Biomedical subjects
I E McInnes
Publications and source records attributed to I E McInnes.
Surgical treatment of biliary stricture with portal hypertension using veno-venous bypass.
The surgical treatment of benign bile duct stricture with portal hypertension may be hazardous and, in some cases, involve a 2-stage procedure. An initial porta-systemic shunt is performed followed by surgical correction of the stricture at a second operation. The use of veno-venous bypass, as described, provides a temporary porta-systemic shunt, allowing a 1-stage repair of the stricture to be carried out.
Oesophagectomy without thoracotomy in the treatment of oesophageal carcinoma.
A group of patients with carcinoma of the oesophagus and cardia has been studied. Subtotal oesophagectomy without thoracotomy has been performed. The operation is briefly described, the complications and results are discussed and it is concluded that the operation of subtotal oesophagectomy without thoracotomy does have a place in the treatment of selected patients with carcinoma of the oesophagus.
The long-term effect of distal lienorenal shunt surgery on portal venous pressure.
To assess whether portal venous pressure remains elevated following distal lienorenal shunt surgery, 11 patients with alcoholic cirrhosis were assessed from 0.5 to 59 months following the creation of a distal lienorenal shunt. These were compared with five patients following mesocaval shunt surgery and nine with cirrhosis alone. Portal pressure was measured by direct transhepatic catheterization of the portal vein or by determining intrahepatic pulp pressure. Splenic pulp pressure was also measured in the shunt groups at the time of assessment of shunt patency by scintisplenoportography. All shunts were patent. Four of five patients studied within 10 months of distal lienorenal shunt surgery had persisting portal hypertension (comparable with that in the cirrhosis alone group) and persisting portasplenic gradient. In contrast, five of six patients studied more than 10 months following surgery had portal pressures similar to that following mesocaval shunt surgery and no portasplenic gradient. Thus, with time, selective decompression tends to become total decompression. Whether this correlates with deterioration of hepatic function requires further study.
Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management.
Two cases of right hepatic hydrothorax occurring in the absence of clinical ascites are reported. Diagnosis was confirmed by the intraperitoneal and intrapleural injection of radioisotope 99mTc-sulfur colloid that demonstrated the one-way transdiaphragmatic flow of fluid from the peritoneal to pleural cavities. In contrast, radioisotope injected into the peritoneal cavity of 5 patients with pleural effusions secondary to pulmonary or cardiac disease failed to traverse the diaphragm and localize in the pleural space. Medical therapy with salt and water restriction and diuretics resulted in both of the patients with hepatic hydrothorax developing signs of intravascular volume depletion without significant mobilization of the pleural fluid. Thoracotomy allowed identification of the diaphragmatic defects that were repaired by chemical and traumatic pleurodesis followed by postoperative peritoneal and pleural drainage. This therapy resulted in complete resolution of the pleural effusions, which have not recurred despite the subsequent development of clinical ascites in both patients.
Long term follow-up of patients following successful selective and non-selective portasystemic shunt surgery.
The long term morbidity and mortality of two consecutive groups of patients undergoing successful shunt surgery for bleeding oesophageal varices has been studied. Twenty-seven patients with a non-selective shunt in the form of a mesocaval Dacron 'H' graft and 21 patients with selective variceal decompression via a distal lienorenal shunt, all of whom had a patent shunt on discharge from hospital, were included in the study. Shunt associated encephalopathy was documented in 77% of the patients following mesocaval shunts and only 19% of patients following distal lienorenal surgery. Other postoperative morbidity was largely related to problems with the synthetic Dacron graft. Late shunt blockage, often resulting in recurrent variceal bleeding, was documented in 25% of these patients and shunt infection was responsible for complicating fatal disseminated sepsis in 18.5%. Long term survival, as assessed by life table analysis, following distal lienorenal shunt surgery was consistently better than that following mesocaval shunts. This was largely due to specific problems which could be directly related to the synthetic nature of the Dacron graft. It is concluded that the mesocaval Dacron interposition graft carries the potentially lethal long term complications of shunt blockage and infection rendering it unsuitable as a portasystemic shunt. Provided that successful surgery can be performed the distal lienorenal shunt may be a more appropriate alternative due to its reduced shunt related morbidity and, possibly, mortality.
The distal lienorenal shunt: perioperative experience with 30 patients.
During the past 51/2 years, thirty consecutive and unselected patients who bled from oesophageal varices underwent distal lienorenal shunt surgery. Eight deaths occurred in the immediate postoperative period. Three of nine emergency patients died because of continued bleeding and, of the five elective patients who died, four were largely the result of technical problems encountered at surgery. In the immediate postoperative period variceal bleeding recurred in five of eight emergency patients despite shunt patency. This did not occur in the elective group. Shunt blockage was relatively common compared to that following conventional porta-systemic shunt surgery; being documented in five of the 24 patients in whom patency was assessed. No clinical, biochemical or histological criteria were identified as predictors of outcome. In particular, the presence of preoperative ascites gave no indication of postoperative problems. However, if ascites developed in the immediate postoperative period, it was a major management problem in 50% of patients. In conclusion, the distal lienorenal shunt has a high perioperative mortality, is commonly complicated by shunt thrombosis and, in the emergency situation, often fails to control bleeding. The technical difficulties encountered at surgery appear largely responsible for the early morbidity and mortality.
Disseminated intravascular coagulation following peritoneo-venous (LeVeen) shunt.
Ten LeVeen shunts were inserted into nine patients with intractable ascites and coagulation studies were performed to determine the incidence, severity, and clinical importance of disseminated intravascular coagulation (DIC) in the initial post-operative period. Two of the shunts failed to function in the immediate post-operative period and the clotting profiles of these patients were unchanged by surgery. The remaining shunts had good initial flow and in all patients there was a deterioration in the coagulation profile consistent with DIC. In four of these patients this was associated with clinical evidence of impaired haemostasis which required surgical ligation of the shunt in two as an emergency measure. The other two patients died as a direct consequence of their bleeding. Of the eight initially patent shunts, one blocked spontaneously and three others were surgically ligated in the early post-operative period. The clotting abnormalities of all of these patients returned to pre-operative levels with the cessation of flow through the shunts. Four patients had continued shunt patency during their hospital stay and, in all, titres of fibrin degradation products remained elevated. The conclusions reached are that adequate flow through the peritoneovenous shunt causes laboratory evidence of DIC in all patients and this can be of major clinical importance; that monitoring of the coagulation profile is a good index of continued shunt patency at least in the early post-operative period; and that DIC may account for the high spontaneous blockage rate.
Repeated shunt surgery in a patient with portal hypertension.
A 45-year-old male with chronic active hepatitis and portal hypertension had a mesocaval interposition graft performed because of repeated uncontrolled bleeding from oesophageal varices. Acute hepatocellular failure, manifested by Grade IV encephalopathy and severe coagulopathy, developed early in the post-operative course despite the absence of hepatic necrosis or other precipitating factors. Both encephalopathy and coagulopathy resolved rapidly following ligation of the shunt. Variceal bleeding recurred and nine months later an emergency distal lienorenal shunt was performed. Post-operatively the shunt was shown to be patent and there has been no encephalopathy or recurrence of variceal bleeding. It is concluded that (1) the splanchnic haemodynamic effects of a mesocaval interposition graft can result in severe hepatocellular failure and this can be reverted by shunt ligation and (2) the distal lienorenal shunt, while effectively reducing the risk of haemorrhage from varices, may be less likely to result in post-operative encephalopathy than more conventional forms of portal decompressive surgery.
The mesocaval "H" graft: experience with 22 cases.
During the past 32 months, 22 consecutive unselected patients who had bled from oesophageal varices have undergone mesocaval "H" graft operations. There have been nine deaths, three in the early and six in the late postoperative periods. Two deaths were the result of bleeding complicating severe primary fibrinolysis and three were due to disseminated sepsis, one originating from an infected shunt. Continued alcohol intake may have contributed to five of the late deaths. Ten of the 19 patients who left hospital developed some degree of hepatic encephalopathy easily controlled by diet and medical therapy. However, in one case the development of grade IV coma necessitated ligation of the shunt to reverse the coma. Patency of the shunt was demonstrated in all but one patient. Recurrence of bleeding occurred only in this patient and the one in whom the shunt was ligated. Although the operation had a comparatively low operative mortality, the long-term mobidity and mortality were no better than those of the more conventional portacaval anastomosis.
Effect of adrenergic antagonists on the peripheral constrictor action of kinekard, a cardioactive plasma fraction.
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