We conclude that anorexia is a main determinant of malnutrition and that it is related to the tumour development independently of dysphagia. In patients with oesophageal carcinoma, the clinical assessment of anorexia must be used for evaluating nutritional status before surgery. The presence of anorexia suggests a widespread tumour or a disseminated cancer and it might explain the poor nutritional effects of palliative intubation in non resectable tumour.

Effects of methoxsalen on the metabolism of acetaminophen in humans

We reported recently that the drug methoxsalen, a potent suicide inhibitor of hepatic cytochrome P-450, decreases the metabolic activation of acetaminophen and prevents its hepatotoxicity in mice. We have now studied the effects of methoxsalen on the metabolism of acetaminophen in humans. In vitro, 100 microM methoxsalen decreased by 40% the covalent binding of a [3H]acetaminophen metabolite to microsomal proteins after incubation of [3H]acetaminophen with human liver microsomes and an NADPH-generating system. In vivo, a single oral dose of methoxsalen (30 mg), given 3 hr before acetaminophen (1 g), decreased by 38% the partial apparent oral salivary clearance of acetaminophen into glutathione-derived conjugates (the end products of its oxidative metabolism) in nine human volunteers. These observations demonstrate that methoxsalen decreases the metabolic activation of acetaminophen in humans.

Results of esophagogastrectomy for carcinoma in cirrhotic patients. A series of 23 consecutive patients

Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 23 patients with histologically proven hepatic cirrhosis. All but two patients were classified as Child's class A and all but three had a prothrombin time over 60% of normal values. Twenty-two esophagogastrostomies were performed through a separate abdominal and right thoracic approach in 15 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Six patients died after operation (26%) as a result of anastomotic leakage in two patients, hepatorenal in three patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (65%), and when associated with hepatorenal syndrome there was a significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection where the above criteria are met. This strict selection allows one to anticipate a lower mortality rate.

Inactivation of human liver cytochrome P-450 by the drug methoxsalen and other psoralen derivatives

The effects of psoralen derivatives on cytochrome P-450 have been studied in human liver microsomes. CO-binding cytochrome P-450 was decreased by 33% after 10 min of incubation with 1.5 mM EDTA, an NADPH-regenerating system and 20 microM methoxsalen (8-methoxypsoralen). No destruction of cytochrome P-450 was observed when either NADPH or methoxsalen was omitted. A similar (27%) decrease in CO-binding required a 100-times higher concentration of allylisopropylacetamide (2 mM). The activities of 7-ethoxycoumarin deethylase and benzo(a)pyrene hydroxylase were decreased by about 50% in the presence of 12.5 microM methoxsalen. At this low concentration, neither cimetidine nor SKF 525-A or piperonyl butoxide had any significant inhibitory effect. Monooxygenase activities were also decreased in the presence of 12.5 microM bergapten (5-methoxypsoralen) or 12.5 microM psoralen, but not with 12.5 microM trioxsalen (trimethylpsoralen). CO-binding cytochrome P-450 was not decreased after 10 min of incubation with 1.5 mM EDTA, an NADPH-regenerating system and 20 microM trioxsalen. We conclude that methoxsalen is an extremely potent suicide inhibitor of cytochrome P-450 in human liver microsomes. Bergapten and psoralen are also inhibitory whereas trioxsalen has little effects. In the latter derivative, a methyl group is attached on the furan ring and may hinder its metabolic activation and the inactivation of cytochrome P-450.

Caustic sclerosing cholangitis. A complication of the surgical treatment of hydatid disease of the liver

In five patients, sclerosing cholangitis developed after the surgical treatment of hydatid cyst of the liver. The cyst communicated with the biliary tree, and a scolicidal solution (2% formaldehyde in two patients and 20% sodium chloride in three) was injected into the cyst. Cholangiography showed strictures affecting the intrahepatic biliary tree in two and both the intrahepatic and extrahepatic biliary tree in three. Sclerosing cholangitis in these patients was likely to result from the caustic effect of the scolicidal solution having diffused from the cyst into the biliary tree. We propose to designate this entity "caustic sclerosing cholangitis". Because of the risk of this complication, and the unproved efficacy of intracystic injection of a scolicidal solution in preventing the dissemination of the parasite, we recommend that this maneuver be abandoned in the surgical treatment of hydatid disease of the liver.

Prevention of coagulopathy after placement of peritoneovenous shunt with replacement of ascitic fluid by normal saline solution

Consumptive coagulopathy may complicate the early postoperative course of peritoneovenous shunting and be responsible for diffuse bleeding or even death. Since this complications has been related to procoagulant substances in ascitic fluid getting access to the systemic circulation, it was demonstrated that the replacement of the ascitic fluid by normal saline solution during shunt insertion decreases the prevalence and severity of postoperative coagulopathy.

[Surgical treatment of hepatocellular carcinoma in cirrhosis. Value of peroperative ultrasonography]

During the past three and half years, 19 patients with hepatocellular carcinoma associated with cirrhosis were operated on. Pain was present in seven patients while 12 were asymptomatic. Alpha foeto-protein was negative in 7 patients. Intraoperative ultrasonography was performed in the last 15 patients. Three right hepatic resections, 5 left hepatic lobectomies and 11 segmentectomies or subsegmentectomies were performed. The operative mortality was 5 p. 100 (one patient). The long term survival in the 3 patients who underwent palliative resection was 6 months. Among the 15 other patients, four died from causes unrelated to their tumor; three patients with tumors larger than 8 cm died from recurrence 12 to 26 months after surgery; and the remaining 7 are still alive without evidence of recurrence 3 to 18 months after surgery. We concluded that in patients with cirrhosis, resection of limited hepatocellular carcinoma is possible, using intraoperative sonography, with low operative mortality. Early detection by repeated ultrasonic examination of the liver in patients with cirrhosis could be the best way to improve the surgical treatment of hepatocellular carcinoma.

[Epidermoid cancer of the thoracic esophagus following mediastinal irradiation]

Squamous cell carcinoma of the esophagus induced by radiation therapy is a rare entity. We report 4 cases observed during the past 4 years. Three women and one man aged from 47 to 78 years developed squamous cell carcinoma of the esophagus 8 to 11 years after radiation therapy. The 3 women had been irradiated for breast cancer and the man for Hodgkin's disease with 40 to 57.5 Gy. Three patients were operated on and the immediate postoperative course was uneventful. Culling data from this report and from the literature we reviewed the different steps concerning the diagnosis and the treatment of this complication of radiation therapy. We suggest that diagnostic and therapeutic modalities should follow the same guidelines as in other esophageal cancers.

Budd-Chiari syndrome: US evaluation

Twelve patients with proved Budd-Chiari syndrome (eight acute and four chronic cases) were examined, using real-time ultrasonography (US). In all acute cases, US study showed at least one hepatic vein with findings suggestive of the syndrome, such as stenosis, dilatation, thick wall echoes, thrombosis, abnormal course, or extrahepatic anastomosis. In chronic cases, hepatic veins were usually not visible. Modifications of liver morphology were present in all patients except those with recent onset of the disease. Caudate lobe hypertrophy was present in only six cases. US study is therefore the procedure of choice for initial diagnosis of acute Budd-Chiari syndrome. Pitfalls were the failure to detect two caval thromboses and one hepatic vein web. Cavography should still be performed systematically, but hepatic phlebography is useful in selected cases only.