Percutaneous Transhepatic Biliary Drainage (PTBD) is performed in surgical jaundice to decompress the biliary tree and improve hepatic functions. However, the risk of sepsis is high in these patients due to immunosuppression and surgical outcome remains poor. This raises a question—can we do away with PTBD? To answer this query a study was carried out in 4 groups of patients bearing in mind the high incidence of sepsis and our earlier studies, which have demonstrated immunotherapeutic potential of Tinospora cordifolia (TC): (A) those undergoing surgery without PTBD (n = 14), (B) those undergoing surgery after PTBD (n = 13). The mortality was 57.14% in Group A as compared to 61.54% in Group B. Serial estimations of bilirubin levels carried out during the course of drainage (3 Wks) revealed a gradual and significant decrease from 12.52 ± 8.3 mg% to 5.85 ± 3.0 mg%. Antipyrine half-life did not change significantly (18.35 ± 4.2 hrs compared to basal values 21.96 ± 3.78 hrs). The phagocytic and intracellular killing (ICK) capacities of PMN remained suppressed (Basal: 22.13 ± 3.68% phago, and 19.1 ± 4.49% ICK; Post drainage: 20 ± 8.48% Phago and 11.15 ± 3.05% ICK). Thus PTBD did not improve the metabolic capacity ofthe liver and mortality was higher due to sepsis. Group (C) patientg received TC during PTBD (n = 16) and Group (D) patients received TC without PTBD (n = 14). A significant improvement in PMN functions occurred by 3 weeks in both groups (30.29 ± 4.68% phago, 30 ± 4.84% ICK in Group C and 30.4 ± 2.99% phago, 27.15 ± 6.19% ICK in Group D). The mortality in Groups C and D was 25% and 14.2% respectively during the preoperative period. There was no mortality after surgery. It appears from this study that host defenses as reflected by PMN functions play an important role in influencing prognosis. Further decompression of the biliary tree by PTBD seems unwarranted.

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SUMMARY The usefulness of selective transplenic decompression of oesophageal varices by distal splenorenal shunt and splenocaval shunt was evaluated in the control of gastrointestinal haemorrhage in patients with portal hypertension of varied aetiology. (Decompression was successful in 69 out of 78 cases.) It was shown that it is superior to total portosystemic shunts, as the incidence of encephalopathy was very low compared with the data from our series of portocaval shunts. The operative mortality has been progressively lowered and has now reached levels comparable with portocaval shunt. Distal splenorenal shunt when performed as an emergency procedure to arrest bleeding has limited usefulness but when performed as an elective or prophylactic procedure its results are comparable with those of portocaval shunt without the untoward complications such as encephalopathy. A modified selective decompression of varices has been described in which the distal end of the splenic vein is anastomosed to the inferior vena cava. Though no long term follow-up studies are available, we believe that this shunt is likely to prove superior to distal sp]enorenal shunt as it has both the advantages of the distal splenoral and the haemodynamic advantage of end-to-side portocaval shunt. We conclude that in patients with portal hypertension of varied aetiology, who have not had a haemorrhagic episode but in whom varices have been demonstrated or who have had one episode of haemorrhage from varices, the splenocaval shunt when feasible or the distal splenorenal shunt offers the optimal method of management at present in India. (Warren et al., 1972(Warren et al., , 1974Thomford et al., 1975) we once again focused our attention on this shunt; hitherto, end-to-side portocaval shunt was the procedure of choice (and is still done in cases where the splenic vein is diseased). Seventy-three cases of portal hypertension with oesophageal varices were treated by end-to-side portocaval shunt from 1965 to 1977.Received for publication 12 May 1978 A newer modification whereby, in 15 cases, the splenic vein was anastomosed to the side of the inferior vena cava instead of the renal vein is also included in this series of 69 shunts.In the present study we attempt to evaluate the effectiveness of splenorenal shunt in controlling gastrointestinal haemorrhage due to portal hypertension of varied aetiology. MethodsIn 69 cases, extrahepatic portal hypertension due to cavernoma was present in 17, primary portal hypertension or non-cirrhotic fibrosis in 14, while in the remaining 38 cases cirrhosis of the liver was the cause of the portal hypertension. The present study includes 10 patients in the paediatric age group (less than 12 years old). The youngest patient in the series was 5 years old, and the oldest was 55 years (Table 1). There were 50 male and 19 female patients. Fourteen patients presented with a lump in the abdomen, 48 had a history of gastrointes-

Acute necrotising pancreatitis is associated with an unacceptably high mortality for which no satisfactory remedy exists. Emblica officinalis (E.o.) is a plant prescribed in Ayurveda, the Indian traditional system of medicine, for pancreas-related disorders. This study was carried out to evaluate the protective effect of E.o. against acute necrotising pancreatitis in dogs. Pancreatitis was induced by injecting a mixture of trypsin, bile and blood into the duodenal opening of the pancreatic duct. Twenty eight dogs were divided into 4 groups (n = 6-8 each): GpI–control, GpII–acute pancreatitis, GpIII–sham-operated, GpIV–pretreatment with 28 mg E.o./kg/day for 15 days before inducing pancreatitis. Serum amylase increased from 541.99 ± 129.13 IU/ml to 1592.63 ± 327.83 IU (p<0.02) 2 hrs after the induction of pancreatitis in GpII. The rise in serum amylase in both GpIII and GpIV was not significant. On light microscopic examination, acinar cell damage was less and the total inflammatory score was significantly lower in the E.o. treated group as compared to GpII. Electron microscopy confirmed this and showed an increased amount of smooth, endoplasmic reticulum and small, condensed granules embedded in a vacuole. More studies are needed to explore the clinical potential of E.o. and its mechanism of action.

The authors report a case of brain abscess following esophageal dilatation for corrosive stricture in a 23-year-old woman. High fever and neurological findings post dilatation led us to suspect this rare complication, which was confirmed by cranial computed tomography. Prompt treatment with antibiotics and surgical drainage led to a favorable clinical outcome. This serious complication should be kept in mind when long-term treatment of corrosive stricture by repeated esophageal dilatation is planned. Prior cases of brain abscess following esophageal dilatation are reviewed.