RU2069975C1 - Surgical method for treating portal hypertension - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making portocavalous by-pass between the greater omentum vein and greater subcutaneous femoral vein. EFFECT: lower risk of hemorrhages from dilated esophagus veins. 1 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used to correct portal hypertension.

There are various methods of surgical treatment of portal hypertension:
Omento-and organopexy (Fegăraşanu I. et al. Surgery of the liver and intrahepatic biliary tract, Bucharest: 1976, p. 537.

 Direct portocaval anastomoses (MA Topchibashev. Portal hypertension and its surgical treatment. Baku: 1961, p. 345.

 Splenoreal anastomoses (MD Patziora. Surgery of portal hypertension. Tashkent: 1984, p. 320.

 Splenocaval bypass grafting (AF Leontiev et al. Method for creating a portocaval anastomosis in patients with portal hypertension. Surgery, 1988, N 7, S. 16-128).

 Resection of the gastroesophageal zone (A. A. Shalimov et al. Surgical treatment and prevention of complications of cirrhosis of the liver. Kiev: 1988, p. 134).

 Omphalosafen bypass grafting (A. Piccont, H. Leveen "Tcansumbilical porfal decompression" Surg.Gynel. Obstct. 1967.7.66-67.

 However, all these methods have several disadvantages. Thus, with omeno- and organopexy, new collateral blood vessels form at least 4-6 months after surgery and are far from always adequate for decompression of portal hypertension.

 When a direct portocaval anastomosis is applied, almost all portal blood, bypassing the liver, flows into the caval system. Therefore, often the postoperative period is complicated by liver failure and encephalopathy.

 Splenorenal anastomoses, although hemodynamically quite an effective method, but because of the difficulty of quick access to anastomosed vessels, the postoperative period is accompanied by multiple complications, such as postoperative pancreatitis, peritonitis and thrombosis of anastomosed veins. In addition, often due to the anatomical structure and topographic location of the vessels of the spleen and kidney, it is not possible to form splenorenal anastomosis.

 The imposition of a splenocaval shunt is a traumatic method and its use in an already heavy contingent of patients is not justified.

 Resection of the gastroesophageal segment is one of the most traumatic operations. Moreover, it does not lead to a decrease in portal pressure. The risk of bleeding remains real.

 Omphalosafen bypass surgery is a relatively gentle method, but it can only be performed in patients with recanalized umbilical vein. Recanalized umbilical vein occurs in 2-8% of patients with portal hypertension.

 As a prototype adopted a method of surgical treatment of portal hypertension by distal splenorenal bypass surgery. The method consists in the fact that the splenic vein anastomose with the left renal vein. In distal splenorenal bypass surgery, it is precisely the varicose veins of the gastroesophageal zone that pose a great risk of bleeding.

 However, the known method have several significant disadvantages. Often, due to the anatomical structure and topographic location of the splenic and left renal veins, it is not possible to form a splenorenal shunt (anastomosis). For the formation of a splenorenal shunt, large surgical access is required. In the process of mobilization of the splenic vein, pancreas is often damaged, resulting in traumatic pancreatitis.

 The objective of the invention is to provide a method for the surgical treatment of portal hypertension, which helps to prevent bleeding from varicose veins of the esophagus.

 The essence of the invention lies in the fact that in the method of surgical treatment of portal hypertension by microsurgical perocardial shunting, a distinctive feature is that the portocaval shunt is performed between the vein of the greater omentum and the large saphenous vein of the femur.

 As a result of using the proposed method, the following technical results are achieved. Using the invention allows to significantly reduce the risk of bleeding from varicose veins of the esophagus, to reduce the volume and invasiveness of the operation to a minimum. The implementation of portal decompression through the veins of the greater omentum and the use of microsurgery by this many times increases the possibility of forming a portocaval anastomosis in case of portal hypertension. With omentosafenic bypass grafting, a partial portal decompression occurs due to the relatively small diameter (5-6 mm) of the perforated anastomosis and, therefore, portohepatic perfusion suffers less. These circumstances make it possible to apply this method both with a high risk of bleeding from varicose veins of the esophagus, and with a relapse of esophageal bleeding after an earlier operation with portal hypertension. The small volume and relatively low invasiveness of the method allows its use in relatively severe patients.

 The prevention of bleeding from varicose veins of the esophagus is due to a decrease in portal pressure and, consequently, a decrease in tension in the varicose veins of the esophagus. At the same time, portal hepatic perfusion is preserved to a sufficient degree, which prevents liver failure and encephalopathy.

 The proposed method is illustrated in the drawing and is as follows.

 Under general anesthesia, an oblique skin incision is made in the left hypochondrium, 10-12 cm long. The abdominal cavity is opened in layers. In the presence of aspitic fluid, it is evacuated. Inspect the veins of the greater omentum. If there is a vein with a diameter of 4 mm or more, then they begin to mobilize the large saphenous vein of the thigh. Through separate skin incisions, starting from the inguinal fold to the lower third of the thigh, a large saphenous vein of the thigh is mobilized on the left. The latter is reversed and through the subcutaneous tunnel lead to the wound in the left hypochondrium. A strand of a large omentum with an enlarged vein is brought to the wound. Under an operating microscope with microsurgical technique with atraumatic thread 7 / 0-8 / 0, a veno-venous anastomosis is formed between the vein of the greater omentum and the great saphenous vein of the femur "end to end". A lock of large omentum is fixed into the wound. The wound is sutured in layers. Impose nodal sutures on the skin.

 Example. Patient K., 27 years old, was admitted to the hospital with a diagnosis of liver cirrhosis with portal hypertension. Varicose veins of the esophagus III degree. Sick since 1983 when the first esophageal bleeding. In 1987 there was repeated bleeding, for which an operation was performed stitching the veins of the esophagus and splenectomy. In 1990, there were episodes of repeated esophageal bleeding.

 Upon admission, the general condition of the patient is relatively satisfactory. Endoscopy: varicose veins of the esophagus III degree, esophagitis. Ultrasound computed tomography with Doppler sonography: a diffuse change in the structure of the liver. Portal blood flow 1050 ml / min. The diameter of the portal vein is 13.4 mm. Blood test: Nv. 121 g / l, L. 4.2. Thrombosis. 210,000 in ml. Total protein 75.8 g / l. Alb. 53.2% Glob. 46.8% Creatinine 96.7 mmol / L.

 The operation has been completed. Under general anesthesia, an oblique skin incision was made in the left hypochondrium, 12 cm long. The abdominal cavity was opened in layers. The veins of the greater omentum are expanded to 7 mm. A large saphenous vein of the thigh was mobilized on the left to the lower third of the thigh and it was brought through the subcutaneous tunnel to the left hypochondrium. A strand of a large omentum with an enlarged vein was introduced into the wound. Under an operating microscope, a veno-venous anastomosis is formed between the vein of the greater omentum and the great saphenous vein of the femur "end to end". The lock of the omentum is fixed in the wound. Layer wound closure. The postoperative period was relatively unremarkable. Re-examination of the patient after 6 months. The general condition of the patient is relatively satisfactory. The patient is working. There was no recurrence of esophageal bleeding. Ultrasound: portal blood flow 815 ml / min. The diameter of the portal vein is 12.2 mm. We pass an osseous-shunt shunt, its diameter is 8 mm. Endoscopy: Varicose veins of the esophagus I degree. Blood test: Nv. 125 g / l L.4.5. Thrombosis. 219000 in ml. Total protein 74.3 g / l. Alb. 55.9% Creatinine 98.6 mmol / L. Bilir. total 21.4 μmol / L. AsAT 0.93. AlAT 0.67.

 The method was developed and performed in 12 patients in the clinic of microsurgery NIUV on the basis of 56 city clinical hospital. The term postoperative observation of patients is from 6 to 22 months. Relapse of bleeding from varicose veins of the esophagus was not observed.

Claims (1)

 A method of surgical treatment of portal hypertension by microsurgical portocaval bypass surgery, characterized in that the portocaval bypass is performed between the vein of the greater omentum and the large saphenous vein of the femur.