John T. Galambos

Ten Years Portal Hypertensive Surgery at Emory: Results and New Perspectives

Five hundred four shunt procedures have been done at Emory University Hospitals between 1971 and 1981 to decompress bleeding esophageal varices. This paper reviews how far the experiences of a prospective randomized study (55 patients) of distal splenorenal shunts against total shunts is supported by the nonrandomized experience (449 patients), and outlines our current methods of management dictated by this experience. The overall operative mortality for 348 selective shunts is 4.1%, and for 156 nonselective shunts, 14.1%. The five-year survival following selective shunt is 59%, and following nonselective shunt is 49%: more than half the selective shunt patients are alive, in contrast to the median survival of 44.5 months for patients having nonselective shunts. Following selective shunt, the survival in nonalcoholic patients is significantly better than the median survival of alcoholic patients of 57 months. Encephalopathy, reported at three years after surgery in the randomized patients was significantly (p < 0.001) lower after selective shunt (12%) compared to nonselective shunt (52%): in the same population at seven years, all patients with patent nonselective shunts have clinical or subclinical encephalopathy, but only 30% of the selective shunt patients have subclinical encephalopathy. Shunt patency, immediately after surgery, is 93% following selective shunt, with only two documented late thromboses: nine of nine patients, at a mean of seven years, retain patency in the randomized study. Shunt occlusion increases with time after interposition nonselective shunts: seven of 13 are occluded at a mean follow-up of seven years in the randomized study. Portal venous perfusion is retained in 93% of patients seven to ten days after selective shunt, but in no patient with a patent nonselective shunt. Late portal perfusion is maintained in nine of the eleven patients in the randomized group studied at a mean of seven years after selective shunt. Restoration of portal perfusion has led to clearing of encephalopathy and improvement in hepatic function in six patients. The following conclusions are made; (1) selective shunts can be done with low operative mortality, and long-term patency with excellent control of bleeding; (2) hepatic portal venous perfusion has been maintained after selective shunt for ten years, and this is vital for preventing encephalopathy and maintaining hepatic function; (3) long-term survival after selective shunt is better than any reported series for nonselective shunt; and (4) selective shunts are the operative procedure of choice for variceal decompression and nonselective shunts should rarely be performed for elective decompression.

A randomized, controlled trial of the distal splenorenal shunt.

In 1971 a prospective, randomized trial was initiated to determine efficacy of the distal splenorenal shunt in the management of cirrhotic patients who had previously bled from esophageal varices. When entry into the trial was terminated in 1976, 26 patients had received the distal splenorenal shunt (selective) and 29 had undergone a nonselective shunting procedure (18 interposition mesorenal, six interposition mesocaval, and five other nonselective shunts). Three operative deaths occurred in each group. Early postoperative angiography revealed preservation of hepatic portal perfusion in 14 of 16 selective patients (88%), but in only one of 20 non-selective patients (5%; p <.001). Quantitative measures of hepatic function (maximal rate of urea synthesis or MRUS and Childs score) were similar to preoperative values in the selective group but were significantly decreased in nonselective patients on the first postoperative evaluation (p <.001 for MRUS; p <.05 for Childs score). Eighty-seven per cent of selective and 81% of nonselective patients have now been followed for three to six years since surgery. Late postoperative evaluation of 29 survivors (12 selective, 17 non-selective) still shows an advantage to the selective group with respect to MRUS, Childs score, and incidence of hepatopetal portal blood flow, but differences are no longer statistically significant. However, if the seven patients with portal flow (five selective; two nonselective) are compared to the 20 with absent portal flow (seven selective; 13 nonselective), the former group has significantly higher values for MRUS (p <.05) and Childs score (p <.025). No patient with continuing portal perfusion has developed encephalopathy as compared to a 45% incidence of this complication in individuals without portal flow (p <.05). No significant differences between selective and nonselective groups have appeared with respect to total cumulative mortality (ten selective; 38%; eight nonselective, 28%), shunt occlusion (two selective, 10%; five nonselective, 18%), or recurrent variceal hemorrhage (one selective, 4%; two nonselective, 8%). Overall, significantly fewer selective patients have developed postoperative encephalopathy (three selective, 12%; 15 non-selective, 52%; p <001). Therefore, we conclude that the distal splenorenal shunt, especially when its objective of maintaining hepatic portal perfusion is achieved, results in significantly less morbidity than nonselective shunting procedures.

Dacron® Interposition Shunts for Portal Hypertension An Analysis of Morbidity Correlates

Analysis of 79 Dacron® interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encepha-lopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Childs classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Peliosis Hepatic in a Patient With Marasmus

Peliosis hepatitis is a rare disorder previously seen in tuberculosis and malignant disorders and now seen with anabolic steroid use or after renal transplantation. We report the first case of peliosis hepatis in a patient with marasmus and no previously reported predisposing condition. Of interest, the peliosis hepatis resolved rapidly (over 2-3 wk) as determined by computed tomography scan and the patient presented with a cholestatic enzyme pattern that resolved with development of the lesion.

Radionuclide angiography of the liver and spleen. Noninvasive method for assessing the ratio of portal venous to total hepatic blood flow and portasystemic shunt patency.

Radioactivity verus time curves were generated for the first pass of technetium-99m pertechnetate through the left ventricle, kidneys, spleen and liver, after a 20 mCi peripheral intravenous bolus injection. The rate of change of radioactivity in these organs before recirculation is proportional to blood flow through the organ. The hepatic perfusion index, defined as the ratio of portal flow to total hepatic blood flow, was correlated with the angiographic grade of portal perfusion. The hepatic perfusion index in seven normal subjects was 66.0 +/- 3.4 percent (mean +/- standard error of the mean), and in 22 cirrhotic patients with decreasing angiographic perfusion of grades 1 to 4 the index was 54 +/- 4.6, 37 +/- 2.6, 17 +/- 4.7 and 3 +/- 1.1 percent, respectively. The correlation between the calculated perfusion index and the angiographic grade of portal flow was highly significant (p less than 0.001). The passage of radionuclide through the spleen differed before and after shunt surgery in patients with portal hypertension. The slope to height ratio, based on the downslope of the splenic curve, was significantly greater (p less than 0.01) in the shunted patients and provided a simple index for assessing shunt patency.

Liver injury following jejunoileal bypass. Are there markers

Ninety-five of 105 patients who underwent jejunoileal bypass had preoperative and at least one set of postoperative liver tests and liver biopsy within 18 months of surgery. There were numerous and, at times, impressive histologic or biochemical abnormalities in obese patients who were not operated. No correlation was found between postoperative liver injury and the preoperative concentration of serum albumin or SGOT, or with the certain histologic lesions (steatosis, lobular necrosis or inflammation). However, the preoperative pericellular fibrosis persisted or progressed in eight of 11 of the patients. The rate of postoperative weight loss did not seem to influence liver morphology but the initial velocity of weight loss could not be determined in this study. Liver biopsy specimens demonstrated a trend for greater postoperative decreases of serum albumin concentrations (p < 0.05) in those patients who developed more severe lesions. This study failed to demonstrate the presence of preoperative histologic or biochemical markers that could reliably predict the development of liver injury following jejunoileal bypass. The only exception was pericellular fibrosis, which was found in the preoperative liver biopsy specimens. Pericellular fibrosis is probably a risk factor for lobular fibrosis after jejunoileal bypass surgery in obese patients.

The mortality of bleeding esophageal varices in a private University Hospital

The mortality of patients with bleeding esophageal varices was studied in a private hospital where the modalities of treatment are considered optimal. Of the sixty-two patients in the study, twenty (32 per cent) died. Mortality was higher (p is less than 0.02) for those who had ascites or bilirubin more than 5 mg/dl, albumin less than 3 gm/dl, prothrombin time more than 4 seconds of control, or blood transfusions of more than 5 liters. The lower mortality in this study as compared with other studies among indigent population is the result of either private patients having less severe liver disease or having more effective care of both.

Evaluation of patients with portal hypertension.

In order to select the most suitable management of portal hypertension, a full evaluation of the patient is desirable. The aspects studied should include the possible causes of portal hypertension and the disease and function of the liver, as well as the psychosocial aspects of this condition. The usual reason to investigate the presence and causes of portal hypertension is the detection of gastroesophageal varices. The estimated probability of bleeding from the varices and the cause of the varices should be investigated. If cirrhosis is detected, then its cause or mechanism should be clarified and the activity of the process estimated in semiquantitative terms. If therapy is available, it should be initiated. The evaluation of liver function is based on quantitative measurements of hepatocellular metabolic function (such as the galactose elimination capacity or antipyrine clearance), liver volume (weight), liver blood flow, and systemic hemodynamics (cardiac output index).