J. L. Dawson

INCREASED LONG-TERM SURVIVAL IN VARICEAL HAEMORRHAGE USING INJECTION SCLEROTHERAPY: Results of a Controlled Trial

Analysis of 107 patients with cirrhosis and recent variceal haemorrhage included in a prospective randomised trial of endoscopic injection sclerotherapy showed that in the sclerotherapy group 22 (43%) of the 51 patients had episodes of haemorrhage during the period of treatment, but in only 4 did bleeding occur after the varices had been obliterated. This contrasts with episodes of bleeding in 42 (75%) of the 56 patients receiving standard medical management-a highly significant difference. The overall risk of bleeding per patient-month of follow-up was reduced threefold with sclerotherapy. Of 22 patients followed up for at least one year after obliteration of varices, 14 had no evidence of reappearance of varices within this period and, by means of cumulative life-analysis tables, survival was shown to be significantly improved in the sclerotherapy group.

PROSPECTIVE CONTROLLED TRIAL OF INJECTION SCLEROTHERAPY IN PATIENTS WITH CIRRHOSIS AND RECENT VARICEAL HÆMORRHAGE

64 patients with cirrhosis and recent variceal haemorrhage were studied in a prospective randomised trial of injection sclerotherapy by means of a flexible oesophageal sheath. 12 (33%) of the 36 patients in the sclerotherapy group, suffered further bleeds from varices compared with 19 (68%) of the 28 patients receiving standard medical treatment. The risk of bleeding per patient-month of follow up decreased more than threefold with sclerotherapy and the number of patients rebleeding after 2, 6, and 12 months was significantly reduced (p < 0.05). 1-year survival without further bleeding improved significantly with sclerotherapy (46% compared with 6%, p < 0.02), although the difference in overall survival assessed by cumulative life-table analysis was not statistically significant. The main complication of the technique was the development of oesophageal ulcers in some patients.

TREATMENT OF HIGH BILEDUCT CARCINOMA BY INTERNAL RADIOTHERAPY WITH IRIDIUM-192 WIRE

Abstract Eight patients with high bileduct carcinoma were treated by a new technique of internal radiotherapy with iridium-192 wire after biliary drainage had been established. Seven patients had satisfactory initial biliary drainage, and six patients are still alive 11 months (median time) after treatment. The procedure produced no systemic side-effects and it prolonged survival in patients in whom restoration of bile drainage had been satisfactory.

Internal biliary drainage and local radiotherapy with iridium-192 wire in treatment of hilar cholangiocarcinoma

Curative surgery is not possible in the vast majority of patients who present with hilar cholangiocarcinoma. Palliative therapy to relieve jaundice, either at laparotomy or percutaneously, is therefore necessary. The mean survival of these patients is of the order of 8.5 months (Wheeler et al., 1981). We report a significant increase in mean survival to 16.8 months in patients treated with internal biliary drainage when combined with local irradiation to the tumour with iridium-192.

Liver Transplantation in Man—II, a Report of two Orthotopic Liver Transplants in Adult Recipients

Two patients with primary hepatic malignancy were treated by hepatectomy and orthotopic liver transplantation. In both cases the donor liver was infused with cold solutions and kept chilled without continuous perfusion. There was immediate satisfactory hepatic function in both transplants. The first patient died after 11 weeks from overwhelming bacterial and fungal infections probably secondary to hepatic infarction due to thrombosis of the recipient hepatic artery. The thrombus occurred at the site of the arterial clamp. In an attempt to control the growth before transplantation, the patient had been treated with large doses of chlorambucil, which resulted in extreme marrow depression and septicaemia. The second patient developed cholestatic jaundice during the second and third weeks after transplantation, with histological evidence of mild rejection, which was controlled by increasing the dose of immunosuppressive agents. He is now well, having returned to work six weeks after the operation. Though the first patient showed no evidence of rejection, it is concluded that patients receiving liver allografts should receive immunosuppressive therapy.

Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.

Ligation of the hepatic artery in the treatment of heart failure due to hepatic haemangiomatosis

An infant presenting with high-output cardiac failure and a single large diffuse haemangioma of the liver is described. Corticosteroid therapy failed to produce any improvement, but hepatic artery ligation was followed by dramatic disappearance of the signs of cardiac failure and a decrease in the size of the liver without any evidence of lasting liver damage.

Liver Transplantation in Man—III, Studies of Liver Function, Histology, and Immunosuppressive Therapy

The experience gained from 13 hepatic transplant operations is described, with particular reference to the findings in nine patients who survived the immediate operative period. A major problem was found to be infection. Fulminant pneumonia caused death in two adults, at a time when liver function was virtually normal. Infection related to bile fistula and sepsis may be overcome by an improved method of biliary drainage by cholecyst-dochostomy, which was carried out in the last two patients. Jaundice in the second week due to rejection was observed in several patients. The striking histological change was centrilobular cholestasis. The jaundice, which was not prevented by administration of antilymphocyte globulin, was rapidly controlled by temporarily increasing die dose of prednisone. One patient who survived for four and a half months and who had a poor tissue match subsequently developed chronic rejection with progressive cholestatic jaundice. Five of the patients were able to go home and at time of publication two are alive and well 14 and 20 weeks after treatment.

Mesentericocaval "Jump" Graft in Management of Portal Hypertension: Experience with 24 Cases

A series of 24 patients with cirrhosis have undergone mesentericocaval shunt operations for the relief of portal hypertension. Overall the results have been satisfactory. Four of the five patients treated as an emergency and 17 of the 19 who had the operation two to six weeks after haemorrhage had been controlled left hospital alive and well. Separation of the patients into three categories according to the findings of clinical and biochemical tests, however, showed that subsequent survival was satisfactory for patients in categories A and B but that all four patients in category C had died within one year after surgery. Assessment at three months showed that in three patients moderate hepatic encephalopathy had developed. Evidence that the shunt remains patent was shown by a low incidence of repeated gastrointestinal haemorrhage and a marked diminution in variceal size in 18 of the 19 cases examined serially. Radiographic techniques for confirming shunt patency were compared and cannulation of the graft via the femoral vein was found to provide a reliable and rapid means of assessment.

Local Radiotherapy of Biliary Malignancies

Patients presenting with obstructive jaundice due to a cholangiocarcinoma involving the hilum of the liver pose a major problem in management. Despite recent advances in preoperative assessment of resectability and in operative techniques (Blumgart 1978; Williamson et al. 1980), in most reports the rate of attempted radical curative resection has remained very low (Inouye and Whelan 1978; Akwari and Kelly 1979; Evander et al. 1980; Blumgart 1982) and the operative mortality is still 10%–20% (Lannois et al. 1979; Evander et al. 1980). In contrast, effective palliation can often be achieved with low operative mortality if the obstruction is relieved by a cholangioenteric anastamosis (Cahow 1979) or by operative insertion of a transhepatic U tube (Terblanche et al. 1972).