The significance of portal vein thrombosis after distal splenorenal shunt

The aims of this study were to determine the incidence of portal vein thrombosis after the distal splenorenal shunt, to identify any predictive factors, and to assess the clinical significance of this complication. Preoperative and postoperative angiograms and clinical evaluation were reviewed in 124 patients who underwent distal splenorenal shunts. Total and partial portal vein thrombosis were seen on 13 (10.5%) and 22 (17.7%) postoperative angiograms, respectively. The only preoperative variable correlating with development of portal vein thrombosis was portal venous perfusion, which was significantly lower in patients with than in those without portal vein thrombosis. In six of 10 patients with postoperative pancreatitis, portal vein thrombosis developed. The frequency of early postoperative complications was significantly greater in patients with total portal vein thrombosis than in those with partial or no thrombosis. Long-term follow-up has shown no significant effects of portal vein thrombosis on late ascites, encephalopathy, or survival.     

Effect of vasopressin on portal venous pressure

Portal venous pressure measurements were made through percutaneous transhepatic portal vein catheterization in 29 cirrhotics with portal hypertension and in seven controls before and after intravenous vasopressin infusion in a dosage of 0.24 IU/min. In cirrhotic patients the decrease in portal pressure was 8.5% being not statistically significant, while in the control group the decrease was 12% (p less than 0.05). Five of six cirrhotic patients (85%) whose acute bleedings were previously controlled with i.v. vasopressin infusion had reversed portal vein flow. On the other hand, only three of ten (30%) patients whose bleeding failed to be controlled with vasopressin had reversed flow in the portal vein. The difference between these two groups is statistically significant (p less than 0.05) and may suggest that variceal bleeding is most effectively controlled with i.v. vasopressin in cirrhotics with well developed collaterals and reversed portal vein flow.     

Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus?

Summary Thirteen patients with normal pressure hydrocephalus were operated upon with an externally manoeuvrable shunt system (Sophy SU8) in order to investigate its influence on clinical outcome, intracranial pressure and cranial CT parameters. The opening pressure was set at high at surgery and lowered stepwise at intervals of three months to medium and low. The clinical condition, intracranial pressure and cranial CT parameters were examined at the end of the 3 months interval on each pressure level.The patients improved within the first 3 months inspite of an unchanged mean intracranial pressure and remained in a stable clinical condition during the rest of the study period. The intracranial pressure was significantly reduced at 9 months. The ventricular index, Evans index, temporal horn and third ventricle width were reduced 3 months post-operatively and did not change significantly during the rest of the study. The pre-operative third ventricle width was correlated to high psychometric test results after shunt surgery. Reduction in ventricular index, Evans index and third ventricle width after surgery correlated to improvement in psychometric scoring.The clinical improvement after shunt surgery for normal pressure hydrocephalus is seen within 3 months and is independent of the adjusted valve pressure.     

The effect of the distal splenorenal shunt on hypersplenism.

Twenty-four patients with leukopenia and/or thrombocytopenia improved these deficiencies after distal splenorenal shunts. The average white blood cell count for 23 neutropenic patients increased by an average 1000 cells/cu.mm p less than .01. The average platelet count for 13 thrombocytopenic patients increased by more than 40,000, p less than .02. Analysis of the data showed that patients older than 50 years, with a history of alcoholic liver disease and sinusoidal hypertension greater than 15mm Hg were most likely to correct leukocyte and platelet defects after distal splenorenal shunts.     

腹内高压对门静脉压、中心静脉压影响的实验研究

目的研究腹内压升高对大鼠中心静脉压和门静脉压的影响。方法将20只成年雄性SD大鼠分别通过颈静脉插管、穿刺门静脉主干法来测定中心静脉压和门静脉压，运用氮气气腹法制作大鼠腹内高压动物模型。建立气腹后分别在0、5、10、15、20、25、30、35、40、45mmHg压力值下测得中心静脉压和门静脉压。结果中心静脉压和腹内压之间的直线回归方程为Y=2．824＋0．045X，相关系数r=0．984（P〈0．01）；门静脉压和腹内压之间的直线回归方程为Y=8．887＋0．939X，相关系数r=0．998（P〈0．01）。结论腹内压与中心静脉压和门静脉压有很好的相关性，可以根据腹内压监测中心静脉压和门静脉压的变化。     

门静脉压力无创测定应给予重视

正门静脉高压症(portal hypertension,PHT)是肝硬化门静脉系统血流动力学异常导致的综合征,随着病程的进展,会出现食管胃底静脉曲张破裂出血、脾功能亢进、难治性腹水、肝性脑病等临床表现,因此门静脉压力的测定具有重要临床价值。最早对于门静脉压力的评估,是在进行腹部手术时通过测定肠系膜上静脉的压力来实现的,但是该法仅适用于术中,无法广泛应用于临床,     

腹内高压对门静脉压、中心静脉压影响的实验研究

目的研究腹内压升高对大鼠中心静脉压和门静脉压的影响。方法将20只成年雄性SD大鼠分别通过颈静脉插管、穿刺门静脉主干法来测定中心静脉压和门静脉压,运用氮气气腹法制作大鼠腹内高压动物模型。建立气腹后分别在0、5、10、15、20、25、30、35、40、45mmHg压力值下测得中心静脉压和门静脉压。结果中心静脉压和腹内压之间的直线回归方程为Y=2.824+0.045X,相关系数r=0.984(P<0.01);门静脉压和腹内压之间的直线回归方程为Y=8.887+0.939X,相关系数r=0.998(P<0.01)。结论腹内压与中心静脉压和门静脉压有很好的相关性,可以根据腹内压监测中心静脉压和门静脉压的变化。     

The distal splenorenal shunt

Our initial use of the distal splenorenal shunt (DSRS) in 1973 was fostered by disappointment with the results of so-called total shunts. This selective shunt was, when anatomically feasible, our preferred therapy until 1980, when surgical referral was affected by enthusiasm for sclerotherapy. Our study of 71 DSRSs is uncontrolled because we could not recruit patients for a prospective randomized trial that involved either no treatment of operations that had proven faults. Our experience shows that operative risk (4%) and incidence of postshunt encephalopathy (6%) are low, that the rate of shunt occlusion is acceptable (10%), and that bleeding is as well controlled as with other shunts. Survival rates correlate with the cause of portal hypertension and with hepatic functional reserve. Analysis of the causes of death shows that the natural history of cirrhosis and coexistent disease are major determinants of prognosis.     

The distal splenorenal shunt

Distal splenorenal shunt (DSRS) provides selective decompression of gastroesophageal varices, with maintenance of portal hypertension and prograde portal flow to the cirrhotic liver. Accurate patient evaluation is essential to select appropriate patients for DSRS. Variceal bleeding control is greater than 85% and is as effective as total portosystemic shunts. Maintenance of prograde portal flow is greater than 90% in nonalcoholic disease, but only 50% in alcoholic cirrhosis; the latter is improved by total splenopancreatic disconnection. Hepatic function is better maintained when portal flow is maintained. Encephalopathy is lower after DSRS than after total shunts. Survival is not significantly improved after DSRS in patients with alcoholic cirrhosis compared to outcome after total shunts. The survival in patients with nonalcoholic disease is significantly improved over that of alcoholics.     

Results of a modified distal spleno-renal shunt for portal hypertension.

Twenty-five patients were treated with a distal spleno-renal shunt modified after that of Warren. The operative mortality was 4/25. One patient had an early thrombosis. All post-operative angiography otherwise showed patent shunts. After a median observation time of 43 months, 10/20 patients included in the followup were dead. The chief cause of death was liver failure. Encephalopathy has been common although generally of minor degree. Hypersplenism, judged by thrombocyte count, was not significantly affected by the operation. Six of 21 patients have had gastrointestinal hemorrhage after the operation but no hemorrhage proved fatal. Postoperatively esophageal varices size was considerably diminished in most cases as judged by contrast x-ray. Ascites has not been a problem in this series. Postoperative angiography showed a marked and rapid reduction of portal blood flow to the liver with progressively more blood deviated through the coronary vein towards the shunt. This reduction in portal flow is a possible explanation of the high frequency of postoperative liver failure. This version of the distal spleno-renal shunt has probably no advantages over the portacaval shunt.     

Operative morbidity after shunt surgery for portal hypertension

The operative morbidity observed in a consecutive series of 286 patients who underwent shunt surgery for portal hypertension is reported. 149 patients out of 286 (52.1%) had a postoperative complication, which required reoperation in 11 cases (5 intestinal perforations, 2 bleeding peptic ulcers, 1 eventratio, 1 cholestasis, 1 acute pancreatitis, 1 strangulated hernia). 42 patients out of the 149 with complications died of the complication (operative mortality 14.6%). Operative morbidity and mortality appeared higher in patients operated as emergencies. Whereas elective shunts gave better results. The problem involved in preventing and treating the serious complications following shunt surgery for portal hypertension are discussed.     

脾肾静脉分流联合断流术的临床疗效及对门静脉系统血流动力学的影响

目的 评价近端脾肾静脉分流加门奇断流联合手术和门奇断流术的临床疗效及对门静脉系统血流动力学的影响。方法 回顾性总结近8年采用脾肾分流加门奇断流联合手术和门奇断流术治疗门静脉高压症245例，于术前一周和术后2周应用核磁共振血管造影测量门静脉、脾静脉和肠系膜上静脉的直径，流速和流量，并于术中动态测量门静脉压力。结果 联合手术组术后较术前门静脉血流量下降，肠系膜上静脉流量增加，差异有统计学意义（P〈0．05），门静脉直径和自由门静脉压下降差异有统计学意义（P〈0．01）。联合手术组与断流组相比，门静脉血流量的减少差异没有统计学意义，而自由门静脉压的下降差异有统计学意义（P〈0．01）。联合手术组术后再出血率明显低于断流组，而肝功能和脑病发生率两组间差异无统计学意义。结论 联合手术可结合断流和分流手术的优点，既明显降低出血率又不增加脑病发生，应成为治疗门静脉高压症合并出血的首选术式。     

脾肾静脉分流联合断流术的临床疗效及对门静脉系统血流动力学的影响

目的评价近端脾肾静脉分流加门奇断流联合手术和门奇断流术的临床疗效及对门静脉系统血流动力学的影响。方法回顾性总结近8年采用脾肾分流加门奇断流联合手术和门奇断流术治疗门静脉高压症245例,于术前一周和术后2周应用核磁共振血管造影测量门静脉、脾静脉和肠系膜上静脉的直径,流速和流量,并于术中动态测量门静脉压力。结果联合手术组术后较术前门静脉血流量下降,肠系膜上静脉流量增加,差异有统计学意义(P<0.05),门静脉直径和自由门静脉压下降差异有统计学意义(P<0.01)。联合手术组与断流组相比,门静脉血流量的减少差异没有统计学意义,而自由门静脉压的下降差异有统计学意义(P<0.01)。联合手术组术后再出血率明显低于断流组,而肝功能和脑病发生率两组间差异无统计学意义。结论联合手术可结合断流和分流手术的优点,既明显降低出血率又不增加脑病发生,应成为治疗门静脉高压症合并出血的首选术式。