Abdominal drainage in cirrhosis by use of glass button

ABDOMINAL DRAINAGE IN CIRRHOSIS BY USE OF GLASS BUTTON CHESTER L . DAVIDSON, M .D . Jamaica, New York

HOMAS Tannahill , in 193o reported the use of a glass button in the treatment of ascites in cirrhosis of the liver . He stated its use lay in the fact that it prevented repeated paracentesis . Credit was given to Professor Peter Paterson of Glasgow University for the

design has been used . A typical case history follows A. B., a thirty-nine year old Italian male laborer, was first seen in May, 1934 . He was a heavy drinker of wine, consuming i to 2 galIons daily . His complaint was progressive in-

T

A

B

C

Fic . i . Original button of Tannahill with subsequent modification .

type of button . One case was reported by Tannahill of alcoholic cirrhosis . It was in 1934 that this method was demonstrated to the author at the General Hospital in Montreal . It was successful in preventing repeated tapping of the abdomen . In 1896 Drummond and Morrison' reported the first surgical treatment of ascites . For years the Talina-Morrison' procedure was the only surgical procedure for the relief of ascites . Mayo' and others reported poor results and such a high mortality rate with this procedure that it was dropped by most surgeons . In 1946 Crosby and Cooney' reported five cases of cirrhosis treated by a button of their design with satisfactory improvement . Certain diseases of the human as well as the animal body are prone to produce ascites . The most common diseases encountered are cirrhosis of the liver, cancer, tuberculosis, heart disease and kala-azar . The actual mechanism of the production of ascites still eludes us . There are various factors known but many of the popular concepts as to its cause have been eliminated by experimental work done at Mayo Clinic . 6 This report will deal with thirty-six cases of ascites in which the original button of Paterson with modification of the position as well as the

August, 1 952

crease in the size of his abdomen, loss of appetite and general weakness . Previous medical treatment had not benefited the patient . He was 6 feet 3 inches tall with a dissipated expression, dry tongue and moist skin but no jaundice . The heart was small for so large a person (weight 218 pounds) ; there were no murmurs and the lungs were clear . The abdomen was large and distended; marked dilated veins and "spiders" were present as well as fluid . The liver was palpable three fingerbreadths below the costal cartilage ; spleen and kidneys were not palpable . Red blood count was 4,215,000, hemoglobin 11 .5, white blood count 11,500, neutrophils 8o per cent, non-protein nitrogen 31 mg . and total protein 5 .9 gm. Wassermann test was negative . Liver function tests were not done . Blood pressure on numerous occasions was low, averaging 110/70 . Under local anesthesia two buttons of the original type were inserted after the removal of 2o L. of straw-colored fluid . The patient has not been tapped since . He no longer drinks wine and in May, 1948, total protein was 7.3 . The buttons have not been removed . All the cases reported in this series whose results have been classified as excellent have had equally as good results . The original button as shown by Tannahill

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each side . (Fig . 2 .) Under procain, (2 per cent) local anesthesia a 2 inch incision is made through the skin and subcutaneous tissue . A similar incision is made into the anterior rectus sheath, the rectus muscle is retracted laterally, a stab incision I cm. long is made between two TABLE I RESULTS Type of Cases

No . of Cases

Tuberculosis Malignancy Cardiac

2 2 I 26 t 4

Cirrhosis

FIG . 2 . Insertion of button through rectus sheath .

was a bobbin type made of glass, approximately 1 .5 cm. in diameter and I cm . or more if desired in length . (Fig. IA .) This type of button was used in thirteen cases : two cases of abdominal tuberculosis, two of malignancy with ascites, one of cardiac ascites and eight of cirrhosis of the liver. One case of cirrhosis was very far advanced with marked liver damage . In one of the patients with cirrhosis whose result had been satisfactory for two years the ascites returned . He was reoperated upon and it was found that the abdominal opening in both buttons was plugged with omentum . This necessitated modification of the button . (Fig . iB.) The original button was then modified to have a basket over the abdominal opening to prevent if possible a recurrence of obstruction . Two of the modified original buttons were inserted at that time, in different locations . The patient did well for six months when the ascites recurred . In the meantime, further modification (Fig . IC) had been added . Again the patient was given the benefit of the latest modification which had a basket over each opening and he has not been tapped for four years . TECHNIC

Two buttons are inserted about I inch below the umbilicus, beneath the rectus muscle on

Result

Failure Failure Failure Excellent Fair Failure

hemostats and the abdomen is opened . All fluid is evacuated from the abdominal cavity by suction . The button is then threaded on black silk of sufficient length and a hemostat placed on the end . This is done to prevent loss of the button within the abdomen . The button is then thrust into the opening . (Fig. 2 .) The silk is removed and the rectus muscle allowed to assume its normal position . The rectus sheath and skin are closed with fine interrupted black silk . This procedure is then repeated on the opposite side with a complete new operating set . Figure 3 shows the buttons in place in cross section . To date no deaths have been attributed to this procedure . There has been one infection around one of the buttons . This occurred two months after the patient had had a bowel resection for a large strangulated hernia, and necessitated incision and drainage but not removal of the button . The results of this series of thirty-six cases may be found in Table I . COMMENTS

It has been estimated that I L. of ascitic fluid may contain as much as loo gm . of protein . It seems rational to the writer that by keeping the protein waste at a minimum the general condition of the patient would improve and add greatly to the general treatment . It is known today that the liver will accept damage to a greater degree than formerly thought . This was brought out by Mclndoe 7 and others . The two failures in abdominal tuberculosis, the

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FIG . 3 . Cross section showing position of buttons.

two failures in malignancy and the one in cardiac disease were sufficient to warrant us not to use this procedure in any further cases of these types . The four failures were in far advanced cases of cirrhosis in which reversal was not possible . It would seem that the indications are early cases of ascites due to cirrhosis . The procedure is not intended in any way to supercede the modern medical management but is offered as an adjunct in the treatment . SUMMARY

i . A modification of the method reported by Tannahill is presented . The button has been modified and the position of the button has been changed . 2 . The results of thirty-six cases in which patients were treated by use of buttons are presented .

August, 1952

3 . A new technic of insertion is presented . 4 . The procedure is advocated to prevent loss of protein in early cirrhosis of the liver with ascites . REFERENCES I . TANNAHILL, T . Operative treatment of ascites . Brit . M. J., 1 : 281, 1930. 2 . DRUMMOND, D . and MORRISON R . Case of ascites due to cirrhosis of the liver cured by operation . Brit . M . J ., 2 : 728, 1896 . 3 . TALINA, S . Chirurgische Offnung neuer Seitenbolun fuer das Blut der Vena Porta . Berl . klin . Wchnscbr ., 35 : 833 -836, 1898 . 4 . MAYO, W . J . Surgical treatment of hepatic cirrhosis . Ann . Surg ., 8o : 419-424, 1924 . 5 . CROSBY, R . C . and COONEY, E . A. Surgical treatment of ascites . New England J . Med., 235 : 581, 1946 . 6 . VOLWILER, W ., BOLLMAN, J . L . and GRINDLAY, J . H . A comparsion of two types of experimental ascites . Proc. Staff Meet ., Mayo Clin ., 25 : 31, 1950 . 7 . McINDOE, A . H . Vascular lesions of portal cirrhosis . Arcb . Patb . o Lab . Med., 5 : 23-40, 1928 .