Single-balloon enteroscopy for treating Roux-en-Y choledochojejunostomy stenosis after liver transplantation: a case report

Endoscopic treatment of biliary tract complications after Roux-en-Y surgery is still a challenge. With balloon enteroscopy, we can reach previously inaccessible areas changing the management of biliopancreatic diseases in patients with surgically altered anatomy. We report a case of single-balloon enteroscopy plus endoscopic retrograde cholangiopancreatography for the treatment of a pinpoint stricture in a hepaticojejunal anastomosis after liver transplantation.

Aortic clamping in pancreas transplantation: is there any harm to the transplanted kidney graft?

INTRODUCTION

Some special situations may require aortic clamping during pancreas transplantation (PT). The most important problem is ischemic injury to a previous transplanted kidney. We sought to demonstrate experience with aortic clamping in PT without special kidney allograft protection measures and its impact on kidney function.

METHODS

Retrospective study that analyzed 6 patients who underwent PT (5 pancreas after kidney and 1 simultaneous pancreas-kidney) with aortic clamping. In all cases, the pancreas graft was placed on the right with retrocolic portal-enteric drainage. Serum creatinine was evaluated pre- and posttransplantation.

RESULTS

The average clamping time was 19 minutes. The mean serum creatinine was 1.1, 1.15, 0.95, and 1.0, respectively, at pre and postoperative days 1 and 7 and at hospital discharge. Patient, kidney, and pancreatic graft survivals were 100%, 100%, and 83%, respectively.

CONCLUSION

The need for aortic clamping in selected cases of PT did not seem to affect the transplanted kidney, even without protective measures, provided that the ischemic time was short.

Liver transplantation in bearers of hepatitis B associated or not with delta hepatitis in the age of the new antiviral drugs: is hyperimmune globulin still necessary?

Hepatitis B (HBV) is a public health problem worldwide; one-third of the population has already been in contact with HBV, and 350 million people are chronic carriers of virus. The appearance of hyperimmune gamma globulin and antiviral drugs has allowed that group to undergone hepatic transplantation, achieving satisfactory results to prevent a relapse. But the use of hyperimmune gamma globulin has an extremely high cost, and combined therapies with new antiviral drugs seem to be a therapeutic alternative. We analyzed 21 patients with hepatitis B associated or not with Delta hepatitis over a mean follow-up period of 19.5 months, concluding that use of only nucleotide analogues has sufficient to achieve satisfactory results.

Analysis of reoperations and their impact on the results of pancreas transplantation

BACKGROUND

Many factors, including the advances in surgical techniques and immunosuppression, have been brought significant improvement to graft and patient survivals of patients undergoing pancreatic transplantations. However, one third of these patients require reoperations (ReOps).

PURPOSE

We sought to evaluate the distribution of ReOps in the early or late postoperative period and analyze their impact on patient and graft survivals.

PATIENTS AND METHODS

This unicenter, retrospective study was performed using data from 182 patient charts after pancreas transplantation from January 2000 through December 2007.

RESULTS

We performed 88 ReOps on 73 patients; 43 early and 41 late operations. The simultaneous pancreas-kidney transplantation group showed a greater incidence of premature ReOps. The group undergoing early ReOp showed a lower survival rate (87.2%) compared with the nonoperated group, but a similar survival rate (97.5%) to the late ReOp group. In relation to the survival of pancreatic grafts after 1 year, the early ReOp group showed inferior survival to the late ReOp group, both of which were significantly worse results then those of the group without ReOp.

CONCLUSION

ReOps were related to the success of the procedure. When they were performed in the first 3 months they had a negative impact on patient and graft survival.

Prolactin-induced changes in protein expression in human pancreatic islets

Ex vivo islet cell culture prior to transplantation appears as an attractive alternative for treatment of type 1 diabetes. Previous results from our laboratory have demonstrated beneficial effects of human prolactin (rhPRL) treatment on human islet primary cultures. In order to probe into the molecular events involved in the intracellular action of rhPRL in these cells, we set out to identify proteins with altered expression levels upon rhPRL cell treatment, using two-dimensional (2D) gel electrophoresis and mass spectrometry (MS). An average of 300 different protein spots were detected, 14 of which were modified upon rhPRL treatment (p<0.01), of which 12 were successfully identified using MS and grouped according to their biological functions. In conclusion, our study provides, for the first time, information about proteins that could be critically involved in PRL's action on human pancreatic islets, and facilitate identification of new and specific targets involved in islet cell function and proliferation.

No induction versus anti-IL2R induction therapy in simultaneous kidney pancreas transplantation: a comparative analysis

The optimal immunosuppressive regimen for simultaneous kidney pancreas transplantation (SKPT) is still not established. We conducted a study to compare the safety and efficacy of no induction versus anti-IL-2 receptor induction protocols in SKPT recipients receiving the same maintenance regimen.

METHODS

Sixty-three SKPT recipients were divided into two groups: no induction group (n = 42) and anti-IL-2 receptor induction group (n = 21). All patients were maintained on tacrolimus, mycophenolate mofetil, and prednisone. Primary endpoints were 1-year acute rejection incidence and patient and graft survivals.

RESULTS

Demographic characteristics were similar between the groups. Acute rejection incidence at 1 year was equal in both groups (28.6%). Kidney and pancreas allograft survival in the no induction group were 78.6% and 76.2%, and in the anti-IL-2R induction group, 81% and 71.4%, respectively (P = NS). Patient survival was also similar: 83.3% in the no induction versus 85.7% in the anti-IL-2R induction group. Deaths due to sepsis were higher in the anti-IL-2R induction group, albeit not significantly.

CONCLUSION

The use of a no-induction protocol in SKPT is safe and effective immunosuppression that also reduces transplantation costs.

Influence of pancreas transplantation alone on native renal function

Pancreas transplantation alone (PTA) has become an accepted treatment of nonuremic diabetic patients, when the risks of secondary complications of diabetes mellitus are greater than those of the surgical procedure and the posttransplant immunosuppression. As a decrease in native renal function is expected, we followed this parameter among patients who underwent PTA. From January 1997 through January 2005, we performed 69 PTA in 66 patients. All patients showed glucose hyperlability with hypoglycemic unawareness, or two or more diabetic complications as well as creatinine clearance (CrCl) > or = 45 mL/min. Immunosuppression was based on tacrolimus, mycophenolate mofetil and prednisone. Twenty-four hour CrCl were performed after all successful PTA. We divided patients in two groups according to the pretransplant CrCl: group 1, CrCl < or = 70 mL/min (n = 20) and group 2, CrCl > 70 mL/min (n = 25). The data were analyzed using Student's t-test (P < or = .05 was considered significant). Twenty-one patients were excluded from the analysis because of death (n = 5) or graft loss (n = 8) during the first year or follow-up shorter than 1 year (n = 8). The mean value of CrCl decreased 28.8% (85.0 +/- 31 versus 60.5 +/- 36 mL/min; P < .001). There was also a 39.3% reduction among group 1 subjects (P = .003), including 10 who displayed CrCl < or = 30 mL/min. There was also a 24.4% reduction among group 2 (P = .008), but no patient developed end-stage renal disease. In conclusion, native renal function decreased significantly after PTA, but was well tolerated among patients with CrCl > 70 mL/min. Patients with CrCl < 70 mL/min show a significant risk of worsened renal function.

Pancreas Retransplantation: Outcomes of 20 Cases

The objective of this paper was to evaluate our initial experience with pancreas retransplantation. From January 26, 1996 to February 2005, 285 pancreas transplantations were performed, including 20 (7%) retransplants. The causes of primary graft loss were graft thrombosis in 11 (55%, 7 venous and 4 arterial); 4 (20%) chronic rejections; 2 (10%) ischemia/reperfusion injury; 1 severe graft pancreatitis; 1 primary nonfunction; and 1 sepsis. Venous drainage was placed in the iliac vessels in 14 (70%), vena cava in 5 (25%), and portal drainage in 1. The exocrine drainage was vesical in 16 (80%) and enteric in 4 (20%). In 14 cases (70%), the primary graft was removed before and in 6 (30%) at the time of retransplantation. Immunosuppression was based on antilymphocyte induction, tacrolimus, mycophenolate mofetil, and steroids in all patients. One-year patient and graft survivals were 95% and 85%. In conclusion, pancreas retransplants were feasible with results comparable to a primary pancreas transplantation.

Anesthesia for pancreas transplantation alone or simultaneous with kidney

Improvements in perioperative care, namely, organ preservation solutions, immunosuppression, and increased experience of surgical, anesthetic, and intensive care teams, have contributed to the success of pancreas transplantation. The objective of this study was to present data on anesthesia for pancreas transplantation alone (PTA) or simultaneous with kidney (SPKT), evaluating crystalloid, albumin and blood component infusions, graft ischemic times, and weights and ages of recipient. We evaluated patients undergoing SPKT (n=73), PTA (n=49), or SPKT with kidney living donor (n=8). Aggressive monitoring and therapy were used to avoid hypoperfusion, optimized with intravenous fluids, vasoative drugs, and correction of metabolic disturbances. Three SPKT patients were not extubated at the end of surgery. There were no other complications related to anesthesia in any patient. Although it is a high-risk surgery, PTA or SPKT is routine in our practice. Adequate perioperative care is important not only for the safety of the procedure but also for graft viability, contributing to a promising long-term treatment of insulin-dependent diabetic patients.

Enteric conversion after bladder drained pancreas transplantation experience of 14 cases

The method of exocrine diversion in pancreas allograft continues to be controversial due to the advantages versus disadvantages of bladder versus enteric techniques. Bladder drainage (BD) exposes the patient to urological and metabolic problems that may require conversion to enteric drainage (ED). The purpose of this study was to review our initial experience of conversion from BD to ED for patients who underwent pancreas transplantation originally with bladder diversion. Among 114 pancreas transplantation performed with BD, from January 1996 to April 2003, 60 were simultaneous pancreas-kidney transplantation (SPKT), 35 were pancreas transplantation alone (PA), and 19 were pancreas after kidney transplantations (PAK). Twenty-three (20.2%) cases were excluded due to early death of the patient or the graft, yielding an analyses of 91 patients. Enteric conversion (EC) was performed in 14 (15.4%) patients with a mean follow-up of 15.7 months (range, 3-51 months) after transplantation including 8 (8.8%) SPKT, 4 (4.4%) PAK, and 2 (2.2%) PA. No surgical morbidity or mortality was observed related to EC. All patients had complete resolution of the initial problem with preservation of pancreatic function. EC represents an easy, safe procedure with low morbidity and mortality rates, representing the option of choice for patients with persistent urological or metabolic disturbances.

Glycemic control during pancreas transplantation: continous infusion versus bolus

Pancreas transplantation is a method to restore endogenous insulin secretion in insulin-dependent diabetic patients. Because glycemia >150 mg/dL may harm pancreatic graft beta cells, early glucose control using insulin administration is recommended during transplantation. The aim of this study was to evaluate the benefits of strict glycemic control during pancreas transplantation by comparing two types of insulin and glucose administration: continuous infusion and bolus. Capillary glucose was measured every 30 minutes after anesthetic induction for pancreas transplantation alone or simultaneously with kidney transplantation. Intravenous regular insulin was administered for values >150 mg/dL or glucose for values <100 mg/dL. The following timepoints were evaluated: anesthetic induction, before pancreatic graft reperfusion, and the first 4 minutes after reperfusion. Pancreatic graft ischemia time was significantly lower in the bolus group (P <.02). Immediately after reperfusion, there was a small increase in glycemia with a decrease in subsequent measurements in both groups. No significant difference in glycemia was observed between the groups at any time. Induction values were greater than all other timepoints in both groups. Glycemic control is important; it was successfully obtained with both methods. The trend to decrease glucose after reperfusion suggest early graft function.

Microencapsulation and tissue engineering as an alternative treatment of diabetes

In the 70's, pancreatic islet transplantation arose as an attractive alternative to restore normoglycemia; however, the scarcity of donors and difficulties with allotransplants, even under immunosuppressive treatment, greatly hampered the use of this alternative. Several materials and devices have been developed to circumvent the problem of islet rejection by the recipient, but, so far, none has proved to be totally effective. A major barrier to transpose is the highly organized islet architecture and its physical and chemical setting in the pancreatic parenchyma. In order to tackle this problem, we assembled a multidisciplinary team that has been working towards setting up the Human Pancreatic Islets Unit at the Chemistry Institute of the University of São Paulo, to collect and process pancreas from human donors, upon consent, in order to produce purified, viable and functional islets to be used in transplants. Collaboration with the private enterprise has allowed access to the latest developed biomaterials for islet encapsulation and immunoisolation. Reasoning that the natural islet microenvironment should be mimicked for optimum viability and function, we set out to isolate extracellular matrix components from human pancreas, not only for analytical purposes, but also to be used as supplementary components of encapsulating materials. A protocol was designed to routinely culture different pancreatic tissues (islets, parenchyma and ducts) in the presence of several pancreatic extracellular matrix components and peptide growth factors to enrich the beta cell population in vitro before transplantation into patients. In addition to representing a therapeutic promise, this initiative is an example of productive partnership between the medical and scientific sectors of the university and private enterprises.

Use of a donor aortic cross for arterial reconstruction of the pancreaticoduodenal allograft

Combined liver-pancreas procurement generally requires back bench reconstruction of the arterial blood supply with a donor Y-iliac graft to the pancreas graft. A modified vascular reconstruction that uses donor aortic cross including the brachiocephalic trunk and the left carotid artery as a single arterial patch is presented. This is useful when iliac grafts are unavailable or are being used as an alternative technique.

Cholelithiasis in cirrhotic patients. (Analysis of cholelithiasis among patients with liver cirrhosis in São Paulo, Brazil)

During the past 20 years, several authors have reported increased prevalence of cholelithiasis in liver cirrhosis. This biliary disease has been implicated with the deterioration of liver function, liver disease of alcoholic origin or even the presence of hypersplenism in this patient population. This study analyzes the incidence and possible factors which are responsible for promoting cholelithiasis in cirrhosis. The study included 110 cirrhotic patients of a private center specialized in treating liver diseases. The incidence of cholelithiasis was 27.3% (25.3% in males and 33.3% in females). There was no correlation between liver function defined by Child's classification or through the laboratory examinations (AST, ALT, AP, GGT, PT, Alb, TB, DB, PA) and the presence of gallstones. No evidence was found that the etiology of cirrhosis or the presence/absence of hypersplenism affected the prevalence of cholelithiasis in this population. In conclusion, an increased prevalence of cholelithiasis was verified in this population of cirrhotics but the pathogenesis is still obscure.

[Surgical treatment of solitary liver cysts]

Solitary hepatic cysts an uncommon disease in the past, which incidental diagnosis is increasing with the advent of ultrasound and computed tomography, are nowadays very frequent. Cysts that reach massive proportions often become symptomatic and necessitate surgical intervention. Surgical wide unroofing technique is a simple procedure advocated for the treatment of symptomatic patients. Ten patients with solitary liver cysts were submitted to wide unroofing with good immediate and late results.

[Hepatic hemangioma. Analysis of 103 cases. Clinical considerations and imaging methods]

Hemangiomas are the most common benign vascular tumor found in the liver. In this study, 103 cases of hepatic hemangiomas were analysed in a retrospective manner. Image aspects such as those seen in ultrassonography, computed tomography, nuclear magnetic resonance and arteriography are discussed. The incidence was higher amongst the female sex, between individuals from 40 to 60 years old, which presented predominantly without symptoms (66%) and localized mainly in the right hepatic lobe (74%). The meaning of those aspects, when adopted, permits the clinicians to differentiate benign from malignant nodular lesions in the liver.

Laparoscopic cholecystectomy in cirrhotic patients

Cholecystectomy in cirrhotic patients is commonly followed by high morbidity and mortality. In our study, laparoscopic cholecystectomy was performed in 12 cirrhotic patients (eight Child A and four Child B) in an effort to obtain lower complication and mortality rates. The mean age of the group was 51.8 years; seven of the 12 patients were men. Four patients had liver disease from virus B, five from virus C, one because of alcohol, and two had cryptogenic liver cirrhosis. The average operative time was 157 min. Intraoperative cholangiography could be performed in eight cases. No mortality or need to perform laparotomy occurred. Only one patient required blood transfusion (8.3%). Postoperative complications occurred in four patients, but these were easily controlled and included renal failure, diabetic impairment, hematoma with ascitic leakage through the wound, and wound abscess, one case each. No postoperative liver failure was observed. All patients walked and were refed in the first 24 h after surgery. They were dismissed in an average period of 2.5 days. Our primary view demonstrated that laparoscopic cholecystectomy was safe and well tolerated by selected cirrhotic patients (Child A and B) with clear indication for surgery.

[Hepatic artery aneurysm: treatment with left hepatectomy. Report of a case]

A 71-year-old female with a rupture of left intrahepatic artery aneurysm with acute upper abdominal pain, weight loss and fever. The diagnosis was established with doppler ultrasound, contrasted abdominal computer tomography scanning and celiac and mesenteric artery angiography. Prompt recognition and left hepatectomy led to a favourable outcome.

[Pyogenic liver abscesses: analysis of 36 cases treated by percutaneous drainage]

Thirty-six patients with pyogenic liver abscess treated by percutaneous drainage plus antibiotic therapy were reviewed. The most frequent symptoms were fever (75%) and pain (72.2%), and the most common physical signs were liver enlargement (58.3%) and jaundice (33.3%). The mean time interval from admission to diagnosis was 16 days. CT scans and ultrasonography were diagnostic in 100% of the patients. The percutaneous drainage was effective in one attempt in 19 patients, two attempts in 8, three attempts in 8 patients and more than four attempts in only one patient. There were three patients with hemoperitoneum (8.7%) as a post-drainage complication, one of them needed to be treated surgically. Mean hospital stay was of 24.8 days and the mortality rate was 5.5%. Percutaneous drainage plus antibiotic therapy is then an efficient therapeutic approach to the treatment of pyogenic liver abscess.

Intestinal anastomoses

Anastomotic dehiscence remains the main cause of morbidity and mortality of intestinal resections, mainly the colorectal (77, 95, 110). Very often in the literature the words dehiscence and fistula are misused for the same meaning. Nevertheless, attention must be paid to the fact that these two situations may be distinct. Dehiscence is defined as the failure of healing of the anastomoses, while fistula is the leakage of the intestinal content into the peritoneal cavity. So, the evidence of fistula is always accompanied by dehiscence, although a dehiscence may not develop into a fistula, should it be blocked by omentum or surrounding organs (110, 117). The incidence of overt dehiscence varies from 0.1% to 30% in the literature (13, 15, 17, 27, 31, 40, 44, 46, 76, 77, 81, 96, 113, 120, 123, 126, 133, 135). The Colon Cancer Project of the Saint Mary's Hospital in London, a multicentric study of patients submitted to bowel resections revealed a post operative mortality of 22% in patients with dehiscence and 7% for uncomplicated anastomoses. This led to the struggle various authors to achieve better results, regarding techniques and suture materials, such as the number of planes involved, inverted or everted sutures, wound healing and the influence of local and systemic factors, like infections, antibiotics, NSAIDs on sutures. Recently, surgical stapling gained importance among surgeons, due to its technical advantages. However, this is still very controversial and must undergo further investigations (93, 107, 109, 112, 115, 116). So, in order to understand the pathophysiology of the complications and to reduce morbidity and mortality, related to intestinal anastomoses, it is necessary to study the events involved in intestinal healing after resection, as well as the technique, materials used and the factors related to anastomotic failure.

[Immunological parameters in the differential diagnosis of ascites secondary to peritoneal carcinomatosis, hepatic cirrhosis, and congestive heart failure]

As a contribution to the study of ascites in patients with liver cirrhosis, congestive heart failure and peritoneal carcinomatosis evaluate in serum and ascites the concentrations of alphafetoprotein, carcinoembryonic antigen and fibronectin, they might suggest a diagnosis for the basic pathology. Forty-seven patients were studied, from whom 23 with cirrhosis, 17 peritoneal carcinomatosis and 7 with congestive heart failure. We conclude that: a) none of the tools usually employed in the analysis of ascitic fluid alone can make the base pathological process responsible for producing ascites; b) fibronectins were more useful for differential diagnosis between cirrhosis and carcinomatosis; c) alpha-fetoprotein and carcinoembryonic antigen were not useful for the definition for differential diagnosis.

[Hepatic hemangiomas. The importance of the image]

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

Prognostic value of preoperative tests in the surgical treatment of ascites with the implant of Le Veen shunts in cirrhotics

In the period of January 1978 to October 1988, 32 Le Veen shunts (LVS) were implanted in 20 patients, out of which 16 were alcoholic cirrhotics and 4 postnecrotic cirrhotics. In the present study, we correlated preoperative laboratory data of these patients with their postoperative evolution, comparing the clinical results of patients who survived more than 30 days (13 patients = 65%) with the results of those who died within the same period (7 patients = 35%). For that matter, 14 laboratory tests were performed in order to measure the serum levels of hematocrit, hemoglobin, urea, creatinine, sodium, potassium, bilirubin, albumin, AST, ALT, alkaline phosphatase, fibrinogen, gamma GT and prothrombin activity. After statistical analysis, we observed that 6 of the 14 tests performed could be considered of prognostic value in the following decreasing order of importance: fibrinogen, alkaline phosphatase, prothrombin activity, urea, gamma GT and bilirubin. We observed that all the 7 patients who died prematurely presented 3 or more of these levels altered, when compared with standard values. Based on these data, we concluded that serum levels of fibrinogen, alkaline phosphatase, urea, gamma GT, bilirubin and activity of prothrombin proved to be important factors in determining the prognosis of immediate survival in cirrhotic patients who underwent LVS implantation. We also concluded that when 3 or more of these factors are altered, the implant of LVS is contraindicated, whatever clinical criteria for indication and contraindication were taken into account.

Proximal gastric vagotomy. A comparative study between the standard technique and the extended technique associated with denervation of the greater curvature

Forty-six patients in the postoperative period of proximal gastric vagotomy (PGV) for duodenal ulcer (DU) were studied comparatively to verify whether the dividing of the gastroepiploic nerves (Rosati's maneuver) can reduce or not the occurrence of recurrent ulcer as it was proposed. Twenty-one patients who underwent PGV associated with Rosati's maneuver (PGV-R) were compared to 25 after standard PGV (PGV-S), according to several criteria: (1) clinical evaluation; (2) pre and postoperative basal and pentagastrin-stimulated gastric acidity; (3) postoperative basal and pentagastrin-stimulated serum pepsinogen; (4) postoperative basal and sham feeding-stimulated serum gastrin; (5) postoperative endoscopy; (6) endoscopic Congo red test. Both groups were similar (P greater than 0.05) as to age, sex, levels of preoperative gastric acidity and had a 24.4 month average follow-up (12 to 58 months). There has been no significant difference between the techniques studied as to clinical, secretory, morphological or hormonal gastric tests, although PGV-R proved more effective in reducing basal gastric acidity than PGV-S (P less than 0.05). We concluded that Rosati's maneuver does not improve the results obtained with PGV, although it provided greater reduction of basal gastric acidity than PGV-S.

[Surgical treatment of ascites with Le Veen shunt in patients with alcoholic liver disease]

Studies were carried out on 16 alcoholic cirrhotics with clinically intractable ascites who underwent the implant of peritoneovenous (LeVeen) shunts. Our purpose was to find out how this group of patients responded to this kind of surgical treatment for ascites. Fifteen of these patients were male and one female, with a median age of 51.3 years. According to Child classification, 7 were Child B and 9 Child C. Thirty-three surgeries were conducted, in that 5 were performed for revision of the shunt positioning and 12 for the replacement of the valves. A total of 28 shunts were used. Postoperative immediate mortality occurred in 5 patients (4 Child C and one Child B). The median late postoperative follow-up of the 11 patients who survived was 25.8 months. We concluded that LeVeen shunt implantation is a valid palliative therapeutic resource for the treatment of ascites in alcoholic cirrhotics. The results obtained with this patient population are similar to those observed in cirrhotics who presented other etiologies. We also concluded that late mortality was not related to the implant of a LeVeen shunt but was due to the normal course of the disease.

[Diagnosis of hepatocellular carcinoma performed by searching for serologic tumor markers]

Serum levels of alkaline phosphatase, gamma-glutamyltranspeptidase, -1 fucosidase and glutathione-S-transferase are increased in 60, 90, 75 and 64% of patients with hepatocellular carcinoma. In these patients the mean plasma fibrinogen levels is 461.78 mg/dl, while mean serum copper is 200.50 mg/dl. Serum levels of desgamma-carboxiprothrombin is over 900 mg/dl in 67% of the patients (60% of them have HB virus, mostly anti HBe positive). Forty to 95% of them have increased levels of -fetoprotein (AFP). The authors suggest that cirrhotic patients, with or without HB virus, specially those with increased AFP, should have ultrasound examination of the liver every 6 months. This method of imaging has been shown to be more sensitive than AFP (72% versus 25%) in the detection of hepatocellular carcinoma smaller than 2 cm in diameter.

Serum pepsinogen before and after proximal gastric vagotomy in duodenal ulcer treatment

Serum pepsinogen (SP) behavior was evaluated under basal conditions and under betazole stimulation in 59 patients: 14 controls, nine unoperated duodenal ulcers (DU) and 36 DU after proximal gastric vagotomy (PGV), 14 with and 22 without recurrent ulcer. The mean follow-up of the 36 patients who underwent PGV was 38.7 months. SP was higher in unoperated DU than in the control group (p less than 0.05). After PGV in DU, there is a significant decrease of SP for both the patients with and without recurrent ulcer (p less than 0.05), being statistically similar to the control group. No difference of SP was observed between DU with and without recurrent ulcer after PGV. We concluded that SP can differentiate normal subjects from DU patients, although it is not a sensitive indicator of recurrent ulcer after PGV.

[Hepatocyte necrosis and intrahepatic cholestasis in the postoperative period of patients undergoing heart surgery with the use of extracorporeal circulation: significance of clinical, epidemiologic, surgical and laboratory parameters in evaluating prognosis]

Sixteen patients with jaundice after heart surgery with extracorporeal circulation, were studied. They were divided in 2 groups, according to the postoperative outcome; either death (group I) or hospital discharge (group II). Clinical, epidemiological, surgical and laboratorial aspects were compared in order to ascertain their role in the outcome. The results were analysed by the Student-t test. The main cause of death was low output syndrome, which occurred in 10 cases (62.5%), 5 of them died (31%). A statistically significant difference was observed in the postoperative values of serum GOT (p less than 0.01), GPT (p less than 0.01) and total bilirubin (p less than 0.01), which were then considered prognostic indicators in these patients.

[Surgical treatment of portal hypertension in patients with liver cirrhosis]

Surgical options in the treatment of portal hypertension in cirrhotics are reviewed, regarding elective and emergency cases as well as the results in alcoholics and non-alcoholics. After literature review and personal experience analysis, it is concluded that endoscopic sclerotherapy should be the treatment of choice in cirrhotic patients with bleeding esophageal varices. When this fails, distal splenorenal shunt is indicated for compensated Child A and B. Regarding Child C and decompensated Child B, the choice should be a portocaval or meso caval shunts or esophageal transection with a stapler associated to splenectomy.

[Use of the Leveen shunt in the treatment of clinically intractable ascites]

From January 1978 to August 1987, 21 patients received a peritoneovenous shunt using the Le Veen valve (LVV). The indications criteria were the long-term diuretic therapy failure (mean time = 24.4 months) or resistence to medical therapy during hospital internment. The 21 patients underwent 36 surgeries, being 4 valve position review and 11 changes of LVV. The mean age was 51.6 years. Fifteen patients had alcoholic cirrhosis, 3 postnecrotic cirrhosis, one Budd-Chiari syndrome, one mansoni Schistosomiasis, and one malignant ascites. Ten were Child B and 9 Child C patients. Eight patients with history of previous esophageal varices bleeding (EVB) underwent endoscopic sclerotherapy (EE) before LVV implantation. Seven patients died in the early postoperative period (3 Child B and 4 Child C patients). Three patients died due to EVB and the others as consequence of hepatic failure (one), cardiac insufficiency (one), sepsis (one), and bronchopneumonia (one). The mean follow-up was 19.9 months (1-61). Early LVV occlusion occurred in 4 patients and late valve occlusion in others 4 patients. The LVV changes were done at ambulatorial preceeding. Ten patients (47.6%) died in late follow-up and in these cases death was related to the main disease course. It is concluded that: 1) LVV is a useful therapy in patients with intractable ascites, since it is not the terminal manifestations of disease; 2) early mortality is related to liver function and late mortality to main disease course; 3) ascitic patients with EVB should undergo endoscopic sclerotherapy before LVV implantation.