Standard nomenclature for primary hepatic tumors. A critical need.
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Biomedical subjects
Publications and source records attributed to E T Mays.
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Primary hepatic tumors developed in 13 young women who had been ingesting contraceptive steroids. Nine tumors were benign, and four malignant. Six tumors ruptured spontaneously and caused life-threatening hemorrhage. Benign tumors were successfully resected in eight women. One woman died during hepatic resection for malignant hepatoma; in two other cases of hepatocellular carcinoma, tumors were nonresectable. In two patients, the tumor was left in situ after neoplasm had been excluded by biopsy. The increase of such tumors in women of childbearing age warrants the suspicion that these contraceptive steroid hormones play an etiologic role.
Anions of fatty acids infused intravenously into dogs clearly duplicate the clinical syndrome of post-traumatic pulmonary insufficiency (congestive atelectasis, shock lung, traumatic wet lung). Neutral fat embolized to the lungs is incapable of producing this syndrome within the time investigated. The incubation of fatty acid anions with human serum albumin before injection obviates the severe desaturation of blood and ultrastructure disruption caused by FAA alone.
Hospital and anesthesia records of 39 patients who had hepatic artery ligation for severe hepatic trauma were analyzed retrospectively to acquire information on any relationships between choice of anesthetic, preoperative physical condition of the patient, type and incidence of complications, and mortality. Patients who had lost the most blood received neuroleptanalgesia, ketamine, or cyclopropane; those with more stable cardiovascular status received halothane; those in severe circulatory compromise received only oxygen and muscle relaxants. Trends in results of postoperative liver function tests were not related to type of anesthesia. Of the 12 deaths, seven were due to massive bleeding, three to septicemia, one to multiple complications, and one to hepatorenal failure 18 days postoperatively. Choice of anesthetic agent appeared to have no significant influence on postoperative morbidity and mortality; rather, the choice of anesthesia depended on the preoperative physical (especially hemodynamic) status of the patient, which in turn reflected the apparent blood loss estimated at induction.
Suturing of deep ruptures of the liver frequently produces complications of hemobilia, secondary hemorrhage and intrahepatic cavitation with sepsis and liver failure. Such complications require second and third risky operations in already critically ill patients. Such wounds should not be sutured, adequate drainage should be provided, low pressure venous bleeding should be controlled with temporary gauze tampons and arterial bleeding should be stopped by hepatic artery ligation. Such treatment obviates dangerous hepatic resections and morbid thoracoabdominal incisions and prevents hematobilia, secondary hemorrhage, intrahepatic cavitation and sepsis with hepatic failure.
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Replacement of glucose and albumin in ten patients after hepatic lobectomy shows that hypoglycemia and hypoalbuminemia, the two most common consequences of lobectomy in animals, can be prevented in man. Biosynthesis of protein, cholesterol, and prothrombin are reduced temporarily. In patients having emergency lobectomy, the serum bilirubin and glutamic oxaloacetic transaminase concentrations are statistically greater than in patients having elective lobectomy. Serum ammonia is not elevated and bromsulphalein excretion is normal after bilirubin returns to less than 1 mg/100 ml. Lactic dehydrogenase concentrations in serum are increased and fluctuate in the presence of sepsis or respiratory insufficiency: Mean creatine phosphokinase peaks at concentrations higher than those reported in acute myocardial infarction and returns to normal in three days. Compensatory hyperplasia of the residual lobe occurred in all patients.
Selective ligation of sundry hepatic arteries in patients with hepatic trauma obviated death from hepatic bleeding in 59 of 60 patients treated with this method of hemostasis. Hepatic insufficiency did not occur in survivors. Reconstitution of intrahepatic arterial flow is rapidly accomplished by collateral arteries. When the source of hemorrhage is perihepatic, that is, hepatic veins and retrohepatic vena cava, hepatic artery ligation is ineffective. Two patients died from this kind of hemorrhage.
The possible association between oral contraceptives and benign liver tumors has recently been reported. To date the majority of cases have been diagnosed as benign hepatomas (liver cell adenomas). We have had the opportunity to study 13 such cases. Eight have been examples of focal nodular hyperplasia of the liver; however, in addition, there were examples of hepatocellular carcinoma, liver cell adenoma, and possible liver cell hamartoma; all were in women on "the pill." Gynecologists are alerted to the fact that many of the patients present with symptoms of acute abdomen, syncope or shock, and intrahepatic or intraperitoneal bleeding. Prompt diagnosis and treatment may be lifesaving.
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