J. Terblanche

PREOPERATIVE EXTERNAL BILIARY DRAINAGE IN OBSTRUCTIVE JAUNDICE: A Prospective Controlled Clinical Trial

57 patients with obstructive jaundice were randomly allocated to surgery with preoperative external biliary drainage (29 patients) and without preoperative external biliary drainage (28 patients). 22 patients ultimately underwent laparotomy after a mean of 11.7 days of drainage and 25 had surgery without preoperative drainage. The postoperative complication rate was low and similar in both groups but complications associated with the drainage procedure were substantial. Perioperative mortality was 4/28 (14%) in the drainage group and 4/27 (15%) in the non-drainage group. There seems to be no advantage associated with routine preoperative external biliary drainage before surgery for obstructive jaundice.

FAILURE OF REPEATED INJECTION SCLEROTHERAPY TO IMPROVE LONG-TERM SURVIVAL AFTER OESOPHAGEAL VARICEAL BLEEDING: A Five-year Prospective Controlled Clinical Trial

The role of sclerotherapy in long-term management after oesophageal variceal bleeding was assessed by comparing repeated sclerotherapy by means of a rigid oesophagoscope in 37 patients with control medical management in 38 patients. Varices were eradicated in 21 of the 22 patients analysed (95%) in the sclerotherapy group, but recurred in 13 of the 21 patients (average 21.5 months). Varices persisted in 13 of 14 surviving controls. The sclerotherapy patients had fewer recurrent bleeds than control patients (43 versus 73); the majority occurred before variceal eradication and were mild. However, there was no difference in survival in the two groups. The commonest cause of death was liver failure (37 patients). 32 complications occurred in 24 patients during 258 injections. Repeated sclerotherapy failed to improve survival in this trial, although varices were eradicated and recurrent variceal bleeds were prevented with adequate follow-up.

PROSPECTIVE CONTROLLED TRIAL OF TRANSHEPATIC BILIARY ENDOPROSTHESIS VERSUS BYPASS SURGERY FOR INCURABLE CARCINOMA OF HEAD OF PANCREAS

53 patients with obstructive jaundice due to incurable carcinoma of the head of the pancreas were randomly allocated to percutaneous transhepatic placement of a permanent biliary endoprosthesis (PTE) or bypass surgery. After exclusions 25 patients in each group were treated. Technical success was achieved in 21 patients (84%) in the PTE group and 19 (76%) in the surgery group. The incidence of postprocedural complications (PTE 7, surgery 8) and 30-day mortality (PTE 2, surgery 5) were similar. Recurrent jaundice occurred more often in the PTE (8/21) than the surgery group (3/19). Duodenal obstruction developed in 3 patients in the PTE group. Although the initial median postprocedural hospital stay was significantly shorter in the PTE than the surgery group, the difference was no longer significant when readmissions for blocked endoprosthesis and gastric outlet obstruction were taken into account. There was no difference in the median survival time in the two groups (PTE 19 weeks, surgery 15 weeks).

Long term outcome of endoscopic drainage of pancreatic pseudocysts

Objective: Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. Methods: All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. Results: Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (>1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. Conclusion: Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of <1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.

Randomised trial of targeted chemotherapy with lipiodol and 5-epidoxorubicin compared with symptomatic treatment for hepatoma.

Lipiodol injected into the hepatic artery is selectively retained in hepatomas so has been used as a vehicle for cytotoxic drugs. This study compared treatment with 5-epidoxorubicin emulsified in lipiodol and infused into the hepatic artery with symptomatic treatment alone in a randomised trial. Of 136 patients with hepatoma 78 (57%) were not eligible, eight (6%) refused to take part, and 50 entered the trial (chemotherapy: n = 25, symptomatic treatment: n = 25). The two groups had similar prognostic indices. Seven of 25 patients allocated to chemotherapy were unable to receive it. The slight survival disadvantage associated with chemotherapy was not significant (median survival 48 days compared with 51 days, log rank chi 2 = 0.07, p > 0.05). Patients given chemotherapy spent significantly longer in hospital, however (median three days compared with one, p = 0.0008). Changes in symptoms and indices of tumour growth did not differ significantly between the two groups. It is concluded that infusion of 5-epidoxorubicin emulsified in lipiodol for hepatoma increased morbidity but did not affect survival. In addition, most patients were unsuitable for this treatment because of advanced disease. The patients in the trial had a short median survival time so the conclusions may not be valid for other patients with hepatoma.

Animal models of fulminant hepatic failure

The six requirements for a satisfactory animal model of fulminant hepatic failure are reversibility, reproducibility, death from liver failure, a therapeutic window, a large animal model, and minimal hazard to personnel. Different models may be required to evaluate the various types of liver failure seen in man. The available models include surgical anhepatic and devascularization procedures, as well as hepatotoxic drug administration using agents such as carbon tetrachloride, acetaminophen, or galactosamine. Currently combined surgical and drug models appear to provide the best model but the search for the ideal models continues.The six requirements for a satisfactory animal model of fulminant hepatic failure are reversibility, reproducibility, death from liver failure, a therapeutic window, a large animal model, and minimal hazard to personnel. Different models may be required to evaluate the various types of liver failure seen in man. The available models include surgical anhepatic and devascularization procedures, as well as hepatotoxic drug administration using agents such as carbon tetrachloride, acetaminophen, or galactosamine. Currently combined surgical and drug models appear to provide the best model but the search for the ideal models continues.

Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy.

In a five-year study of massive upper gastrointestinal hemorrhage, 143 patients had esophageal variaes diagnosed on emergency endoscopic examination. Seventy-one patients had active bleeding from varices and required Sengstaken tube tamponade during at least one hospital admission. The remaining patients included 33 with varietal bleeding which had stopped and 39 who were bleeding from another source. Sixty-six of the former group of 71 patients were referred for emergency injection sclerotherapy. These 66 patients were followed prospectively to August 1980, and had 137 episodes of enduscopically proven variceal bleeding requiring Seng-staken tube control followed by injection sclerotherapy during 93 separate hospital admissions. Definitive control of hemorrhage was achieved in 95% the patients admitted to the hospital (single injection 70%; two or three injections 22%). The death rate per hospital admission was 28%. No patient died of continued variceal bleeding, and exsanguinating variceal hemorrhage no longer poses a major problem at our hospital. The cumbiued use of initial Sengstaken tube tamponade followed by injection sclerotherapy has simplified emergency treatment in the group of patients who continue to bleed actively from esophageal varices, despite initial conservative treatment

An Animal Model of Fulminant Hepatic Failure: A Feasibility Study

An attempt was made to produce animal model of fulminant hepatic failure in the pig by intragastric administration of acetaminophen (N-acetyl-p-aminophenol). The effect of varying doses was observed in phenobarbital-pretreated and untreated animals. Assessment of optimal dose was made in terms of duration of survival and coma in animals exhibiting biochemical and histological evidence of liver necrosis. Significant liver necrosis was observed in enzyme-induced pigs only, whereas in the noninduced pigs respiratory arrest was considered a likely cause of death. Although liver necrosis occurred consistently at a dose of 0.5 to 1.1 g per kg of acetaminophen in phenobarbital-pretreated animals, survival time and coma duration were unpredictable. Only one-fifth of the total number of phenobarbital-pretreated pigs administered acetaminophen in this dose range fulfilled the prescribed criteria for a satisfactory model. There was a good correlation between survival time and duration of coma, although survival time did not correlate with acetaminophen dose, or with any of the following: peak plasma acetaminophen levels, thrombocytopenia, fall in hematocrit or fibrinogen, or alteration in other biochemical parameters. In addition to the unpredictable duration of survival and coma, the occurrence of acute anemia in 60% of the enzyme-induced animals was a major detraction from the possible usefulness of this model to evaluate various therapeutic regimes.

Hyperpyrexia During Anaesthesia

Work in pigs has shown that malignant hyperpyrexia during anaesthesia may occur without suxamethonium having been given. A virtually constant feature in reported cases and in our own observations is that all subjects developing hyperpyrexia had received nitrous oxide and halothane.

U tube drainage in the palliative therapy of carcinoma of the main hepatic duct junction.

This condition is probably more frequent than previously recognized, with an erroneous diagnosis of intrahepatic cholestatic jaundice, sclerosing cholangitis, or primary biliary cirrhosis being made. At present, palliative treatment produces better results than hepatic transplantation.