- Email: [email protected]
Problems in general surgery: Portal hypertension (volume 9, number 3)
BOOK REVIEWS John M. Porter, MD, Book Review Section Editor
"Redo" vascular surgery: Renal aorto-iliac and infrainguinal areas Carlo Spartera, et al., New York, 1992, Raven Press, 352 pages. $90. "T~edo" Vascular Surgery: Renal, Aorto-Iliac and Infrainguinal Areas is divided into four sections, including one devoted to basic considerations in atherosclerosis development, along with sections on redo surgery of the renal, aortoiliac, and infrainguinal areas. Because the chapters are synopses of presentations by numerous contributors, the book is more a collection of essays than a volume with a central theme. The chapters relating to the pathogenesis of atherosclerosis are excellent. They include a summary of the role of the endothelial cell in arterial disease, a clear and concise description of clomng mechanisms, a well-illustrated section on hemodynamic factors associated with the development of arterial thickening, and an in-depth discussion of prosthetic grafts. This section concludes with a short chapter on the pharmacology of preventing graft occlusion. Authors from many countries contributed to this book. It is generally understandable, although some of the chapters suffer from a lack of clarity in translation and occasional spelling errors. The American reader will be more comfortable with the chapters written by American authors, because they are used to this writing style. However, the book contains much valuable information from many parts of the world. The range of topics covered is very broad. Some of the sections are interesting but seem out of place in the book because they do not deal specifically with redo surgery. An example is the ultrasound assessment of renal allograft function. In some instances the chapters are tabular summaries of a voluminous number of publications from all over the world, rather than a concise synthesis of the existing literature with a specific set of recommendations by an expert in the field. The section on recurrent aortoiliac disease is particularly good, containing chapters on the management of aortoiliac graft occlusion and an outstanding chapter on the thrombolytic treatment of late graft occlusion. There are good technique chapters on reoperative procedures in the aortoiliac area and a good summary of thoracobifemoral bypass grafts. Many surgeons will purchase this book expecting to learn techniques in reoperative vascular surgery, and there are good descriptions of operative procedure s in redo arterial surgery. In general, however, the chapters dealing with the technical aspects of these difficult operations are not well illustrated. In view of the price of the book, better diagrams and pictures would be expected. In summary, the book is a good collection of ideas
about the causes, diagnosis, and treatment of redo arterial surgery. Suggestions for improvement would include better translation of some chapters, more concise recommendations by some of the authors, and better illustrations of operative techniques. Blair A. Keagy, MD University of North Carolina Chapel Hill, IV.C.
Problems in general surgery: Portal hypertension (volume 9, number 3) Eric B. Rypins, Philadelphia, 1992, J.B. Lippincott, 175 pages, $35. Vascular surgeons' general distaste for managing the complications of portal hypertension- including bleeding esophagogasttic varices, ascites, hypersplenism, portosystemic encephalopathy-is a curious developmental quirk, because each of these problems arises from abnormalities of vascular pressure, flow, and tissue perfusion. Eric Rypins has edited an issue of Problems in General Surgery that provides, in only 175 pages (12 chapters authored by 33 contributors), a succinct, comprehensive, and timely overview of this rapidly changing field for those of us who involve ourselves with these challenging patients. Among these contributors, Blei's metaanalysis of prospective randomized trials of J3-blockers underscores a survival advantage and protection against repeat variceal bleeding in patients so treated. However, most of these data come from European studies: for unclear reasons the argument is much less persuasive in North America. Yamamoto and Van Stiegmann show that endoscopic rubber band ligation of varices may be as effective as injection variceal sclerotherapy, with substantially fewer of the esophageal cQmplications associated with the latter, more established technique. Rosch and colleagues discuss their experience with angiographic portacaval shunt (transjugular intrahepatic portosystemic shunt), a technique pioneered in Oregon by the senior author in concert with the late Charles Dotter. The conceptual appeal of transjugular intrahepatic portosystemic shunt notwithstanding, its not-trivial incidence of technical failure and its substantial cost, and the absence of even short-term follow-up data cry out for prospective randomized trials. Rikkers and Jin summarize the advantages and shortcomings of the distal splenorenal shunt, now the most commonly performed surgical portal decompression. Despite this procedure's theoretical underpinning (simultaneous variceal decompression and preservation of prograde portal venous flow), the design of the distal splenorenal shunt has become steadily more complicated, and available data do not demonstrate a survival advantage for patients receiving this procedure in comparison to those
1079
JOURNALOF VASCULARSURGERY December 1993
1080 Book reviews
undergoing standard "total" portal decompression. Discussing another technically challenging clinical entity, Sitzmann, Klein, and Cameron summarize current medical, radiologic, and operative management of the BuddChiari Syndrome, a condition in which the senior author has had a seminal involvement. Bready and colleagues from the University of Texas Health Sciences Center at San Antonio provide a lucid description of the simttltaneous diagnostic and therapeutic protocol that must be undertaken in treating patient with cirrhosis with apparent variceal hemorrhage. And two novel topics in this area are discussed by the editor's former colleagues at the University of California at Irvine- portal hypertensive gastropathy, by Sarfeh and Tarnawski, and the demonstration ofhepatocellular perfusion and function with nuclear medicine techniques, by Mllne. Finally, Campbell and colleagues describe the University of Michigan experience with hver transplantation for variceal bleeding. They demonstrate, as have others, that such patients do at least as well after fiver replacement as patients with other causes of terminal liver failure; importantly, they discuss in some detail the ethical and public policy dilemma confronting a society with seemingly limitless numbers of people with alcohol addiction and cirrhosis but with only a few livers to transplant. Surprisingly absent from this compendium is a discussion of the concept and technique of partial portal decompression- the idea that graded decompression of the portal system, down to physiologic portal pressure levels but not below, can result in reliable protection against variceal hemorrhage while mitigating some of the morbidity associated with total portal decompression. Modesty (Rypins and Sarfeh have been leading proponents of this concept) or the lack of prospective randomized comparisons with total shunts (said to be in progress) may be the explanation. Only rarely these days can a topic be covered so thoroughly in less than 200 pages. Rypius and his authors provide an admirable clinical update for the practicing clinician, the resident, or the student with time and inclination enough to learn "what's hot" in the treatment of patients with portal hypertension. Kaj H. Johansen, MD University of Washington Schoolof2~edicine Seattle, Wash.
Current critical problems in vascular surgery, volume 4 Frank J. Veith, St. Louis, 1992, Quality Medical Publishing, 470 pages, $85.
This anthology of vascular disease-related papers is gathered from the annual symposium "Current Critical Problems in Vascular Surgery" and is predicated on the concept that one cannot step into the same river twice; that certitudes will change with time, experience, and analysis; and that change is an essential ingredient in knowledge.
This collection is offered annually to represent current thought and teaching of recognized authorities on vascular topics, both medical and surgical. Subjects highlighted in this symposium range from general issues of interest to all physicians, including both surgeons and nonsurgeons, and more specific topics of special interest to vascular surgeons. An example of a general topic superbly presented is the "primer" on health care policy in the United States, a review presenting history, current dilemmas, and furore (possible) options in a concise, clear form. Ninety pages are devoted to lower extremity revascularization. Several presentations use the point-counterpoint technique for debate of issues: the use of greater saphenous vein versus polytetrafluorethylene, above- versus belowknee grafting, and tho, role of concomitant arteriovenous fistula creation are all revisited. Other topics of interest include the natural history of superficial femoral artery stenosis, the fate of the remaining nonharvested greater saphenous vein, reoperative leg surgery, and the prevention of leg wound complications. The section on venous surgery is interesting and current, although both the long- and intermediate-term outcomes of venous operative procedures are presently unknown. The controversial areas of endovascular and thrombolytic therapy in the arterial system evoke the anticipated emotion and bias of the essayist. The papers reviewing aortic surgery present an interesting overview of a number of specific topics. Representative subjects include optimal graft configuration, surgical approach, selection of patients, and complications (i.e., paraplegia). All are useful, appropriate, and well-written. Carotid artery and upper extremity evaluation and treatment and cardiac risks are all covered with appropriate new information. The writing and editing style of this book is that of the format of the JOUR_~aLOF VASCULAr, SUR~a:C. As expected with a compilation of chapters from numerous authors, the readability of the individual articles varies. One gets the impression the "book" could have been put together in a loose-leaf binder or possibly in two or three medical journal-sized printings. This resource volume is most appropriate for those surgeons actively involved in clinical vascular surgery. The controversies described are those encountered on a daily basis by vascular surgeons and serve to remind us that understanding changes with time. Gerald Baur, MD Boise, Idaho
The crisis in clinical research: Overcoming institutional obstacles Edward H. Ahrens, Jr., New York, 1992, Oxford University Press, 236 pages, $29.95. The stated purpose of this book is to provide an analysis of the factors contributing to a crisis in or an endangerment
"Redo" vascular surgery: Renal aorto-iliac and infrainguinal areas Carlo Spartera, et al., New York, 1992, Raven Press, 352 pages. $90. "T~edo" Vascular Surgery: Renal, Aorto-Iliac and Infrainguinal Areas is divided into four sections, including one devoted to basic considerations in atherosclerosis development, along with sections on redo surgery of the renal, aortoiliac, and infrainguinal areas. Because the chapters are synopses of presentations by numerous contributors, the book is more a collection of essays than a volume with a central theme. The chapters relating to the pathogenesis of atherosclerosis are excellent. They include a summary of the role of the endothelial cell in arterial disease, a clear and concise description of clomng mechanisms, a well-illustrated section on hemodynamic factors associated with the development of arterial thickening, and an in-depth discussion of prosthetic grafts. This section concludes with a short chapter on the pharmacology of preventing graft occlusion. Authors from many countries contributed to this book. It is generally understandable, although some of the chapters suffer from a lack of clarity in translation and occasional spelling errors. The American reader will be more comfortable with the chapters written by American authors, because they are used to this writing style. However, the book contains much valuable information from many parts of the world. The range of topics covered is very broad. Some of the sections are interesting but seem out of place in the book because they do not deal specifically with redo surgery. An example is the ultrasound assessment of renal allograft function. In some instances the chapters are tabular summaries of a voluminous number of publications from all over the world, rather than a concise synthesis of the existing literature with a specific set of recommendations by an expert in the field. The section on recurrent aortoiliac disease is particularly good, containing chapters on the management of aortoiliac graft occlusion and an outstanding chapter on the thrombolytic treatment of late graft occlusion. There are good technique chapters on reoperative procedures in the aortoiliac area and a good summary of thoracobifemoral bypass grafts. Many surgeons will purchase this book expecting to learn techniques in reoperative vascular surgery, and there are good descriptions of operative procedure s in redo arterial surgery. In general, however, the chapters dealing with the technical aspects of these difficult operations are not well illustrated. In view of the price of the book, better diagrams and pictures would be expected. In summary, the book is a good collection of ideas
about the causes, diagnosis, and treatment of redo arterial surgery. Suggestions for improvement would include better translation of some chapters, more concise recommendations by some of the authors, and better illustrations of operative techniques. Blair A. Keagy, MD University of North Carolina Chapel Hill, IV.C.
Problems in general surgery: Portal hypertension (volume 9, number 3) Eric B. Rypins, Philadelphia, 1992, J.B. Lippincott, 175 pages, $35. Vascular surgeons' general distaste for managing the complications of portal hypertension- including bleeding esophagogasttic varices, ascites, hypersplenism, portosystemic encephalopathy-is a curious developmental quirk, because each of these problems arises from abnormalities of vascular pressure, flow, and tissue perfusion. Eric Rypins has edited an issue of Problems in General Surgery that provides, in only 175 pages (12 chapters authored by 33 contributors), a succinct, comprehensive, and timely overview of this rapidly changing field for those of us who involve ourselves with these challenging patients. Among these contributors, Blei's metaanalysis of prospective randomized trials of J3-blockers underscores a survival advantage and protection against repeat variceal bleeding in patients so treated. However, most of these data come from European studies: for unclear reasons the argument is much less persuasive in North America. Yamamoto and Van Stiegmann show that endoscopic rubber band ligation of varices may be as effective as injection variceal sclerotherapy, with substantially fewer of the esophageal cQmplications associated with the latter, more established technique. Rosch and colleagues discuss their experience with angiographic portacaval shunt (transjugular intrahepatic portosystemic shunt), a technique pioneered in Oregon by the senior author in concert with the late Charles Dotter. The conceptual appeal of transjugular intrahepatic portosystemic shunt notwithstanding, its not-trivial incidence of technical failure and its substantial cost, and the absence of even short-term follow-up data cry out for prospective randomized trials. Rikkers and Jin summarize the advantages and shortcomings of the distal splenorenal shunt, now the most commonly performed surgical portal decompression. Despite this procedure's theoretical underpinning (simultaneous variceal decompression and preservation of prograde portal venous flow), the design of the distal splenorenal shunt has become steadily more complicated, and available data do not demonstrate a survival advantage for patients receiving this procedure in comparison to those
1079
JOURNALOF VASCULARSURGERY December 1993
1080 Book reviews
undergoing standard "total" portal decompression. Discussing another technically challenging clinical entity, Sitzmann, Klein, and Cameron summarize current medical, radiologic, and operative management of the BuddChiari Syndrome, a condition in which the senior author has had a seminal involvement. Bready and colleagues from the University of Texas Health Sciences Center at San Antonio provide a lucid description of the simttltaneous diagnostic and therapeutic protocol that must be undertaken in treating patient with cirrhosis with apparent variceal hemorrhage. And two novel topics in this area are discussed by the editor's former colleagues at the University of California at Irvine- portal hypertensive gastropathy, by Sarfeh and Tarnawski, and the demonstration ofhepatocellular perfusion and function with nuclear medicine techniques, by Mllne. Finally, Campbell and colleagues describe the University of Michigan experience with hver transplantation for variceal bleeding. They demonstrate, as have others, that such patients do at least as well after fiver replacement as patients with other causes of terminal liver failure; importantly, they discuss in some detail the ethical and public policy dilemma confronting a society with seemingly limitless numbers of people with alcohol addiction and cirrhosis but with only a few livers to transplant. Surprisingly absent from this compendium is a discussion of the concept and technique of partial portal decompression- the idea that graded decompression of the portal system, down to physiologic portal pressure levels but not below, can result in reliable protection against variceal hemorrhage while mitigating some of the morbidity associated with total portal decompression. Modesty (Rypins and Sarfeh have been leading proponents of this concept) or the lack of prospective randomized comparisons with total shunts (said to be in progress) may be the explanation. Only rarely these days can a topic be covered so thoroughly in less than 200 pages. Rypius and his authors provide an admirable clinical update for the practicing clinician, the resident, or the student with time and inclination enough to learn "what's hot" in the treatment of patients with portal hypertension. Kaj H. Johansen, MD University of Washington Schoolof2~edicine Seattle, Wash.
Current critical problems in vascular surgery, volume 4 Frank J. Veith, St. Louis, 1992, Quality Medical Publishing, 470 pages, $85.
This anthology of vascular disease-related papers is gathered from the annual symposium "Current Critical Problems in Vascular Surgery" and is predicated on the concept that one cannot step into the same river twice; that certitudes will change with time, experience, and analysis; and that change is an essential ingredient in knowledge.
This collection is offered annually to represent current thought and teaching of recognized authorities on vascular topics, both medical and surgical. Subjects highlighted in this symposium range from general issues of interest to all physicians, including both surgeons and nonsurgeons, and more specific topics of special interest to vascular surgeons. An example of a general topic superbly presented is the "primer" on health care policy in the United States, a review presenting history, current dilemmas, and furore (possible) options in a concise, clear form. Ninety pages are devoted to lower extremity revascularization. Several presentations use the point-counterpoint technique for debate of issues: the use of greater saphenous vein versus polytetrafluorethylene, above- versus belowknee grafting, and tho, role of concomitant arteriovenous fistula creation are all revisited. Other topics of interest include the natural history of superficial femoral artery stenosis, the fate of the remaining nonharvested greater saphenous vein, reoperative leg surgery, and the prevention of leg wound complications. The section on venous surgery is interesting and current, although both the long- and intermediate-term outcomes of venous operative procedures are presently unknown. The controversial areas of endovascular and thrombolytic therapy in the arterial system evoke the anticipated emotion and bias of the essayist. The papers reviewing aortic surgery present an interesting overview of a number of specific topics. Representative subjects include optimal graft configuration, surgical approach, selection of patients, and complications (i.e., paraplegia). All are useful, appropriate, and well-written. Carotid artery and upper extremity evaluation and treatment and cardiac risks are all covered with appropriate new information. The writing and editing style of this book is that of the format of the JOUR_~aLOF VASCULAr, SUR~a:C. As expected with a compilation of chapters from numerous authors, the readability of the individual articles varies. One gets the impression the "book" could have been put together in a loose-leaf binder or possibly in two or three medical journal-sized printings. This resource volume is most appropriate for those surgeons actively involved in clinical vascular surgery. The controversies described are those encountered on a daily basis by vascular surgeons and serve to remind us that understanding changes with time. Gerald Baur, MD Boise, Idaho
The crisis in clinical research: Overcoming institutional obstacles Edward H. Ahrens, Jr., New York, 1992, Oxford University Press, 236 pages, $29.95. The stated purpose of this book is to provide an analysis of the factors contributing to a crisis in or an endangerment