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Follow-up of Patients with Portal Hypertension and Esophageal Varices Treated with Percutaneous Obliteration of Gastric Coronary Vein

Percutaneous transhepatic catheterization of the portal vein was performed in 21 patients with liver cirrhosis and esophageal varices. Coronary and short gastric veins were selectively catheterized and obliterated. The examination was performed to stop bleeding in 6 patients and was successful in 5. Follow-up examination showed recanalization of previously obliterated veins in 13 of 16 patients.

Percutaneous cytodiagnosis of carcinoma of the pancreas and bile duct.

Fifty-one percutaneous fine-needle aspiration biopsies guided by selective angiography and 57 by percutaneous transhepatic cholangiography (PTC) were performed in 88 patients. Fifty-two of the patients had a tumor localized to the pancreas and 19 a tumor of the extrahepatic biliary tract. In 17 patients the suspicion of neoplasia was possible to rule out. In 60% of the patients with pancreatic carcinoma and in 53% of the patients with biliary duct carcinoma correct cytological diagnosis was obtained. No false positive results were found. The diagnostic reliability was the same under guidance of angiography as PTC. The experience of the examiner markedly influenced the accuracy of the method. Exact correlation between the cytologic and histologic reports was found in cases where representative material was obtained at the aspiration. None of the 108 punctions was followed by complications. Since the method is harmless and has a high success rate especially in experienced hands it is an important adjunct to the management of pancreatic and bile duct lesions.

TRANSIENT HEPATIC DEARTERIALIZATION FOLLOWED BY REGIONAL INTRA-ARTERIAL 5-FLUOROURACIL INFUSION AS TREATMENT FOR LIVER-TUMORS

Twenty consecutive patients with secondary liver tumors were treated with a new method of liver dearterialization, performed by transient occlusion of the hepatic artery with strangulating slings, and followed by regional intra-arterial infusion of 5-fluorouracil. Tumor regression was confirmed by angiography, laboratory tests and symptom relief in more than 50% of the patients. For patients with metastatic colorectal carcinoma the mean survival time after operation was 17 months and the median survival time was 11 months. The most common complications were abscesses and aneurysms. The treatment is judged suitable for patients with a tumor of moderate severity involving both liver lobes and without extrahepatic tumor growth.

Percutaneous transhepatic portography.

The technique, indications, contraindications and complications of percutaneous transhepatic portography and selective catheterization of the major and minor veins draining the splanchnic organs based on the experience of 200 cases are described. The advantage of this method is discussed and compared with transjugular and transumbilical portography.

Selective phlebography of the pancreas

Angiography of the pancreas has solely been based on selective examination of the celiac and superior mesenteric arteries and their branches, since a method for venous approach has not been available. Catheterization of the portal vein via the umbilical vein in adults is now an established method and at transhepatic cholangiography portal vein branches are often punctured. Using the umbilical vein approach of the portal vein in portography for liver metastases pancreatic veins were accidentally found available for selective catheterization. This was the incitement for a planned investigation of the pancreatic veins, now presented as a preliminary report.

Vascular Changes in Chronic Pancreatitis

The diagnosis of carcinoma of the pancreas and chronic pancreatitis is often difficult. Should surgery be contemplated or decided upon, an accurate differentiation between these conditions is important since even at operation this may not be easy (GLENN & THORBJARNARSON 1964). Angiography has become almost the only simple means of investigating the pancreas. Much work has been done to try to differentiate the angiographic findings in carcinoma of the pancreas from those in chronic pancreatitis since ODMAN (1958) suggested that chronic pancreatitis might present special vascular changes. Some investigators of angiography in pancreatic disease have reported it possible to make a diagnosis with a high degree of accuracy (HERNANDEZ et colI. 1967, SAMMONS et colI. 1967, ROSCH & BRET 1965, LECHNER & POKIESER 1971), while others have been less confident (RANNIGER & SALDINO 1966, NEBESAR & POLLARD 1967). Only a few authors have stated that diagnostic difficulties seldom arise since vascular changes in both conditions are characteristic (REUTER et colI. 1969, 1970, BOOKSTEIN et colI. 1969). Opinions regarding the angiographic findings in chronic pancreatitis thus range from the normal to marked vascular changes. Chronic pancreatitis is a progressive condition with calm periods and acute exacerbations that ultimately leads to total destruction of the pancreatic paren-

Porto-systemic collaterals in cirrhosis of the liver. Selective percutaneous transhepatic catheterization of the portal venous system in portal hypertension.

In 93 patients with cirrhosis of the liver and portal venous hypertension the main tributaries of the portal vein were examined by percutaneous transhepatic catheterization. The appearance and degree of porto-systemic collaterals were analysed. Esophageal varices were demonstrated in 82 patients. No correlation was found between the portal venous pressure and the extent of porto-systemic communications.

Angiographic diagnosis of inflammatory disease of the pancreas.

Angiography has in recent years become an important method in the evaluation of pancreatic disease. Most reports of the findings have so far dealt with the diagnosis of carcinoma in which a high degree of accuracy is now achieved (LUNDERQUIST 1965, BOOKSTEIN et coll, 1969, LECHNER et coll, 1970, BOIJSEN 1970, OLSSON 1970, BUCHELER et coll. 1971). Differentiation between carcinoma and pancreatitis is however, often difficult and a thorough knowledge of the vascular changes in the latter is therefore necessary to increase further the accuracy of angiographic investigations (BAUM et coll, 1965, RANNINGER & SALDINO 1966, NEBESAR & POLLARD 1967, SAMMONS et coll. 1967 and MOSKOWITZ et coll. 1968) . A more dynamic attitude towards surgical treatment in inflammatory disease of the pancreas has gradually gained acceptance, and operations directly on the pancreas in this condition are now more frequently performed than in the past (WARREN et coll. 1964, CREUTZFELDT et coll, 1970, DIXON & ENGLERT 1971). Operation may bring relief from pain, and the risk of complications such as acute hemorrhagic necrosis, abscess formation, diabetes mellitus or severe gastrointestinal bleeding may be reduced. Angiography may offer valuable information

Accuracy of angiography in the diagnosis of carcinoma of the pancreas.

The incidence of carcinoma of the pancreas is rising (BEALL et call. 1970, KRAIN 1970). At the same time the results of surgery in this type of malignancy are Foor (GLENN & TI-IORBJARNARSON 1964, BEALL et call. 1970, FEDUSKA et call. 1971, POPE & FISCH 1971), due to the fact that early symptoms are absent or uncharacteristic. The patient usually fails to seek medical advice until late, when jaundice has developed or pain has become intractable (KLINTRUP 1966, CHILD & FREY 1966, BEALL et coll.}; the tumour because of local and distant spread is then seldom operable. Angiography has during the past decade become increasingly used in the diagnosis of pancreatic disease. It is, however, doubtful if it is possible even by this method to make the diagnosis early enough to insure successful removal of a new growth of the pancreas. Many surgeons therefore believe that there is no place for angiography in pancreatic disease. All investigators of angiography in carcinoma of the pancreas however affirm that the diagnosis is possible; only the incidence of vascular changes and thus the degree of accuracy is controversial (LUNDERQUIST 1965, MEANEY & BOUNOCORE 1965, ROSCH & BRET 1965, HERNANDEZ et call. 1967, NEBESAR & POLLARD 1967, NUSBAUM ~t call.

CT Staging of Oesophageal Carcinoma

It has been generally accepted that the normal oesophagus, usually in its entire length, is surrounded by fat which facilitates assessment of tumour extension at CT examination in patients with carcinoma. As this contradicts the clinical experience at the hospital, 25 normal subjects and 36 patients with carcinoma of the oesophagus were investigated with computed tomography. In the middle part, where most tumours arise, the oesophagus as a rule was poorly delineated against important structures such as the left main bronchus and the pericardium (left atrium). In the upper and lower oesophagus the delineation was usually better, but none of the normal subjects had a good or at least discernible fat plane in every slice. The typical tumour appeared as a concentric thickening of the wall with broad contact surfaces without interposed fat with adjacent structures such as the trachea, left main bronchus, left atrium, aorta or vertebrae. Most patients received 24 Gy MV treatment followed by surgery and then 40 Gy of radiation. Ten tumours with broad contact surfaces were easily excised while of the five lesions which were relatively well demarcated two needed sharp dissection. These facts make it very difficult to anticipate the surgical findings at CT. The only reliable sign of inoperability was big bulky tumours encroaching on neighbouring organs.