Nonstandard vascular anastomoses in the surgery of portal hypertension

The non-standard porto-caval vascular anastomoses were performed in 32 patients in a series of 167 patients operated for portal hypertension. Some special features of certain variants of non-standard shunt operations, their near and late results are described. It was shown that the use of non-standard porto-caval vascular anastomoses under unfavourable topographo-anatomical conditions extends the possibilities of decompression of the portal system in patients with syndrome of portal hypertension.     

Shunting procedures in portal hypertension in children (author's transl)

31 children aged 2,5 to 14 years suffering from portal hypertension underwent shunting operations (cavosplenal and cavomesenteric anastomoses). The follow-up period covers 2 months to 8 years. Patent anastomoses could be demonstrated in 26 patients.     

Combined operations for prophylaxis of gastroesophageal bleedings at the patients with portal hypertension

Results of portocaval bypass (1st group), suture ligation of gastric and esophageal varicose veins (2nd group), and combined operations (3rd group) performed in early postoperative period at 759 patients with liver cirrhosis and extrahepatic portal hypertension are analyzed. Long-term results were studied at 549 patients. Early recurrence of bleeding was occurred at 41 (12.9%) patients of 1st group, at 17 (8.5%) of 2nd, and at 2 (4%) patients of 3rd group. Lethality due to bleeding recurrence at 1st group was 5.1% among the patients with liver cirrhosis and 1.9% among ones with extrahepatic portal hypertension. Recurrence of bleeding at 2nd group was seen at 52.8% patients with liver cirrhosis, and at 36.4% - with extrahepatic portal hypertension. Lethality due to bleeding recurrence in this group was 7%. The best results were achieved in 3rd group: the recurrence of bleeding was diagnosed at 2 (7.7%) cases, there was 1 lethal outcome. It is concluded that combined surgical procedures at the patients with portal hypertension permit to reduce the rate of early recurrences of bleeding in 2.5 times. It allow to perform widely the partial portocaval anastomoses at the patients with liver cirrhosis and the bypass procedures at extrahepatic portal hypertension.     

Re-evaluation of the opinions regarding vascular portacaval anastomosis in the surgical treatment of portal hypertension]

Experience in the establishment of vascular portocaval anastomoses in 66 patients with cirrhosis of the liver and 52 patients with extrahepatic portal hypertension was studied. Selective portocaval anastomoses produced the best immediate and late-term results in cirrhosis of the liver, side-to-side or H-type splenorenal anastomoses were found to be optimal, they were marked by minimal trauma to the pancreas and adequate decompression of the gastroesophageal channel with maximal maintenance of the portohepatic blood flow. Maximal decompression of the portal system is expedient in extrahepatic portal hypertension; this is mostly accomplished by means of H-type mesentericocaval anastomosis with an autograft formed from the internal jugular vein. Introduction of selective anastomoses into practice and the use of an autovenous graft and precision techniques considerably widened the possibilities of vascular portocaval anastomosis in the treatment of gastroesophageal hemorrhages and made it possible to improve the results of these operations.     

Study of 187 portacaval anastomoses. Statistical analysis of prognostic factors. II. Comparative study of the results of anastomoses with and without interruption of the portal trunk. Discussion]

The authors report a comparative retrospective study of 124 end-to-side portal anastomoses and 63 side-to-side anastomoses. The influence of a certain number of clinical and pathological factors on mortality and immediate and long-term survival, were statistically verified. The quality of the functional result result was analysed in each group of operated patients. Comparison of the results of trunkular anastomoses with or without interruption of the portal vein, showed both as regards, post-operative and late mortality, that the functional results were definitely in favor of end-to-side anastomosis. Thus side-to-side anastomoses gave 40,4 p. 100 of good results and 59,6 average or poor results, as against 60 p. 100 gave rise to portal systemic encephalopathy in 17 p. 100 of cases as against 35 p. 100 in the case of the side-to-side anastomosis. Only the sub-group of operated patients with hepatic vein thrombosis seemed to benefit from side-to-side anastomosis.     

Infectious complications after splenectomy in patients with cirrhosis of the liver

Based on an examination of 105 patients with cirrhosis of the liver with the syndrome of portal hypertension complicated by gastroduodenal bleedings who were subjected to splenectomy (in 86 patients there were proximal splenorenal anastomoses) the authors make a conclusion that infectious complications in the postoperative period in the group under analysis were developing against the background of the concomitant and predisposing conditions and can be compared in their incidence with infectious complications after other similar in severity operative interventions on organs of the abdominal cavity. In remote terms after operation the normalization of the indices of both cellular and humoral immunity was noted.     

Effect of the surgical treatment of portal hypertension on central hemodynamics

The complex investigation of central hemodynamics by methods of sphygmography and tachooscillography was carried out in 98 patients with the syndrome of portal hypertension (59 with cirrhosis of the liver and 39 without cirrhosis) who were subjected to various operations. Central hemodynamics was shown to be normalized by shunting operations especially by proximal splenorenal venous anastomosis in combination with splenectomy. Organ anastomoses in combination with splenectomy are inferior in this respect to vascular anastomoses and ligation of the splenic artery.     

Endovideosurgical methods of treatment of portal hypertension syndrome

Laparoscopic devascularization of the stomach with ligation and transection of the left gastric vein and short gastric veins, ligation of the spleen artery was performed in patients with portal hypertension caused by intrahepatic (2 cases) and subhepatic (1 case) block in order to prevent esophageal bleedings. The first experience with treatment of portal hypertension using endovideosurgical technology has shown that the patients endure the laparoscopic operations satisfactorily even against the background of liver cirrhosis and hepatic failure. Laparoscopic devascularization of the stomach with the transection of the main tributaries to varicose veins of the esophagus represents an effective and minimally traumatic method of prophylactics of esophageal bleedings especially when shunting operations are not possible. Endovideosurgical operations should be considered indicated to patients with pronounced hepatic failure and to patients with extended thromboses and cavernous transformation of the portal system vessels when they can not be used for portal anastomoses.     

Late results of ligation of the splenic artery and its embolization in portal hypertension syndrome

From study of the results of exclusion of the spleen in 87 patients with portal hypertension by ligation of the splenic artery (47) or its truncal embolization (40) with a Gianturko-type spiral, the authors conclude that in some cases these operations reduce portal pressure, manifestations of hypersplenism, and risk of bleeding, but do not guarantee that they will not develop. Ligation of the splenic artery or its truncal embolization is justified as an independent operative intervention when decompression anastomoses cannot be formed or the risk of their performance is extremely high.     

Aspiration-lavage treatment in suture incompetence of the duodenal anastomoses and stump following gastric resection]

An analysis of results of 26 patients has been made who had incompetent sutures of anastomoses and stump of the duodenum at the nearest postoperative period after gastric resection. In 14 patients (main group) aspiration-lavage method of drainage was used, in 12 patients (control group) other methods of treatment of incompetent sutures were employed. The advantage of the aspiration-lavage method of treatment over other methods is shown.     

改良的限制性门腔静脉侧侧分流术

目的: 探讨防止限制性门腔静脉侧侧分流术后吻合口扩大的方法. 方法: 对16例肝硬化门脉高压症病人行限制性门腔静脉分流术时,采用不吸收线连续缝合吻合口形成自然的限制环. 结果: 所有病例随访6~39个月,随访率达100%.术后未有再出血和肝性脑病的发生,经彩超检查发现术后吻合口无扩大,术后肝功能均有不同程度的改善(P<0.001). 结论: 改良的限制性门腔静脉侧侧分流术是治疗肝硬化门脉高压症的有效方法.     

Mesentericocaval shunt (MCS) with autologous jugular vein

We report our personal experience of 114 patients with portal hypertension treated with mesentericocaval shunt (MCS) and 167 with portocaval anastomosis (PCA). In addition, the 2 procedures were evaluated in a controlled trial of 21 MCS patients and 25 PCA patients. We found no significant difference in the results of the 2 operations in terms of operative mortality rate, incidence of hepatic encephalopathy, and long-term survival. The surgical procedure of MCS is no easier to perform than PCA; it requires the preparation of the graft, 2 vascular anastomoses, and longer operative time. It seems appropriate to select this operation only with those patients who, for anatomical reasons, cannot undergo PCA.     

门静脉高压症脾切除贲门周围血管离断术后早期门静脉血栓形成的预测

目的 探讨肝炎后肝硬化门静脉高压症脾切除贲门周围血管离断术后,早期门静脉血栓形成(PVT)的易患因素及术后早期预测PVT的可能.方法 对2004年1月至2009年11月间,27例肝炎后肝硬化门静脉高压症脾切除贲门周围血管离断术后早期PVT形成的患者,与同期住院的未发生PVT的37例患者进行临床资料的回顾分析与对比.结果 单因素及多因素分析显示,与肝炎后肝硬化门静脉高压症脾切除贲门周围血管离断术后早期PVT形成有关的因素有4个,即术后术前PLT比值、术后D二聚体、术后全血黏度、术后门静脉流速.每例患者术后PVT的总的预测正确率为87.3%.结论 患者术后术前PLT比值、术后D二聚体、术后全血黏度增高、术后门静脉流速减缓是肝炎后肝硬化门静脉高压症脾切除贲门周围血管离断术后早期PVT形成的易患因素.     

Acute hepatorenal failure as a component of multiorgan failure syndrome in patients after surgical intervention

The etiology, pathogenesis, clinical features of acute postoperative hepatorenal failure (APHRF) in 50 surgical patients were studied. APHRF was considered as a component of the multiorgan insufficiency syndrome. The general somatic factors contributing to APHRF development were established: chronic pathology of the liver and kidneys, chronic cardiogenic pathology, hypertension. The risk factors for APHRF development before, at operation and at the nearest period after it were distinguished: shock, hemorrhage, massive transfusion of blood, or its components, hypoxia, systemic arterial hypotension. The attention is attracted to the significance of combination of the systemic arterial hypotension with the contributing general somatic factors and risk factors before, at operation and at the nearest period after it in APHRF development.     

Results of total embolization of varicose veins of the gastroesophageal zone in portal hypertension in children

The operation is aimed at embolization of all the varicose veins of the gastroesophageal zone which are the source of bleeding in portal hypertension. Under the corresponding anatomical conditions the total embolization results in the decreased portal tension due to the development of effective direct portocaval anastomoses.     

Roux-en-Y bleeding after living donor liver transplantation: a novel technique for surgical treatment

Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference (P =.47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3-4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy.     

肝炎肝硬化病人脾切除术后门静脉血栓形成的相关因素分析

目的 分析肝炎肝硬化门静脉高压症病人脾切除术后门静脉系统血栓形成的相关因素.方法 我院2000年8月至2007年6月共为226例肝炎肝硬化门静脉高压症病人施行了脾切除或脾切除加断流术.本文对其中154例进行回顾性分析.根据是否形成血栓将病例分为门静脉系统血栓形成和无血栓形成两组.用Logistic回归分析术前术后门静脉压力下降水平、术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素水平、术中出血量各指标与门静脉系统血栓形成的关系.结果 在154例病人中,门静脉系统血栓形成31例,123例无血栓形成.Logistic单因素分析和多因素回归分析均显示门静脉系统血栓形成与门静脉压力下降水平有关;术前凝血酶原比值(PTR)、术前纤维蛋白原水平(FIB)、术前及术后1、7、14 d血小板水平、术前门静脉直径、术前胆红素、术中出血量水平与门静脉血栓形成无关.结论 术前、术后门静脉压力下降水平可能是影响门脉高压脾切除术后门脉系统血栓形成的重要因素,术后门静脉压力下降越多,门静脉系统血栓形成几率越高.     

Surgical anatomy of the veins as applied to the formation of a renoportal venous anastomosis in the surgical treatment of arterial hypertension]

The possibilities of creating left reno-portal venous anastomoses (RPVA) in man have been studied on 47 fresh human cadavers. The conditions for the formation of anastomoses depended on the shape of the junction of the portal vein branches and their mutual localization against the left renal vein. An adequate, as to its width, anastomosis of the end of the renal vein with the end of the common trunk of the splenic and inferior mesenteric veins was formed in 46.7% of cases. In the rest of cases some other forms of anastomosis were created. RPVA was applied in the clinic in 6 patients suffering from severe and malignant arterial hypertension.     

影响门静脉高压脾切除术后并发症的围手术期多因素分析

目的 分析门脉高压脾切除术后的并发症及围手术期影响因素,探讨预防其并发症的措施.方法 对杭州市第六人民医院115例门脉高压行脾切除病人的临床资料进行分析,着重分析围手术期管理及并发症发生情况.结果 共有85例(73.9%)发生术后并发症,其中死亡7例(6.09%).对影响并发症发生的因素进行分析,发现病人肝功能Child-Pugh分级、手术前、后门静脉压力水平、手术后平均血糖水平及术中、术后中心静脉压水平均与并发症密切相关.结论 门脉高压脾切除术后并发症发生率较高,对肝功能差的病人应慎行之,并应做好围手术期血糖、门静脉压力及中心静脉压的控制,减少并发症的发生率.     

选择性断流术治疗门静脉高压症影响因素的回归分析

目的探讨影响选择性断流术治疗门静脉高压症术后转归的因素。方法回顾性分析接受选择性断流术的160例门静脉高压症患者的临床资料,根据术后并发症的发生情况将患者分为高危组和低危组。并将其作为因变量,将32个围手术期的临床指标作为自变量,进行回归分析。结果单因素分析显示：在高危组和低危组中,黄疸史、Child-Turcotte-Pugh分级、术前总胆红素、凝血酶原时间延长值、切脾前自由门静脉压、腹水量、术后1周白细胞计数和术后1周血红蛋白水平均有显著差异（P〈0．05）。多因素分析显示：自由门静脉压的降幅、术前总胆红素、凝血酶原时间延长值、腹水量、术后1周白细胞计数及术后1周血红蛋白水平在两组间差异有统计学意义（χ^2=53．337,P〈0．01）。结论影响选择性断流术治疗门静脉高压症预后的因素为自由门静脉压的降幅、术前总胆红素、凝血酶原时间延长值、腹水量、术后1周白细胞计数和术后1周血红蛋白水平。