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12. Braddick OJ, Atkinson J, Wattam-Bell J, Day J. The onset of binocular function in human infants. Human Neurobiol 1983; 2: 65-69. 13. Braddick OJ, Wattam-Bell J, Atkinson J. Orientation: specific cortical responses in early infancy. Nature 1986; 320: 617-19. 14. Atkinson J. How does infant vision change in the first three months of life? In: Prechtl HER, ed. Continuity of neural functions. Clin Dev Med 1984; 94: 159-78. 15. Dubowitz LMS, Mushin J, De Vries L, Arden GB. Visual function in the newborn infant: is it cortically mediated. Lancet 1986; i: 1139-41. 16. Dubowitz LMS, Mushin Y, Morani FA, Placzek M. The maturation of visual acuity in neurologically normal and abnormal new-born infants. Behav Brain Res 1983; 10: 39-46. 17. Fielder AP, Evans NM. Is the geniculo-striate system a pre-requisite for nystagmus? Eye 1988; 2: 380-82. 18. Whiting S, Jan JE, Wong PRH, Floodmark O, Farell K, McKormick AQ. Permanent cortical visual impairment in children. Dev Med Child Neurol 1985; 27: 730-39.

Emergency portacaval shunts An emergency portacaval shunt effectively stops variceal haemorrhage and prevents recurrent variceal bleeding. Why did this successful emergency operation fall into disfavour? The reasons were probably a combination of high operative mortality when the procedure was carried out by the average surgeon (especially in poor risk alcoholic patients with cirrhosis), emergence of unpredictable postoperative chronic encephalopathy, and development and widespread use of emergency sclerotherapy. Some groups have continued to use emergency portacaval shunting, and the value of this approach has lately been re-emphasised. Spina and colleagues1 in Milan reported their experience of 88 patients admitted for active variceal haemorrhage over 9 years; 35 of these patients underwent emergency shunts, usually a side-to-side portacaval shunt. Included in this series were patients in their hospital who had not responded to conservative measures, including sclerotherapy, and those specifically admitted for emergency shunts. Half had alcoholic cirrhosis and 31 were in the poor risk Child’s grades B or C. Emergency shunting controlled variceal bleeding in all but 1. There were 3 operative deaths. At long-term endoscopic follow-up varices had disappeared in 18 patients and were substantially smaller in another 14. Chronic encephalopathy developed in 20%, but was severe in only a third of these. The Italian workers recommend emergency portal-systemic shunting for those in whom conservative treatment, including sclerotherapy, is unsuccessful and suggest that the operation be done early. Although their arguments are enticing, this was a non-randomised study from a specialist institution and the procedure was undertaken by one surgeon. What is the current status of emergency portacaval shunts? Orloff in California has been a keen advocate of emergency portacaval shunts over the years and he has documented a decreasing mortality as his group have become more experienced.2 The controlled trial of Cello et aP is often mentioned. This group compared emergency shunts with emergency sclerotherapy in poor risk patients with alcoholic cirrhosis. They documented that rebleeding from acute

varices, duration of hospital stay for bleeding, and transfusion requirements were significantly greater in the sclerotherapy group. In addition, 40% of the patients discharged from hospital in the sclerotherapy group ultimately required surgical treatment. Costs and long-term survival did not differ significantly. Although emergency shunts were successful, these researchers concluded that sclerotherapy was as satisfactory for the acute management of variceal haemorrhage in poor risk patients. They also proposed that patients treated with sclerotherapy in whom varices were not obliterated and in whom bleeding continued should be considered for a subsequent elective shunt. Two other reports4,5 have likewise supported emergency shunts. Thus it is agreed that an emergency portacaval shunt is an effective treatment option when sclerotherapy fails. Can such failure be defined ? Two groups6,7 have suggested that any patient who does not respond to two emergency injection treatments should be classed as a sclerotherapy failure and should immediately

undergo a surgical procedure. The main alternative to shunting is transabdominal transgastric oesophageal transection with a staple gun. Because this operation is reputedly simpler, it has been more widely used than shunts for sclerotherapy failures. A randomised trial showed that transection 7 was as safe as sclerotherapy for emergency treatment, but the researchers nevertheless recommended sclerotherapy as the first line of treatment. Unlike

portacaval shunting, staple gun emergency transection does not effectively prevent long-term recurrence of variceal bleeding. Thus, the role of emergency portacaval shunting has not yet been clearly established. It is one of the two main options for sclerotherapy failures, but whether it will become a routine procedure in some subsets of patients remains to be determined. Major surgical procedures are likely to be used more frequently for acute variceal bleeding because sclerotherapy fails to control bleeding in up to 10% of patients and has probably been over-used in the past. 1.

Spina GP, Santambrogio R, Opocher E, et al. Emergency portosystemic shunt in patients with variceal bleeding. Surg Gynecol Obstet 1990; 171: 456-63.

Orloff MJ, Bell RH Jr, Hyde PV, Skivolocki WP. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcohol cirrhosis. Ann Surg 1980; 192: 325-40. 3. Cello JP, Grendell JH, Crass RA, Weber TE, Trunkey DD. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up. N Engl J Med 2.

1987; 316: 11-15. 4. Villeneuve JP, Pomier-Layrargues 5.

G, Dugay L, et al. Emergency portacaval shunt for variceal hemorrhage: a prospective study. Ann Surg 1987; 206: 48-52. Sarfeh IJ, Rypins EB, Mason GR. A systematic appraisal of portacaval H-grafts diameters. Clinical and hemodynamic perspectives. Ann Surg

1986; 204: 356-63. 6. Bornman PC, Terblanche

J, Kahn D, et al. Limitations of multiple injection sclerotherapy sessions for acute variceal bleeding. S Afr Med J 1986; 70: 34-36. 7. Burroughs AK, Hamilton G, Phillips A, Mezzanotte G, McIntyre N, Hobbs KEF. A comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices. N Engl J Med 1989; 321: 857-62.

Emergency portacaval shunts.

952 12. Braddick OJ, Atkinson J, Wattam-Bell J, Day J. The onset of binocular function in human infants. Human Neurobiol 1983; 2: 65-69. 13. Braddick...
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