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1.
BACKGROUND: The safety of spleen conservation without preservation of the splenic artery and vein was proved on the basis of short-term observation, but the long-term results of this procedure have been uncertain. To clarify the hemodynamic changes of splenogastric circulation of patients undergoing spleen-preserving pancreatectomy with excision of the splenic artery and vein, we retrospectively analyzed patient outcome with particular reference to the assessment of hemodynamic changes of splenogastric circulation. METHODS: Ten patients who had undergone spleen-preserving pancreatectomy with excision of the splenic artery and vein were retrospectively analyzed. In all patients both the short gastric and left gastroepiploic arteries and veins were preserved. All patients were observed for a minimum of 52 months. Collateral venous pathways were evaluated by computed tomography and endoscopy. RESULTS: Early complications such as splenic infarction and atrophy did not occur in any of the patients, but computed tomography revealed perigastric varices in 7 patients (70%) and submucosal varices in 2 patients (20%). Endoscopy showed gastric varices in 2 patients in whom submucosal gastric varices were identified on computed tomography. Gastrointestinal bleeding from gastric varices occurred in 1 patient. In 1 patient without gastric varices, a gastrorenal shunt was demonstrated on computed tomography. CONCLUSIONS: This study confirmed that gastric varices frequently occurred in patients who underwent spleen-preserving pancreatectomy with excision of the splenic artery and vein. 相似文献
2.
Esophageal varices produced in dogs 总被引:1,自引:0,他引:1
In attempts to produce esophageal varices in dogs, we designed a procedure based on the concept of hyperdynamic flow. The first stage operation involved the achievement of an arteriovenous shunt between the left renal artery and the proximal splenic vein, in concert with the distal splenic venous-left renal venous shunt. About one month after the initial operation, sixteen of the twenty-eight dogs had tolerated the manipulations. Both shunts proved to be functioning well in six of sixteen survivors, in which an ameroid constrictor was placed around the splenic vein just proximal to the confluence of the left gastric vein. Again one month later, in five of these six, esophageal varices were evidenced, both endoscopically and histologically. Arterialization of left gastric vein concomitant with the distal splenorenal shunt, gave rise to a hyperdynamic state in the upper stomach and resulting in reproducible esophageal varices. 相似文献
3.
Esophageal varices produced in dogs 总被引:1,自引:0,他引:1
In attempts to produce esophageal varices in dogs, we designed a procedure based on the concept of hyperdynamic flow. The
first stage operation involved the achievement of an arteriovenous shunt between the left renal artery and the proximal splenic
vein, in concert with the distal splenic venous-left renal venous shunt. About one month after the initial operation, sixteen
of the twenty-eight dogs had tolerated the manipulations. Both shunts proved to be functioning well in six of sixteen survivors,
in which an ameroid constrictor was placed around the splenic vein just proximal to the confluence of the left gastric vein.
Again one month later, in five of these six, esophageal varices were evidenced, both endoscopically and histologically. Arterialization
of left gastric vein concomitant with the distal splenorenal shunt, gave rise to a hyperdynamic state in the upper stomach
and resulting in reproducible esophageal varices. 相似文献
4.
It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein. 相似文献
5.
Modified distal splenorenal shunt with expanded polytetrafluoroethylene interposition 总被引:1,自引:0,他引:1
Two types of modified distal splenorenal shunt with expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc., Elkton, Md.) interposition were performed in 18 consecutive patients with esophageal or esophagogastric varices. There were 12 men and six women ranging in age from 32 to 76 years. The causes of portal hypertension were cirrhosis of the liver in 15 patients, chronic hepatitis in two, and idiopathic portal hypertension in one. In five patients the left gastric vein branched off from the splenic vein; bilateral gastric venous decompression was achieved by preserving the splenic vein. Porta-azygos disconnection was routinely performed by confirming repeated intraoperative direct splenoportography. The operations were elective in seven and were emergencies in five patients. Six patients underwent a prophylactic shunt; all patients had "red color signs" endoscopically, and three of them had concomitant hepatocellular carcinoma. Postoperative morbidity was minimal and there was no mortality. Shunt patency was confirmed angiographically in all patients 14 to 56 days after surgery. The varices disappeared or significantly improved in all patients. No patients had variceal bleeding postoperatively. Hepatic encephalopathy was transiently seen in one (the oldest) patient. 相似文献
6.
S Bengmark B Brjesson J Hoevels B Joelsson A Lunderquist T Owman 《Annals of surgery》1979,190(4):549-554
The percutaneous transhepatic portal vein catheterization (PTP) with selective obliteration of the coronary vein and/or the short gastric veins in treating bleeding esophageal varices was introduced in 1974. In order to prevent recanalization of the vessels Bucrylate (isobutyl-2-cyano-acrylate) has been used in 43 patients 55 times during a period of 34 months (October 1975 to July 1978). The obliterative treatment was followed by rebleeding in 35% of the cases and continued bleeding occurred in two patients. Fourteen patients were treated on 16 occasions during acute bleedings, and five of these (36%) died within two months from a portal vein thrombosis caused by the obliterative procedure. Because of these findings PTP with obliteration of the veins feeding the esophageal varices is not recommended as an elective way of treatment. It should only be used in the acute bleeding patient when transesophageal sclerosering therapy, continuous vasopressin infusion and balloon tamponade have failed. Fifty-six per cent of the patients acutely treated stopped bleeding for more than one week, thus avoiding an emergency shunt or devascularization operation which are associated with a high mortality rate. 相似文献
7.
Twenty patients with liver cirrhosis were treated by surgery for bleeding from isolated gastric varices.
The presence of tortuous and engorged gastric veins connecting with a large splenorenal shunt was
demonstrated by transhepatic portography in all patients. The surgical procedures consisted of
splenectomy, proximal gastrectomy, paragastric devascularization, and ligation of the splenorenal
shunt. Sixteen patients survived the surgery. Four deaths were caused by emergency operation for
uncontrollable hemorrhage in extremely poor risk patients. Of the 16 survivors, 15 had been followed
wth endoscopy and portography for a mean period of 42 months. The other one died of hepatocellular
carcinoma three years after surgery. There was no bleeding episode during the period of follow-up in
these patients. Recurrent esophageal varices of mild degree were documented by endoscopy and
portography in three patients. Portography demonstrated that several newly formed retroperitoneal
veins arising from the junction of the portal and superior mesenteric veins joined to form recurrent
varices in these three patients. There was no significant change of the mean portal venous pressure
before and after surgery. Our data reveals that elective surgery may provide satisfactory results in
patients with isolated gastric varices. Transhepatic portography is the method of choice in radiologic
investigation for prominent gastric varices. 相似文献
8.
A 23 years old woman was admitted on emergency for an upper digestive tract bleeding and endoscopy found gastric varices. CT scan revealed a splenomegaly, a twisted aspect of the splenic pedicle and varices in the gastrosplenic ligament. Arteriography showed a narrow splenic artery and varices in the gastrosplenic ligament. After a recurrent bleeding, splenectomy was performed. There was a chronic volvulus of a wandering spleen; the splenic venous flow was passing through the left gastroepiploic vein and a gastrosplenic vein. Chronic volvulus of a wandering spleen with gastric varices is an unfrequent pathology, diagnosed by imaging and requiring splenectomy. 相似文献
9.
N Koyanagi K Inokuchi K Beppu K Nagamine M Hashizume K Sugimachi 《The Japanese journal of surgery》1985,15(2):134-139
The time of appearance of the left gastric vein on serial celiac arteriograms in patients with portal hypertension and esophageal varices was compared with that of the portal vein to assess regional hemodynamics in the left venous portion of the stomach, an area located in close proximity to the varices. In two thirds of all the patients with cirrhosis or non-cirrhotic idiopathic portal hypertension (IPH), the left gastric vein was visualized earlier or simultaneously than or with the portal vein, while in all but one patient with prehepatic portal obstruction, there was a delayed opacification of the left gastric vein. These results suggest the presence of a hyperdynamic circulatory state which promotes venous hypertension in the left gastric venous area of the stomach of a considerable number of patients with cirrhosis or IPH. In such a hemodynamic state, selective decompression of varices can be achieved by a left gastric venous caval shunt. 相似文献
10.
Nobuhiro Koyanagi Kiyoshi Inokuchi Kazushige Beppu Kenji Nagamine Makoto Hashizume Keizo Sugimachi 《Surgery today》1985,15(2):134-139
The time of appearance of the left gastric vein on serial celiac arteriograms in patients with portal hypertension and esophageal
varices was compared with that of the portal vein to assess regional hemodynamics in the left venous portion of the stomach,
an area located in close proximity to the varices. In two thirds of all the patients with cirrhosis or non-cirrhotic idiopathic
portal hypertension (IPH), the left gastric vein was visualized earlier or simultaneously than or with the portal vein, while
in all but one patient with prehepatic portal obstruction, there was a delayed opacification of the left gastric vein. These
results suggest the presence of a hyperdynamic circulatory state which promotes venous hypertension in the left gastric venous
area of the stomach of a considerable number of patients with cirrhosis or IPH. In such a hemodynamic state, selective decompression
of varices can be achieved by a left gastric venous caval shunt. 相似文献
11.
Magnetic resonance imaging (MRI) was performed in seven patients before and after portosystemic shunting to evaluate venous changes accompanying nonselective and selective shunt construction. The size and number of the intrahepatic portal and hepatic veins, left perirenal veins, and left upper quadrant varices were evaluated at MRI before and after shunt construction. MRI correctly diagnosed patent shunts in all seven patients. A marked decrease in the size of intrahepatic veins after a total or nonselective shunt suggests adequate portal vein and variceal decompression. Dilatation of left perirenal veins in the presence of a patent mesorenal or splenorenal shunt suggests hypertension of the left renal vein and possibly inadequate decompression of esophageal varices. 相似文献
12.
Kobayashi T Sato Y Yamamoto S Oya H Kokai H Hatakeyama K 《Transplantation proceedings》2012,44(2):591-593
This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC−]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H2O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(−), GV: Lg-c, F2, Cw, RC−) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations. 相似文献
13.
Y Yokoyama 《Nihon Geka Gakkai zasshi》1990,91(2):234-245
Radioisotopic splenoportography was performed in 55 patients with portal hypertension, in whom 52 had various degrees of esophagogastric varices, and in 20 patients without portal hypertension. In the patients with varices, collateral images were obtained in 50 patients (96%) by this method and no image was obtained in the patients without varices. The rate of positively imaged collaterals was as follows: Esophageal varices 69%, the left gastric vein 85%, the short gastric veins 48%, RI stasis in esophagogastric region 65%, the azygos vein 46%, the subclavian vein 25%, the para-umbilical veins 46%, splenorenal /gastrorenal shunts 19%, the inferior mesenteric vein 17%, the left intercostal veins 6%, and Arantius's duct 4%. These rates were superior to that obtained from the conventional transarterial portography. There were some correlations between RI-images by this method and clinical and laboratory findings; patients with ascending collaterals alone tended to have extensive and severe varices and higher rate of bleeding, on the other hand, variceal bleeding was not found and episodes of portosystemic encephalopathy frequently occurred in patients with descending collaterals alone. After successful sclerotherapy, RI-images of esophageal varices disappeared in 92% of the patients. Radioisotopic splenoportography appears to be a useful diagnostic and follow-up modality for patients with portal hypertension and esophagogastric varices. 相似文献
14.
15.
The results of a modified Sugiura devascularisation
procedure were assessed in 14 patients with thrombosis
of the portal and splenic vein requiring surgery
for variceal hemorrhage, with no vein suitable
for orthodox shunt surgery. The venous anatomy
was determined by ultrasonography with Doppler
studies and portovenography. Liver biochemistry as
well as liver architecture on histopathology was
normal in all. The surgery was elective in 9 cases for
documented bleed from diffuse fundal gastric
varices (FGV) and emergency in 5 cases, 3 having
bleeding FGV and 2 for failure of emergency
esophageal variceal sclerotherapy. All were subjected
to a transabdominal extensive devascularisation
of the upper two third of the stomach and lower
7–10cm of the esophagus. Stapled esophageal
transection (n=11) or esophageal variceal under-running
(n=1) was performed in all with esophageal
varices. FGV were underrun. Follow up endoscopies
were done six monthly. There were 9 males and 5
females with a mean age of 17.2 years (SD 12.8).
There was no operative mortality. Acute variceal
bleeding was controlled in all patients. Over a mean
follow up of 38 months, all but one remain free of
recurrent bleeding. We conclude that a modified
Sugiura devascularisation procedure is effective in
the immediate and medium term control of variceal
bleeding in patients with “unshuntable” portal
hypertension. 相似文献
16.
Yuichiro Ogawa Sozo Hirose Hirofumi Yukaya Naofumi Nagasue Yukiharu Sasaki Kazumasa Morinaga Yukihisa Miyoshi Yoshihiro Seto 《Surgery today》1980,10(4):310-314
Left gastric vena caval shunt (Inokuchi) was performed in four patients with liver cirrhosis; electively in two and prophylactically
in two cases. The overall results have been satisfactory in terms of the effect on esophageal varices and postoperative complications.
This procedure appeared to be superior to distal splenorenal shunt or other direct surgical procedures in several aspects.
Since left gastric vena caval shunt does not require particularly elaborate surgical techniques and can be performed safely
even in patients with considerably impaired hepatic function, it can be recommended as an ideal surgical procedure to be performed
in elective and prophylactic surgical candidates. 相似文献
17.
Experiments have been performed on 25 pigs creating a shunt through the liver substance between the portal vein and the vena cava. The technique involves passage of a small caliber (5 mm) probe via an incision in the portal vein to a major branch of the left hepatic vein. Directed toward a finger on the middle hepatic vein, a 9-mm diameter tunnel is created through 3 cm of liver tissue to the hepatic venous outflow tract. A rigid cryoprobe (?70°C) created a 9-mm diameter tunnel between the portal and hepatic veins through the substance of the liver.Six of 11 animals sacrificed between 5 and 56 days postoperatively had patent shunts; these unheparinized animals had normal portal pressures.The technique is designed ultimately to provide a relatively atraumatic method for creating an emergency portocaval shunt in patients with bleeding esophageal varices. 相似文献
18.
目的探讨MRI指导胃镜下硬化治疗胃底曲张静脉出血及评价其早期疗效的价值。方法收集73例接受胃镜下硬化治疗胃底静脉曲张出血患者,治疗前应用MRI评估胃底曲张静脉团的范围及其供血、引流途径,并根据MRI估算硬化治疗所需硬化剂用量。治疗后再次行MR检查,比较治疗前后胃底曲张静脉团体积、胃左静脉管径的变化,并比较胃镜与MRI评价疗效的价值。结果治疗前MRI能全面评估曲张静脉团的范围、体积及其供血、引流途径;治疗后MRI示曲张静脉团缩小,胃左静脉管径缩小(P均0.01)。MRI与胃镜对无效的判断一致,对有效及显效的判断差异有统计学意义(P0.01)。结论胃底静脉曲张硬化治疗前,MRI评估有助于为出血风险较高患者选择合理治疗方案。应用MRI可观察硬化治疗即时疗效,较胃镜更直观、全面。 相似文献
19.
Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. 总被引:9,自引:0,他引:9
BACKGROUND/AIM: The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose. METHODS: Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43-71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes. RESULTS: We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 +/- 66 mm H(2)O, whereas in patients with isolated gastric varices it was 262 +/- 44 mm H(2)O (p < 0.01). CONCLUSION: We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices. 相似文献
20.
OBJECTIVE: To determine the natural history of pancreatitis-induced splenic vein thrombosis with particular attention to the risk of gastric variceal hemorrhage. SUMMARY BACKGROUND DATA: Previous studies have suggested that splenic vein thrombosis results in a high likelihood of gastric variceal bleeding and that splenectomy should be performed to prevent hemorrhage. Recent improvements in cross-sectional imaging have led to the identification of splenic vein thrombosis in patients with minimal symptoms. Our clinical experience suggested that gastric variceal bleeding in these patients was uncommon. METHODS: A computerized index search from 1993 to 2002 for the medical records of patients with a diagnosis of pancreatitis was performed. Fifty-three patients with a diagnosis of pancreatitis and splenic vein thrombosis were identified. The medical records of these patients were reviewed, and follow-up was completed, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ). RESULTS: Gastrosplenic varices were identified in 41 patients (77%) with varices evident on computed tomography (CT) in 40 of 53 patients, on esophagogastroduodenoscopy (EGD) in 11 of 36 patients, and on both CT and EGD in 10 of 36 patients. This risk of variceal bleeding was 5% for patients with CT-identified varices and 18% for EGD-identified varices. Overall, only 2 patients (4%) had gastric variceal bleeding and required splenectomy. Functional quality of life was better than historical controls surgically treated for chronic pancreatitis. CONCLUSION: Gastric variceal bleeding from pancreatitis-induced splenic vein thrombosis occurs in only 4% of patients; therefore, routine splenectomy is not recommended. 相似文献