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The Eck Fistula in Animals and Humans Thomas E THE ECK FISTULA IN ANIMALS AND HUMANS THOMAS E. STARZL. Ph.D., M.D. KENDRICK A. PORTER, M.D. ANTONIO FRANCAVILLA, M.D. I - I, i I I j . ,I i I i 1I0JJ-:IH·!l) ii:IJ1-(iH7-7,j~·:::~9:i 19ii:1. Y l'~lr Bouk \il'd ic~t1 l'ubll~hl'r~. 1m FOREWORD Dr. Starzl's monograph is so extraordinary we have asked two uthet' eminent surgical students of the portal circulation to com­ TABLE OF CONTENTS ment. Dr. Dean Warren's appreciation precedes the monograph and Dr. William V, McDermott's critique follows it. FIII(i-:\\IIIW. .609 CI)~I!\IL:\T .689 MAIm 1\1. ({AVln'lI, rvl.LJ. SEI.F-ASSESSMENT (~I '1';ST!Or-;s · 690 E D1TOIl-IN-C III EF Tm: P()IlTA(',.\\",\1. SII{lNT IEcK'S FISTI;I.A): A CENTI'HY III' CIINTIl()\'EHSY . .693 TilE I\III(WINAI. Nxn'HE IIF TilE IlEI'AT()TH{)I'1I1t" SI'IIST,\NI'~:S .702 COMMENT FlINI'TH IN OF TilE ECK F,STULA L,VER . ,706 This monograph of Eck's fistula by Starzl is the most author­ HEI.EY,.\Nn: OF Ar-;I~IAL STlllJ1ES T() HUMAN PIIYSII)I.{)I;Y. · 710 itative publication since that by Pavlov and his associates in E('K'S FISTI'I..\ F(l1( I\.IET·\III1I.W 01l.JECTJ\'ES IN 1I1':'.L\:-';S . · 71-1 1893. Pavlov pointed out the near-total lack of scientific data available frolll Eck's study, but commented that the operation I'{)HT"I.-SYSTE~I It" SIIl'l"T FIIH CII:\II'I.JCATI{)NS ()F POIlT.·\!. would be important because it could open doors for the clarifi­ HYI'EHTENSI()N. .727 cation of important problems in the pathology, physiology, and SII:'-IM,\IlY . ,734 pharmacology of the liver. No one has grasped this opportunity with the brilliance and A('KN( )\\·I.E1l( ;~IE:\"TS · 73-1 dedication of Starzl, and in this arena he has no peers, I know C()~I~n:NT . .746 of no other source from which this outstanding scientific and clinical correlation could have come. SEI.F-AsSESS~1 ENT A NS\\'EHS . ,752 W. DEAN W;\HHEN, 1\1.D. 688 689 SELF-ASSESSMENT QUESTIONS 1. The most important hepatotrophic hormone or substance is: a. Phenylalanine. is a Professor of Surgery at the University b. Glucagon. of Pittsburgh School of Medicine. His clin­ c. Epinephrine. ical practice is at the Presbyterian Univer­ d. Insulin. sity Hospital, The Children's Hospital of 2. Side-to-side portacaval shunts reduce encephalopathy by Pittsburgh, and the Oakland Veterans Ad­ maintaining partial portal perfusion of the liver. True or ministration Hospital. His interest in the false? specific effects of portal venous blood dates back to 1956. The way in which research 3. Dean Warren is Dean of the following medical school: in this field has interrelated with liver a. Washington University. transplantation, another of his interests, b. Johns Hopkins. has been described in this monograph. c. Emory. Much of the progress that was made in un­ d. None of the above. derstanding "hepatotrophic" physiology 4. The unique feature of the Warren shunt is its: was made possible by Dr.; Starzl's long­ a. High flow. standing collaborations with the two Eu­ b. Unusual efficiency in decompressing esophageal varices. ropean co-authors of this article. c. Partial maintenance of hepatopetal portal flow. 5. In animals or humans with normal livers, completely di­ verting portacaval shunt causes: a. Hepatocyte atrophy. b. Deglycogenation. c. Reduction and disruption of rough endoplasmic reticu­ is Chairman of the Department- of Pathol- lum. ogy, The St. Mary's Hospital and Medical School, London. In September, 1963, Ken d. Intracellular fat deposition. Porter and Torn Starzl (then at The Uni­ 6. The risks of encepalopathy after portacaval shunt are versity of Colorado) met at a meeting greater the more normal the preexisting hepatic function. about renal transplantation, held at the True or false? National Science Foundation in Washing­ 7. The metabolic effects of completely diverting portacaval ton, D.C. The results being obtained with shunt have been used to treat at least three inborn errors of this procedure in Colorado were so striking metabolism. True or false? that Dr. Porter returned to Denver with 8. Both completely diverting and selective portal-systemic Dr. Starzl to review what was going on shunts greatly improve the life survival curves of patients there. From that visit came a collaboration with esophageal varices. True or false? that has lasted for more than two decades. Dr. Porter's chapters in Dr. Starzl's books 9. Complete portal diversion causes subtle and clinically insig­ on renal (964) and hepatic (1969) trans­ nificant changes in a few kinds of hepatic function. True or plantation were monographs in their own false? right. Dr. Porter's talents soon turned to 10. The liver has important and easily demonstrable immuno­ an assessment in various experimental logic functions. True or false? models of the effect upon liver morphology of portal venous as opposed to systemic Answers are found at the end of the article. blood. The histopathologic changes became the most important end points in many of the complex experiments that were used to examine the hepatotrophic hypothesis. As befits an Englishman, Dr. Porter's princi­ 690 pal side interest is gardening. 691 should influence decisions about the appropriateness, timing, and type of portacaval shunt in patients with portal hyperten­ sion and esophageal varices, or in the small number of patients w,hose. inborn errors of metabolism can be ameliorated by portal diverSIOn. is Professor of Biological Chemistry and THE PORTACAVAL SHUNT (ECK'S FISTULA): A CENTURY Chairman of the Department of Gastroen­ tcrology at the University of Bari, Italy. OF CONTROVERSY His principal work in the field of portal The understanding of Eck's fistula"'has gone through sevel'al physiology began in 1971 during a fellow­ stages. In this discussion, the beginnings of each stage will be ship at the University of Colorado. By us­ described in order of occurrence. Often, however, significant de­ ing biochemical techniques which identi­ fied the metabolic footprints of hormone tails continued to accrue for years or decades about each funda­ actions, he added a new dimension to re- mental step. Consequently, the remarks in the following sec­ search on the specificity of portal venous tions refer to studies widely separated in time, in some instances blood. The way in which Dr. Francavilla's as much as 100 years apart, biochemical studies supported and ex- tended the histopathologic observations of Dr. Porter was a classic demonstration of ECK VERSUS PAVLOV the power of interdisciplinary research. Dr. Two remarkable articles on portal physiology were published Francavilla's work in this field has contin- in the 19th century, Both authors were Russian. Their similar­ ued to the present time and is currently concerned with the biochemical events and ity ended there. control of hepatic regeneration. Dr. Fran- Nicholas Eck was a 29-year-old military surgeon without cavilla's hobbies include soccer and the training in laboratory investigation whose unique contribution production of Puglia (rcginna I Baril wines. to the medical literature was an article scarcely more than 1 page long.:! In it, he cited the widespread belief that a liver de­ prived of its portal blood flow could not sustain life. He stated that he had overturned this erroneous opinion by constructing TilE DUAL BLOOD SUPPLY of the liver has been known for completely diverting portacaval anastomoses (later known as several centuries. However, the physiologic implications of this Eck's fistula) in eight dogs. Seven animals died during 01' shortly anatomical arrangement have become intelligible only in recent after the operation, The eighth recovered fully and was observed years. The fact that an artery passed to the liver was never con­ for 211:.! months before it escaped from the laboratory, never to be fusing, since there was no reason to suspect that it carried blood found. different from that pumped through other organs. Eck envisioned the clinical use of his operation and. gave an In contrast, the portal vein was suspect. Because the blood in explicit although brief account of this technique. His purpose he this vessel was returning from the intestine and other splanch­ described as follows: nic organs, it could possess nutrients or other constituents from the non hepatic splanchnic viscera to which the liver would be I am conducting these experiments with the purpose of clarifying some exposed in high concentration on first pass. The possibility that physiologic problems as well as to determine if it would be possible to treat some cases of mechanical ascites by means of forming such a fis­ such portal substances could be important to liver health be­ tula. I consider the main reason to doubt that such an operation can be came known as the hepatotrophic hypothesis; confirmation of carried out on human beings has been removed because it has been this hypothesis has been one of the most important recent de­ established that the blood of the portal vein, without any danger to the velopments in hepatic physiology. I body, could be diverted directly into the general circulation and this by The hepatotrophic concept has direct relevance to many clini­ means of a perfectly safe operation. cal problems, including those of liver transplantation and he­ patic regeneration. I, 2 However, our main concern in this mono­ His optimism may have been excessive in view of the perioper­ graph is to explore how knowledge of hepatotrophic physiology ative mortality of 88tK. 692 693 Eck concluded his article with the comment, "I had to post­ ferior vena cava were approximated with an oval row' of inter­ pone further experiments because I was called to join the active rupted sutures, inside of which a suture loop was inserted to army." Although his work in surgical physiology had ended, im­ permit the adjacent vessel walls to be avulsed or cut with a spe- cially designed scissors (Fig 1).
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