116
and caval angiography, liver function tests, and liver biopsy contribute to decisions on management. For the patient presenting with western type acute occlusion thrombolytic therapy may be successful if given at a very early stage. If the patient’s condition deteriorates rapidly from progressive secondary hepatocellular damage, then early liver transplantation may be necessary, although there is a view that progressive liver cell failure can be reversed if the sinusoids can be acutely decompressed by means of a side-to-side portosystemic shunt or a mesocaval shunt. For either shunt to work it must drain into a low-pressure system. Theoretically, the inferior vena cava below the liver is such a system, but the pressure at this point can be high owing to compression of the hypertrophied caudate lobe (segment I). Measurement of infrahepatic caval pressure is thus mandatory, either before or at the time of surgery. If the pressure is only of the same magnitude as the portal pressure then either the shunt must be connected to an alternative low-pressure venous system above the liver or the caval obstruction must be overcome by creating a shunt between the superior mesenteric vein or portal vein and the right atrium or innominate vein. Unfortunately this procedure is associated with a high thrombosis rate (up to 30%), and a cavo-porto-atrial shunt may carry less risk. Relief of caval strictures can be achieved either by means of expanding metal stents inserted into the narrowed section of the cava with a percutaneous transfemoral vein puncture technique or by means of a surgical bypass procedure on the cava carried out at the same time as the portal decompression
operation. There is general agreement that in the more chronic eastern forms of the disease treatment should be directed at attempting to relieve the major venous obstructions. In Japan, surgeons undertake web splitting (with a finger or instrument introduced into the upper cava through the right atrium), venacaval-atrial bypass procedures using prosthetic shunts, or complex operations designed to open the cava and hepatic veins, remove thrombus, and then reanastomose them to the right atrium. Interventional radiologists offer balloon angioplasty, followed by insertion of expanding metal stents into or through the occluded cava and hepatic veins. Unfortunately comparative studies of these different approaches have not been done. The value of liver transplantation in the management of Budd-Chiari syndrome is hotly debated, but the cause of the disease is a major deciding factor. If untreated, the syndrome carries a bad prognosis, especially in the western type when progressive liver failure develops. Transplantation carries a 30% mortality, but long-term survivors (up to 17 years) are also known. However, there are reports of similar survival periods either with no
following appropriate decompression surgery. transplant surgeons have difficulty in producing convincing evidence to support their chosen form of treatment, at least in the early stages of the disease before significant hepatocellular failure develops. There is some agreement that if initial decompression surgery fails and the patient’s liver function continues to deteriorate then transplantation is indicated. treatment or
Thus
After all the debate where do
we
stand? The numbers of
patients with the syndrome, especially in the west, are probably too small to justify controlled prospective studies, except multicentre ones, which seem to be ruled out at present because of the enthusiasm of each clinician for his own approach. It is probable that personal prejudices of the clinicians involved will continue to dictate treatment.
Another congress will be held in three years’ time, in London. Then an attempt will be made to classify the disease and identify for each type a dedicated programme of management. That may be a start to establishing a rational approach to this complex clinical problem. University Department of Surgery, Royal Free Hospital and School of Medicine, London NW3 2QG, UK
K. E. F. HOBBS
Medicine and the Law Anaesthesia
awareness: an
orthopaedic case
A case in which the health authority had admitted liability but the sum to be paid to the plaintiff as compensation had not been agreed came before Mr Justice Schiemann in the High Court on Oct 18, 1991. The plaintiff had required surgery on his leg that involved deep cutting and drilling down to the bone. He was told that he would have an injection and that when he woke up the operation would be over. Unfortunately, consciousness returned when he was in the operating theatre; he could hear nurses talking and was aware of a tube down his throat. He had been given a muscle relaxant drug but he wiggled his toes in an attempt to draw attention to the fact that he was awake. The nurses remarked on the fact that the patient’s toes were moving but a man’s voice said it was "just reflexes" and that the nurses should ignore it. Somebody then grasped his leg and applied a tourniquet to his groin, and he heard a man say that this should be removed after 541 minutes. It was then that the patient realised that the operation, far from being over, was only just about to start, and that he was conscious and sensitive to pain but unable to move.
What then followed was nightmarish. The plaintiff experienced a burning pain to his leg from the scalpel, and four holes were drilled into the bone. He was artificially ventilated. He felt very sick and stopped breathing in the hope that this would indicate that something was wrongbut the machine started "breathing for him". The judge accepted the plaintiffs account of his experience and its aftermath. The failure to agree damages had meant that the plaintiff had concentrated on his operation in a way that he might not have done had agreement been reached. The plaintiff had started recalling his operation when in bed, perhaps because he was lying down as he had been in the operating-theatre, so the consequences "include the possibility that he may have to relive the experience". There was no conventional figure for compensation in cases such as this. In Ackers v Wigan Area Health Authority (19912 Med LR 232) damages were awarded for insufficient anaesthesia during a caesarean section. However, there were significant differences between the two cases, the judge said. For the experience on the operating table the judge awarded the man /J5000, and in general damages for pain, suffering, and loss of amenity he awarded 10 000. In Ackers the pain had not been as acute as that here but it lasted longer. That patient had been awarded k 12 000 (plus C 1775 in respect of treatment for consequent psychiatric illness). Phelan
0’
Cumbria Health Authority
(QBD Schiemann V). Med L R [1991]
419.
Diana Brahams
and caval angiography, liver function tests, and liver biopsy contribute to decisions on management. For the patient presenting with western type acute occlusion thrombolytic therapy may be successful if given at a very early stage. If the patient’s condition deteriorates rapidly from progressive secondary hepatocellular damage, then early liver transplantation may be necessary, although there is a view that progressive liver cell failure can be reversed if the sinusoids can be acutely decompressed by means of a side-to-side portosystemic shunt or a mesocaval shunt. For either shunt to work it must drain into a low-pressure system. Theoretically, the inferior vena cava below the liver is such a system, but the pressure at this point can be high owing to compression of the hypertrophied caudate lobe (segment I). Measurement of infrahepatic caval pressure is thus mandatory, either before or at the time of surgery. If the pressure is only of the same magnitude as the portal pressure then either the shunt must be connected to an alternative low-pressure venous system above the liver or the caval obstruction must be overcome by creating a shunt between the superior mesenteric vein or portal vein and the right atrium or innominate vein. Unfortunately this procedure is associated with a high thrombosis rate (up to 30%), and a cavo-porto-atrial shunt may carry less risk. Relief of caval strictures can be achieved either by means of expanding metal stents inserted into the narrowed section of the cava with a percutaneous transfemoral vein puncture technique or by means of a surgical bypass procedure on the cava carried out at the same time as the portal decompression
operation. There is general agreement that in the more chronic eastern forms of the disease treatment should be directed at attempting to relieve the major venous obstructions. In Japan, surgeons undertake web splitting (with a finger or instrument introduced into the upper cava through the right atrium), venacaval-atrial bypass procedures using prosthetic shunts, or complex operations designed to open the cava and hepatic veins, remove thrombus, and then reanastomose them to the right atrium. Interventional radiologists offer balloon angioplasty, followed by insertion of expanding metal stents into or through the occluded cava and hepatic veins. Unfortunately comparative studies of these different approaches have not been done. The value of liver transplantation in the management of Budd-Chiari syndrome is hotly debated, but the cause of the disease is a major deciding factor. If untreated, the syndrome carries a bad prognosis, especially in the western type when progressive liver failure develops. Transplantation carries a 30% mortality, but long-term survivors (up to 17 years) are also known. However, there are reports of similar survival periods either with no
following appropriate decompression surgery. transplant surgeons have difficulty in producing convincing evidence to support their chosen form of treatment, at least in the early stages of the disease before significant hepatocellular failure develops. There is some agreement that if initial decompression surgery fails and the patient’s liver function continues to deteriorate then transplantation is indicated. treatment or
Thus
After all the debate where do
we
stand? The numbers of
patients with the syndrome, especially in the west, are probably too small to justify controlled prospective studies, except multicentre ones, which seem to be ruled out at present because of the enthusiasm of each clinician for his own approach. It is probable that personal prejudices of the clinicians involved will continue to dictate treatment.
Another congress will be held in three years’ time, in London. Then an attempt will be made to classify the disease and identify for each type a dedicated programme of management. That may be a start to establishing a rational approach to this complex clinical problem. University Department of Surgery, Royal Free Hospital and School of Medicine, London NW3 2QG, UK
K. E. F. HOBBS
Medicine and the Law Anaesthesia
awareness: an
orthopaedic case
A case in which the health authority had admitted liability but the sum to be paid to the plaintiff as compensation had not been agreed came before Mr Justice Schiemann in the High Court on Oct 18, 1991. The plaintiff had required surgery on his leg that involved deep cutting and drilling down to the bone. He was told that he would have an injection and that when he woke up the operation would be over. Unfortunately, consciousness returned when he was in the operating theatre; he could hear nurses talking and was aware of a tube down his throat. He had been given a muscle relaxant drug but he wiggled his toes in an attempt to draw attention to the fact that he was awake. The nurses remarked on the fact that the patient’s toes were moving but a man’s voice said it was "just reflexes" and that the nurses should ignore it. Somebody then grasped his leg and applied a tourniquet to his groin, and he heard a man say that this should be removed after 541 minutes. It was then that the patient realised that the operation, far from being over, was only just about to start, and that he was conscious and sensitive to pain but unable to move.
What then followed was nightmarish. The plaintiff experienced a burning pain to his leg from the scalpel, and four holes were drilled into the bone. He was artificially ventilated. He felt very sick and stopped breathing in the hope that this would indicate that something was wrongbut the machine started "breathing for him". The judge accepted the plaintiffs account of his experience and its aftermath. The failure to agree damages had meant that the plaintiff had concentrated on his operation in a way that he might not have done had agreement been reached. The plaintiff had started recalling his operation when in bed, perhaps because he was lying down as he had been in the operating-theatre, so the consequences "include the possibility that he may have to relive the experience". There was no conventional figure for compensation in cases such as this. In Ackers v Wigan Area Health Authority (19912 Med LR 232) damages were awarded for insufficient anaesthesia during a caesarean section. However, there were significant differences between the two cases, the judge said. For the experience on the operating table the judge awarded the man /J5000, and in general damages for pain, suffering, and loss of amenity he awarded 10 000. In Ackers the pain had not been as acute as that here but it lasted longer. That patient had been awarded k 12 000 (plus C 1775 in respect of treatment for consequent psychiatric illness). Phelan
0’
Cumbria Health Authority
(QBD Schiemann V). Med L R [1991]
419.
Diana Brahams
