Percutaneous transhepatic obliteration and surgical stapling transection of the oesophagus with the EEA gun were compared prospectively in the treatment of uncontrolled oesophageal variceal haemorrhage unresponsive to conservative measures. Twenty patients with cirrhosis, with a patient portal vein and who were considered suitable for general anaesthesia and surgery, were randomised to two treatment groups (10 patients each). Immediate arrest of haemorrhage was achieved in 17 patients (nine surgery, eight obliteration). In one other patient, stapling transection succeeded where attempted transhepatic obliteration failed, and in another patient obliteration succeeded where attempted transection had failed. One patient continued to bleed and died following attempts at both procedures. Two other patients also died in hospital, without rebleeding following surgery. Variceal rebleeding during the same hospital admission occurred in two patients in the obliteration group and in none after surgery. Oesophageal stapling transection compares very favourably with a non-surgical technique such as transhepatic obliteration of varices in the emergency treatment of uncontrolled variceal haemorrhage in patients with moderate liver failure.

PURPOSE:In a prospective multicenter study, efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) were evaluated in the treatment of the complications of portal hypertension using a new self-expanding mesh-wire stent (Memotherm).METHODS:One hundred and eighty-one patients suffering from variceal bleeding (either acute or recurrent) or refractory ascites were enrolled. Postinterventional follow-up lasted for 8.4 months on average. Differences were analyzed by the log-rank test (chi-square) or Wilcoxon test.RESULTS:Shunt insertion was completed successfully in all patients (n = 181 patients, 100%). During follow-up, shunt occlusion was evident in 23 patients, and shunt stenosis was found in 33 patients (12.7% and 18.2%, respectively). Variceal rebleeding occurred in 20 of 139 patients (14.4%), with at least one episode of bleeding before TIPS treatment. The overall mortality rate of the patients treated by TIPS was 39.8%. In 51.4% of these cases (37 of 72 patients), however, the patients died within 30 days after TIPS placement. Analysis of subgroups showed that patients who underwent emergency TIPS for acute variceal bleeding had a significantly higher early mortality compared with other patient groups (p = 0.0014).CONCLUSION:In the present prospective multicenter study, we were able to show that insertion of Memotherm stents is an effective tool for TIPS. The occlusion rates seem to be comparable to those reported for the Palmaz stent. It could be shown that in particular, those patients who were treated for acute bleeding were at high risk of early mortality. Consequently, in such a critical condition, the indication for TIPS has to be set carefully.

Background Percutaneous stent placement is an accepted method of palliation in malignant biliary obstruction. Factors predicting early mortality after this procedure have not been identified. Methods We performed a retrospective study of 141 patients with malignant biliary obstruction who underwent percutaneous stent placement for biliary decompression to identify the risk factors associated with early mortality (≤ 30 days). Results Of 14 clinicopathological and laboratory variables analysed blood urea, albumin, haemoglobin and alkaline phosphatase were found to be significant on univariate analysis. The age and gender of the patient along with cancer type, level of obstruction, presence of pyrexia and bilirubin level had no influence on early mortality. Stepwise logistic regression identified the haemoglobin level and blood urea to be independently significant in predicting early mortality. Overall 30‐day mortality was 20.5% (29/ 141). Patients with blood urea over 4.3 mmol/l and a haemoglobin less than 10.9 g/dl had a mortality rate of 52% (12/23) compared with 14% (17/118) in the remainder. Using these two variables a regression equation has been derived which allows calculation of the probability of survival at 30 days after the percutaneous procedure. Conclusions Laboratory variables in patients with malignant obstructive jaundice can be used to predict mortality following percutaneous stent insertion.

BACKGROUND Endoscopic stenting is an effective method of relieving biliary obstruction in patients with unresectable malignancy. If this fails, optimal management is controversial. Percutaneous insertion of plastic or mesh metal stents has been advocated. AIM To review the outcome of percutaneous plastic stents and compare this with contemporary data from the literature on mesh metal stenting. PATIENTS AND METHODS Over a period of six years, 400 patients had attempted endoscopic stenting for distal malignant biliary obstruction which failed in 54 (13.5%). These 54 patients were treated with percutaneously placed plastic stents. RESULTS Percutaneous stenting was technically successful in 48 patients (89%). Early complications occurred in 13 patients (24%), the commonest being acute cholangitis in seven (12%). There was no procedure-related mortality but a 30-day mortality of 11 % (n = 6). Ten patients (18%) required re-admission after 30 days for stent block (mean period 4 months). Forty-seven patients (87%) were followed up until death. The median survival for the patients undergoing palliative stenting was 3 months (5 days to 17 months). CONCLUSIONS These results suggest that percutaneous plastic stents can be used safely and effectively in patients who have failed endoscopic stenting.

BackgroundHeight of portal pressure correlates with severity of alcoholic cirrhosis. Portal pressure indices are not however used routinely as predictors of survival.AimsTo examine the clinical value of a single portal pressure measurement in predicting outcome in cirrhotic patients who have bled.MethodsA series of 105 cirrhotic patients who consecutively underwent hepatic venous pressure measurement were investigated. The main cause of cirrhosis was alcoholic (64.8%) and prior to admission all patients had bled from varices.ResultsDuring the follow up period (median 566 days, range 10–2555), 33 patients died, and 54 developed variceal haemorrhage. Applying Cox regression analysis, hepatic venous pressure gradient, bilirubin, prothrombin time, ascites, and previous long term endoscopic treatment were the only statistically independent predictors of survival, irrespective of cirrhotic aetiology. The predictive value of the pressure gradient was much higher if the measurement was taken within the first or the second week from the bleeding and there was no association after 15 days. A hepatic venous pressure gradient of at least 16 mm Hg appeared to identify patients with a greatly increased risk of dying.ConclusionsIndirectly measured portal pressure is an independent predictor of survival in patients with both alcoholic and non-alcoholic cirrhosis. In patients with a previous variceal bleeding episode this predictive value seems to be better if the measurement is taken within the first two weeks from the bleeding episode. A greater use of this technique is recommended for the prognostic assessment and management of patients with chronic liver disease.

Background: Uncontrolled variceal haemorrhage is the main indication for transjugular intrahepatic portosystemic shunt, However, mortality is 50% for this high-risk group We have evaluated clinical and laboratory variables prior to transjugular intrahepatic portosystemic shunt in order to establish predictors of mortality, validated prospectively,Method: Over a 4-year period, 367 patients were admitted with variceal bleeding, In 53 patients endoscopic therapy for acute variceal bleeding failed and they had emergency transjugular intrahepatic portosystemic shunt, Failure of therapy was defined as continued bleeding after 2 endoscopy sessions (n=39) or vasoconstrictor-resistant bleeding from gastric/ectopic varices (n=15). Thirty-three variables were analysed from data available immediately prior to transjugular intrahepatic portosystemic shunt.Results: Twenty-six patients died within 6 weeks. In a multivariate analysis, 6 factors had independent prognostic value: moderate/severe ascites, requirement for ventilation, white cell blood count (WBC), platelet count (PLT), partial thromboplastin time with kaolin (PTTK) and creatinine. A prognostic index (PI) score was derived, in which presence of moderate/severe ascites, or need for ventilation, scored 1: PI=1.54 (Ascites)+1.27 (Ventilation)+1.38 Ln (WBC)+2.48 In (PTTK)+1.55 Ln (Creat)-1.05 Ln (PLT). Using this equation, 42% (n=10) of deaths occurred in the fifth quintile (PI greater than or equal to 18.52), where the mortality was 100%, The score was prospectively validated in a further 31 patients, giving 100% positive predictive value, Eleven further patients died, including all seven with a PI>18.5. No survivors had a PI>18.3.Conclusion: Despite immediate control of bleeding by transjugular intrahepatic portosystemic shunt, patients with uncontrolled variceal haemorrhage have a high mortality particularly when associated,vith markers of advanced Liver disease, sepsis and multiorgan failure. The use of transjugular intrahepatic portosystemic shunt is probably not justified in this subgroup. Our prognostic index can help identify such patients, and, if validated elsewhere, will help in deciding when to use transjugular intrahepatic portosystemic shunt.

BACKGROUND:Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed.METHODS:Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm.RESULTS:Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention.CONCLUSION:Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.

Carcinoid tumors are the most common neuroendocrine tumors in the gastrointestinal tract, and between 10% and 30% of these tumors are gastric in origin. Three types of gastric carcinoid tumors are recognized: type I, associated with chronic atrophic gastritis type A; type II, associated with multiple endocrine neoplasia; and type III, sporadic and the most malignant. We present a patient with an aggressive, sporadic-type gastric carcinoid that metastasized to the liver. Her symptomatic treatment included the somatostatin analog octreotide. Octreotide scintigraphy demonstrated that this tumor avidly bound the peptide. The patient's gastric carcinoid (assessed by endoscopy and endoscopic ultrasound) regressed and she underwent hepatic artery embolization for her liver metastases. After initial partial CT resolution the tumor grew, compressing the inferior vena cava. The patient underwent orthotopic liver transplant with excellent recovery, although she was subsequently found to have two small lung metastases. She has responded well to adjuvant Indium-111 octreotide receptor targeted therapy. This case highlights the therapeutic options for metastatic neuroendocrine tumors, including liver transplantation and adjuvant receptor targeted therapy.

BACKGROUND & AIMS:The optimal emergency treatment for gastric fundal variceal bleeding is still unclear. In this study, the efficacy of transjugular intrahepatic portosystemic stent/shunt (TIPS) in patients with uncontrolled gastric fundal vs. esophageal variceal bleeding was compared.METHODS:One hundred twelve consecutive patients with uncontrolled variceal bleeding required emergency TIPS, 84 with esophageal varices (EV group) unresponsive to endoscopic and vasoconstrictor therapy and 28 with gastric fundal varices (GV group) unresponsive to vasoconstrictor therapy. Clinical and biochemical data were retrieved, and the two groups were compared.RESULTS:Variceal bleeding was controlled in all patients after TIPS except for 1 in each group. There were no significant differences between the two groups in terms of markers of disease severity, severity of bleeding, or portal hemodynamics. During a median follow-up period of 7 months, 20 in the EV group (24%) and 8 in the GV group (29%) developed clinical rebleeding. Most early rebleeding (within 7 days after TIPS) was related to esophageal ulceration secondary to previous sclerotherapy. Rates of mortality were similar in both groups.CONCLUSIONS:These results suggest that emergency TIPS is equally effective in the immediate short-term control of gastric fundal variceal bleeding compared with esophageal variceal bleeding.

Improvement in our current knowledge of epidemiology, natural history and treatment modalities form the background to generalize the use of ultrasound screening in cirrhosis. The cumulative probability of developing cancer is extremely high in cirrhotics and allows to focus screening programs on a well defined risk group thus maximizing cost-effectiveness. This review article highlights scientific evidences in favour of a generalized practice of US screening.

Transjugular intrahepatic portasystemic shunt (TIPS) is now considered as an option for the control of intractable variceal bleeding1. The high incidence of stenosis and occlusion (50 per cent significant stenosis at 6 months2) favours its use as a bridge to more definitive therapy such as surgical shunting or orthotopic liver transplantation (OLT). The specific difficulties presented to the surgeon by the metal stent have not been considered, although they have been reported anecdotally'. The surgical comp!ications of TIPS insertion have been reviewed.

Percutaneous transhepatic cholangiography (PTC) and stenting is an established method for the management of malignant biliary obstruction. Complications include sepsis, haemobilia and bile leakage. A case of peritoneal metastases following PTC and drainage in a patient with potentially operable carcinoma of head of pancreas is reported. This complication has not been documented previously.

BACKGROUND:Membranous obstruction of the inferior vena cava is a rare cause of hepatic venous outflow obstruction in Caucasians. There has been much debate in the literature about its aetiology.METHODS AND RESULTS:We describe a Caucasian with hepatic venous outflow obstruction due to an inferior vena cava web, who was found to have hypercoagulability due to factor V Leiden. Following balloon rupture of the membrane and anticoagulation, his symptoms resolved and he has remained well for a year.CONCLUSIONS:The age at presentation in this patient, the presence of hypercoagulability and the excellent response to membrane rupture and anticoagulation suggest that in this case the membrane may have been derived from organised thrombus. Balloon rupture of the membrane and anticoagulation appears to be an effective treatment in such cases.

Background—The detection of hepatocellular cancers (HCC) is a major role of preoperative imaging in patients with end stage liver disease being considered for orthotopic liver transplantation (OLT).Aims—To assess the sensitivity of iodised oil computed tomography (IOCT).Patients and methods—A prospective evaluation in 50 consecutive patients undergoing OLT included ultrasound scan, contrast enhanced CT, angiography (with intra-arterial injection of iodised oil), and a second CT (IOCT) 10 days later. Following transplantation the explant liver was serially sectioned for pathological evaluation. Soft tissue radiographs of the liver slices were used to match histological lesions with CT findings.Results—Eleven patients were excluded due to protocol violations. Of the remaining 39, histological evaluation revealed no cancers in 33 explant livers, in keeping with negative preoperative imaging. Six explant livers contained 55 HCCs, 84% of which were less than 1 cm in diameter. Pretransplant IOCT detected 3/6 patients with cancer (50%) but only 7% of cancerous lesions. Ultrasound, contrast CT, and angiography each detected 2/6 patients with cancer and 4% of cancerous lesions.Conclusion—IOCT is an insensitive method for the detection of small HCCs in livers with advanced cirrhosis but in this study was slightly superior to ultrasound, CT, and angiography.

We wish to describe a new radiological sign related to the inferior vena cava following liver transplantation. A high density circumferential ring may be seen on an axial CT scan (Figure 1).

The sharp demarcation between diseased and normal mucosa often observed in ulcerative colitis remains unexplained by current hypotheses of disease pathogenesis. To investigate whether this demarcation occurs at the watershed of vascular territories, the colonic arterial anatomy of 10 patients with ulcerative colitis was studied by in-vitro angiography and macroscopic and histological examination of total colectomy specimens. Of the 10 perfusion-fixed colectomy specimens studied, 7 had pancolitis associated with a complete marginal artery (Arteria marginalis coli) that spanned the entire length of the large bowel. 3 specimens had sharply demarcated disease in which the marginal artery arose from the inferior mesenteric artery and ended abruptly at the point of mucosal demarcation. The colon proximal to this point was histologically normal. These findings suggest that the proximal extent of colitis is determined by the limit of the marginal artery. We suggest that some .characteristic of the mucosal microvasculature in the territory of the inferior mesenteric artery, possibly embryological in origin, predisposes the dependent colon to develop ulcerative colitis.

Octreotide is thought to reduce splanchnic and variceal blood flow with minimal effects on the systemic circulation in cirrhotic patients with portal hypertension. However, we noticed significant bradycardia in some patients immediately after administration of bolus doses of octreotide. Therefore, we investigated the effect of intravenous octreotide on systemic hemodynamics in 59 patients with cirrhosis. In two double-blind, placebo-controlled protocols, 32 patients received a 25-micrograms bolus and 20 patients received an infusion of 50-micrograms/hr of octreotide/placebo. Immediately after the bolus dose of octreotide was administered, there were significant reductions in pulse rate (77 +/- 3 vs. 65 +/- 3 beats per minute, P < .01) and cardiac output (9.2 +/- 0.8 vs. 7.9 +/- 0.8 L/min; P < .01) and significant increases in mean arterial pressure (81 +/- 3 vs. 87 +/- 3 mm Hg; P < .05), mean pulmonary artery pressure (9.1 +/- 1.0 vs. 16.6 +/- 1.5 mm Hg; P < .01), right atrial pressure (3.8 +/- 0.8 vs. 6.6 +/- 1.0 mm Hg; P < .01), right ventricular pressure (7.1 +/- 0.6 vs. 12.5 +/- 1.3 mm Hg; P < .01), pulmonary capillary wedge pressure (4.8 +/- 0.8 vs. 11.2 +/- 1.4 mm Hg; P < .01), systemic vascular resistance, and pulmonary vascular resistance. Thirty minutes after the start of the infusion, there were significant increases in mean right atrial pressure, right ventricular pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure. This study suggests that intravenous octreotide has significant effects on the systemic circulation in patients with cirrhosis and that these effects appear to be more marked after administration of bolus doses.