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Over an 80 month period, 53 transthoracic endoscopic sympathectomies were performed in 34 patients. The indications for surgery were palmar hyperhidrosis in 20 procedures (38%), palmar and axillary hyperhidrosis in eight procedures (15%), Raynaud's phenomenon in 23 procedures (43%), and combined palmar hyperhidrosis and Raynaud's phenomenon in two procedures (4%). Follow-up data, obtained by a self-assessment postal questionnaire, was available for 47 procedures in 30 patients (91%). Fourteen out of 15 procedures (93%) performed for palmar hyperhidrosis, all eight procedures (100%) for palmar and axillary hyperhidrosis and 14 out of 22 procedures (64%) performed for Raynaud's phenomenon produced an immediate improvement in symptoms. These improvements were sustained in 13 procedures (87%) performed for palmar hyperhidrosis, all procedures performed for palmar and axillary hyperhidrosis (100%) but only 10 procedures (45%) performed for Raynaud's phenomenon at a median follow-up of 16, 34 and 44.5 months respectively. There were no deaths nor postoperative Horner's syndrome in these patients. The only minor complications were two small pneumothoraces. Compensatory sweating was observed after 24 procedures (51%). These results confirm that transthoracic endoscopic sympathectomy is a simple, safe and effective procedure. In patients with hyperhidrosis, the results are excellent and prolonged; in patients with Raynaud's phenomenon, immediate improvement can be achieved but the symptoms may return with time.

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Cerebral edema has now been noted to occur frequently in patients dying of fulminant hepatic failure. In the present study, intracranial pressure was monitored in an animal model of acute liver failure. Acute liver failure was induced surgically by hepatic devascularization. Serial monitoring of the electroencephalogram revealed progressive slowing of the frequency with decreasing amplitude. Elevation of the blood ammonia was also observed from baseline values of 64 +/- 12 SE to 744 +/- 97 mumol/liter. Monitoring of the intracranial pressure with a subdural pressure transducer demonstrated a progressive and reproducible rise from 12.8 +/- 2.5 mm Hg immediately after the operation to a mean value of 51.6 +/- 11.8 mm Hg just before death 6--12 hr later. At autopsy, the brains of the test animals were found to be swollen with flattened cortical gyri. In the control animals, intracranial pressure rose slightly but returned toward normal levels (8.0 +/- 2.5 mm Hg) 8 hr after laparotomy and remained normal until their death. There was a statistically significant difference between intracranial pressure levels of the test animals and those of the controls (P less than 0.01). Intravenous methylprednisolone (2.0 g initially followed by 0.5 g every 2 hr) administered immediately before and after hepatic devascularization prevented rises in intracranial pressure but had no effect when given 4 hr after operation. The early and progressive increase in intracranial pressure was an unexpected finding, and an assessment of such a sequence in patients with fulminant hepatic failure is currently in progress.

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A comparison of two hepatobiliary imaging agents, 99Tcm-dihydrothioctic acid (99Tcm-DHT) and (99Tcm-pyridoxylidene glutamate (99Tcm-PG) has been carried out in 44 non-jaundiced patients. Thirty-one patients were admitted for investigation of upper abdominal pain and 13 patients were volunteers who were undergoing treatment for unrelated conditions. Satisfactory liver images were obtained with both agents in patients without liver disease, but they were inferior to those seen after 99Tcm-sulphur colloid. 99Tcm-PG produced clearer images of the gall-bladder and bile ducts than 99Tcm-DHT. Non-visualization of the gall-bladder was interpreted as gall-bladder disease; in patients with inflammatory gall-bladder disease no gall-bladder image was seen (nine 99Tcm-DHT, nine 99Tcm-PG). The gall-bladder was also not demonstrated in two of the volunteers' group (one 99Tcm-DHT, one 99Tcm-PG), nor was a gall-bladder seen in five patients whose abdominal pain was not due to acute cholecystitis. Despite this, there was agreement between the results of imaging and oral cholecystography in 21 out of 22 subjects. 99Tcm-PG is non-toxic, cheap and rapidly excreted by the liver into the bile. A 99Tcm-PG scan would be useful when rapid diagnosis is required in suspected acute cholecystitis when conventional contrast radiology is unlikely to be of value.

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99Tcm-pyridoxylidene glutamate (99Tcm-PG) scans have been carried out in 24 jaundiced adults (mean total bilirubin 255 mumol/l and 11 infants with prolonged obstructive jaundice (mean total bilirubin 165 mumol/l). Absence of radioactivity in the gut was interpreted as complete biliary obstruction which was the cause of jaundice in ten adults and six infants. Using this criterion occlusion or patency of the bile ducts was correctly determined in 21 adults and eight infants. False-negative gut images were found in one adult and two infants, and three scans were inconclusive (two adults, one infant). The scan was unable to show details of the site of obstruction or pathology but the technique was simple and atraumatic and was safely performed in patients with serious complications, e.g. renal failure, coagulation defects, septicaemia. In infants the 99Tcm-PG scan compared well with the 131I rose bengal faecal excretion test and with liver biopsy in the investigation of prolonged obstructive jaundice. Repeat scans in infants with biliary atresia were used to assess postoperative bile drainage. It is suggested that 99Tcm-PG scanning is useful screening test in difficult cases of jaundice. It is especially useful in frail patients, and patients with complications.

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An investigation into the aetiology, diagnosis, and treatment of biliary atresia was carried out because the prognosis remains so poor.In an electron microscopical study no viral particles or viral inclusion bodies were seen, nor were any specific ultrastructural features observed. An animal experiment suggested that obstruction within the biliary tract of newborn rabbits could be produced by maternal intravenous injection of the bile acid lithocholic acid.A simple and atraumatic method of diagnosis was developed using(99) (m)Tc-labelled compounds which are excreted into bile. Two compounds, (99m)Tc-pyridoxylidene glutamate ((99m)Tc-PG) and (99m)Tc-dihydrothioctic acid ((99m)Tc-DHT) were first assessed in normal piglets and piglets with complete biliary obstruction. Intestinal imaging correlated with biliary tract patency, and the same correlation was found in jaundiced human adults, in whom the (99m)Tc-PG scan correctly determined biliary patency in 21 out of 24 cases. The (99m)Tc-PG scan compared well with liver biopsy and (131)I-Rose Bengal in the diagnosis of 11 infants with prolonged jaundice.A model of extrahepatic biliary atresia was developed in the newborn piglet so that different methods of bile drainage could be assessed. Priorities in biliary atresia lie in a better understanding of the aetiology and early diagnosis rather than in devising new bile drainage procedures.

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The use of spontaneous respiration of oxygen, nitrous oxide, and halothane via Jackson Rees's modification of Ayre's T-piece and a flexible 'snout' mask proved to be a simple and effective way of anaesthetizing neonatal pigs--'micropigs'--in the first few days of life without resorting to endotracheal intubation. No airway obstruction occurred as long as the head was extended with firm traction on the jaw and provided the nostrils were not pressed up against the wall of the mask. The anaesthetic technique described provided adequate muscle relaxation and analgesia for extensive abdominal surgery. The animals recovered rapidly and there were no postoperative complications.

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Seventeen scans on ten young pigs were performed after injection of Technetium-99m labelled dihydrothioctic acid (99Tcm-DHT) and Technetium-99m labelled pyridoxylidene glutamate (99Tcm-PG) using a gamma-camera. Sequential images of the liver, gall-bladder and intestine were observed in all healthy animals. 99Tcm-DHT produced the clearer liver images, whereas 99Tcm-PG produced more rapid and intense gall-bladder images. Analysis of hepatic bile in three animals also suggested a more rapid and higher concentration of 99Tcm-PG than 99Tcm-DHT (36% vs. 4% of the injected dose over two hours). Bowel images were not seen in an animal that had undergone exicision of the extrahepatic biliary tract, but scans performed after hepaticojejunostomy demonstrated intestinal transit of isotope. This study shows that the hepatobiliary system can be easily imaged using Technetium-99m labelled compounds which are excreted into bile. These agents may be useful in the diagnosis of obstructive lesions of the extrahepatic biliary tract of adults and infants.

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It is proposed that some cases of biliary atresia and neonatal hepatitis may be initiated by an adverse effect of unsaturated monohydroxy bile acids on the fetal and infantile hepatobiliary system. The hypothesis is founded on morphological observations in patients with biliary atresia and on the toxic effects of monohydroxy bile acids on the hepatobiliary system.

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Isolated chylopericardium is a rare cause of pericardial effusion. Intrapericardial chyle was first noticed by Hasebroek (1888) at necropsy. Twenty years ago Groves and Effler (1954) first reported a clinical case of isolated chylopericardium. The present case is similar to theirs in several respects, and is the nineteenth case to be reported. To our knowledge this is the first British report of an isolated chylopericardium and is the fourth case of isolated chylopericardium due to a mediastinal lymphangiomatous hamartoma to be successfully treated.

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