RU2483681C2 - Method of treating portal hypertension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to angiosurgery of patients with portal hypertension. Left renal vein is tied up and transected 1-1.5 cm rightward from inflow of left testicular or ovarian vein into it. Superior mesenteric vein is tied up and transected 2-2.5 cm from its confluence with splenic vein. Anastomosis of 'end-to-end' type is applied between proximal end of superior mesenteric vein and distal end of left renal vein. Zone of anastomosis is fixed with framework from demineralised bone.

EFFECT: method makes it possible to form organ-preserving portocaval anastomosis, prevent anastomosis deformation and impairment of venous outflow from kidney, in addition, "end-to-end" anastomosis is more physiological and less labour-consuming.

1 dwg

Description

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

The end-terminal mesentericorenal anastomosis is superimposed to achieve decompression of the gastroesophageal pool of the portal system, is organ-preserving and represents the operation of choice when it is impossible to impose splenorenal anastomosis.

According to the literature, despite the large number of proposed variants of portocaval anastomoses, their results do not always satisfy surgeons (Patsiora M.D., 1974; Eramishantsev A.K., 2001; Koshev V.I. et al., 2001). Traditional methods of decompression of the portal system by applying direct portocaval anastomoses provide adequate decompression of the portal system and reliable prevention of gastroesophageal bleeding, however they are too traumatic, with many complications, especially in the form of liver failure and hepatoportal encephalopathy (Patienta M. D., 1974; .K., 2001; Koshev V.I. et al., 2001).

Selective portocaval anastomoses with portal vein roots, in particular with the splenic and superior mesenteric veins, which allow selective decompression without the development of severe portosystemic encephalopathy, are widely used.

However, bypass surgery for extrahepatic portal hypertension may be constrained by technical aspects. In patients who underwent splenectomy with thrombophlebitis of the splenic vein, cavernous transformation of the splenic and portal veins, splenorenal bypass surgery is not possible. Mesenteric shunting in this group of patients is the operation of choice.

The closest are microsurgical scaffold end-end splenorenal anastomoses with preservation of the kidney between the crossed splenic and left renal veins. Patent No. 2319464; No. 2321360.

In patients who underwent splenectomy with thrombophlebitis of the splenic vein, cavernous transformation of the splenic and portal veins, splenorenal bypass surgery is not possible. Mesenteric shunting in this group of patients is the operation of choice.

For the first time in 1953, Marion P. proposed an end-to-side renal mesenteric anastomosis, which, in fact, is a prototype of our proposed technique. In this case, the central end of the left renal vein was sutured to the side of the superior mesenteric with the preservation of the kidney and spleen. Subsequently, this operation was successfully performed by K.N. Tsatsanidi (in 1969) and M.D. Patsiora (in 1974).

A significant drawback of anastomoses with veins of small diameter is an increased risk of thrombosis. V.I.Koshev et al. Proved that the main cause of thrombosis is deformation of the anastomotic zone and changes in the laminar blood flow self-oscillating. The use of frame devices significantly reduces the risk of thrombosis (Koshev V.I. et al., 2001). An end-to-side anastomosis is technically more complicated, fixing a frame device requires additional time. Violation of the laminar blood flow (due to the oncoming flow) in the zone of anastomosis of this type is a predisposing factor in the development of thrombosis.

The novelty of the proposed method is to reduce the recurrence of gastroesophageal bleeding by reducing the risk of thrombosis.

A significant difference is that the left renal vein is ligated and intersected 1-1.5 cm to the right of the left testicular (ovarian) vein flowing into it, the superior mesenteric vein is ligated and intersected 2-2.5 cm from its confluence with the splenic the anastomosis is superimposed end-to-end between the distal end of the superior mesenteric vein and the proximal end of the left renal vein, and the anastomosis zone is fixed with a demineralized bone framework.

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 mesentery of the colon, we find the superior mesenteric vein (1) (see drawing), select for 5-6 cm, open the parietal peritoneum, select the left renal vein (2), make sure the testicular (ovarian) vein is present and localized (3) . We estimate the difference in the diameter of the vessels. We cross the superior mesenteric vein so that its diameter corresponds to the diameter of the renal vein. We dress the end of the mesenteric vein 2-2.5 cm from the place where it flows into the portal vein (4). At the proximal end of the mesenteric vein, we put on a ring of demineralized bone (5) of the appropriate 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. We bandage the proximal end, take the distal to the clamp. We apply an end-to-end anastomosis between the proximal end of the mesenteric 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. The laparotomy wound is sutured in layers tightly.

The method was carried out on 34 non-fixed corpses of people of both sexes and 18 outbred dogs weighing 10-18 kg. In the long term, animals are healthy. When examining cadaveric material, a visual inspection of the anastomosis was performed - it has a rounded shape, the walls are smooth, no screwing of the shells is noted; hydropression - anastomosis withstands pressure of 420-460 mm of water. Art. (normal - 20-25 mm water. Art.), which indicates its mechanical strength.

When performing intraoperative portography within 1-3 months, the anastomosis was passable, its deformation and narrowing were not observed. With a histological examination, epithelization occurs after 6-7 days, healing to the entire depth of the wound at the sites of comparison of the vascular wall occurs after 14-16 days. In all cases, there was no failure of the sutures or narrowing of the anastomosis.

Protocol No. 12. Mongrel dog weighing 9 kg. Under intravenous anesthesia, an upper median laparotomy was performed. A mesentericorenal anastomosis was superimposed under optical magnification from 8 to 32 times with the help of microsurgical instruments by connecting the proximal end of the dissected superior mesenteric vein and the distal end of the left renal vein end-to-end 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 the 2nd day 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. 7. The corpse of a man R., 45 years old, who died from a cause unrelated to the pathology of the portal system. An 8-fold optical magnification using a microsurgical technique superimposed a mesentericorenal anastomosis by connecting the crossed superior mesenteric and left renal veins of the end-to-end type according to the described procedure.

The site of veins with an anastomosis is excised, it has a rounded shape. During hydropressing, the anastomosis withstands pressure of 490 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.

There are no analogs of mesentericorenal anastomosis of the end-to-end type in the modern literature.

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

The use of veins of comparable diameter, the anatomical proximity of the vessels, similar morphometric characteristics of the walls of the compared vessels provide the technical simplicity of the method. The use of an external skeleton of demineralized bone prevents the deformation of the anastomosis, the collapse phenomenon and cicatricial narrowing of the anastomosis. The use of microsurgical technique provides an accurate comparison of homogeneous layers of the walls of the superior mesenteric and left renal veins.

An end-to-end anastomosis is more physiological and less labor-consuming, a laminar blood flow is maintained in the anastomosis zone, and fixing the frame device does not present technical difficulties.

Literature

1. Eramishantsev A.K. Surgical treatment of portal hypertension syndrome in Russia // Ros. journal gastroenterol., hepatol., coloproctol. - 2001. - T. XI, No. 4. - S.75-77.

2. Koshev V.I., Petrov E.S., Ivanova V.D., Pirogov V.P. Hydrodynamic aspects of portal hypertension: Monograph. - Samara; Samara State Medical University, 2001 .-- 226 p.

3. Lesovik B.C. Anatomical and experimental justification of the microsurgical framework of the end-end splenorenal anastomoses in portal hypertension. Abstract. dis. ... cand. honey. sciences. - Orenburg, 2007 .-- 114 p.

4. Patient M.D. Surgery of portal hypertension. - M .: Medicine, 1974. - 407 p.

5. Tsatsanidi K.N. Repeated operations for relapses of bleeding from varicose veins of the esophagus in patients with portal hypertension: Abstract. dis. ... Dr. honey. sciences. - M., 1971.

6. Prototype: Marion P. Anastomose spleno-renale, mesentericocave pour obstructions portales extrahepatiques // J. De Chir. - 1958. - Vol. 76. - No. 5. - P.658.

Claims (1)

A method of treating portal hypertension, including the application of an anastomosis between the superior mesenteric 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 superior mesenteric vein is ligated and cut into 2-2.5 cm from the place of its confluence with the splenic one, anastomosis is applied end-to-end between the proximal end of the superior mesenteric vein and the distal end of the left renal vein, the anastomosis zone is fixed with a demineralized frame no bone.

Images