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Segmental auxiliary liver transplantation (SALT) has been carried out in 13 mongrel dogs to assess the possibility of a certain size of liver segment to accept without sequelae the total splanchnic and arterial blood normally diverted to the liver of the host. Prednisone (1 mg/daily) and azathioprine (2 mg/kg daily) were used as immunosuppression. Five dogs died during the first hours after the operation. Three because of technical failure and two of acute portal hypertension secondary to total portal and arterial blood diversion in dogs with liver segments of 195 +/- 49 g as a result of overloading of the graft. The remaining 8 dogs were divided into: 4 dogs into which a liver segment (195 +/- 49 g) was transplanted (group A) and 4 dogs in which a liver segment (385 +/- 85 g) was used (group B). Partial portal and total arterial blood diversion in group A dogs was not associated with portal hypertension but resulted in poor function of the graft and in poor survival. In contrast, the graft in group B dogs was able to cope with both total or partial portal blood and with a normal arterial blood diversion. Infection and graft rejection prohibited long-term survival (8-28 days). Data from this study support the view that the present technique of SALT with a graft corresponding to 300-400 g in mongrel dogs of about 30 kg is a potential alternative as temporary liver support in the diseased animal.

Arteriovenous aneurysm of the lung may give rise to sequelae such as cyanosis, clubbed fingers and toes, polycythemia, dyspnea, hypertrophy of the heart and neurological changes resulting from paradoxical embolic processes. A true complication of arteriovenous aneurysm is a rupture, which can result in hemoptysis or hemothorax. Hemoptysis due to intrabronchial rupture is a relatively frequent complication. According to Leutscher (1954) - in a monograph presenting a detailed analysis of 130 of the cases of arteriovenous aneurysm published up to 1954 hemoptysis is mentioned as a complication in 25 per cent of cases. Hemoptysis occurred in three of the five cases hitherto reported from this clinic. Intrapleural rupture of the arteriovenous aneurysm, resulting in hemothorax, however, proves to be an exceedingly rare complication which Leutscher found mentioned in only three of the 130 cases; it has not previously occurred in our material. This paper describes a woman showing this unusual complication. The description is given both in view of the rarity and possible difficulties in diagnosing this condition, and in view of the fact that an emergency operation in recognized cases may be life saving. CASE REPORT A woman, aged 37, had Rendu-Osler disease and frequent epistaxis. In 1946 (at age 25) she began to cough, with occasional expectoration of blood-tinged sputum. In 1947, while walking in the open, she suffered a violent hemoptysis resulting in a collapse. X-ray film examination of the thorax at the time revealed a homogeneous, virtually round opacity with a diameter of about one inch beside the hilum of the left lung. There was a markedly positive Mantoux tuberculin reaction. There was no fever, nocturnal hyperhidrosis or emaciation. Repeated testing of sputum and fasting gastric contents for acid-fast rods remained negative. The process was nevertheless regarded as tuberculosis, and she was given treatment accordingly, by rest for 18 months. Subsequently she remained asymptomatlc for several years. About 1950, she began to notice that dyspnea ensued more rapidly than previously. During the last five months preceding our examination, the left hemithorax was painful both in repose and during movements “as 11 Inflamed.” The pain radiated to the back, between the shoulder blades. We saw a slightly cyanotic, somewhat dyspneic woman in good nutritional condition, with small telanglectases on the tip of the tongue, the upper and the lower lip and in the nail bed of several fingers. Fingers and toes showed no sign of clubbing. Physical examination of the thorax (Cardiological Department, Prof. Dr. D. Durrer) yielded the following findings. Lungs: vesicular respiration; resonant percussion sounds; lung-liver borderline: sixth rib in front and 12th thoracic posteriorly. There was moderate displacement of the pulmonary outline. Heart: one flngerbreadth enlargement to the left, with a diastolic souffle (grade 1) at the apex, A2 of greater intensity than P2. In the left anterior second intercostal space and on the back, medial to the apex of the right scapula, a vascular murmur was audible which occurred late during systole and did not resemble a typical diamond-shaped “stenotic” souffle. Pulmonary function was normal (vital capacity 116 per cent; one-second value 78 per cent). ECG: intermediary position of the heart; no anomaly. The oxygen saturation in the brachial artery was 92.5 per cent In repose, 88.5 per cent after two minutes’ effort, and 97.5 per cent after 10 minutes’ oxygen respiration. X-ray film examination revealed an opacity in the left upper and the right lower lobe; It appeared to be homogeneous, with smooth contours and showing pulsations at fluoroscopy. The condition was diagnosed as bilateral pulmonary arterlovenous aneurysm. This diagnosis was confirmed by angiocardiography. In the left upper and the right lower lobe, sFi.om the Surgical Clinic A of the Wilhelmina Gasthuis, University of Amsterdam.

An extensive array of nerve fibers ramify around the afferent blood vessels of the liver and the extrahepatic and intrahepatic biliary pathways, and are thought to be involved in regulation of blood flow. Although the role of sympathetic innervation is established, little is known about the location or role of regulatory peptidergic innervation in the liver. We examined the anatomic distribution of a wide variety of regulatory peptides and several neural antigens by in situ immunohistochemistry in the rat and in man. A rich peptidergic plexus of nerve fibers and ganglion cells was observed around the arterial vessels in both species, with intense immunoreactivity for neuron-specific enolase, neurofilaments, neuropeptide Y, substance P, and vasoactive intestinal polypeptide. S-100 protein immunoreactivity was seen principally in large nerve bundles, suggesting that the majority of nerves in this area were unmyelinated. In contrast, the portal vessels revealed very little peptidergic innervation. No staining was observed with antibodies directed against insulin, glucagon, gastrin, serotonin, met-enkephalin-Arg-Gly-Leu, cholecystokinin, or growth hormone. These findings indicate the presence of a rich, although selective, peptidergic plexus surrounding afferent hepatic blood vessels. This plexus may play an important role in regulation of hepatic blood flow.

Sodium ipodate (SI) is an oral cholecystographic agent that also affects thyroid hormone metabolism. It inhibits the peripheral T4 to T3 conversion and the thyroidal hormone release. We investigated the safety and efficacy of SI (500 mg daily during 5 days) in the preparation for subtotal thyroidectomy of 7 Graves' hyperthyroid patients in whom treatment with thionamides was unsuccessful due to allergy or noncompliance. Plasma T3 levels (mean +/- SD) decreased from 4.90 +/- 1.80 nmol/l on day 0 to 1.70 +/- 0.30 nmol/l on day 4 of treatment. Thyroidectomy performed on day 5 of treatment was uneventful. In comparison with 14 Graves' hyperthyroid patients who underwent thyroidectomy during the same period after conventional preparation with thionamides and potassium iodide, the therapeutic outcome 1 year postoperatively was similar in both groups. However, in the mildly hypothyroid patients prepared with SI, the plasma thyroid-stimulating hormone level was transiently higher 3 and 6 months postoperatively. It is concluded (1) that SI is a safe and efficacious drug in the preparation of Graves' hyperthyroid patients for thyroidectomy; (2) the therapeutic outcome 12 months postoperatively is similar in SI and in conventionally prepared Graves' hyperthyroid patients, and (3) postoperative mild or subclinical hypothyroidism is more pronounced in SI than in conventionally prepared patients.

In an effort to develop effective rules for the management of penetrating thoracic injuries, all records of 515 patients treated for sharp chest injuries between 1961 and 1985 at the University Hospitals of Amsterdam (Binnengasthuis, Wilhelmina Gasthuis and Academic Medical Centre), were reviewed. The analysis reveals that of these patients 321 (62 per cent) could be treated conservatively, because of a non-penetrating injury, while 140 had a penetrating injury, of whom 77 had to be operated on. Eleven patients died (2.1 per cent). Data concerning these patients are discussed separately. Based on our analysis, and supported by recent literature, an aggressive approach towards penetrating thoracic injury in haemodynamically unstable patients is justified.