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Omentopexy in the treatment of cirrhosis of the liver
OMENTOPEXY
IN THE TREATMENT OF THE LIVER J.
E. S TRODE,
M.D.,
OF CIRRHOSIS
F.A.C.S.
Surgeon, Queen’s, KRuikeoIani Children’s crnd St. Francis Hospitxls HONOLULU,
T
HE medical treatment of cirrhosis of the Iiver is most discouraging. Of I I 2 cases carefulIy seIected by Chapman, SneII and Rowntree’ as being most suitabIe for medica treatment out of a series of more than 300 cases diagnosed as porta cirrhosis, 34 per cent of the patients had died in sixteen months after onset of ascites, and 75 per cent at the end of six years. They state: Our experience in the treatment of decompensated porta cirrhosis indicates if cases are carefuIly selected about 30 per cent of the patients will make good response to the treatment described and wilI receive marked symptomatic benefit from its use. The end results are not so satisfactory. Viewed either from the medica or surgica1 standpoint one of the chief difficuIties in the treatment of this condition lies in the fact that the diagnosis is rareIy arrived at before porta decompensation has taken pIace as evidenced by abdomina1 ascites or gastric hemorrhages. In a.n analysis of 244 cases of porta cirrhosis by as found at routine postMcCarthy2 mortem examination of I 1,912 ad&s he found 64.4 per cent were active as reveaIed by cIinica1 history and examination, and 35.5 per cent Iatent or not productive of cIinica1 evidence. As was to be expected the pathoIogica1 deveIopment in the Iatent cases was Iess advanced than in the active cases. Since 1889 when TaIma first suggested the possibiIity of benefit from omentopexy in cirrhosis of the Iiver, and Morrison some six years Iater performed the first successful operation it has been the observation of I35
T.
H.
many that the deveIopment of adequate coIIatera1 circuIation between the portal and systemic venous systems is the most worthy therapeutic approach to be considered in the treatment of this condition. That spontaneous deveIopment of normaIIy existing anastomosis between these two systems may take pIace sufficientIy to reIieve porta congestion and prevent clinica1 symptoms undoubtedIy occurs and no doubt accounts for the Iatent cases found at autopsy. and for most cases recovering under medIca treatment. The accompanving diagram iIIustrates the anastomo& most commonly found, though individual variations occur with each case. Also is shown the anastomosis that forms between the vesseIs of the omentum and the epigastric vesseIs when the former is implanted into the abdomina1 waI1. Kegaries” of the Mayo Clinic has recentIy reported on the venous pIexus of the esophagus and its cIinica1 significance. He found even in the absence of porta obstruction concIusive evidence of a channe1 of anastomosis between the porta and cava1 circuIation at the cardio-esophagea1 juncture. AIso he confirmed the resuIts of other workers of a connection between the spIenic and esophagea1 veins by way of the veins that accompany the vasa brevia and the coronary veins. The cIinica1 significance of these findings is that in cirrhosis of the Iiver back pressure on the coronary vein may occur and be transmitted sufficientI) to the cardioesophageal veins to resuh in varices and hematemesis on their rupture. SuccessfuI ligation of the coronary vein in the treatment of this condition has been reported by Rowntree, \Valters and
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sis he found to be the resuIt of obstruction and infection of the biIiary ducts usuaIIy from gaIIstones, and in cases not too far advanced proper operative procedures on the biIiary ducts gave reIief. BiIiary cirrhosis is not the type of cirrhosis being discussed in this paper. Though my experience has necessariIy been Iimited, the outcome in most instances where surgery has been used in cirrhosis of the Iiver has been gratifying, so much so that a reconsideration of the subject seems worth whiIe. In the surgica1 treatment of the condition under discussion one has at his disposa1 three procedures that may prove of vaIue. First and most important the increasing of anastomosis between the porta and systemic circuIation, so that bIood returning from the abdomina1 viscera wiI1 be shunted around the atrophic liver thus One is struck in reviewing the literature preventing porta congestion with resuIting with the fact that some cases are apparentIy abdomina1 ascites, and other cIinica1 manicured whiIe others, the greater number, are not festations. ImpIanting the omentum into benefited at aII. It was with the hope of trying the abdomina1 waI1 by the method preto arrive at some expIanation of this fact that we took up the study of our own cases, ten in viousIy described by others is the procedure number. WhiIe our resuIts have not been of choice, though some have advised strikingIy good they have been good enough roughing the surface of the Iiver, spIeen to make us fee1 that the operation of epipIopexy and other viscera1 organs, This is producis a usefu1 one, one which we can expect to tive of considerabIe shock and is of doubtresuIt in cure in probabIy IO per cent of the fu1 vaIue. Second, decreasing the volume cases and in benefit to a much Iarger percentage. of bIood passing through the porta system. WiIIiam J. Mayo’ divides cirrhosis of the It has been estimated that from 2.5 to Iiver into two fairIy definite groups: First, 35 per cent of the porta bIood passes porta cirrhosis the resuIt of deposits of through the spIeen, therefore removal of connective tissue around the radicIes of the this organ decidedry Iessens the mount of porta vein causing ascites and hemorrhages coIIatera1 circuIation necessary to take care of the porta congestion. And third, from the stomach, and second, biIiary cirrhosis the resuIt of deposits of connective the Iigation of veins to decrease varices as tissue around the biIiary duct system causpreviousIy indicated. The technique of omentopexy is coming chronic jaundice. In the former he parativeIy simpIe and reIativeIy devoid of concIudes that spIenectomy and the TaImaMorison operation combined may have operative shock if the patient’s condition has not become too debiIitated. A right or value, though pointing out the added operative risk of removing the spIeen and Ieft rectus incision aIongside and above the advising estimating the functiona capacity umbiIicus is made, through which exploraof the Iiver beforehand. In the secondary tion of the Iiver or other abdomina1 viscera spIenic type of porta cirrhosis occurring in is carried out. Any interference with the Iate stages of spIenic anemia spIeneccirculation in the round Iigament, such as tomy gave spIendid resuIts. BiIiary cirrhomay occur from transverse incision, is to McIndoe.4 They point out that where back pressure from the spIeen is aIso encountered Iigation of the coronary vein aIone may not be sufficient, but in addition either Iigation of the vasa brevia or spIenectomy may have to be done. From a perusa1 of the avaiIabIe Iiterature for the past ten years and from persona1 conversation with men at various mainIand cIinics over the same period of time it is apparent to me that the operative treatment of cirrhosis of the Iiver, aside from paracentesis for reIief of symptoms, is a procedure not heId in very high esteem by most observers. EIiot and CoIp5 from their experiences concIuded that omentopexy in cirrhosis of the Iiver is of benefit in carefuIIy seIected cases. Gibbon and FIick6 state:
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be avoided as on severa occasions immense dilatation of its veins has been observed and was undoubtedIy serving a most usefu1 purpose in attempting to offset porta obstruction. If a Iarger area for contact with the omentum seems desirabIe than may be procured under one rectus muscIe, the rectus sheath of the opposite side may be opened and the omentum tacked beneath this muscIe. The omentum is drawn out and as much as possibIe, spread about between the posterior surface of the rectus muscIe and fascia and sutured in pIace. The posterior rectus fascia is then sutured snugI?, but not sufflcientIy tightIy to constrict crrcuIation, about the pedicIe of the omenturn. FoIIowing operation, during which time the estabIishment of coIIatera1 circuIation is taking pIace, reaccumuIation of Auid may occur and aspiration become necessary. One case, postoperativeIy, required seven aspirations over a period of five months, and a,nother tweIve during three months. A carefu1 cIosure of the structures of the abdomina1 waI1 is necessary in order to prevent the possibiIity of subsequent incisiona hernia deveIoping. This occurred in one individua1 in which infection of the abdomina1 waI1 took pIace. In the cases here presented an exact pathoIogica1 differentiation into the various types of cirrhosis, so frequentIy made by various writers on the subject, has not been attempted. To me such cIassifications usuaIIy Iack any definite Iine of demarcation, and are probabIy of more scientific interest than practica1 vaIue. In the differentia1 diagnosis one may occasionaIIy be in doubt as to whether the condition is cirrhosis of the liver, tuberculosis invoIving the peritoneum, or maIignancy. An exploratory incision shouId be used in such a (hIemma. RE:PORT
OF
CASES
CASE I. Queen’s Hosp. No. 30,797. MaIe, aged thirty-six. Entered the hosp. February 5, 1925.
Operation February 6, 1925. Discharged February 23, 1925. History of syphilis in 1912. Inadequate treatment. Wassermann reaction in December 1924, 4 plus. EnIarged noduIar Iiver and enlarged spleen. History of gastric hemorrhages for the past year. Given more antiluctic treatment followed by severe hemorrhages, tapped 6 times and given severa hIooc1 transfusions between December 15 and February 6, 1925 at which time omentopexy was done. At operation liver was shrunken, hobnail, spIeen enIarged. FoIIowing operation he was aspirated, at lengthening intervaIs, seven times, the Iast on JuIy 18, 1925. From this time on improvement was steady and continuous, without antiIuetic treatment which he refused. In July, rg2g he came for examination stating he felt well, and was working daily as an electrician. The Iiver was not paIpabIe, the spleen two and one-haIf fingerbreadths below the costal margin. There was some free fluid in the abdomen. Radiating upward and downward from the sight of the omentopexy there were visible, enormousIy diIatec1 veins. He was seen a short time ago and stated his abdomen hacl caused him no further troubIe, though he st,iIl has an easiIy paIpabIe mass in the spIenic area. He has had two smaI1 gastric hemorrhages during the past year. Perhaps ligation of the coronary vein or the short gastric veins would be of value for the controI of these hemorrhages. CASE II. Queen’s Hosp. No. 70,702. .Japanese maIe, aged fifty-two. Entered the hospital October 20, 1931. Operation October 21, 193 I. Discharged November 7, 193 I. Onset one month previous to hospita1 admission with vomiting of blood, coIIapse and deIirium lasting two clays. Transfused at this time. One week Iater abdominal ascites developed, and palpable spIeen Iirst noted. Has been heavy drinker for many years. Previous to operation abdomen tapped twice, 4 Iiters of straw-coIored fluid removed each time. Hgb. 50 per cent, K.B.C. 2,800,000, Ieucocytes 4000, polymorphonuclears 70 per cent, small Iymphocytes 28 per cent. Given 500 CC. titrated bIood twice preoperatively. At operation, under spinal anesthesia through Ieft rectus incision, abdomen found to contain fair amount of straw-coiored fIuid. Liver smaI1, atrophic hobnail. SpIeen enIarged to probabIy three times norma size. Abdomen otherwise negative. Veins of round ligament
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greatIy dilated. Omentopexy. Patient made a good immediate recovery. He has been given intensive antiIuetic treatment, and two years
nese maIe, aged thirty-one. Entered the hospita1 May 6, 1931. Operation August 7, 193 I. Discharged August 15, 1931 (to con-
FIG. 2. Technique
FIG. I. Norma1 anastomosis between portal and systemic circulation, and that produced by omentopexy.
postoperative (November 29, 1933) the Wassermann reaction was I plus. On December 24, 1932 there was a return of ascites and 3 liters of fIuid were removed. At the time of operation an enIarged spIeen was noted but it did not seem advisable and perhaps unnecessary to remove it. On June 6, 1934 the patient returned with reaccumuIation of abdomina1 ffuid and 3000 C.C. were removed. On June 18, 1934, 1800 C.C. were aspirated. The hemogIobin at this time was 40 per cent, and red ceII count 2,400,000. He was given three transfusions, two previous to, and one during operation, and the spIeen which weighed 820 gm. was removed on June 25, 1934. More omentum was aIso impIanted into the abdomina1 waI1. It is one month postoperative now and no fluid has reaccumulated, and the patient looks and feeIs better than at any time since being under my care. The accompanying photograph (Fig. I) shows the enIargement of the inferior mesenteric veins since the omentopexy, and previous to the spIenectomy. Queen’s Hosp. No. 67,337. ChiCASE III.
of omentopexy.
valescent home). Patient had been admitted to the hospita1 1929 and severa times first in January, subsequentIy at which times a diagnosis was made of chronic parenchymatous nephritis. The urine had constantIy shown marked aIbumin, hyaIin and granuIar casts, and the bIood chemistry a high non-protein nitrogen, urea and creatinine. Three weeks previous to present admission he vomited bright red bIood. A week Iater the abdomen began to sweI1. No history of aIcohoIism. Examination of abdomen showed much free fluid. After aspiration of 3700 C.C. ffuid definite enIargement of spIeen feIt extending 3 fingerbreadths beIow Costa1 margin. Liver not paIpabIe. R.B.C. 2,700,000, 3700, poIynucIear Hgb. 44 per cent, W.B.C. Ieucocytes 70 per cent, smaI1 Iymphocytes 26 per cent, Iarge Iymphocytes 2 per cent, eosinophiIes 2 per cent. X-ray chest negative. Urine: trace aIbumin, otherwise negative. StooI negative. Wassermann and Kahn reaction negative. Aspirated ffuid straw coIored. Sp.G. I .004. Smear, few Iymphocytes. BIood pressure I 14/60. Patient in very poor condition. Edema of scrotum and Iegs. Given two transfusions Operation May 22, 1931, spina anesthesia. SmaII, atrophic, hobnai1 liver. SpIeen removed. EnIarged (wt. 727 gm.). Omentopexy. Microof spIeen showed marked scopic section inflammatory reaction with increase in connective tissue. This patient’s postoperative recovery has been most spectacuIar. The Iast aspiration was on August 14, 1931. When Iast seen (January 26, 1934) two years and eight months after
operation, he was feeling well, had returned to work, there was no sign of abdominal fluid. The inferior epigastric veins were markedly diIated and tortuous. The urine was free of aIbumin and there were no casts. Hgb. 72 per cent, K.B.C. 4,350,000, WI3.C. 9800, polynuclear Ieucocytes 36 per cent, smaI1 Iymphocytes 58 per cent, platelet count 230,000, large Iymphocytes 2 per cent, transitiona 9 per cent, eosinophiles 2 per cent, mast ceIIs 3 per cent. Dates of aspirations: Preop:--May 7, 1931-3700 C.C. C.C. i%y 13, 1931-2900 %J’ 20, 1931-1550 C.C. Postop.-June 1, 1931-900 C.C. June 15, 1931-3750 C.C. June 18, 1931-3750 C.C. June 26, 193 I-3950 C.C. .hIy 3, 1931-4000 C.C. July 9, 1931-4000 C.C. .July 15, 1931-3000 C.C. JuIy 20, 1931-3300 C.C. JuIy 25, 1931-1000 C.C. July 31, 1931-3200 C.C. August 7, 1931-4000 C.C. August 14, 1931-4000 C.C. CASE IV. Queen’s Hosp. No. 44,315. Japanese femaIe, aged thirty-four. Entered the hospita1 September 28, 1927. Operation September 30, 1927. Discharged October 14, 1927. History of graduaIIy enIarging abdomen with paIpabIe mass in spIenic region of six months’ duration. Genera1 physical examination negative. Abdomen distended, containing much free fluid, with spleen 3 fingerbreadths below Costa1 margin. 1v.n.C. 2400, poIynucIear Ieucocytes 68 per cent, small Iymphocytes 24 per cent, Iarge Iymphocytes 4 per cent, eosinophiles 4 per cent. R.B.~:. 3,600,000. Hgb. 50 per cent. Wassermann reaction negative. The icterus index was 2, and the serum biIirubin test was negative. Blood pressure 130/80. Urine negative. At operation the abdomen was found filled with straw-coIored fluid, the Iiver was smaI1 and atrophied, but not markedIy so, the spIeen was enIargec1. The spIeen was removed without difficulty, foIIowed by omentopexy. Weight of spleen 523 gm. (three times normal). Microscopic section showed marked fibrosis, MaIpighian bodies atrophied. The patient made an uneventfu1 recovery and required no postoperative tapping, though the fluid reaccumuIated to a considerabIe degree for two months then disappeared. When Iast examined
on January 3, 1934 ( six years after operation) she was in excehent health. She had given birth to three normal chiIdren since operation
FIG. 3. Sho\ving d&ted
inferior epignstric omentopesy.
wins
after
and there was no sign of abdominal fIuid. The veins in the abdomina1 ~a11 were not enlarged. The two foregoing cases may come under the ckkfication of spIenic anemia or Banti’s disease and possibIy would have recovered by splenectomy aIone. In Cases I and v the patients aIso had enIarged spleens which were not removed, and thev also recovered, or at least showed great cknicai improvement. Examination of the abdominaI walls now show marked enIargement of the epigastric vein in Cases I, II, III and v, but not IV. Just what reIiable criteria one may depend upon in determining when to remove an enIarged spleen in the presence of cirrhosis of the liver has not been determined. One is usually dealing with a debihtated individua1 and adding splenectomy to omentopexy converts a fairIy simple procedure into one of considerabIe Removal of the spleen unmagnitude.
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doubtedIy relieves the porta circuIation of a considerabIe voIume of bIood and in cases of spIenic anemia evidentIy has a specific action on the course of the disease. CASE v. Queen’s Hosp. No. 79,877. American maIe, aged forty-six. Entered the hospita1 April 25, 1933. Operation ApriI 29, 1933. Discharged June 6, I933 (to convaIescent home). EnIarging abdomen for two months with distress. Jaundice for past two weeks, with itchiness of skin. EnIarged noduIar Iiver extending to umbihcus, enIarged spIeen extending 4 fingerbreadths beIow Costa1 margin, abdomina1 ffuid. Wassermann and Kahn reactions negative. R.B.C. 4,280,000, Hgb. 80 per W.B.C. 4100, poIynucIear Ieucocytes cent, 71 per cent, smaI1 Iymphocytes 23 per cent. Urine negative except trace of aIbumin. Non-protein nitrogen 28.5 mg. per 100 C.C. bIood. Blood sugar IOO mg. per IOO C.C. bIood. van den Bergh’s test, direct reaction positive, 57.75 mg. biIirubin per Iiter. BIood pressure 124/60. X-ray of chest negative. ApriI 26, abdomen aspirated and 4900 C.C. of straw-coIored fluid removed. Specific gravity 1014. Heavy aIbumin, biIe negative. Preoperative diagnosis, probabIy carcinoma invoIving Iiver, possibIe cirrhosis of the Iiver. ExpIoration ApriI 29, under IocaI I933 anesthesia showed enIarged noduIar Iiver with cirrhotic changes producing hobnai1 appearance. No evidence of malignancy seen. Omentopexy done. Postoperative course: Some infection of the abdomina1 waI1 occurred and an incisiona hernia has deveIoped. May 14, 1933, IOOO C.C. straw-coIored fluid aspirated. May 27, 1933 van den Bergh’s test 31.5 mg. biIirubin per liter of bIood. June 6, 1933 sent to convaIescent home much improved. Since this time he has had no further medica treatment, is abIe to be about and wouId return to Iight work if job were avaiIabIe. CASE VI. Queen’s Hosp. No. 83,094. Chinese, maIe, aged thirty-seven. Entered the hospita1 December 6, 1933. Operation December 13, 1933. Discharged December 29, 1933 (to convaIescent home). History of swoIIen abdomen for one and onehalf weeks. No other symptoms except sIight abdomina1 discomfort heavy mea1. after
Examination, Occasiona user of aIcoho1. except for abdomina1 ascites, negative. Liver and spIeen not paIpabIe. Wassermann and Kahn reactions negative. Urine negative. Hgb. 80 per cent. R.B.C. 4,100,000, W.B.C. 4100, poIymorphonucIears 52 per cent, smaI1 lymphocytes 43 per cent, Iarge Iymphocytes 3 per cent, eosinophiIes 2 per cent. X-ray of chest negative. December 8, 1933, 1500 C.C. of straw-coIored ffuid aspirated from abdomen. Sp. G. 1011, sIightIy aIkaIine. Smear showed few Iymphocytes. At operation, a considerabIe amount of straw-coIored fluid in abdomen. Liver smaI1, showed typica changes of cirrhoUneventfuI postoperative sis. Omentopexy. recovery. Patient seen February 3, 1934. No reaccumuIation of abdomina1 fluid, veins in abdominal waI1 above and beIow region of omentopexy becoming distinctIy dilated. WouId Iike to return to work if job avaiIabIe. CASE VII. Queen’s Hosp. No. 69,165. Chinese, maIe, aged seventy. Entered the hospitaI August 3, 1931. Operation August 7, 1931. Discharged August 31, 1931. Came under observation on August 3, 1931 with history of pain over gaII-bIadder region of severa days’ duration. There was tenderness and muscIe spasm in right upper quadrant. No abdomina1 masses or fluid made out. The temperature was 99.6%., W.B.C. 5600, urine negative. GaII-bIadder visuaIization showed a faint shadow with poor emptying, suggestive to the roentgenoIogist of possibIe gaII-bladder disease. The pain became more severe and expIoration seemed justified with a preoperative diagnosis of gaIIstone coIic. At operation under spina anesthesia the Iiver was found to be markedIy atrophic and hobnai1 in character. There was some free fluid in the abdomina1 cavity. The gaI1 bIadder Iooked and feIt normaI. The stomach, pancreas and other adjacent organs appeared to be normaI. An omentopexy was done. The patient made an uneventful recovery and was not seen again after Ieaving the hospita1. When attempting to trace the outcome of this patient in preparation for this paper it was Iearned that he had died about one year foIIowing operation, and the cause of death as given by another physician was carcinoma of stomach and Iiver. Whether this diagnosis was correct, or whether he died from porta decompensation I have not been abIe to determine.
NEW
SERIES VOL.XXVIII, No. I
CASE
VIII.
Queen’s
Strode-Omentopexy Hosp.
No.
49,924.
P. l-l., aged thirty-three. Entered the hospital October 2, 1928. Operation October 17, 1928. Died October 26, 1928. During past year frequent removal of abdominaI fluid up to 8 Iiters. On admission to hospital emaciated, abdomen distended with fluid, liver not enlarged. SpIeen palpable. Operation under local anesthesia showed marked atrophy, hobnail liver with splenic enlargement. Omentopexy. Patient did we11 until eighth clay. DeveIoped hiccough, became weaker and expired on 10th postoperative day. Autopsy showed omentum in pIace, heaIing well, small amount of peritonea1 fluid, atrophic liver, hypertrophic spleen. Death was attributed to hepatic toxicosis. CONCLUSION
These case reports cover the experience I have had, both good and bad, with the surgical treatment of cirrhosis of the Iiver. Though the cases have been few and the Iapse of time in some instances too short to draw finaI conchrsions, the resuIts have been most encouraging. Even in advanced stages of portal decompensation an omentopexy can be done with a minimum degree of shock in properly prepared patients. With patience, and at times prolonged postoperative care, one may hope even
American
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expect not only to reheve the patient of his but probably enable chnical symptoms, him to return to a usefu1 occupation. With the possibIe exception of splenectomy in certain seIected cases, or more rarely the ligation of veins to contro1 varices, the development of adequate anastomosis between the porta and systemic circuIation, is the onIy therapeutic approach worthy of serious consideration in the treatment of cirrhosis of the Iiver. REFERENCES CHAPMAN, C. B., SNELL, A. M.,
and ROWNTREE, porta cirrhosis. J. A. A/I. A., 9,: No. 4, 237-244 (JuIy 25) 1931. 2. MCCARTHY. J. S. Latent portal cirrhosis of the Liver.
I.
L. G. Decompensated
Arch. Pa&l., 3. 4.
5.
6.
7.
16: 816-838, 19-.
KEGARIES, D. L., B. S. The
venous plexus of the oesophagus. Its clinica significance. Surg. Gynec. Obst., 58: 46-51 (Jan.) 1934. ROWNTREE, L. G., WALTERS, W., and MCINDOE, A. H. End result of tying of the coronary vein for prevention of hemorrhage from oesophageaf varices. Proc. .%a$ Meeting Mayo Clin., 4: 263264, 1929. ELIOT, E., JR. and COLP, R. The operation of omentopexy in cirrhosis of the liver. Surg. Gynec. Obst., 28: 309-318 (March) 1919. GIBBON, J. I-I., and FLICK, J. B. The present status of epiplopexy with the report of ten cases. Ann. Surg. 75: 449-458 (Apr.) 1922. MAYO, W. J. The surgical treatment of hepatic cirrhosis. Ann. Surg., 80: 419-424 (Sept.) 1924.
IN THE TREATMENT OF THE LIVER J.
E. S TRODE,
M.D.,
OF CIRRHOSIS
F.A.C.S.
Surgeon, Queen’s, KRuikeoIani Children’s crnd St. Francis Hospitxls HONOLULU,
T
HE medical treatment of cirrhosis of the Iiver is most discouraging. Of I I 2 cases carefulIy seIected by Chapman, SneII and Rowntree’ as being most suitabIe for medica treatment out of a series of more than 300 cases diagnosed as porta cirrhosis, 34 per cent of the patients had died in sixteen months after onset of ascites, and 75 per cent at the end of six years. They state: Our experience in the treatment of decompensated porta cirrhosis indicates if cases are carefuIly selected about 30 per cent of the patients will make good response to the treatment described and wilI receive marked symptomatic benefit from its use. The end results are not so satisfactory. Viewed either from the medica or surgica1 standpoint one of the chief difficuIties in the treatment of this condition lies in the fact that the diagnosis is rareIy arrived at before porta decompensation has taken pIace as evidenced by abdomina1 ascites or gastric hemorrhages. In a.n analysis of 244 cases of porta cirrhosis by as found at routine postMcCarthy2 mortem examination of I 1,912 ad&s he found 64.4 per cent were active as reveaIed by cIinica1 history and examination, and 35.5 per cent Iatent or not productive of cIinica1 evidence. As was to be expected the pathoIogica1 deveIopment in the Iatent cases was Iess advanced than in the active cases. Since 1889 when TaIma first suggested the possibiIity of benefit from omentopexy in cirrhosis of the Iiver, and Morrison some six years Iater performed the first successful operation it has been the observation of I35
T.
H.
many that the deveIopment of adequate coIIatera1 circuIation between the portal and systemic venous systems is the most worthy therapeutic approach to be considered in the treatment of this condition. That spontaneous deveIopment of normaIIy existing anastomosis between these two systems may take pIace sufficientIy to reIieve porta congestion and prevent clinica1 symptoms undoubtedIy occurs and no doubt accounts for the Iatent cases found at autopsy. and for most cases recovering under medIca treatment. The accompanving diagram iIIustrates the anastomo& most commonly found, though individual variations occur with each case. Also is shown the anastomosis that forms between the vesseIs of the omentum and the epigastric vesseIs when the former is implanted into the abdomina1 waI1. Kegaries” of the Mayo Clinic has recentIy reported on the venous pIexus of the esophagus and its cIinica1 significance. He found even in the absence of porta obstruction concIusive evidence of a channe1 of anastomosis between the porta and cava1 circuIation at the cardio-esophagea1 juncture. AIso he confirmed the resuIts of other workers of a connection between the spIenic and esophagea1 veins by way of the veins that accompany the vasa brevia and the coronary veins. The cIinica1 significance of these findings is that in cirrhosis of the Iiver back pressure on the coronary vein may occur and be transmitted sufficientI) to the cardioesophageal veins to resuh in varices and hematemesis on their rupture. SuccessfuI ligation of the coronary vein in the treatment of this condition has been reported by Rowntree, \Valters and
136
American Journal of Surgery
Strode-Omentopexy
sis he found to be the resuIt of obstruction and infection of the biIiary ducts usuaIIy from gaIIstones, and in cases not too far advanced proper operative procedures on the biIiary ducts gave reIief. BiIiary cirrhosis is not the type of cirrhosis being discussed in this paper. Though my experience has necessariIy been Iimited, the outcome in most instances where surgery has been used in cirrhosis of the Iiver has been gratifying, so much so that a reconsideration of the subject seems worth whiIe. In the surgica1 treatment of the condition under discussion one has at his disposa1 three procedures that may prove of vaIue. First and most important the increasing of anastomosis between the porta and systemic circuIation, so that bIood returning from the abdomina1 viscera wiI1 be shunted around the atrophic liver thus One is struck in reviewing the literature preventing porta congestion with resuIting with the fact that some cases are apparentIy abdomina1 ascites, and other cIinica1 manicured whiIe others, the greater number, are not festations. ImpIanting the omentum into benefited at aII. It was with the hope of trying the abdomina1 waI1 by the method preto arrive at some expIanation of this fact that we took up the study of our own cases, ten in viousIy described by others is the procedure number. WhiIe our resuIts have not been of choice, though some have advised strikingIy good they have been good enough roughing the surface of the Iiver, spIeen to make us fee1 that the operation of epipIopexy and other viscera1 organs, This is producis a usefu1 one, one which we can expect to tive of considerabIe shock and is of doubtresuIt in cure in probabIy IO per cent of the fu1 vaIue. Second, decreasing the volume cases and in benefit to a much Iarger percentage. of bIood passing through the porta system. WiIIiam J. Mayo’ divides cirrhosis of the It has been estimated that from 2.5 to Iiver into two fairIy definite groups: First, 35 per cent of the porta bIood passes porta cirrhosis the resuIt of deposits of through the spIeen, therefore removal of connective tissue around the radicIes of the this organ decidedry Iessens the mount of porta vein causing ascites and hemorrhages coIIatera1 circuIation necessary to take care of the porta congestion. And third, from the stomach, and second, biIiary cirrhosis the resuIt of deposits of connective the Iigation of veins to decrease varices as tissue around the biIiary duct system causpreviousIy indicated. The technique of omentopexy is coming chronic jaundice. In the former he parativeIy simpIe and reIativeIy devoid of concIudes that spIenectomy and the TaImaMorison operation combined may have operative shock if the patient’s condition has not become too debiIitated. A right or value, though pointing out the added operative risk of removing the spIeen and Ieft rectus incision aIongside and above the advising estimating the functiona capacity umbiIicus is made, through which exploraof the Iiver beforehand. In the secondary tion of the Iiver or other abdomina1 viscera spIenic type of porta cirrhosis occurring in is carried out. Any interference with the Iate stages of spIenic anemia spIeneccirculation in the round Iigament, such as tomy gave spIendid resuIts. BiIiary cirrhomay occur from transverse incision, is to McIndoe.4 They point out that where back pressure from the spIeen is aIso encountered Iigation of the coronary vein aIone may not be sufficient, but in addition either Iigation of the vasa brevia or spIenectomy may have to be done. From a perusa1 of the avaiIabIe Iiterature for the past ten years and from persona1 conversation with men at various mainIand cIinics over the same period of time it is apparent to me that the operative treatment of cirrhosis of the Iiver, aside from paracentesis for reIief of symptoms, is a procedure not heId in very high esteem by most observers. EIiot and CoIp5 from their experiences concIuded that omentopexy in cirrhosis of the Iiver is of benefit in carefuIIy seIected cases. Gibbon and FIick6 state:
NE\\
SERIES
\<,I..
YSVIII,
No.
Strode--0mentopexy
I
be avoided as on severa occasions immense dilatation of its veins has been observed and was undoubtedIy serving a most usefu1 purpose in attempting to offset porta obstruction. If a Iarger area for contact with the omentum seems desirabIe than may be procured under one rectus muscIe, the rectus sheath of the opposite side may be opened and the omentum tacked beneath this muscIe. The omentum is drawn out and as much as possibIe, spread about between the posterior surface of the rectus muscIe and fascia and sutured in pIace. The posterior rectus fascia is then sutured snugI?, but not sufflcientIy tightIy to constrict crrcuIation, about the pedicIe of the omenturn. FoIIowing operation, during which time the estabIishment of coIIatera1 circuIation is taking pIace, reaccumuIation of Auid may occur and aspiration become necessary. One case, postoperativeIy, required seven aspirations over a period of five months, and a,nother tweIve during three months. A carefu1 cIosure of the structures of the abdomina1 waI1 is necessary in order to prevent the possibiIity of subsequent incisiona hernia deveIoping. This occurred in one individua1 in which infection of the abdomina1 waI1 took pIace. In the cases here presented an exact pathoIogica1 differentiation into the various types of cirrhosis, so frequentIy made by various writers on the subject, has not been attempted. To me such cIassifications usuaIIy Iack any definite Iine of demarcation, and are probabIy of more scientific interest than practica1 vaIue. In the differentia1 diagnosis one may occasionaIIy be in doubt as to whether the condition is cirrhosis of the liver, tuberculosis invoIving the peritoneum, or maIignancy. An exploratory incision shouId be used in such a (hIemma. RE:PORT
OF
CASES
CASE I. Queen’s Hosp. No. 30,797. MaIe, aged thirty-six. Entered the hosp. February 5, 1925.
Operation February 6, 1925. Discharged February 23, 1925. History of syphilis in 1912. Inadequate treatment. Wassermann reaction in December 1924, 4 plus. EnIarged noduIar Iiver and enlarged spleen. History of gastric hemorrhages for the past year. Given more antiluctic treatment followed by severe hemorrhages, tapped 6 times and given severa hIooc1 transfusions between December 15 and February 6, 1925 at which time omentopexy was done. At operation liver was shrunken, hobnail, spIeen enIarged. FoIIowing operation he was aspirated, at lengthening intervaIs, seven times, the Iast on JuIy 18, 1925. From this time on improvement was steady and continuous, without antiIuetic treatment which he refused. In July, rg2g he came for examination stating he felt well, and was working daily as an electrician. The Iiver was not paIpabIe, the spleen two and one-haIf fingerbreadths below the costal margin. There was some free fluid in the abdomen. Radiating upward and downward from the sight of the omentopexy there were visible, enormousIy diIatec1 veins. He was seen a short time ago and stated his abdomen hacl caused him no further troubIe, though he st,iIl has an easiIy paIpabIe mass in the spIenic area. He has had two smaI1 gastric hemorrhages during the past year. Perhaps ligation of the coronary vein or the short gastric veins would be of value for the controI of these hemorrhages. CASE II. Queen’s Hosp. No. 70,702. .Japanese maIe, aged fifty-two. Entered the hospital October 20, 1931. Operation October 21, 193 I. Discharged November 7, 193 I. Onset one month previous to hospita1 admission with vomiting of blood, coIIapse and deIirium lasting two clays. Transfused at this time. One week Iater abdominal ascites developed, and palpable spIeen Iirst noted. Has been heavy drinker for many years. Previous to operation abdomen tapped twice, 4 Iiters of straw-coIored fluid removed each time. Hgb. 50 per cent, K.B.C. 2,800,000, Ieucocytes 4000, polymorphonuclears 70 per cent, small Iymphocytes 28 per cent. Given 500 CC. titrated bIood twice preoperatively. At operation, under spinal anesthesia through Ieft rectus incision, abdomen found to contain fair amount of straw-coiored fIuid. Liver smaI1, atrophic hobnail. SpIeen enIarged to probabIy three times norma size. Abdomen otherwise negative. Veins of round ligament
138
American
Journal of Surgery
Strode-Omentopexy
greatIy dilated. Omentopexy. Patient made a good immediate recovery. He has been given intensive antiIuetic treatment, and two years
nese maIe, aged thirty-one. Entered the hospita1 May 6, 1931. Operation August 7, 193 I. Discharged August 15, 1931 (to con-
FIG. 2. Technique
FIG. I. Norma1 anastomosis between portal and systemic circulation, and that produced by omentopexy.
postoperative (November 29, 1933) the Wassermann reaction was I plus. On December 24, 1932 there was a return of ascites and 3 liters of fIuid were removed. At the time of operation an enIarged spIeen was noted but it did not seem advisable and perhaps unnecessary to remove it. On June 6, 1934 the patient returned with reaccumuIation of abdomina1 ffuid and 3000 C.C. were removed. On June 18, 1934, 1800 C.C. were aspirated. The hemogIobin at this time was 40 per cent, and red ceII count 2,400,000. He was given three transfusions, two previous to, and one during operation, and the spIeen which weighed 820 gm. was removed on June 25, 1934. More omentum was aIso impIanted into the abdomina1 waI1. It is one month postoperative now and no fluid has reaccumulated, and the patient looks and feeIs better than at any time since being under my care. The accompanying photograph (Fig. I) shows the enIargement of the inferior mesenteric veins since the omentopexy, and previous to the spIenectomy. Queen’s Hosp. No. 67,337. ChiCASE III.
of omentopexy.
valescent home). Patient had been admitted to the hospita1 1929 and severa times first in January, subsequentIy at which times a diagnosis was made of chronic parenchymatous nephritis. The urine had constantIy shown marked aIbumin, hyaIin and granuIar casts, and the bIood chemistry a high non-protein nitrogen, urea and creatinine. Three weeks previous to present admission he vomited bright red bIood. A week Iater the abdomen began to sweI1. No history of aIcohoIism. Examination of abdomen showed much free fluid. After aspiration of 3700 C.C. ffuid definite enIargement of spIeen feIt extending 3 fingerbreadths beIow Costa1 margin. Liver not paIpabIe. R.B.C. 2,700,000, 3700, poIynucIear Hgb. 44 per cent, W.B.C. Ieucocytes 70 per cent, smaI1 Iymphocytes 26 per cent, Iarge Iymphocytes 2 per cent, eosinophiIes 2 per cent. X-ray chest negative. Urine: trace aIbumin, otherwise negative. StooI negative. Wassermann and Kahn reaction negative. Aspirated ffuid straw coIored. Sp.G. I .004. Smear, few Iymphocytes. BIood pressure I 14/60. Patient in very poor condition. Edema of scrotum and Iegs. Given two transfusions Operation May 22, 1931, spina anesthesia. SmaII, atrophic, hobnai1 liver. SpIeen removed. EnIarged (wt. 727 gm.). Omentopexy. Microof spIeen showed marked scopic section inflammatory reaction with increase in connective tissue. This patient’s postoperative recovery has been most spectacuIar. The Iast aspiration was on August 14, 1931. When Iast seen (January 26, 1934) two years and eight months after
operation, he was feeling well, had returned to work, there was no sign of abdominal fluid. The inferior epigastric veins were markedly diIated and tortuous. The urine was free of aIbumin and there were no casts. Hgb. 72 per cent, K.B.C. 4,350,000, WI3.C. 9800, polynuclear Ieucocytes 36 per cent, smaI1 Iymphocytes 58 per cent, platelet count 230,000, large Iymphocytes 2 per cent, transitiona 9 per cent, eosinophiles 2 per cent, mast ceIIs 3 per cent. Dates of aspirations: Preop:--May 7, 1931-3700 C.C. C.C. i%y 13, 1931-2900 %J’ 20, 1931-1550 C.C. Postop.-June 1, 1931-900 C.C. June 15, 1931-3750 C.C. June 18, 1931-3750 C.C. June 26, 193 I-3950 C.C. .hIy 3, 1931-4000 C.C. July 9, 1931-4000 C.C. .July 15, 1931-3000 C.C. JuIy 20, 1931-3300 C.C. JuIy 25, 1931-1000 C.C. July 31, 1931-3200 C.C. August 7, 1931-4000 C.C. August 14, 1931-4000 C.C. CASE IV. Queen’s Hosp. No. 44,315. Japanese femaIe, aged thirty-four. Entered the hospita1 September 28, 1927. Operation September 30, 1927. Discharged October 14, 1927. History of graduaIIy enIarging abdomen with paIpabIe mass in spIenic region of six months’ duration. Genera1 physical examination negative. Abdomen distended, containing much free fluid, with spleen 3 fingerbreadths below Costa1 margin. 1v.n.C. 2400, poIynucIear Ieucocytes 68 per cent, small Iymphocytes 24 per cent, Iarge Iymphocytes 4 per cent, eosinophiles 4 per cent. R.B.~:. 3,600,000. Hgb. 50 per cent. Wassermann reaction negative. The icterus index was 2, and the serum biIirubin test was negative. Blood pressure 130/80. Urine negative. At operation the abdomen was found filled with straw-coIored fluid, the Iiver was smaI1 and atrophied, but not markedIy so, the spIeen was enIargec1. The spIeen was removed without difficulty, foIIowed by omentopexy. Weight of spleen 523 gm. (three times normal). Microscopic section showed marked fibrosis, MaIpighian bodies atrophied. The patient made an uneventfu1 recovery and required no postoperative tapping, though the fluid reaccumuIated to a considerabIe degree for two months then disappeared. When Iast examined
on January 3, 1934 ( six years after operation) she was in excehent health. She had given birth to three normal chiIdren since operation
FIG. 3. Sho\ving d&ted
inferior epignstric omentopesy.
wins
after
and there was no sign of abdominal fIuid. The veins in the abdomina1 ~a11 were not enlarged. The two foregoing cases may come under the ckkfication of spIenic anemia or Banti’s disease and possibIy would have recovered by splenectomy aIone. In Cases I and v the patients aIso had enIarged spleens which were not removed, and thev also recovered, or at least showed great cknicai improvement. Examination of the abdominaI walls now show marked enIargement of the epigastric vein in Cases I, II, III and v, but not IV. Just what reIiable criteria one may depend upon in determining when to remove an enIarged spleen in the presence of cirrhosis of the liver has not been determined. One is usually dealing with a debihtated individua1 and adding splenectomy to omentopexy converts a fairIy simple procedure into one of considerabIe Removal of the spleen unmagnitude.
140
American
Journal
of Surgery
StrodeOmentopexy
doubtedIy relieves the porta circuIation of a considerabIe voIume of bIood and in cases of spIenic anemia evidentIy has a specific action on the course of the disease. CASE v. Queen’s Hosp. No. 79,877. American maIe, aged forty-six. Entered the hospita1 April 25, 1933. Operation ApriI 29, 1933. Discharged June 6, I933 (to convaIescent home). EnIarging abdomen for two months with distress. Jaundice for past two weeks, with itchiness of skin. EnIarged noduIar Iiver extending to umbihcus, enIarged spIeen extending 4 fingerbreadths beIow Costa1 margin, abdomina1 ffuid. Wassermann and Kahn reactions negative. R.B.C. 4,280,000, Hgb. 80 per W.B.C. 4100, poIynucIear Ieucocytes cent, 71 per cent, smaI1 Iymphocytes 23 per cent. Urine negative except trace of aIbumin. Non-protein nitrogen 28.5 mg. per 100 C.C. bIood. Blood sugar IOO mg. per IOO C.C. bIood. van den Bergh’s test, direct reaction positive, 57.75 mg. biIirubin per Iiter. BIood pressure 124/60. X-ray of chest negative. ApriI 26, abdomen aspirated and 4900 C.C. of straw-coIored fluid removed. Specific gravity 1014. Heavy aIbumin, biIe negative. Preoperative diagnosis, probabIy carcinoma invoIving Iiver, possibIe cirrhosis of the Iiver. ExpIoration ApriI 29, under IocaI I933 anesthesia showed enIarged noduIar Iiver with cirrhotic changes producing hobnai1 appearance. No evidence of malignancy seen. Omentopexy done. Postoperative course: Some infection of the abdomina1 waI1 occurred and an incisiona hernia has deveIoped. May 14, 1933, IOOO C.C. straw-coIored fluid aspirated. May 27, 1933 van den Bergh’s test 31.5 mg. biIirubin per liter of bIood. June 6, 1933 sent to convaIescent home much improved. Since this time he has had no further medica treatment, is abIe to be about and wouId return to Iight work if job were avaiIabIe. CASE VI. Queen’s Hosp. No. 83,094. Chinese, maIe, aged thirty-seven. Entered the hospita1 December 6, 1933. Operation December 13, 1933. Discharged December 29, 1933 (to convaIescent home). History of swoIIen abdomen for one and onehalf weeks. No other symptoms except sIight abdomina1 discomfort heavy mea1. after
Examination, Occasiona user of aIcoho1. except for abdomina1 ascites, negative. Liver and spIeen not paIpabIe. Wassermann and Kahn reactions negative. Urine negative. Hgb. 80 per cent. R.B.C. 4,100,000, W.B.C. 4100, poIymorphonucIears 52 per cent, smaI1 lymphocytes 43 per cent, Iarge Iymphocytes 3 per cent, eosinophiIes 2 per cent. X-ray of chest negative. December 8, 1933, 1500 C.C. of straw-coIored ffuid aspirated from abdomen. Sp. G. 1011, sIightIy aIkaIine. Smear showed few Iymphocytes. At operation, a considerabIe amount of straw-coIored fluid in abdomen. Liver smaI1, showed typica changes of cirrhoUneventfuI postoperative sis. Omentopexy. recovery. Patient seen February 3, 1934. No reaccumuIation of abdomina1 fluid, veins in abdominal waI1 above and beIow region of omentopexy becoming distinctIy dilated. WouId Iike to return to work if job avaiIabIe. CASE VII. Queen’s Hosp. No. 69,165. Chinese, maIe, aged seventy. Entered the hospitaI August 3, 1931. Operation August 7, 1931. Discharged August 31, 1931. Came under observation on August 3, 1931 with history of pain over gaII-bIadder region of severa days’ duration. There was tenderness and muscIe spasm in right upper quadrant. No abdomina1 masses or fluid made out. The temperature was 99.6%., W.B.C. 5600, urine negative. GaII-bIadder visuaIization showed a faint shadow with poor emptying, suggestive to the roentgenoIogist of possibIe gaII-bladder disease. The pain became more severe and expIoration seemed justified with a preoperative diagnosis of gaIIstone coIic. At operation under spina anesthesia the Iiver was found to be markedIy atrophic and hobnai1 in character. There was some free fluid in the abdomina1 cavity. The gaI1 bIadder Iooked and feIt normaI. The stomach, pancreas and other adjacent organs appeared to be normaI. An omentopexy was done. The patient made an uneventful recovery and was not seen again after Ieaving the hospita1. When attempting to trace the outcome of this patient in preparation for this paper it was Iearned that he had died about one year foIIowing operation, and the cause of death as given by another physician was carcinoma of stomach and Iiver. Whether this diagnosis was correct, or whether he died from porta decompensation I have not been abIe to determine.
NEW
SERIES VOL.XXVIII, No. I
CASE
VIII.
Queen’s
Strode-Omentopexy Hosp.
No.
49,924.
P. l-l., aged thirty-three. Entered the hospital October 2, 1928. Operation October 17, 1928. Died October 26, 1928. During past year frequent removal of abdominaI fluid up to 8 Iiters. On admission to hospital emaciated, abdomen distended with fluid, liver not enlarged. SpIeen palpable. Operation under local anesthesia showed marked atrophy, hobnail liver with splenic enlargement. Omentopexy. Patient did we11 until eighth clay. DeveIoped hiccough, became weaker and expired on 10th postoperative day. Autopsy showed omentum in pIace, heaIing well, small amount of peritonea1 fluid, atrophic liver, hypertrophic spleen. Death was attributed to hepatic toxicosis. CONCLUSION
These case reports cover the experience I have had, both good and bad, with the surgical treatment of cirrhosis of the Iiver. Though the cases have been few and the Iapse of time in some instances too short to draw finaI conchrsions, the resuIts have been most encouraging. Even in advanced stages of portal decompensation an omentopexy can be done with a minimum degree of shock in properly prepared patients. With patience, and at times prolonged postoperative care, one may hope even
American
Journal
of Surgery
141
expect not only to reheve the patient of his but probably enable chnical symptoms, him to return to a usefu1 occupation. With the possibIe exception of splenectomy in certain seIected cases, or more rarely the ligation of veins to contro1 varices, the development of adequate anastomosis between the porta and systemic circuIation, is the onIy therapeutic approach worthy of serious consideration in the treatment of cirrhosis of the Iiver. REFERENCES CHAPMAN, C. B., SNELL, A. M.,
and ROWNTREE, porta cirrhosis. J. A. A/I. A., 9,: No. 4, 237-244 (JuIy 25) 1931. 2. MCCARTHY. J. S. Latent portal cirrhosis of the Liver.
I.
L. G. Decompensated
Arch. Pa&l., 3. 4.
5.
6.
7.
16: 816-838, 19-.
KEGARIES, D. L., B. S. The
venous plexus of the oesophagus. Its clinica significance. Surg. Gynec. Obst., 58: 46-51 (Jan.) 1934. ROWNTREE, L. G., WALTERS, W., and MCINDOE, A. H. End result of tying of the coronary vein for prevention of hemorrhage from oesophageaf varices. Proc. .%a$ Meeting Mayo Clin., 4: 263264, 1929. ELIOT, E., JR. and COLP, R. The operation of omentopexy in cirrhosis of the liver. Surg. Gynec. Obst., 28: 309-318 (March) 1919. GIBBON, J. I-I., and FLICK, J. B. The present status of epiplopexy with the report of ten cases. Ann. Surg. 75: 449-458 (Apr.) 1922. MAYO, W. J. The surgical treatment of hepatic cirrhosis. Ann. Surg., 80: 419-424 (Sept.) 1924.