Cystic variant of embryonal sarcoma of liver

Embryonal sarcoma of the liver is an unusual tumor. The cystic form is rare and can mimic hydatid disease. We present a case that was mistakenly treated as a hydatid cyst for 3 months. Surgery was successful in removing the mass.

Necrotising arteritis in amoebic colitis

Massive intestinal haemorrhage rarely occurs in amoebic colitis. We report a case of caecal amoebic ulcer in a 61 year old diabetic male who presented with massive lower intestinal haemorrhage requiring blood transfusion and emergency surgical intervention. Histologically, trophozoites of Entamoeba histolytica were seen invading the wall of the submucosal arteries, causing necrotising arteritis. Rupture of a necrosed artery probably caused massive haemorrhage.

Endoscopic esophageal variceal sclerotherapy using 3% aqueous phenol

Endoscopic esophageal variceal sclerotherapy was performed in 301 patients with portal hypertension (emergency, 72 and elective, 229) using 3% aqueous phenol as sclerosant. The cause of portal hypertension was cirrhosis of the liver in 189 patients (Child's class A-48, B-66, and C-75), extrahepatic portal venous obstruction (EHPVO) in 90, and non-cirrhotic portal fibrosis in 22 patients. In the emergency group, active bleeding was controlled in 87% of cases. Re-bleeding occurred in 101 of 290 (35%) surviving patients. Obliteration of varices was achieved in 228 (84%) patients, with a mean of 5.14 +/- 2.27 sclerotherapy sessions. Of 301 patients, 29 (9.6%) had an early in-hospital mortality (30.5% in emergency and 3% in elective group), with 16 deaths due to variceal bleeding. Of the remaining 272 patients, 40 (15%) died during follow-up, of which only 11 died of variceal bleeding. Complications, such as superficial ulcers, dysphagia, and strictures, were observed in 14%, 7% of emergency, and 3% of elective patients. None of the patients developed systemic toxicity. In conclusion, 3% aqueous phenol is an effective, safe, and economical sclerosant for esophageal variceal sclerotherapy.

Primary Budd-Chiari syndrome: its significance for the choice of surgical management of a patent right inferior hepatic vein

Budd-Chiari syndrome is still a major problem and the overall prognosis for the patients is dismal and disappointing. The case history of a patient with not only outflow obstruction of the hepatic vein but also complete obstruction of the retrohepatic inferior vena cava is presented. She had a patent right inferior hepatic vein which partially decompressed the liver via a rich network of venous collaterals. Management included an inferior vena cava to inferior vena cava shunt using a Goretex graft. The patient fared well and the postoperative course was satisfactory. The case history of this patient illustrates the importance of precise pre-operative investigations for the choice of the type of surgical management. Each patient has to be considered individually on the basis of his or her mechanical peculiarities.

Comparative trial of three different schedules for endoscopic esophageal variceal sclerotherapy

We analyzed our experience in 125 patients with variceal bleeding to compare the efficacy and complications of various schedules of endoscopic variceal sclerotherapy. The schedules for the first three injections were as follows: (A) 3-5 ml of aqueous phenol injected at intervals of three weeks (Group I, n = 28), one week (Group II, n = 30) and three days (Group IIIa, n = 33), and (B) 2-3 ml of phenol at each site at intervals of 3 days (Group IIIb, n = 34). Subsequent injections were given at four week intervals for all groups. Varices could be obliterated significantly earlier (p less than 0.001) in patients injected at 3-day intervals (mean +/- SD 9.12 +/- 5.95 weeks) as compared with those injected at 1-week (13.50 +/- 10.28 weeks) and 3-week (20.55 +/- 7.77 weeks) intervals. The rebleeding rate was not significantly less in the 3-day interval group (Group IIIa--16.66% and Group IIIb--17.64%) as compared with the 1-week (23.3%) and 3-week (28.5%) groups. However the mortality due to rebleed was significantly less (p less than 0.05) in patients injected at 3-day interval (nil), as compared with those injected at 1-week (13.3%) and 3-week (10.7%) intervals. Mucosal ulcerations and stricture formation were observed significantly (p less than 0.001) more frequently in patients undergoing sclerotherapy at 3-day intervals (Group IIIa--51.5% and 18.18%) with 3-5 ml of phenol as compared with those injected similar volume at 1-week (16.66% and 3.3%) and 3-week (7.1% and 3.5%) intervals respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Small-bowel perforations. A study of 32 cases

We studied 32 consecutive cases of small-bowel perforations treated in a single surgical unit during the last three years. Clinical features are typical and diagnosis is not difficult. Suprapubic peritoneal paracentesis in head-high position is the most accurate diagnostic investigation. Ultimate results are not related to cause, but are directly proportional to the degree of contamination of the peritoneal cavity, delay in manifestation, antibiotic resistance of the contaminating organism, and the method of treatment of the perforation. There were two deaths in the 16 patients who had exteriorization of the suture line (12.5%), compared with seven deaths in the group of 16 patients who did not have exteriorization (43.75%). Exteriorization of the suture line (16 cases) is a superior method of treatment and significantly lowers the mortality.

Selective transplenic decompression of oesophageal varices by distal splenorenal and splenocaval shunt

The usefulness of selective transplenic decompression of oesophageal varices by distal splenorenal shunt and splenocaval shunt was evaluated in the control of gastrointestinal haemorrhage in patients with portal hypertension of varied aetiology. (Decompression was successful in 69 out of 78 cases.) It was shown that it is superior to total portosystemic shunts, as the incidence of encephalopathy was very low compared with the data from our series of portocaval shunts. The operative mortality has been progressively lowered and has now reached levels comparable with portocaval shunt. Distal splenorenal shunt when performed as an emergency procedure to arrest bleeding has limited usefulness but when performed as an elective or prophylactic procedure its results are comparable with those of portocaval shunt without the untoward complications such as encephalopathy. A modified selective decompression of varices has been described in which the distal end of the splenic vein is anastomosed to the inferior vena cava. Though no long term follow-up studies are available, we believe that this shunt is likely to prove superior to distal splenorenal shunt as it has both the advantages of the distal splenoral and the haemodynamic advantage of end-to-side portocaval shunt. We conclude that in patients with portal hypertension of varied aetiology, who have not had a haemorrhagic episode but in whom varices have been demonstrated or who have had one episode of haemorrhage from varices, the splenocaval shunt when feasible or the distal splenorenal shunt offers the optimal method of management at present in India.