Implantable peritoneovenous shunts have facilitated the management of patients with medically intractable ascites. The more commonly reported complications occur with an incidence of 20–50%. Rare and problematic complications are becoming increasingly frequent. Two unusual complications, 1) progressive respiratory insufficiency and death secondary to pulmonary embolization of ascites fluid containing cholesterol crystals, and 2) shunt malfunction caused by the formation of a fibrous envelope around the venous catheter are presented. Pathogenesis, diagnosis and therapy of each of these unusual complications is discussed.
Abstract Cancer of the pancreas is an uncommon entity in the pediatric population and there have been only three reports of what may be termed papillary epithelial neoplasm of the pancreas. We recently treated a young patient with this tumor, and comparison with the previously reported cases suggests a specific histologic and clinical picture, preferred treatment approach, and likely prognosis.
A double-blind placebo-controlled trial of intravenous prostaglandin PGE1 (40 micrograms/h) was conducted in adult orthotopic liver transplant recipients. Infusion was started intraoperatively and continued for up to 21 days. Patients were followed up for 180 days postoperatively. Among 172 patients eligible for treatment in the study, 160 could be evaluated (78 PGE1; 82 placebo). Patient and graft survival were similar (PGE1: 16 deaths, 9 retransplantations [7 survivors]; controls: 15 deaths, 6 retransplantations [3 survivors]). In patients with surviving grafts, however, PGE1 administration resulted in a 23% shorter mean duration of hospitalization following transplantation (PGE1: 24.4 days; controls: 31.8 days; P = .02) and a 40% shorter length of time postoperatively in the intensive care unit (PGE1: 8.2 days; controls 13.7 days; P = .05). Reduced needs for renal support (P = .03) or surgical intervention other than retransplantation (P = .02) were also noted with PGE1 use. Further, PGE1 administration resulted in a trend toward improved survival rates in patients with mild renal impairment (preoperative serum creatinine 1.5 mg percent or greater; P = .08). Neither the incidence of acute cellular rejection nor of primary nonfunction was significantly different in the two groups. Phlebitis was the only complication that was more common during PGE1 administration, (PGE1: 9; controls: 4). These results suggest that PGE1 use in hepatic allograft recipients reduces morbidity and may result in sizable cost reductions.
A randomized, controlled study of the effect of alternate-day prednisone therapy on renal transplant recipients was done on 53 patients followed for 610 patient months. There was no difference between the 17 recipients of related donor organs who received alternate-day prednisone (experimentals) and their 15 controls who received daily prednisone nor between the 11 experimental and 10 control recipients of cadaver donor organs as regards: rejections per patient month, change in serum creatinine, doses of azathioprine or prednisone, or weight. Likewise the controls and experimentals of the related and cadaver groups did not seem different in either their blood pressure change or their tendency to lose their Cushingoid facies. Alternate-day steroids had no obvious effect on the development of posterior subcapsular cataracts in either related or cadaver organ recipients.
It is not known whether the histopathology of the liver allograft can be predicted from biochemical measurements in serum with the same confidence as in the native liver. To answer this question we compared the histopathological diagnoses in 170 biopsy specimens from 70 adult transplant recipients obtained during the first 180 days, with the concentrations of the serum bilirubin and the activities of AST, ALT and alkaline phosphatase measured at the same time. The most frequent diagnosis was cholestasis (n = 45), which was mild, moderate or severe and which may have been complicated by rejection (n = 28) or ischemia (n = 14). Hepatitis (n = 14), ischemia with rejection (n = 6) and spotty focal necrosis (n = 6) were diagnosed less frequently. Fifteen biopsy specimens were reported as histopathologically normal. In general, biochemical measurements discriminated poorly between different histopathological diagnoses. The histopathologically normal liver often showed an abnormal pattern of enzymes and an increase in the serum bilirubin level. As a result histopathologically normal biopsy specimens were indistinguishable biochemically from those with hepatitis. When two pathological conditions were found to coexist (e.g., cholestasis with either rejection or ischemic necrosis, or ischemic necrosis with rejection), the effect on the serum biochemistry was usually not additive and in some instances returned the biochemical abnormalities toward normal. With the exception of the serum bilirubin level, which increased with the severity of uncomplicated cholestasis, we could not identify a specific pattern of biochemical changes corresponding to a given histopathological diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)
An analysis of six cases of parastomal ileal conduit hemorrhage in patients with portal hypertension is presented. The presence of coexisting esophageal varices, documented in only one of six cases (17%), suggests preferential retrograde portal flow through mesenteric venous (as opposed to coronary-azygos) coilateral channels. Venous phase mesenteric angiography offers the best diagnostic specificity and provides inferential evidence regarding overall liver blood flow. Operative therapy should be based on assessment and understanding of the splanchnic circulatory derangements which accompany intrahepatic portal obstruction.
