Francesco M. Serafini

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a “bridge to transplantation.” All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child’s class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P<0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P <0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P <0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

The utility of contrast studies and drains in the management of patients after Roux-en-Y gastric bypass.

Background: The role of routine post-operative contrast examination (UGI) and drainage of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGBP) is controversial.The authors determined if early routine post-operative UGI detects occult anastomotic leaks, thereby altering treatment and withholding early feeding. Methods: Prospective data on 100 consecutive patients who underwent RYGBP from September 1998 to September 2000 was reviewed. Closed suction drains were routinely used. Within 36 hr postoperatively, all patients underwent UGI to evaluate the gastrojejunostomy. Patients were given liquids if the UGI showed no leak, and drains were removed 24 hr later. A blinded radiologist reviewed all the UGI. Results: 87 women and 13 men underwent 75 open and 25 laparoscopic RYGBP. BMI was 52.0 kg/m2. 3 patients whose UGI showed a leak were treated nonoperatively with antibiotics, maintenance of drains, nasogastric tube and NPO. 2 of those patients developed purulent drainage within 24 hr after the UGI. None of the three patients required reoperation. 4 UGI were not available for the blinded reviewer who graded the remaining as satisfactory (94) and unsatisfactory (2). This reviewer disputed a leak in 1 of 3 previously reported leaks and reported a leak in a previously negative study. The latter patient subsequently required surgery for an uncontrolled leak. Conclusions: UGI can be used to withhold early oral intake in patients with radiographic leaks that would otherwise progress to clinically significant leaks. Surgical drains facilitate the non-operative management of such anastomotic leaks. Planned early UGI and surgical drains minimize the morbidity of anastomotic leaks after bariatric surgery.

Clinical Predictors of Sleep Apnea in Patients Undergoing Bariatric Surgery

Background: Sleep apnea is a frequent and unappreciated condition of morbidly obese patients. If unrecognized it could lead to significant postoperative complications. A clinical tool to assess the severity of sleep apnea is not available.We prospectively determined whether the Epworth Sleepiness Scale (ESS) or body mass index (BMI) predict the severity of sleep apnea in morbidly obese patients. Methods: 66 consecutive patients evaluated for bariatric surgery from June to November 1999 were examined and prospectively administered a health questionnaire including the ESS. Patients with an ESS ≥ 6 were referred for polysomnography with calculation of Respiratory Disturbance Index (RDI). Sleep apnea was graded as mild (RDI 6-20), moderate (RDI 21-40) and severe (RDI>40). Clinical variables such as BMI and ESS score were compared using regression analysis. Data are mean ± SEM. Results: 4 men and 23 women (27/66) who scored >6 on the ESS completed a sleep study. Mean ESS was 13 ± 4.5. Sleep apnea was mild in 13 patients, moderate in 7, severe in 6, and absent in 1. Mean age was 43 ± 9.5 years. BMI was 52 ± 10 kg/m2. Linear regression analysis did not demonstrate correlation between ESS score and severity of sleep apnea (r2=0.03, p>0.05). Multiple regression analysis demonstrated no correlation between BMI, patient snoring, and RDI score. Conclusions: Sleep apnea is frequent in candidates screened for bariatric surgery. ESS is a useful tool to investigate daytime sleepiness and other manifestations of sleep apnea. However, the ESS does not predict the severity of sleep apnea. Clinical suspicion of sleep apnea should prompt polysomnography.

New Directions in Systemic Therapy of Pancreatic Cancer

BACKGROUND The aggressiveness of pancreatic adenocarcinoma makes it a deadly disease, with its incidence rate and fatality rate almost equal. Surgery represents the only means to provide cure to patients with pancreatic cancer, though the 5-year survival is less than 10%. METHODS We review the data on surgical and systemic therapies and provide more details on a newer biologically based medical approach. RESULTS Neoadjuvant chemotherapy protocols are confined to one or two institutions, and adjuvant chemotherapy and chemoradiation therapy protocols are far from being standardized. Chemoradiation therapy for locally advanced pancreatic cancer offers limited benefits. Protocols that include gemcitabine and 5-fluorouracil, while comparing favorably to historical controls, offer median survivals at approximately 8 months. CONCLUSIONS More effective protocols with combinations of approaches agents are needed to improve the treatment of pancreatic cancer.

Adenoma of the Ampulla of Vater:A Genetic Condition?

The etiology of adenoma of the ampulla of Vater is not well understood. Previous authors reported the association of this neoplasm with polycystic kidney disease of two fraternal sisters. They concluded that these two conditions were somehow related. We describe a case of ampullary adenoma associated with polycystic kidney disease. This presentation raises again the question of a possible link between these two diseases.

Small-diameter prosthetic H-graft portacaval shunt: Definitive therapy for variceal bleeding

Partial portal decompression has become a popular option in the treatment of complicated portal hypertension. This study was undertaken to report long-term follow-up after partial portal decompression obtained utilizing 8 mm prosthetic H-graft portacaval shunts. A total of 110 consecutive patients underwent H-graft portacaval shunting through a protocol that detailed care and studies from 1988 to 1996. Prospective follow-up recorded efficacy of partial portal decompression, shunt patency, morbidity of shunting, and survival. Seventy males and 40 females, whose average age was 54 ±12.7 years (standard deviation), underwent shunting. Cirrhosis was due to alcohol abuse in 64%. Fourteen percent were in Child’s class A, 55% in Child’s class B, and 31% in Child’s class C. Shunts were undertaken as emergencies in 20%, urgently in 13%, and electively in 67%. Shunting decreased portal pressure in all patients (30 ±5.3 mm Hg to 19.9 ±5.5 mm Hg; P <0.001). Early and late thrombosis was 6.4% and 3.6%, respectively. Late rebleeding occurred in 5.4%. Perioperative (30-day) mortality was 11.8%, and was highest for patients in Child’s class C. Three-year survival was 53 %. Five-year survival was 41%. Partial portal decompression is achieved with H-graft portacaval shunting. Rebleeding, shunt occlusion, and encephalopathy are uncommon. In this series of unselected older patients with alcoholic cirrhosis, 5-year survival after H-graft portacaval shunting was greater than 40% with minimal intervention.

Transjugular intrahepatic portasystemic stent shunt in the treatment of variceal bleeding in hepatocellular cancer

Hepatocellular carcinoma (HCC) generally arises in the cirrhotic liver. Exacerbating the consequences of cirrhosis, HCC leads to the development of arteriovenous (AV) shunting between the hepatic artery and the portal system. Arteriovenous communications are a unique characteristic of hepatocellular carcinoma and occur in more than 60% of patients affected by HCC (1). Hemorrhage associated with varices in patients with HCC is often fatal. The cachectic state due to the cancer and coagulopathy due to the underlying cirrhosis in ̄ uence the prognosis of these patients. Ho and co-workers, for example, determined that more than 45% of 287 patients with HCC died acutely from variceal bleeding (2). Pharmacotherapy, hepatic artery embolizat ion, sclerotherapy, surgical resection, and surgical shunting represent the conventional treatments used in the management of variceal hemorrhage in patients with HCC. Unfortunately, such procedures are accompanied by a high morbidity and mortality. Also, unfortunately, the risk of recurrence of bleeding is highest with therapies having the least procedural morbidity. Transjugular intrahepat ic portasystemic stent shunting (TIPSS) has gained popularity in treating variceal hemorrhage due to portal hypertension, but TIPSS has not been utilized to treat portal hypertension complicated by HCC. We report the occurrence of variceal hemorrhage in a patient with advanced cirrhosis and HCC, in whom angiography demonstrated a large arterioportal communication. In this patient, after failure of several sessions of sclerotherapy, bleeding was completely controlled with a TIPSS. Our concern was that TIPSS would increase the arterioportal shunting and, thereby, decrease nutrient hepatic blood ̄ ow and lead to further hepatic dysfunction or failure. The patient was released 5 days after shunting without symptoms or signs of encephalopathy, increased hepatic dysfunction, or cardiac failure, and without any further bleeding. This is the ® rst report of a TIPSS procedure in a patient with cirrhosis, HCC, and a large arterioportal shunt.

Renal haemodynamics and function following partial portal decompression

BACKGROUND This study was undertaken to prospectively evaluate the impact of partial portal decompression on renal haemodynamics and renal function in patients with cirrhosis and portal hypertension. METHODS Fifteen consecutive patients (median age 49 years) with cirrhosis underwent partial portal decompression through portacaval shunting or transjugular intrahepatic portosystemic shunting (TIPS). Cirrhosis was caused by alcohol in 47%, hepatitis C in 13%, both in 33% and autoimmune factors in 7% of patients. Child class was A in 13%, B in 20% and C in 67% of patients. The median score on the Model for End-stage Liver Disease (MELD) was 14.0 (mean 15.0 +/- 7.7). Serum creatinine (SrCr) and creatinine clearance (CrCl) were determined pre-shunt, 5 days after shunting and 1 year after shunting. Colour-flow Doppler ultrasound of the renal arteries was also undertaken with calculation of the resistive index (RI) and pulsatility index (PI). Changes in the portal vein-inferior vena cava pressure gradient with shunting were determined. RESULTS With shunting, the portal vein-inferior vena cava gradients dropped significantly, with significant increases in PI in the early period after shunting. Creatinine clearance improved in the early post-shunt period. However, SrCr levels did not significantly improve. At 1 year after shunting, both CrCl and SrCr levels tended towards pre-shunt levels and the increase in PI did not persist. DISCUSSION Partial portal decompression improves mild to moderate renal dysfunction in patients with cirrhosis. Early improvements in renal function after shunting begin to disappear by 1 year after shunting.

Renal function and hemodynamics following partial portal decompression: a prospective analysis

Renal function and hemodynamics following partial portal decompression: a prospective analysis

Cystic and tubular congenital duplication of the esophagus: two case reports

Congenital esophageal duplication is a very rare occurrence. The cystic type accounts for the majority of cases, while the tubular type is far less common. We report two cases of congenital esophageal duplication in adults, one of the cystic type and the other of the tubular type.