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Aim: Adenocarcinoma of the pancreas can present with invasion of the vena porta or the superior mesenteric vein (SMV). Pancreatectomy with resection of the vena porta and/or the SMV remains controversial although the procedure is potentially curative. The aim of this study was to validate the indication for resection on the basis of our experience and evidence from recently published studies., Methods: Studies published in the last 10 years on pancreatectomy (duodenocephalopancreatectomy, total and distal pancreatectomy) with resection of the vena porta and/or the SMV were retrieved from the Medline database and reviewed. A total of 18 studies meeting the inclusion criteria were analyzed for information about indications, type of intervention, use of adjuvant therapies, histopathology, perioperative results and survival in 620 patients with adenocarcinoma of the pancreas undergoing pancreatectomy with resection of the vena porta and the SMV. This data set was then compared with our experience with this procedure from the last 3 years., Results: The mortality and postoperative complication rates varied between 0% and 7.7% and 12.5% and 54%, respectively. The median survival varied from 12 to 22 months; the 1 year survival rate was between 31% and 83%; the 5-year survival rate was between 9 and 18% according to the studies reviewed., Conclusion: On the basis of evidence from the literature and our experience, en bloc resection of the vena porta and/or the SMV during pancreatectomy appears to be a safe procedure with acceptable outcomes, and should be considered in patients with pancreatic cancer presenting with venous invasion. Venous resection increases the surgical cure rate, prolonging survival in patients selected according to correct indications.

A.A. refer a case report on a patient observed in emergency condition for acute bleeding from digiunal bowel by a GIST. Starting from clinical case, describe a brief profile of clinical, histogenetic, diagnostic and prognostic characteristics of the GIST also delineated by recent reports from literature; agree with other A.A. about treatment procedure represented always by resection of affected intestinal tract and never by enucleation for inconstant and unforeseeable biologic comportment by this tumours.

In this experimental study the authors report an experience in the evaluation of hepatic blood flow with intraoperative echo-Doppler during orthotopic liver transplantation and side-to-side or end-to-side portacaval shunt. Doppler ultrasonography studied the flow of portal vein, hepatic artery and inferior vena cava before the recipient hepatectomy, and after reperfusion during liver grafting. Furthermore echo-Doppler of the portal system was performed to confirm portacaval shunt efficacy. Usually intraoperative Doppler ultrasonography may give informations about the patency of the shunt and regarding the development of early hepatic artery thrombosis during liver transplantation, but often unclear is the exact evaluation of the velocity of the blood flow through the liver. Further experimental studies and clinical evaluations need to find safe parameters and markers of vascular alteration using this superior diagnostic procedure.

The authors report their experience, from 1983 to 1992, in the treatment of portal vein thrombosis and discuss various aetiological factor of obstruction also underlining the frequent and important association with portal hypertension. The authors emphasize the crucial role of the modern diagnostic techniques such as endoscopy and imaging radiology (U.S., C.T., angiography). Although these techniques not always allow a conclusive evidence in relation to aetiology, however, it is possible to have a rationale for the treatment, i.e. medical, sclerotherapeutic or surgical. As related to the surgical procedures, the authors--based on their personal experience--believe the best are the non-derivative ones.

One hundred and thirty-eight transplants were performed between April 1986 and June 1990 in 116 patients of whom 9 (7.75%) were affected by liver cirrhosis complicated by portal vein thrombosis. Occlusion of the vascular lumen was total in 3 cases, semitotal in 1 case and the percentage of obstruction ranged between 25% and 75% in the remaining patients. Venous dissection and thrombectomy were performed in 6 cases and simple thrombectomy in 3 cases in order to obtain a satisfactory blood flow. Anastomosis was effected using the spleno-mesenteric confluence in 2 cases and the portal vein itself in other patients. Recurrent thrombosis occurred in the first 4 patients in the series, but it was only fatal in 2 cases. The paper analyses the data obtained from the study and in conclusion confirms the use of transplant in cirrhotic patients with portal vein thrombosis.

Preoperative clearance of a single dose of BSP was assessed in 72 candidates for porto-systemic shunt in cirrhosis of the liver. Comparison between those who had died (24) and those who had survived (48) several years later showed statistically significant differences with regard to equivalent liver volume, first uncorrected exponential (Ki), absolute clearance, and 45' retention. A certain degree of differentiation could be made out among the survivors, whereas those who had died could not be distinguished from the series as a whole, nor could correlations be established with the length of survival. No practical advantage was displayed by the more complex, computer-processed parameters as opposed to those that were more immediately available.

A comparison between lymphangiovenous and lymphadeno-venous anastomoses has been realized in rats with mesenteric lymphostasis. The lymphangiovenous anastomoses have showed a better patency than lymphonode-venous shunt owing to technics and biologic problems. Their function was verified until 15th p.o. day, while all lymphonode venous shunt were closed at 10 th p.o.. The shunt occlusion may be related with lymphatic newborn vessels, which exclude the anastomoses from lymph flow.

The authors analyze vascular liver modifications after porta-caval shunt in the rat. The examination of the portal vascular bed obtained by neoprene latex injection allows the definition of different morphologic phases, throughout these liver reaches new structural balance, with an efficacious lobular perfusion. In the same periods histological findings show a cell damage, without necrosis, followed by a recovery after 8 months. In distance, in normal rat porta-caval shunts induce a reduction of the liver volume, both the lobular structures have normal functions and morphology.

Marked gastric acid hypersecretion by comparison with a control group was noted following the collection of samples 2 hr after ligation of the pylorus in rats 20 days after subjection to total portosystemic deviation or deviation of the mesenteric flow only into the vena cava.

The Authors report their experience concerning two cases of pancreatic carcinoma in which growth involvement of retropancreatic venous peduncle required the removal of a tract 6 and 8 cm long of the mesenteric-portal axis and its replacement with knitted dacron graft. The first patient died 8 months later due to massive pulmonar and hepatic metastases. The second patient died in the early post-operative course due to septic shock and dacron graft did not show any evidence of lumen obstruction at post-mortem examination. In spite of the lack of controlled clinical trials which provide a well defined method of staging for carcinoma of the pancreas, the authors' experience shows the possibility of extending radical resections also to cases which usually are considered unresectable and in absence of politetrafluoroethylene graft also with the use of interposed knitted dacron graft good results can be achieved.

Obstacles of vascular type may hinder or prevent pancreatic destruction for tumours of the pancreas or periampullary tumours. Out of 72 major pancreatic demolitions (cephalic duodenopancreatectomy or subtotal pancreatectomy from rt to lt) there were vascular difficulties on 26 occasions (36%), of which 15 were in existence prior to development of the neoplasia (anomalies of rise and course of peripancreatic vessels, stenosis/obliteration of the common hepatic artery in pancreatic head or periampullary tumours) and 11 due to tumoral growth (direct involvement of the mesenteric-portal tract, the hepatic artery and the superior mesenteric artery). The technical solutions used are discussed individually in the light of the physiopathological repercussions consequent on any temporary or permanent interruption of important hepatic and splanchnic vascularisation vessels (hepatic artery and various mesenteric a.), in relation to operating mortality and the prospects of long-term survival. In the most complex cases of direct vascular involvement by the neoplasia, the Author's trend was orientated to a position which, while accepting demolition decisions useful for the widening of the surgical radicality margins, nevertheless avoids extensive demolition solutions imposed by conditions of necessity or considerations of principle that probably do not bring significant advantages as regards long-term prognosis for these tumours.

The article reports an original technique of arterialisation of the portal vein in the rat, after porto-cava shunt, with termino-latreal anastomosis between the proximal stump of the portal vein and the aorta; compared with other techniques, this method has the advantage of avoiding right nephrectomy.

Satisfactory results obtained, lasting for years in some cases, following azygos-portal disconnection in selected patients with bleeding oesophageal varices, portal hypertension, splenopathy and gastroduodenal ulcer are referred to. It is suggested that wider use should be made of this technique, particularly in patients in poor condition, because the long-term picture does not include the hyperammoniaemic encephalopathy often associated with extensive portosystemic shunts.

Two cases of Budd-Chiari's Syndrome are presented. These refer to two women aged 34 and 33 years respectively. The aetiology of the first case is linked to polycythaemia rubra and the use of oral contraceptives; that of the second case to a fibrous perihepatitis involving the outlet of the suprahepatic veins, with a tenacious action of stenosis. The surgical therapy used was a latero-terminal left porto-renal shunt in the first case, and a decapsulation and ligature of the common hepatic artery in the second case. In the discussion the aetiopathogenetic, diagnostic and therapeutic problems inherent in the Syndrome are analysed, also on the basis of the most recent experiences reported in the relevant literature.

The clinical case of a sixty-two year old woman suffering for about six years from rare episodes of cramplike pains in the right hypochondriac region, radiated to the homolateral scapula, is described. After diagnosis of biliary calculosis, the patient was admitted to hospital and her gallbladder removed. During the operation a number of venous ectasias of the portal system were evidenced at the hepatic hilus, and their biopsy led to a diagnosis of portal cavernoma. The possible part played by the cavernoma in producing the patient's clinical picture is discussed, with reference also to other cases of cavernoma of varying location. This is followed by a review of the literature, in which stress is placed on the different aetiopathogenetic interpretations of angiomas and in particular of portal cavernomas. The possible evolution of angiomas and present treatment trends are also mentioned.

Gamma-aminobutyric acid (GABA) values were determined in 4 groups of Sprague-Dawley rats 45-50 days after end-to-side porto-cava (PC), mesentericosplenic-cava (MSC) and mesenteric-cava (MC) anastomosis, and a false operation (FO) respectively. Values were significantly increased in the anastomosed animals. If, as may be supposed, this finding points to altered cerebral metabolism, its observation in the MSC and MC groups militates against the general view that encephalopathy in the experimental animal only occurs as a result of total deviation of the portal flow.