Biomedical subjects
Publications and source records attributed to A Lunderquist.
The portal vein flow pattern in different degrees of portal hypertension is discussed based on the findings at arterial and transhepatic portography. Injection studies on normal and cirrhotic cadaver liver have been used to explain the microcirculation of the liver when hepatic vein catheterisation and wedged pressure recordings are performed.
Portal and hepatic veins were injected with Microfil in the normal and cirrhotic livers of cadavers. Based on pathologic and anatomic studies previously reported and on the present investigation, the authors explain the background of wedged hepatic pressure recording and the findings when contrast medium is injected into a catheter wedged in a hepatic vein.
The complications of percutaneous transhepatic catheterization of the portal vein and its tributaries were assessed in 406 patients in whom 440 examinations had been performed and 8 unsuccessful attempts. Clinically relevant complications consisting of abdominal or external hemorrhage occurred in 24 cases with fatal outcome in 3. Complications involving the right pleural space occurred in 13 patients: collection of ascitic fluid in 6, bile effusion in 5 and bleeding in 2. Laparotomy was needed in 7 cases due to intraabdominal hemorrhage. The gallbladder was unintentionally punctured in 4 cases. Furthermore, a variety of minor complications of little clinical significance, such as extravasation of contrast medium, subintimal injection of contrast medium and minor intrahepatic hematomas, were observed.
Ultrasound and angiography of the pancreas were performed in 68 patients. Ultrasound reached an accuracy of 64.5 per cent and angiography 76.4 per cent. Both methods excluded disease of the gland in all patients without clinical evidence of disease at follow-up. Both methods had higher accuracy in the diagnosis of carcinoma than of pancreatitis. Although angiography has higher accuracy, ultrasound is recommended for screening of patients with abdominal pain. Because of the differential diagnostic difficulties, percutaneous fine-needle biopsy is recommended, when a pancreatic lesion is demonstrated. Angiography is used mainly to predict operability and prognosis.
The results of a prospective study of 19 patients with pancreatic cancer treated with regional intraarterial 5-FU infusion with or without oral tesolactone are reported. No primary mortality was noted. No measurable tumor remission was seen. The median survival time from the state of infusion therapy was 6.5 months. Median time of hospitalization from the start of infusion therapy was 2 months, which corresponds approximately to 30% of remaining survival time. No significant improvement of quality of life was registered during the treatment period. The results indicate that intrrarterial regional 5-FU--neither with nor without testolactone--cannot be recommended for patients with irresectable pancreatic cancer.
Seventeen patients were investigated to localize carcinoid tumor growth in the small intestine and liver. Portography, selective phlebography of the intestinal veins, arteriography, and hormone assay (Serotonin, substance P) after simultaneous catheterization of the celiac artery and portal and caval veins were performed. Most of the patients have been operated on and findings at surgery have been compared with the preoperative localization methods. In 3 cases with small bowel carcinoids and typical fibroplastic changes of the mesentery, phlebography as well as arteriography demonstrated well the degree of mesenteric involvement. None of the methods demonstrated the primary tumors. Arteriography was superior in demonstration of liver metastasis. The hormone assay was a useful complement to angiographic techniques in the diagnosis and localization of tumor growth.
The intrahepatic portal venous flow in cirrhosis of the liver was evaluated by percutaneous transhepatic portography and hepatic arteriography. Spontaneous reversal of flow in segmental portal vein branches was documented. Changes in hepatic arterial inflow and portal venous pressure may result in intermittent changes in the direction of flow in segmental portal venous branches within the cirrhotic liver. Segmental reversal of blood flow seems to be the precursor of total hepatofugal portal flow.
Eleven patients with portal hypertension were treated with subcutaneous transposition of a resected spleen. In eight of the patients the operation was performed after variceal bleeding. In this group there was one operative mortality--a 77-year-old woman. Another patient died after 28 months in upper gastrointestinal bleeding. Autopsy showed varices in the gastric fundus and a cancer in the cardia. The other six patients are alive and in good health after 41--60 months. The operation was performed in another three patients, who had not bled. The indication was hypersplenism and esophageal varices in two and severe thrombocytopenia in one. Two of these patients (both with advanced hepatic disease) died postoperatively. The operation is proposed as an alternative method in the treatment of portal hypertension--especially when the main problem is hypersplenism. The operation has no negative effects on liver function and does not cause encephalopathy. Hypersplenism is cured. The survival time and freedom from postoperative bleeding among those who bled preoperatively is in the present material very satisfactory. However, the operation cannot be recommended for the prophylactic treatment of patients with esophageal varices who have not bled--at least not in the patient with advanced hepatid dysfunction.
The percutaneous transhepatic portal vein catheterization (PTP) with selective obliteration of the coronary vein and/or the short gastric veins in treating bleeding esophageal varices was introduced in 1974. In order to prevent recanalization of the vessels Bucrylate (isobutyl-2-cyano-acrylate) has been used in 43 patients 55 times during a period of 34 months (October 1975 to July 1978). The obliterative treatment was followed by rebleeding in 35% of the cases and continued bleeding occurred in two patients. Fourteen patients were treated on 16 occasions during acute bleedings, and five of these (36%) died within two months from a portal vein thrombosis caused by the obliterative procedure. Because of these findings PTP with obliteration of the veins feeding the esophageal varices is not recommended as an elective way of treatment. It should only be used in the acute bleeding patient when transesophageal sclerosering therapy, continuous vasopressin infusion and balloon tamponade have failed. Fifty-six per cent of the patients acutely treated stopped bleeding for more than one week, thus avoiding an emergency shunt or devascularization operation which are associated with a high mortality rate.
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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.
Three cases of glucagonoma syndrome caused by glucagon producing pancreatic islet cell tumors are reported. Modern procedures for diagnosis, localization, and classification are presented and advocated.
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To evaluate its potential as an alternative to angiography in the diagnosis of pancreatic tumors, we performed selective vein catheterization for hormone assay on 11 patients with islet cell tumors and islet cell hyperplasias. In all patients, the abnormal pancreatic tissue was correctly localized preoperatively by this method.
Percutaneous transhepatic intubation and combined internal-external drainage of the biliary system was performed in 15 patients with occlusion of the extrahepatic bile ducts due mainly to cholangiocarcinoma, metastases of the hepatoduodenal ligament, and tumors of the periampullary region. The technique is described and the value of the procedure in temporary decompression and combined internal-external bile drainage prior to radical surgery is demonstrated. Its advantages as a palliative method are evident in far-advanced malignancy when extensive and complicated surgical procedures are ill-advised.
The results of a retrospective three year study of forty-six patients with cancer of the liver treated with regional intraarterial infusion of 5-FU are reported. No primary mortality was noted. Oblective overall remission rate was 43 per cent. Overall median survival from onset of treatment was six months. The one year survival rate was 33 per cent and the two year survival rate 11 per cent. Patients with an objective response had a significantly prolonged survival as compared with nonresponders, especially in the colorectal group: sixteen months versus four months. Survival was not related to tumor size and involvement of the liver. During treatment 42 per cent of the patients developed extrahepatic metastases. Quality of life was improved in 63 per cent of the patients. The results indicate that infusion therapy induces reasonable response and palliation but is inadequate for the control of extrahepatic tumor growth.
In 37 patients with extrahepatic cholestasis of different origin, percutaneous transhepatic intubation of the bile ducts was performed for combined internal and external drainage. In 5 cases with stones in the extrahepatic bile ducts and in 12 cases with periampullary tumors, the bile ducts were drained preoperatively. In 3 of these patients, temporary drainage was performed because of postoperative complications. Thirteen patients with non-resectable tumors received a permanent drainage as palliation. In 4 patients temporary drainage was performed during radiation/cytostatic therapy. One patient with an iatrogenic bile duct lesion and one patient with an inflammatory tumor in the liver hilum had a drainage catheter placed because a bile duct resection with creation of a biliodigestive anastomosis was not possible. In one patient with a non-resectable periampullary carcinoma the drainage catheter was replaced by a teflon bile duct endoprosthesis inserted by the percutaneous transhepatic approach. The complications of non-operative percutaneous transhepatic bile drainage are discussed.
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.