A prospective controlled comparison of portal-systemic (PSS) and distal splenorenal shunts (DSRS) in cirrhotic patients who had survived hemorrhage from esophagogastric varices was undertaken 5 yr ago at five hospitals by the Boston-New Haven Collaborative Liver Group. The clinical and endoscopic criteria for massive hemorrhage were satisfied in 155 patients. Thirty-four patients were excluded, primarily because of uncontrolled hemorrhage. Thirty-four were rejected because the were poor operative risks and 21 because they did not satisfy criteria. Thirteen patients refused to participate; the remaining 53 were randomized; 29 to receive PSS and 24, DSRS. The two groups were similar in clinical, laboratory, and manometric characteristics. The DSRS group was older and tended to have had more previous hemorrhages. Followup ranged from 1 to 56 months (mean 21). After PSS, which was performed by 10 different surgeons, 6 patients died during the hospital admission (21%) compared to 2 after DSRS (12%). There were 6 late deaths in the PSS group and 4 in the DSRS group. Portal-systemic encephalopathy occurred in 5 of the 23 survivors of PSS (23%), and in 6 of the 19 who survived DSRS (32%. Two patients in the PSS group bled (9%), 1 after thrombosis and 1 after stenosis of the shunt. Three patients in the DSRS group bled (16%) and all had thrombosis of the shunt. PSS was associated with an unexplained but inordinately high operative mortality. Although the DSRS was accomplished with an acceptably low operative mortality, it was associated with frequent portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage. Similar incidences of portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage were observed in the PSS group. More patients and longer followup are necessary to determine which of these portal decompressive procedures is superior.

Clinical Trials as Topic↗

PubMedDate not supplied

Ethanol, thyroid hormones and acute liver injury: is there a relationship?

Alcoholic liver disease continues to be an important cause of morbidity and mortality, and the hypermetabolic hypothesis continues to be an attractive area for research. However, the current state of knowledge does not allow unequivocal acceptance or rejection of the role of thyroid hormone and antithyroid medication in alcoholic hepatitis. Clinical trials will help to establish or disprove the veracity of this hypothesis. What has been established is that chronic ethanol ingestion enhances EMR (19-22) which probably reflects the degree of hepatocellular necrosis, at least when relatively mild (25). The influence of thyroid hormone or a hyperthyroid-like state on EMR would be established if it could be shown that different antithyroid medications inhibit the enhanced EMR in chronic alcoholics. This effect has been shown in rats (125), but not in man. It is not apparent that events in the rat model can be readily applied to man. Furthermore, proof that antithyroid medications can inhibit enhanced EMR in chronic ethanol-consuming patients may allow this feature to be used to select patients who may best benefit from such treatment. A controlled randomized clinical trial using different anti-thyroid medications in alcoholic hepatitis may shed light on this important question. At the very least, demonstration of inhibition of enhanced EMR by antithyroid medications may provide the rationale for research concerning the role of thyroid hormone (or a similar hypermetabolic factor) in alcohol-mediated hepatocellular injury.

Alcohol Oxidoreductases↗

PubMedDate not supplied

Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: a randomized controlled trial.

Between 1975 and 1983, 303 cirrhotic patients with endoscopically proven major variceal hemorrhage were admitted to the participating hospitals of the Boston-New Haven Collaborative Liver Group. Of these, 274 were evaluated for admission to a prospective, randomized controlled trial comparing portal-systemic shunts with distal splenorenal shunts. The criteria for inclusion were as follows: (i) a portohepatic pressure gradient greater than or equal to 12 mmHg; (ii) angiographic evidence of antegrade portal venous flow; (iii) angiographic demonstration that the inferior vena cava and portal, splenic and left renal veins were anatomically suitable for either a portal-systemic or distal splenorenal shunt, and (iv) the patient was a reasonable operative risk. Eighty-one patients from the six participating hospitals fulfilled the criteria and consented to participate. Thirty-eight patients were randomly assigned to have portal-systemic shunt and 43 to have distal splenorenal shunt. After a follow-up period of 11 years (mean = 3.5 years for all patients), survival was found to be similar in the two groups of patients. The 30-day operative mortality was 13% for the portal-systemic shunt group and 9% for the distal splenorenal shunt patients. Late mortality was 55% for the portal-systemic shunt and 37% for the distal splenorenal shunt group. Total mortality was 68% for the portal-systemic shunt and 46% for the distal splenorenal shunt group. None of these differences is statistically significant. In those patients who survived greater than 30 days after surgery, recurrent variceal hemorrhage occurred in four (12%) in the portal-systemic shunt group compared to seven in the distal splenorenal shunt group (18%) (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Portal hypertension: inching ahead therapeutically.

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Adult↗