The intraoperative measurement ofthe afferent circulation ofthe liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anesthetized patients having carcinoma in the splanchnic area, mainly in the head of the pancreas by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377+0.10; 0.614+0.21; 0.992+0.276 l/min respectively. The ratio of hepatic arterical flow to portal venous flow was 0.66+0.259 There was a sharp, significant increase in hepatic arterial flow (29.8+6.1%, p<0,01) after the temporary occlusion of the portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

The classification of tumours originating from the wall of gastrointestinal organs changed dramatically since of electronmicroscopy and immunohystochemistry were introduced. Previously these tumours were classified as leiomyomas, leiomyosarcomas or schwannomas. With the new methods these disorders can be described in more details and unified, and so the change to provide correct prognosis improved. Still, there are some unanswered questions remaining for the pathologists. In our material in the past 5 year we treated 9 patients because of GIST. Most of them were found in the stomach (6), one developed in the oesophagus, one in the small bowel and another one in the rectum. With describe our patients and look at the related articles literature about this important diseases. Though the incidence is under 1% of patients operated on because of gastrointestinal diseases, we would like to share our experiences in treatment.

BACKGROUNDMassive pleural effusions are uncommon but well-documented complications of chronic pancreatitis, usually caused by the development of a pancreaticopleural fistula. The mechanism of the fistula formation is thought to be rupture of the pancreatic duct or pseudocyst.MATERIAL AND METHODSIn the past 7 years we have treated 5 patients with massive pleural effusion of pancreatic origin in the Surgical Department of Semmelweis University Medical School. 4 patients were males; the average age was 52 years (range: 46-59 years).RESULTSAll 5 patients had a history of alcohol abuse and were admitted to the pulmonary department because of respiratory distress. Other symptoms such as abdominal pain, chest pain, or weight loss were not always present. The diagnosis was confirmed by a markedly elevated amylase level in the aspirated pleural fluid. Abdominal ultrasound, CT scan, and ERCP examinations were carried out in order to determine the cause of the pancreaticopleural fistula. Conservative (nonsurgical) treatment was effective within 3 weeks in only one case. The other 4 patients required surgical management. In 3 cases distal pancreatic resection with splenectomy and cholecystectomy was done. In one case cystojejunostomy was performed. All 5 patients have been cured with complete resolution of their pleural effusions.CONCLUSIONSPatients with large pleural effusions may have underlying pancreatitis with a pancreaticopleural fistula. It is important to establish this diagnosis because treatment may require operative interventions.

Summary Background: Authors are presenting a case of papillomatosis of the common bile duct, causing obstructive jaundice, which is a rare diagnosis. Methods: On the base of the preoperative examinations and the operative finding an early malignant tumor of the common bile duct was suspected, and only the postoperative pathohistology examination verified the proper diagnosis. Results: The patient treated with pancreatoduodenectomy is healthy two years after the operation without any complaints. Conclusions: The authors emphasize that the radical operation is mandatory in the case of this benign disease as it has an inclination for recurrence or malignant transformation.

Background: A case of a gallstone penetrating into the duodenal bulb, and simulating pyloric stenosis is reported. The clinical picture is known as Bouveret’s syndrome. Among the rather uncommon occurrences of gallstone ileus, this form of manifestation is of great rarity, only a few cases are known.

The last decade has brought marked changes in the surgical treatment of rectal cancer: as the indication of the sphincter-saving procedures was extended, the rate of the abdomino-perineal excision has decreased even in the case of tumours of the distal third of the rectum. However, even with the use of the modern stapling devices, the anterior resection and colo-anal anastomosis may not always be feasible by the traditional abdominal approach. In these cases the sphincter-saving resection can be performed by a particular approach, the abdomino-transsphincteric technique. The authors present this seldom used operation. From the 1-st of January 1994 to the 31-st of August 1996 14 abdomino-transsphincteric resections have been performed. The mean age of the patients was 62.2 (38-81) years. The lower edge of the tumours was situated at 6.3 (5-8) cm from the anal verge. The anastomosis was performed by the double stapling technique in 8 and by hand suture in 6 cases, its distance from the anal verge was 3.2 (3-4) cm. A colon J-pouch was used in 3 cases and a diverting colostomy was performed routinely. One patient died in the postoperative period and a reoperation (abdomino-perineal excission) was performed because of left colon necrosis: Anastomotic leakage was observed in one case. By the time of the present study, 11 patients have had their colostomies closed. The continence is acceptable in every case and all the patients experience a better subjective quality of life, than it was while wearing the colostomy. The use of this technique has helped to avoid a permanent colostomy in 21 out of 33 cases operated on for cancer of the distal rectal third in the reviewed period.

On the basis of data published in the litterature, the authors accept as a presumpt of their study that sphincter-saving surgery of distal rectal tumours provides as good oncological results as does the abdomino-perineal excision of the rectum. The data of 178 resectable rectal cancers operated on through 1-th of January 1989 to 31-st of December 1996 are retrospectively analized in respect of sphincter preservation. With acceptance of the current oncological principles and the use of new surgical techniques (colo-anal anastomoses, abdomino-transsphincteric resection) the rate of the sphincter preservation shows a consequent rise in the last years: from 45.3 % in 1989 to 86 % in 1996. No abdomino-perineal excision has been performed for tumour of the proximal and middle thirds of the rectum since 1994.

The upper gastrointestinal bleeding is still an everyday problem. 40-50% of these bleedings are originating from peptic ulcer. The rate of rebleeding after initial hemostasis is 30-50%. In this group of patients we can observe the highest morbidity and mortality. The aim of this work is to select those patients who belong to the high risk group from the point of rebleeding. For this purpose we introduced after a retrospective analysis the modified Baylor score. In this scoring system the age, the number and severity of parallel illnesses, the hemostatus by the admittance, the ulcer size and location and the stigmata of recent hemorrhage are taken into consideration. On the basis of this every patient gets a score between 0 and 31. Based on our retrospective analysis we could establish three grades of risk groups: low risk (0-7), middle risk (8-11) and high risk (12 and over). In the low risk group there was no rebleeding. In the middle risk group we observed 4 rebleedings in 19 patients, while in the high risk group there were 32 rebleedings out of 36 cases. As a conclusion we can state, that the modified Baylor score is capable for the selection of high risk patients for rebleeding. With the early elective operations in these cases the high morbidity and mortality can be reduced.

Data regarding the afferent circulation of the liver in patients with primary hepatocellular carcinoma are controversial, we have carried out measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55±0.211 compared with the control value of 0.37±0.102 1/min. (p<0.01). The portal venous flow decreased from 0.61±0.212 l/min, to 0.47±l/min. p<0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly, compared with controls. The ratio of hepatic arterial flow to portal vein flow increased to 1.239±0.246 in patients with hepatocellular carcinoma, which is double of the control value (0.66±0.259 l/min). After resection this ratio did not change. The resection did not alter hepatic artery or portal venous flow significantly, although the total hepatic blood flow decreased significantly (p<0.01). On the basis of our early results it is possible that the ratio of the two circulations may be to deel measured with doppler ultrasound and provide diagnostic information.

The relationship between the changes in portal venous and hepatic arterial blood flows, in the liver is a much disputed question, it has tremendous significance in the practice of transplantation, and an explanation has been available since 1981, when Lautt published the so-called "adenosine washout theory". According to our earlier observations the decrease of portal pressure or flow consistently led to an increase in hepatic artery flow. At the same time changes in hepatic artery flow or pressure seemed to produce only inconsistent effects on the portal circulation. In the present experiments liver transplantation (OLTX) was carried out on mongrel dogs by Starzl's method. Electromagnetic flow probes were placed on the hepatic artery and the portal vein before removal of recipient's liver, and after completion of all vascular anastomoses to the newly inserted liver, during the recirculatory phase of OLTX. The flow probes were connected to a Hellige electromagnetic flowmeter, portal venous and systemic arterial pressures were also recorded. The control HAF was 241 +/- 23 ml/min, the average PVF was 517 +/- 47 ml/min before removal of the recipient's liver. In the recirculatory phase of HAF increased, by 71 +/- 12% (p < 0.001). The PVF decreased in most animals after OLTX. The decrease was in average -40.2 +/- 3.5% (p < 0.001). The THBF calculated by adding the HAF and PVF showed a small, but not significant decrease recirculation. The systemic arterial pressure decreased slightly and portal vein pressure rose in most animals after OLTX. There was a substantial increase in portal inflow resistance and prehepatic arteriolar resistance and a decrease in hepatic artery resistance. The decrease of PVF after OLTX can be explained by progressive fluid accumulation in the liver parenchyma and increased sinusoidal and portal inflow resistance. The prolonged and continuous increase in hepatic artery flow during the recirculatory phase of OLTX may be due to the decrease of portal flow. The exact mechanism, by which a change in portal flow leads to arteriolar dilatation, can be most probably explained by the "adenosine washout theory" of Lautt.

See also: Pancreaticopleural Fistula Treated by Transpapillary Implantation of a Plastic ProsthesisEndoscopy 1998; 30(08): 741-741DOI: 10.1055/s-2007-1001402

The authors describe the case history of 68 year old man. Right atrial myxoma had been diagnosed two years prior to this present observation, however surgical intervention has been contraindicated due to high operative risk. Later the patient was referred to a cardiological evaluation because of chronic atrial fibrillation before a cataract surgery in a symptom free condition. The right atrial myxoma caused inflow obstruction and tricuspid regurgitation was removed before the eye surgery. In addition, tricuspid valve replacement and revascularization of three coronary arteries has been performed. The patient receiving chronic anticoagulant therapy experienced severe gastrointestinal bleeding the source of which turned out to be a partially malignant colon polyposis. The polyps were successfully removed by coloscopy and intra operative coloscopy. No gastrointestinal bleeding has been observed afterwards in spite of the continued anticoagulation. After review of the literature the authors observed that according to their knowledge the common occurrence of the right atrial myxoma and the colon polyposis had not been described before.

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anesthetized patients having carcinoma in the splanchnic area, mainly in the head of the pancreas by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377±0.10; 0.614±0.21; 0.992±0.276 l/min respectively. The ratio of hepatic arterical flow to portal venous flow was 0.66±0.259 There was a sharp, significant increase in hepatic arterial flow (29.8±6.1%, p<0,01) after the temporary occlusion of the portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

Intra-operative measurement of the afferent circulation of the liver, namely hepatic artery and portal venous flow was carried out in 14 anesthetized patients with carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmetry. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.2761/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of the hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is much in dispute, but, as the data presented here show, there is no doubt that the decrease in portal venous flow immediately gives rise to a significant increase in hepatic artery circulation.

BACKGROUND/AIMS The data on the afferent circulation of the liver, in patients with primary hepatocellular carcinoma, are controversial or non-existent. MATERIALS AND METHODS The authors measured hepatic arterial and portal venous flow intra-operatively by transit time ultrasonic volume flowmetry. RESULTS In patients with primary hepatocellular carcinoma, the hepatic artery flow increased to 0.55 +/- 0.21 l, as compared with the control value of 0.37 +/- 102 l/min (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 l/min to 0.47 +/- 0.203 l/min p < 0.01). Owing to the opposite changes in the afferent circulation, the total hepatic blood flow did not change significantly. The ratio of hepatic arterial flow to portal vein flow increased to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is twice the basic control value (0.66 +/- 0.259 l/min). After resection, this ratio showed virtually no change. The surgical intervention, that is resection of the liver, did not significantly alter hepatic artery and portal venous flow, although total hepatic blood flow decreased significantly (p < 0.01). The pronounced increase in the ratio of hepatic arterial flow may be attributed to the decrease in portal venous flow caused by the primary hepatocellular carcinoma. The decrease in venous flow can most probably be explained by compression and infiltration of the intrahepatic branches of the portal vein. As we pointed out, the decrease in portal venous circulation leads to an increase in hepatic arterial flow. CONCLUSIONS On the basis of our initial results, it seems probable that the ratio of the two circulations represents a diagnostic tool for the altered circulation in patients with hepatocellular carcinoma. The significance of this phenomena is not yet quite clear, but a review of the literature shows that similar observations have not been reported. In practical terms this phenomenon may be useful from the point of view of US and Doppler US diagnosis, e.g. in the case of a hypo-echoic or hyperechoir, mass in the liver, increased blood flow in the hepatic, artery, and decreased portal venous flow, a malignant liver tumor is virtually certain. The authors hypothesise that any pathology in the liver may lead to a primary decrease in PVF and a subsequent increase in HAF.