RU2321360C1 - Method for treating portal hypertension - Google Patents

Abstract

FIELD: medicine, angiosurgery.

SUBSTANCE: left renal artery should be tightened and intersected being about 1-1.5 cm to the right against the site of the inflow of left testicular and ovarian veins. Splenic vein should be tightened and intersected being about 2-2.5 cm against the site of its inflow into portal vein. Anastomosis should be applied by "end-to-end" type between proximal end of splenic vein and distal end of left renal vein that prevents the disorder of venous outflow.

EFFECT: higher efficiency of therapy.

2 dwg, 2 ex

Description

The invention relates to medicine, angiosurgery, and can be used in the treatment of patients with portal hypertension.

The distal splenorenal anastomosis is superimposed to achieve decompression of the gastroesophageal pool of the portal system and at the same time maintains the flow of mesenteric blood to the liver.

According to the literature, despite the large number of proposed variants of portocaval anastomoses, their results are far from always satisfying with surgeons (M.D. Patsiora. 1984; V.I. Koshev et al. 2001; A.K. Eramishantsev. 2001, 2002).

A similar method of splenorenal anastomosis was proposed in 1947 by Linton RR, lones CM, Volwilles W. It consisted of applying an end-to-side anastomosis with removal of the spleen, but with preservation of the kidney (Linton RR, lones CM, Volwilles W. Portal hypertension. The treatment by splenectomy and splenorenal anastomosis with preservation of the kidney. // Surg. Clin. North Amer. - 1947. - Vol.27. - No. 5. - P.1162).

The disadvantages of this technique are: removal of the spleen, technical difficulty in performing.

In 1967, WDWarren, R.Zeppa, J.Foton proposed a variant of this anastomosis, which consists in the following: the distal anastomosis is applied with preservation of the spleen according to the "end to side" type (Warren WD, Zeppa R., Foton J. Selective transplenic decompression of gastroesophageal varices by distal splenorenal shunt. // Ann. Surg. - 1967. - Vol. 166. - P.437).

The disadvantages of the method are: a complex technique, frequent postoperative pancreatitis.

Closest to the proposed method is the method of M.D. Patients, proposed in 1954 (M. D. Patzior. Surgery of portal hypertension. - M .: Medicine, 1974. - 407 S.). She suggested applying a side-to-side anastomosis, preserving the kidney and spleen.

The disadvantages of this method are: high technical complexity, high invasiveness, as well as a significant violation of the venous outflow from the kidney due to portal portal vein overload with increased pressure, which can reach 300 to 600 mm of water during portal hyperthesis. Art. (Patient M.D. Surgery of portal hypertension. - M .: Medicine, 1974. - 407 p.). It is known that in case of violation of the venous outflow from the left renal vein with varicocele, venous pressure reaches a level of 13.71 mm of water. Art. (K.D.Maksumov, D.L. Arustamov, I.I. Rushanov, L.R. Parsetova. X-ray anatomy of the left internal spermatic vein and phlebomanometry with varicocele. // Medical journal of Uzbekistan. - 1985. - No. 4. - S.28-30).

The novelty of the proposed method is that there is a separation of blood flow between the stored left kidney and the portal vein system, as a result of which there is no gross violation of the venous outflow from the left kidney, since it will be carried out through the testicular (ovarian) vein.

Significant differences of our method are that the anastomosis is applied according to the "end to end" type between the distal end of the left renal vein, which is intersected 1 - 1.5 cm to the right of the left testicular (ovarian) vein, and the proximal end of the splenic vein, which is crossed 2-2.5 cm from the place where it flows into the portal vein, the anastomotic zone is fixed with a skeleton of demineralized bone. As a result, there is a separation of blood flow between the saved left kidney and portal vein. Venous outflow from the preserved left kidney is carried out into the left testicular (ovarian) vein, and a large volume of venous blood discharge from the splenic vein into the system of the inferior vena cava is ensured by the large diameter of the anastomosis due to the external skeleton.

The technical simplicity of the method is achieved using large diameter veins for anastomosis with close proximity and similar morphometric characteristics. The use of an external skeleton made of demineralized bone prevents subsequent cicatricial narrowing of the anastomosis, the use of microsurgical techniques reduces the risk of anastomotic thrombosis and allows a clear comparison of the layers of the venous wall.

Brief Description of the Drawings:

Arabic numerals in figures 1 and 2 are indicated:

1 splenic vein

2 left renal vein

3 left testicular (ovarian) vein

4 ring of demineralized bone

5 liver

6 spleen

7 portal vein

8 left kidney

The method is as follows. On outbred dogs of both sexes and weights, under thiopental anesthesia, we perform an upper median laparotomy. The operation is performed under optical magnification from 8 to 32 times using microsurgical instruments, microsurgical atraumatic suture material 8/0. After laparotomy, the loops of the small intestine are shifted to the right. In the avascular zone, we open the gastro-colon ligament, mobilizing both bends of the colon. Allocate the splenic vein for 5-6 cm.

We find and isolate the splenic artery in the middle third and bring a ligature under it, so we ligate it only after applying the anastomosis. We open the parietal peritoneum, select the left renal vein (2), make sure the presence and localization of the testicular (ovarian) vein (3). We bring two ligatures under it. We estimate the difference in the diameter of the vessels. We cross the splenic vein (1) along an oblique line, if this also does not allow maximum adaptation of the sizes, then we cut the vein longitudinally to the required length corresponding to the diameter of the renal vein. We dress the end of the splenic vein 2-2.5 cm from the place where it flows into the portal vein. At the proximal end we put on a ring of demineralized bone (4) of the corresponding diameter, apply a “bulldog” -type clamp and lower it in the direction of the renal vein. We cross the renal vein strictly across 1 cm distal to the inflow of the testicular (ovarian) vein (Fig. 1). We bandage the proximal end, take the distal to the clamp. We apply an end-to-end anastomosis between the proximal end of the splenic vein and the distal end of the left renal vein. We begin its formation by superimposing three guide seams-holders, using a continuous inverted seam. We begin stitching from the back wall; upon completion of stitching, we connect both ends of the thread together, avoiding the “pouch” phenomenon. After that, remove the clamps from the renal and splenic veins, in case of bleeding between the sutures, we impose additional sutures. We move the ring from the demineralized bone to the area of the anastomosis and fix it with the help of stitches-holders (figure 2). The laparotomy wound is sutured in layers tightly.

The method was carried out on 12 non-fixed corpses of people of both sexes and 8 outbred dogs weighing 10-18 kg. In the long term, up to 3 months, the animals are healthy.

In the study of cadaveric material, a visual inspection of the anastomosis was performed - it has a rounded shape, the walls are even, no screwing of the shells is noted; hydropression - anastomosis withstands pressure of 420-460 mm of water. Art. (normal pressure on this section of the portal system is 20-25 mm water. Art., and with portal hypertension does not exceed 350-400 mm water. Art.), which indicates its mechanical strength. On histograms, an exact comparison of intimacy is noted throughout.

When portography performed on experimental animals at a period of 1-3 months, the anastomosis is passable, its narrowing is not noted. The place of the superimposed anastomosis can be judged by the fixing ring made of demineralized bone, which is apparently in the picture.

In a histological examination, epithelialization occurs after 6-7 days, healing to the entire depth of the wound in the places where the layers of the vascular wall are matched occurs after 14-16 days without the formation of a rough scar. In all cases, there were no complications associated with the technique of applying the anastomosis: insufficiency of sutures, narrowing of the anastomosis. The healing period of the anastomosis occurs earlier than with conventional methods, and is 14-16 days.

Case Studies

Protocol No. 12. Mongrel dog weighing 8 kg. Under intravenous anesthesia, an upper-middle laparotomy was performed. Using an optical magnification from 8 to 32 times using microsurgical instruments, the distal portocaval anastomosis was superimposed by connecting the proximal end of the dissected splenic vein and the distal end of the left renal vein of the end-to-end type with an external skeleton of demineralized bone according to the described technique. The wound of the anterior abdominal wall is sutured tightly. There were no complications in the postoperative period. Feeding animals with liquid food started on 2 days after surgery. After 3 months, the animal is clinically healthy.

When portography anastomosis pass, its narrowing is not noted.

A histological examination at the site of accretion of the layers of the vascular wall determines a tender connective tissue scar. In the area of the anastomosis, a clear comparison of the layers is noted, the middle membrane and adventitia are fused without scar formation.

Protocol No. 18. The corpse of a woman L. 46, who died from reasons not related to the pathology of the portal system. A portocaval anastomosis was superimposed under an optical magnification of 8 to 32 times using a microsurgical technique by connecting the proximal end of the intersected splenic vein and the distal end of the left renal vein of the end-to-end type with an external skeleton of demineralized bone according to the described technique.

The site of veins with an anastomosis is excised, it has a rounded shape. When hydropressing, the anastomosis withstands the pressure of 480 mm of water. Art. When performing histotopograms, a comparison of intima throughout is noted, the absence of screwing of the membranes of the veins. Due to the technical features of the application of the anastomosis, its narrowing is not noted.

The proposed method of portocaval anastomosis is organ-preserving, differs in technical simplicity of execution, does not cause a gross violation of the venous outflow from the kidney, in the anastomosis zone it has frame properties.

Claims (1)

A method of treating portal hypertension, including the application of an anastomosis between the splenic and left renal veins, characterized in that the left renal vein is ligated and intersected 1-1.5 cm to the right of the left testicular or ovarian vein, the splenic vein is ligated and intersected in 2- 2.5 cm from the place of its entry into the portal vein, an anastomosis is applied according to the "end to end" type between the proximal end of the splenic vein and the distal end of the left renal vein.

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