Survival and Variceal Rehemorrhage After Shunting Support Small-Diameter Prosthetic H-graft Portacaval Shunt

This study was undertaken to report variceal rebleeding and survival after small-diameter prosthetic H-graft portacaval shunts (HGPCS) and to compare actual to predicted survival after shunting. Since 1987 we have prospectively followed patients after undergoing HGPCS to treat bleeding varices failing/not amenable to sclerotherapy/banding. One hundred and seventy patients underwent shunting. Cirrhosis was because of alcohol in 56%, hepatitis in 12%, both in 11%, and other causes in 21%. Child class was A for 10%, B for 28%, and C for 62%. Thirty-three patients died by 6 months, 54 by 24 months, 87 by 60 months, and 112 by 10 years, generally because of liver failure. Fifty-one patients are alive at a median of 48.3 months, 76 months +/- 57.8 (mean +/- SD). Variceal rehemorrhage was documented in 3 (2%) patients. By child class, 5-year/10-year survival rates were as follows: A 66.7/33.3%, B 48.6/15.6%, and C 29.2/7.0%. Actual survival was superior to predicted survival (Model for End-Stage Liver Disease [MELD]), (p < 0.001).Variceal rehemorrhage in patients undergoing small-diameter prosthetic H-graft portacaval shunting was very uncommon. Actual survival was superior to predicted survival (MELD). Long-term survival paralleled degree of hepatic function, although long-term survival was possible even with very advanced cirrhosis. Application of HGPCS is encouraged.     

Does the Permanent Portacaval Shunt for a Small‐for‐Size Graft in a Living Donor Liver Transplantation Do More Harm Than Good?

In order to obviate a small-for-size graft syndrome (SFSGS), a portacaval (PC) shunt had been considered in a case of adult-to-adult living donor liver transplantation (AA-LDLT). In a recent AA-LDLT case, we adopted the PC shunt to resolve SFSGS; however, graft atrophy was observed in the late period of LDLT, thereby resulting in liver dysfunction. Due to the surgical closure of the PC shunt at 11 months post-LDLT, the graft regenerated gradually and resulted in the recovery of the liver function. This experience indicates that the portacaval shunt would overcome SFSGS in the early period of LDLT, while it would cause the graft atrophy and the graft dysfunction in the late period of LDLT.     

A Technique to Reconstruct a Nerve Injured at Its Bifurcation Site Using Autograft and End-to-Side Neurorrhaphy

Peripheral nerves injuries are relatively frequent after high-energy trauma in both upper and lower limb. This case report describes the reconstruction of a 5-cm nerve defect involving the superficial peroneal nerve (SPN) where it divides into its two terminal branches. A 5-cm nerve graft was harvested from the proximal part of the medial dorsal cutaneous nerve (MDN) and interposed to fill the gap between the distal stump of the SPN and the intermediate dorsal cutaneous nerve (IDN). The stump of the MDN was then sutured with an end-to-side (ETS) technique to the IDN, distally to the nerve graft, by opening a window in the epineurium of IDN. The sensory restoration of the dorsal area of the foot after 8 months was evaluated satisfactory from the authors. Tenderness and Tinel’s sign at the lesion site were not present. The patient’s satisfaction was excellent. The results of this case may suggest that a nerve defect involving a bifurcation point can be treated with satisfactory results using one distal stump as donor nerve for a nerve autograft to bridge the nerve gap followed by an ETS neurorrhaphy of donor one on the other stump. In this way, it is possible to reconstruct a bifurcation point by creating a new division point with the same Y-shape in a more distal position, without adding morbidity due to the harvesting of a nerve graft from another area of the body.     

Supercharge End-to-Side Nerve Transfer: Systematic Review

Background: To decrease the time to reinnervation of the intrinsic motor end plates after high ulnar nerve injuries, a supercharged end-to-side (SETS) anterior interosseous to ulnar motor nerve transfer has been proposed. The purpose of this study was to compile and review the indications, outcomes, and complications of SETS anterior interosseous to ulnar motor nerve transfer. Methods: A literature search was performed, identifying 73 papers; 4 of which met inclusion and exclusion criteria, including 78 patients. Papers included were those that contained the results of SETS between the years 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes: intrinsic muscle recovery and complications. Results: Four studies with 78 patients met inclusion and exclusion criteria. Most patients (33.3%) underwent SETS for an ulnar nerve lesion in continuity, the average age was 46.5 years, and the average follow-up was 10 months. The average duration of symptoms before surgery was 99 weeks, all patients had weakness and numbness, nearly all (96%) had atrophy, and half (53%) had pain. Grip and key pinch strength improved 202% and 179%, respectively, from the preoperative assessment. The vast majority (91.9%) recovered intrinsic function at an average of 3.7 months. Other than 8% of patients who did not recover intrinsic strength, no other complications were reported in any of the 78 patients. Conclusions: The SETS is a successful procedure with low morbidity, which may restore intrinsic function in patients with proximal nerve injuries.     

Side-to-End Portacaval Shunt: A Way out of Difficulty

A case is described in which massive hypertrophy of the caudate lobe of the liver made a conventional porta-caval shunt impossible. The end of the divided vena cava was anastomosed to the side of the portal vein. This technique may provide one answer to a difficult technical problem.     

End-to-Side Vascular Anastomosis: A Modified Technique

A modified end-to-side vascular anastomosis utilizing polypropylene sutures is presented. Of the currently available suture materials, polypropylene has the lowest coefficient of friction. It is therefore possible to place each anastomotic line without approximating graft to artery until all sutures are in position. The advantage of combining the visualization afforded by an interrupted anastomosis with the relative speed offered by a continuous anastomosis is thus achieved.     

A comparison of the metabolic changes after the distal splenocaval and portacaval shunts

The distal splenorenal shunt (DSRS) is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, those with an anatomically aberrant relationship between the splenic and left renal veins, and those whose preoperative angiographic findings suggest a risk of developing postoperative renal vein hypertension. For these clinical situations, the selective distal splenocaval shunt (DSCS) is a useful alternative to the DSRS. However, the metabolic consequences of the DSCS have not yet been studied in detail and therefore, using a canine model, the metabolic changes following the DSCS and the portacaval shunt (Eck) were compared. The metabolic changes observed following the Eck were hyperammonia and amino acid imbalance, while those following the DSCS were similar to those of the control dogs. In terms of the hepatic adenosine triphosphate level, which reflects hepatic mitochondrial function, the DSCS dogs were also similar to the control dogs. These data suggest that there was no metabolic disadvantage of the DSCS compared to the control.     

经皮穿刺直接性门腔静脉分流术

直接性门腔分流（DIPS）是在肝后段下腔静脉与门脉之间建立肝内分流，将部分门脉血液直接分流入粗大的下腔静脉，解决了TIPS术后分流道引流静脉——肝静脉易狭窄或闭塞的缺陷。DIPS扩大了介入性门腔分流适应证，使部分难以实施TIPS术的患者也能做介入性门腔分流。由于DIPS分流道内的血流方向与下腔静脉内的血流方向呈锐角，局部血流动力学的改变较小。与TIPS相比术后并发症、近期疗效及分流通畅性无显著差异，但DIPS远期通畅性可能较TIPS术稳定。为此，DIPS术已成为近年来介入性门腔分流的新热点。     

Quantitative studies of liver atrophy after portacaval shunt in the rat

BACKGROUND: It is well known that portacaval shunting ultimately leads to a decrease in liver volume and hepatic function, but the mechanism is uncertain. The aim of the present study was to evaluate the effect of portacaval shunting (PCS) upon the morphological changes that occur in the liver in rats after port caval anastomosis. MATERIALS AND METHODS: Sixty-six male rats underwent either PCS (n = 35) or sham operations (n = 31). Hormone levels were determined in blood samples taken just before removal and weighing of the livers. Hematoxylin and eosin-stained sections were used for quantitative morphometric analysis. Apoptosis, mitosis, and cellular organelles also were assessed quantitatively. RESULTS: There was a significant reduction in the liver mass together with testosterone levels in PCS rats in comparison with sham rats. The distance between presinusoidal and postsinusoidal vessels was reduced from 500 mum in the sham rats to 299 mum in the PCS rats (P = 0.000001). Within the same group, there was a significant reduction in the area of hepatocyte nuclei in zone 3 in comparison with zone 1. Electron microscopy revealed a highly significant (P = 0.0007) reduction in the membrane-bound cytoplasmic organelles of zone 3 hepatocytes in PCS rats in comparison with the sham rats. Apoptosis was increased in zone 3 in PCS rats (P = 0.00001), whereas in zone 1 of the same group, there was an associated increased in mitosis (P = 0.000001). Overall, the degree of apoptosis was in excess of mitosis, resulting in a general loss of liver mass. CONCLUSION: Morphometric analysis at cellular and subcellular levels confirms the morphological findings of liver atrophy in PCS rats. The mechanism of atrophy is a complex one. Portacaval shunting leads to hepatic atrophy that, in turn, results in microcirculatory and hormonal changes that further contribute to liver cell loss in this animal model.     

Clinical Usage of Laparoscopic Technique in Cerebrospinal Fluid Ventriculo-peritoneal Shunt

<正>Laparoscopic technique was used to place peritonesl terminal tube incerebrospinal fluid shunt in six patients with hydrocephalus in our series.Three kinds ofmethods were introduced.The results showed that the laparoscopic fine trocar puncture andsubcutaneous fixation method was the most efficient one.This approach was simple,reliableand less time-consuming.No complications associated with the technique were encountered.     

Arterial Shunt with Pump Infusion Line for the Treatment of Chronic Thoracic Aortic Aneurysms: The "Modified Shunt of Gott"

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.     

Arterialization of the liver prevents testicular atrophy in portacaval shunted rats

Portacaval anastomosis in male is known to induce testicular atrophy. The effect of liver revascularization by the right renal artery on the testes of portacaval shunted rats was examined. After shunting, there was a 75% decrease in testis weight compared to the control value and spermatogenesis was blocked in steps 8–9 of spermiogenesis. The in vitro binding of [¹²⁵I]hCG was only 10% of the control value on a per testis basis and labelled areas in the interstitium of frozen sections subjected to topical autoradiography with [¹²⁵I]hCG were also strikingly reduced. These parameters were maintained to normality in revascularized shunted rats which displayed also normal copulatory and fertilizing abilities. It is suggested that an adequate blood supply to the liver, as provided by arterialization, can preserve testicular integrity in shunted rats, even though the blood is arterial instead of portal.     

Flow- and pressure-adapted portal arterialization in dogs

The effects of portal arterialization after portacaval shunt were studied in dogs. Flow- and pressure-adapted portal arterialization was performed by mounting a Teflon cuff on an autogenous vein bypass graft between the hepatic stump of the portal vein and the right renal artery. Immediately following operation, the total hepatic blood flow and intrahepatic portal venous pressure were within normal range. Eight weeks after operation, the intrahepatic portal venous pressure remained within the preoperative range, while total hepatic blood flow had increased double or triple. However, structual change due to increased flow was absent in the liver, even sixteen months after operation. Body weight, liver enzyme chemistry, ICG clearance rate, and amino acid metabolism were well maintained for the entire period of investigation. These findings suggest that sequelae such as hepatic encephalopathy and impaired hepatic metabolism after portacaval shunt can be avoided by portal arterialization, in the presence of an appropriate flow and pressure.