RU2789284C1 - Method for treating complications caused by a total discharge of blood from the portal system into the inferior vena cava in children undergoing side-to-side splenorenal shunting or splenosuprenal shunting for portal hypertension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to pediatric surgery, and can be used for the treatment and prevention of complications caused by a total discharge of blood from the portal system into the inferior vena cava in children undergoing side-to-side splenorenal shunting or splenosuprenal shunting along about portal hypertension. To do this, the blood flow is blocked in the splenic vein at a level located between the previously imposed portosystemic anastomosis and the mouth of the splenic vein.

EFFECT: invention provides effective treatment of complications caused by total discharge of blood from the portal system into the inferior vena cava; prevention of recurrence of these complications due to correction of blood flow with the provision of portal perfusion of the liver under the conditions of a previously imposed portosystemic shunt; prevention of thrombosis of the portosystemic shunt by correcting the blood flow by transferring it from a total to a selective portosystemic shunt with the availability and simplicity of the technique of the proposed surgical intervention.

6 cl, 5 dwg, 6 ex

Description

The invention relates to medicine, namely to pediatric surgery, can be used in children with portal hypertension syndrome after side-to-side splenorenal shunting or splenosuprarenal shunting for the treatment and prevention of complications such as pulmonary arterial hypertension, liver failure , hyperammonemia and portosystemic encephalopathy

Portal hypertension is a syndrome in which portal venous pressure rises above normal (above 0-10 mm Hg) and increases the hepatic venous pressure gradient (HVPG) over 5 mm Hg. In this case, the cause is a block in the blood flow, and, depending on the level of this block, there are three variants of this syndrome:

• extrahepatic form of portal hypertension (blood flow block is located at the level of the portal vein);

• intrahepatic form of portal hypertension (blood flow block is located at the level of the hepatic capillaries), for example, in liver diseases (fibrosis, cirrhosis, etc.), when the hepatic tissue compresses the intrahepatic blood vessels;

• suprahepatic form of portal hypertension (blood flow block is located at the level of the hepatic veins or inferior vena cava above the level of their confluence with the latter), with Budd-Chiari syndrome.

In childhood, the most common form of extrahepatic portal hypertension occurs, in which the internal diameter of the portal vein is reduced, there is a shortage of blood flow through it, and, in order to restore portal perfusion of the liver, cavernous transformation of the portal vein develops compensatory - portoportal venous collaterals that bypass the level of the block of the portal vein .

It should be noted that due to the blockage of blood flow in portal hypertension, a restructuring of portal hemodynamics occurs, blood is discharged through natural portosystemic collaterals from the portal vein basin into the basin of the inferior or superior vena cava due to the fact that blood from areas of high blood pressure is directed towards low blood pressure. pressure, that is, by any, including roundabout ways, the blood is directed towards the right atrium. In this case, reverse (retrograde) blood flow may occur through the splenic vein (leads to splenomegaly due to accumulation of blood in the spleen), inferior mesenteric vein (leads to the development of hemorrhoids due to stagnation of blood in the hemorrhoidal veins), along the right and left gastric, along the right gastroepiploic veins, as well as along the esophageal veins (leads to varicose veins of the stomach and esophagus, and to gastrointestinal bleeding if they are damaged).

Gastrointestinal bleeding is the most life-threatening complication of portal hypertension. In acute bleeding from varicose veins of the esophagus and stomach, mortality reaches 40-50% and is accompanied by a high risk of recurrence of early bleeding in 30-50% of survivors (II Dzidzava, BN Kotiv, IE Onnicev, SA Soldatov, AV Smorodskiy, SV Shevcov, SA Bugaev , Apollonov A.A. Laparoscopic Distal Splenorenal Anastomosis Clinics in Surgery 2021;6:3157).

The main goal of treating portal hypertension is to prevent this bleeding.

There are endoscopic methods of treatment: sclerosis and ligation of esophageal varices, however, they are only auxiliary methods of treatment and with them there is a high risk of rebleeding (Zhang JS, Cheng W, Li L. Laparoscopic distal splenoadrenal shunt for the treatment of portal hypertension in children with congenital hepatic fibrosis: A case report Medicine (Baltimore) 2017 Jan;96(3):e5843).

The only radical method of treating portal hypertension is shunt surgery on the vessels of the portal vein system (portosystemic shunt surgery).

Many studies have shown that portosystemic shunt surgery can be successfully offered to children of any age, with a success rate of around 90% (Rehman ZU, Nazir Z. Distal Splenorenal Shunt (DSRS) in Children with Extrahepatic Portal Hypertension. J Coll Physicians Surg Pak2019 Dec; 29(12): 1228-1229). Portosystemic shunt surgery is cost-effective, less psychologically traumatic than repeat endoscopic procedures, and a safe and reliable alternative to the latter (Rehman ZU, Nazir Z. Distal Splenorenal Shunt (DSRS) in Children with Extrahepatic Portal Hypertension. J Coll Physicians Surg Pak 2019 Dec;29 (12): 1228-1229).

Of the portosystemic bypass operations, the mesoportal shunt is the gold standard for the treatment of extrahepatic portal hypertension, in which a venous insert is taken (most often the left internal jugular vein), which is anastomosed with the superior mesenteric vein and the left branch of the portal vein (Razumovsky A. Yu., Dronov A. F., Rachkov V. E., Alkhasov A. B., Mitupov Z. B., Feoktistova E. V., Kulikova N. V., Stepanenko N. S. Portal hypertension in children: 28 years of experience in surgical treatment / / Doctor.Ru 2017. No. 12 (141), pp. 43-49). This operation completely restores blood flow in the liver (direction of blood flow: from the inferior mesenteric and splenic veins to the proximal part of the superior mesenteric vein and to the shunt, as well as from the distal part of the superior mesenteric vein to the shunt, then to the left lobe of the liver through the left branch of the portal vein and into the right lobe of the liver through the left branch, bifurcation and right branch of the portal vein). This operation is performed only in the extrahepatic form of portal hypertension, in which the liver vessels are always initially inspected and an attempt is made to apply this shunt.

However, this operation is applicable only in approximately 34% of cases, depending on the anatomical features of the vessels (presence or absence of stenosis of the left branch of the portal vein). Therefore, in other cases, also, depending on the anatomical features (features of the anatomy of the vessels, their location in the body, the presence or absence of their hypertrophy, etc.), other operations of portosystemic shunting are performed.

After the mesoportal shunt, in terms of providing portal perfusion of the liver, the second place is taken by the Distal Splenorenal Shunt (DSRS) in Children with Extrahepatic Portal Hypertension. J Coll Physicians Surg Pak 2019 Dec;29(12 ): 1228-1229), which is a selective portosystemic shunt. This operation is rarely used for extrahepatic and mainly for intrahepatic portal hypertension (when, compared with other forms of portal hypertension, the blood supply to the liver suffers the most).

That is, if the mesoportal shunt completely restores portal perfusion of the liver, then the distal splenorenal shunt separates the pool of the stomach and spleen from the pool of the superior mesenteric and portal veins without changing the direction of blood flow through the portal vein (in order to maintain high venous pressure in the portal vein and portal perfusion of the liver ).

In distal splenorenal bypass surgery, the gastrocolic and splenocolic ligaments are dissected, then the peritoneum is divided along the lower edge of the pancreas to provide access to the splenic vein, which is located below and behind the pancreas. The splenic vein is isolated together with the inferior mesenteric vein, ligating and crossing the short veins from the pancreas to the splenic vein, the parietal peritoneum is opened to the left of the aorta at the level of the gate of the left kidney, the left renal and left adrenal veins are isolated, the splenic vein is ligated and crossed distal to the portal formation site. veins. An end-to-side anastomosis is made between the splenic and left renal veins. At the same time, the distal end of the splenic vein is dissected in the longitudinal direction (to increase its diameter), and a window is created on the wall of the left renal vein at the place where the left adrenal vein flows into it (the left adrenal vein is ligated and crossed).

In the classic version of the distal splenorenal shunting operation proposed by Dean Warren, the gaps of the inferior mesenteric vein are also additionally blocked (clip or tie and cross) (to exclude retrograde blood flow through it with a decrease in the risk of developing hemorrhoids); left and right gastric, right gastroepiploic veins (also to exclude retrograde blood flow through them and to exclude loss of blood volume from the portal vein with a decrease in venous pressure in the portal vein) (Richards WO. W. Dean Warren, MD, FACS, Father of Selective Shunts for Variceal Hemorrhage: Lessons Learned Am Surg 2020 Sep;86(9): 1049-1055). As a result, the blood flow through the superior mesenteric vein and the portal vein is directed to the liver, and the blood from the esophageal venous plexus and the veins of the stomach through the short gastric veins and separately from the left gastroepiploic vein is directed to the splenic vein, and then, through the anastomosis, to the left renal and inferior vena cava.

However, there is a high risk of developing collateral pathways from the portal vein to the splenic vein through the pancreas, along the mesocolon and through the transgastric collaterals within 6-12 months (Henderson JM, Millikan WJ Jr, Galloway JR. The Emory perspective of the distal splenorenal shunt in 1990. Am J Surg 1990 Jul;160(1):54-9). Considering this, and the fact that the described direction of blood flow through the veins of the esophagus and stomach (towards the splenic and further towards the left renal and inferior vena cava) does not change, even if the gaps of the listed veins (left and right gastric, right gastroepiploic veins) due to the presence of low venous pressure in the inferior vena cava, distal splenorenal shunting is now often performed without additional occlusion of the lumen of the left and right gastric, right gastroepiploic veins. In addition, variants of this operation are described without blocking the lumen of the left and right gastric, right gastroepiploic veins together with the inferior mesenteric vein (Zhang JS, Cheng W, Li L. Laparoscopic distal splenoadrenal shunt for the treatment of portal hypertension in children with congenital hepatic fibrosis: A case report Medicine (Baltimore) 2017 Jan;96(3):e5843), which most authors recommend overlapping.

The distal splenorenal shunt is a selective portosystemic shunt and is an alternative to total portosystemic shunts. It maintains high pressure in the portal vein, thereby providing portal perfusion of the liver and significantly reducing the risk of future liver atrophy, portosystemic encephalopathy (William O Richards. W. Dean Warren, MD, FACS, Father of Selective Shunts for Variceal Hemorrhage: Lessons Learned Am Surg 2020 Sep;86(9): 1049-1055). But this operation is often abandoned precisely because of the high frequency of shunt thrombosis after its implementation.

The main disadvantage of distal splenorenal bypass surgery is the frequent thrombosis of the shunt (3-14%) due to the small diameter of the anastomosis, which is why it is rarely used (Karel M Van Praet, Laurens J Ceulemans, Diethard Monbaliu, Raymond Aerts, Ina Jochmans, Jacques Pirenne An analysis on the use of Warren's distal splenorenal shunt surgery for the treatment of portal hypertension at the University Hospitals Leuven. Acta Chir Belg. 2021 Aug;121(4):254-260.).

In general, shunt thrombosis is a major complication in portosystemic shunt surgery. Therefore, for many years, surgeons have preferred operations in which the probable risk of shunt thrombosis is minimal.

When treating an extrahepatic form of portal hypertension, an audit of the vessels of the portal vein system is initially carried out to determine the possibility of applying a mesoportal shunt, the gold standard for its treatment, in which the blood flow in the liver is completely restored.

However, if as a result of revision of the vessels of the portal vein system it turns out that the left branch of the portal vein is narrowed and the imposition of a mesoportal shunt is impossible or impractical, then, depending on the characteristics of the anatomy, other operations of portosystemic shunting are performed, and always, preferably, those in which the risk of occurrence main complication - shunt thrombosis is low.

Most often, the choice falls on operations in which the diameter of the anastomosis is large (hence, the risk of thrombosis is low), such as side-to-side splenorenal shunting, and its analogues - side-to-end splenosuprarenal shunt, splenosuprarenal side-to-side shunt. These anastomoses are total portosystemic shunts (in which all blood from the superior and inferior mesenteric and splenic veins drains through the anastomosis into the left renal and then into the inferior vena cava, that is, towards low venous pressure).

It should be taken into account that after the imposition of total portosystemic shunts, the total discharge of blood from the portal system into the inferior vena cava is accompanied by an increase in pressure in the pulmonary arteries (pulmonary arterial hypertension), a decrease in portal perfusion of the liver, hyperammonemia and, consequently, the development of liver failure and portosystemic encephalopathy in the future. That is, in order to avoid a fatal outcome as a result of bleeding from varicose veins of the esophagus, and if it is impossible to perform mesoportal shunting in the prevailing number of cases, total portosystemic shunts are forced to be applied, in which pulmonary arterial hypertension, liver failure, hyperammonemia and portosystemic encephalopathy develop in the future more often.

To treat these complications, conservative methods of treatment are used, as well as liver transplantation (for liver failure) (Henderson JM, Millikan WJ Jr, Galloway JR. The Emory perspective of the distal splenorenal shunt in 1990. Am J Surg 1990 Jul; 160 (1 ):54-9).

The main cause of portosystemic encephalopathy is elevated levels of ammonia in the blood, which primarily acts as a neurotoxin that causes astrocytes to swell.

As part of a normal physiological process, colon bacteria and intestinal mucosal enzymes break down dietary proteins, resulting in the release of ammonia from the intestine into the portal circulation. In the liver, ammonia is converted to urea.

After non-physiological portosystemic bypass surgery, blood from the portal venous system bypasses the liver, entering the inferior vena cava system, and then to the heart, lungs, and brain. Ammonia crosses the blood-brain barrier, where it is rapidly converted to glutamine by astrocytes. The latter, acting as an osmolyte, draws water into the cells, which causes the astrocytes to swell. The end result of hyperammonemia is cerebral edema and intracranial hypertension.

Individuals with hepatic encephalopathy may have a wide range of neurological and psychiatric manifestations, including changes in intellectual ability, memory, emotional, behavioral, psychomotor performance, and fine motor skills. However, the most common is latent hepatic encephalopathy, which can only be determined using special psychometric tests (disturbances in attention, visual-spatial abilities, fine motor skills and memory are detected).

The 2014 AASLD-EASL Practice Guideline for Hepatic Encephalopathy recommends treatment of hepatic encephalopathy primarily for individuals with overt hepatic encephalopathy (Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver Hepatology 2014;60:715-35).

Medical treatment includes the administration of non-absorbable disaccharides (Lactulose or Lactitol), which reduce ammonia absorption and are considered a first-line treatment for overt hepatic encephalopathy. (Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60: 715-35).

The goal of the proposed antimicrobial therapy is to alter the intestinal microbiosis, resulting in a decrease in endogenous bacterial ammonia production. Rifaximin is currently the antimicrobial agent of choice for the treatment of overt hepatic encephalopathy. (Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071-81).

The combination therapy of Rifaximin with Lactulose has been shown to maintain remission of hepatic encephalopathy better than Lactulose monotherapy, and also reduced the number of hospitalizations associated with hepatic encephalopathy (Sanyal A, Younossi ZM, Bass NM, et al. Randomised clinical trial: rifaximin improves health- related quality of life in cirrhotic patients with hepatic encephalopathy - a double-blind placebo-controlled study Aliment Pharmacol Ther. 2011;34:853-61.). However, Lactulose should be used as initial first-line therapy and Rifaximin as add-on therapy if there is no adequate response to Lactulose.

In addition, for the treatment of hepatic encephalopathy, dietary intake of a certain amount of protein per day (1.2 to 1.5 g/kg/day for adults) is recommended (Cordoba J, Lopez-HelHn J, Planas M, et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study J Hepatol 2004;41:38-43.

Even distribution of small meals (or liquid nutritional supplements) throughout the day is also recommended, as well as snacking at night (Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver Hepatology 2014;60:715-35).

Liver transplantation is indicated for liver failure and recurrent hepatic encephalopathy untreatable by conservative therapy (Vilstrup H, Amodio P, Bajaj J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver Hepatology 2014;60:715-35).

We have set the task of developing a simple radical method for the treatment of complications caused by a total discharge of blood from the portal system into the inferior vena cava (pulmonary arterial hypertension, liver failure, hyperammonemia and portosystemic encephalopathy) in children who underwent portosystemic shunting in the form of splenorenal or splenosuprenal shunting for portal hypertension.

The technical result achieved in the implementation of the invention is:

• effective treatment of complications caused by a total discharge of blood from the portal system into the inferior vena cava: pulmonary arterial hypertension, liver failure, hyperammonemia and portosystemic encephalopathy in children with portal hypertension who underwent side-to-side splenorenal shunting or side-to-side splenosuprarenal shunting; end-to-end”, or splenosuprarenal shunting “side-to-side”;

• prevention of these complications by correcting the blood flow with the provision of portal perfusion of the liver under conditions of a previously applied portosystemic shunt;

• accessibility, simplicity of the technique of the proposed surgical intervention;

• prevention of thrombosis of a previously applied total portosystemic shunt by correcting blood flow by transferring a total portosystemic shunt to a selective portosystemic shunt.

The essence of the invention is as follows.

For the treatment of complications caused by a total discharge of blood from the portal system into the inferior vena cava, in children who have undergone splenorenal or splenosuprenal shunting for portal hypertension, the blood flow through the splenic vein is blocked at a level located between the previously imposed portosystemic anastomosis and the orifice of the splenic vein.

Blocking the blood flow in the splenic vein can be performed by clipping or ligating it.

To perform the proposed surgical method of treatment, laparotomy access or access using laparoscopic techniques can be used.

Additionally, blood flow can be blocked in at least one of the following veins: inferior mesenteric vein, left gastric vein, right gastric vein, right gastroepiploic vein.

Thus, in children with splenorenal side-to-side shunt, splenosuprarenal side-to-end or side-to-side shunts, the listed total portosystemic shunts are essentially converted into a selective portosystemic shunt by closing the lumen (clipping or ligation) of the splenic vein between its mouth and the anastomosis site. As a result, a selective shunt is obtained, in which the direction of blood flow corresponds to the blood flow in Warren's distal splenorenal shunt (only blood from the splenic vein is drained into the inferior vena cava together with venous blood from the stomach and esophagus and blood flow is restored towards the portal vein).

Also, this operation, depending on the anatomical features (the presence of tissue fibrosis after surgery in the abdominal cavity and retroperitoneal space, the location of the vessels in it, the places of their confluence, bifurcations) can be supplemented by closing the lumen (clipping or ligation) of the inferior mesenteric, left and right gastric, right gastroepiploic veins, to prevent retrograde blood flow through them (of which the occlusion of the lumen of the inferior mesenteric vein, as in distal splenorenal shunting, is most desirable).

In any case, the transfer of the listed total portosystemic shunts into a selective portosystemic shunt is sufficient to perform by blocking the lumen of the splenic vein alone between its mouth and the anastomosis site, after which the blood flow is restored towards the portal vein, the venous pressure in it increases, therefore, the blood under high pressure leaks through the area of the portal vein with a reduced internal diameter and also through the cavernous transformation of the portal vein into the liver (portal perfusion of the liver is partially restored), and blood from the veins of the esophagus and stomach through the short gastric veins and, separately, from the left gastroepiploic vein enters into the splenic vein, and then, through the anastomosis - into the left renal and into the inferior vena cava.

Thus, the volume of blood discharge through the shunt is reduced, blood supply to the liver is improved and, accordingly, the risk of developing pulmonary arterial hypertension, liver failure, hyperammonemia and portosystemic encephalopathy is reduced.

The proposed method of surgical treatment also excludes the development of a serious postoperative complication - shunt thrombosis, since a new anastomosis is not applied, but only the lumen of the vessels is closed (veins are clipped or ligated).

This operation is applicable both for extrahepatic and intrahepatic forms of portal hypertension, takes about 35 minutes for laparoscopic and about 50 minutes for laparotomy accesses, does not require heparin therapy, is slightly traumatic, does not require the use of a large amount of analgesia (epidural anesthesia) and, therefore , finding and treating the patient in the intensive care unit and intensive care in the early postoperative period.

The proposed method of treatment requires a hospital stay for four days, antibacterial, symptomatic (including analgesic) and infusion therapies, ultrasound of the vessels of the portal vein system and vascular anastomosis, as well as ultrasound for the presence of fluid in the abdominal cavity for the first and if necessary. , on the third postoperative day (to exclude early postoperative complications).

The invention is illustrated by the following figures.

Figure 1 presents splenorenal shunt "side-to-side"; figure 2 shows splenosuprarenal shunt "side-to-end"; figure 3 shows splenosuprarenal shunt "side-to-side"; figure 4 shows splenorenal shunt "side-to-side" after its transfer to a selective portosystemic shunt by blocking the lumen of the splenic vein; figure 5 shows the side-to-side splenorenal shunt after its transfer to a selective portosystemic shunt by closing the gaps of the splenic, inferior mesenteric, left and right gastric, right gastroepiploic veins.

The arrows in the figures indicate the direction of blood flow.

The figures show the following positions:

1 - splenic vein,

2 - left renal vein,

3 - anastomosis line,

4 - adrenal vein,

5 - crossed and tied off the distal end of the adrenal vein,

6 - clip on the splenic vein,

7 - clip on the inferior mesenteric vein,

8 - clip on the left gastric vein,

9 - clip on the right gastric vein,

10 - clip on the right gastroepiploic vein.

The method is carried out as follows.

The patient is placed in the supine position on the operating table. After induction of general anesthesia (endotracheal anesthesia), either laparoscopy is performed, placing trocars in typical places: one 5/10 mm (optical) port through the umbilical incision, for working instruments - two 5/3 mm ports - at the level of the navel on the right and left along the midclavicular line, one 5/3 mm port in the left hypochondrium along the midclavicular line and one 5/3 mm port under the xiphoid process, or an upper median laparotomy is performed.

Depending on the anatomical features (mainly the presence or absence of a pronounced postoperative adhesive process), access to the pancreas is carried out by dissection of the gastrocolic ligament (preferred access), or the mesentery of the transverse colon. Then, along the lower edge of the pancreas, the peritoneum is divided to provide access to the splenic vein, which is located below and behind the pancreas (the inferior mesenteric vein can become a guide for the initial place of division of the peritoneum, that is, the peritoneum begins to be divided in the area that is distal (left) from the projection of the alleged confluence of the inferior mesenteric vein with the splenic vein/splenic and superior mesenteric veins).

The splenic vein is mobilized in the area located between its orifice and the splenorenal/splenosuprarenal anastomosis. Next, the lumen of the splenic vein is blocked (the splenic vein is clipped or ligated) in the selected area.

Also, if it is technically possible (in the absence of a pronounced fibrous tissue process after the previous/previous surgical interventions), this operation can be supplemented by further mobilization of the inferior and superior mesenteric, portal, left and right gastric, right gastroepiploic veins and, accordingly, alternate occlusion of the lumens inferior mesenteric, left and right gastric and right gastroepiploic veins.

In any case (children with side-to-side splenorenal shunt / splenosuprarenal shunts), to convert a total portosystemic shunt into a selective portosystemic shunt, it is enough to block the lumen of only one splenic vein, but in addition to it, the gaps of another 1-4 veins can be additionally blocked .

When converting a side-to-side splenorenal shunt or splenosuprarenal shunts to a selective splenorenal portosystemic shunt, gaps can most often be occluded:

• only the splenic vein;

• splenic vein and inferior mesenteric vein;

• splenic vein, inferior mesenteric and left gastric veins;

• splenic vein, inferior mesenteric, left and right gastric veins;

• splenic vein, inferior mesenteric, left and right gastric and right gastroepiploic veins.

Also, we note that if there is a feature of the anatomy, when the inferior mesenteric vein flows into the splenic vein, and then the splenic vein merges with the superior mesenteric vein, forming the portal vein, then the lumen of the splenic vein can be blocked in any area proximal to the anastomosis site (between the anastomosis and the site confluence of the inferior mesenteric vein into the splenic vein or between the confluence of the inferior mesenteric vein into the splenic vein and the confluence of the splenic vein with the superior mesenteric vein).

Here are clinical examples of the invention.

Clinical example 1.

The girl L., 11 years old, from the age of seven, the child had splenomegaly, was observed by a hematologist. At age nine, on examination:

• Ultrasound examination of the abdominal organs revealed hepatomegaly (PZR of the right lobe of the liver - 135 mm, an increase in the index of 1 segment up to 45%), a diffuse increase in the echogenicity of the liver parenchyma, its heaviness, pronounced periportal fibrosis and cavernous transformation of the portal vein, narrowing of the portal vein (diameter - 4.5-6 mm, blood flow velocity in it - 20-23 cm/sec.), narrowing of the intrahepatic branches of the portal vein (no more than 2 mm in diameter, blood flow velocity in them - 10 cm/sec.), superior mesenteric vein with a diameter of 8 mm (blood flow rate in it - 20 cm/sec.), splenic vein with a diameter of 5 mm (blood flow rate in it - 28 cm/sec.), splenomegaly (spleen - 200×55 mm);

• FEGDS revealed varicose veins of the esophagus of 2-3 degrees;

• angiography revealed a violation of the outflow into the portal system of the liver, thinning of the intrahepatic branches of the portal vein, depletion of the contrast of the liver parenchyma, discharge to the veins of the stomach and esophagus.

The child was diagnosed with: "Intrahepatic form of portal hypertension, varicose veins of the esophagus of the second or third degree." An operation was performed - liver biopsy (histological conclusion - liver fibrosis), splenosuprarenal shunting "side-to-end".

In the immediate postoperative period, ultrasound revealed a splenosuprarenal shunt (blood flow velocity in it was 41.5 cm/sec), a decrease in the size of the spleen to 147×47 mm, and FEGDS showed grade 2 varicose veins of the esophagus.

At the age of 11 years, when examined by ultrasound, the liver was of normal size (PZR of the right lobe - 103 mm, the left lobe - 80 mm), and the spleen decreased to 122×47 mm. Also on FEGDS, a decrease in the degree of esophageal varicose veins to 1 degree was determined, on angiography, the splenosuprarenal shunt functioned satisfactorily. However, the child complained of fatigue during study and increased drowsiness, and hyperammonemia was noted in the biochemical blood test. Subsequently, MRI of the child's brain revealed signs of accumulation of manganese salts at the level of the basal ganglia and cerebral peduncles (signs of hepatic encephalopathy).

The child was operated in accordance with the proposed method of laparoscopic access. Trocars were installed in typical places: one 10 mm (optical) port through the umbilical incision, for working instruments - two 5/3 mm ports - at the level of the navel on the right and left along the midclavicular line, one 5/3 mm port in the left hypochondrium along the midclavicular line and one 5 mm port under the xiphoid process. During the operation, the gastrocolic ligament was dissected and the cavity of the omental sac was opened. Then the peritoneum was divided along the lower edge of the pancreas. The mobilization of the splenic vein, splenosuprarenal anastomosis, left adrenal, inferior mesenteric veins was performed (further mobilization of the portal, left and right gastric, superior mesenteric and right gastroepiploic veins was prevented by a pronounced fibrous process of tissues near the vessels and significant capillary bleeding during mobilization of the vessels) . The splenic and inferior mesenteric veins were alternately clipped (the splenic vein was clipped in the area located between its mouth and the previously applied splenosuprarenal anastomosis). The trocars were removed, gas was released from the abdominal cavity, and the wounds were sutured in layers.

In the postoperative period, the child was prescribed antibacterial, symptomatic (including analgesic) and infusion therapy. On the first postoperative day, an ultrasound of the liver vessels and a portosystemic shunt was performed, the anastomosis functioned (the blood flow velocity through it was 45 cm/s).

The child was discharged home in a satisfactory condition on the second postoperative day, when in the biochemical blood test there was a decrease in the level of ammonia in the blood by 37 µmol/l.

3.5 months after the operation, the child was admitted to the hospital for a follow-up examination, in which FEGDS did not detect esophageal varicose veins, hepatomegaly was also not detected on ultrasound of the abdominal organs, and the spleen was 140 × 44 mm in size. On ultrasound of the vessels of the portal vein system and portosystemic shunt, there was a significant positive trend in terms of blood supply to the liver. The vascular shunt functioned (blood flow velocity in it was 40 cm/s), the portal vein trunk was 6 mm in diameter (blood flow velocity in it was 40 cm/s), a separate collateral 4 mm in diameter was noted in the portal cavernoma (blood flow velocity in it was 38 cm / s), branches of the portal vein in the right lobe of the liver with a blood flow rate of 20 cm / s, the superior mesenteric vein with a diameter of 6 mm (blood flow rate in it is 21 cm / s). In the biochemical blood test, hyperammonemia was not observed (the level of ammonia in the venous blood was 32 µmol/l).

Clinical example 2.

The boy E., 8 years old, from the age of two, the child had thrombocyto- and leukopenia, splenomegaly, was observed by a hematologist. At the age of four years, when examining ultrasound of the abdominal organs, there was splenomegaly (spleen - 122 × 51 mm), and in the gates of the liver - cavernous transformation of the portal vein; veins of the stomach and esophagus, decreased blood flow through the portal vein. Structural pathologies and indirect signs of accumulation of manganese salts were not reliably determined on MRI of the brain. The child was diagnosed with extrahepatic portal hypertension, esophageal varicose veins of the second degree, and an operation was performed - side-to-side splenorenal shunting.

At the age of eight years, during the examination, a decrease in the size of the spleen was noted on ultrasound (spleen - 114x45 mm) and on FEGDS - a decrease in the degree of varicose veins of the esophagus (first degree), however, when comparing angiograms, a decrease in blood flow in the liver was noted, and on MRI of the head the brain showed signs of CNS damage (changes in the MR signal in the basal ganglia, as a possible consequence of the accumulation of manganese salts in hepatic encephalopathy; focal changes in the cerebral hemispheres). Hyperammonemia was also noted.

The child was operated on by the proposed method laparoscopic access. Laparoscopy was performed in the supine position on the operating table after induction of general anesthesia (endotracheal anesthesia). Trocars were placed in typical locations. The endoscope was passed through a 10 mm optical port placed through the umbilical incision. During the operation, the gastrocolic ligament was dissected and the cavity of the omental sac was opened. Then, along the lower edge of the pancreas, the peritoneum was divided. Mobilization of the splenic vein, splenorenal anastomosis, left renal, inferior mesenteric, portal and left gastric veins was performed (further mobilization of the right gastric, superior mesenteric and right gastroepiploic veins was prevented by a pronounced fibrous process of tissues near the vessels and significant capillary bleeding during mobilization of the vessels ). The child had a feature of the anatomy of the vessels - the inferior mesenteric vein flowed into the splenic vein, and then the splenic vein merged with the superior mesenteric vein, forming the portal vein. Using clips, the lumen of the splenic, inferior mesenteric, and left gastric veins was alternately blocked (the splenic vein was clipped in the area located between the confluence of the inferior mesenteric vein and the confluence of the splenic vein with the superior mesenteric vein). The trocars were removed, gas was released from the abdominal cavity, and the wounds were sutured in layers.

In the postoperative period, the child was prescribed antibacterial, symptomatic (including analgesic) and infusion therapy. On the first postoperative day, ultrasound of the vessels of the portal vein system and the portosystemic shunt was performed, the anastomosis functioned. The child was discharged home in a satisfactory condition on the third postoperative day, when in the biochemical blood test there was a decrease in the level of ammonia in the blood by 41 µmol/l. Six months after the operation, he is scheduled to be re-hospitalized for examinations (ultrasound, angiography, MRI of the brain, measuring the level of ammonia in the venous blood). Clinical example 3.

Boy 3. 12 years old. At the age of five, he was hospitalized with a diagnosis of "Extrahepatic form of portal hypertension", and an operation was performed - splenosuprarenal bypass "side-to-side".

At the age of twelve, the child was admitted to a planned hospitalization with rednecks for poor school performance, memory impairment, and inability to concentrate. In the biochemical blood test there was hyperammonemia up to 117 µmol/L. The child underwent an operation to transfer the side-to-side splenosuprarenal shunt into a selective portosystemic shunt by laparoscopic access in accordance with the proposed method. During the operation, the mesentery of the transverse colon was dissected and the cavity of the omental bag was opened. The peritoneum was divided along the lower edge of the pancreas. The splenic vein was mobilized and its lumen between the orifice and the anastomosis site was closed with a clip. On the third postoperative day, the biochemical analysis of blood showed a decrease in the level of ammonia to 88 µmol/l.

Clinical example 4.

Girl E. 9 years old. At the age of five, she was hospitalized with a diagnosis of "Intrahepatic form of portal hypertension, esophageal varicose veins of the first degree", an operation was performed - splenosuprarenal shunting "side-to-end".

At the age of nine, the child was admitted to a planned hospitalization. In the biochemical blood test there was hyperammonemia up to 77 µmol/L. the child underwent an operation to transfer the side-to-end splenosuprarenal shunt into a selective portosystemic shunt by laparoscopic access in accordance with the proposed method. During the operation, the gastrocolic ligament was dissected and the cavity of the omental sac was opened. The peritoneum was divided along the lower edge of the pancreas. The vessels of the portal system were mobilized and the lumen of the splenic (between its mouth and the anastomosis site) and inferior mesenteric veins were closed by applying clips. On the third postoperative day in the biochemical analysis of blood, a decrease in the level of ammonia about normal values was noted.

Clinical example 5.

Boy K. is 12 years old. At the age of four, he was hospitalized with a diagnosis of "Extrahepatic form of portal hypertension", and an operation was performed - mesoportal shunting. During planned hospitalization, thrombosis of the mesoportal jester was detected, the child underwent surgery: side-to-side splenorenal shunting.

At the age of eleven, the child was admitted to a planned hospitalization with rednecks for reduced school performance, memory impairment, inability to concentrate, and frequent episodes of aggressive behavior. In the biochemical analysis of blood there was hyperammonemia.

The child underwent an operation to transfer the side-to-side splenorenal shunt into a selective portosystemic shunt in accordance with the proposed method.

A laparoscopy was performed, however, there was a pronounced adhesive process in the abdominal cavity and an access conversion was performed. After relaparotomy, the gastrocolic ligament was dissected and the cavity of the omental sac was opened. The peritoneum was divided along the lower edge of the pancreas. The vessels of the portal system were mobilized and the lumens of the splenic (between its mouth and the anastomosis site), inferior mesenteric, left and right gastric veins were closed by ligation. In the early postoperative period, ultrasound signs of improved blood supply to the liver and a decrease in the level of ammonia in the blood by 16 µmol/l were noted. Clinical example 6.

Boy K. is 16 years old. At the age of six years, he was hospitalized with a diagnosis of "Intrahepatic form of portal hypertension", and an operation was performed - side-to-side splenorenal shunting.

At the age of fifteen, he entered a planned hospitalization with rednecks for a decrease in school performance, memory impairment, forgetfulness, and drowsiness during study. In the biochemical analysis of blood, the level of ammonia reached up to 111 µmol/L. An operation was performed to transfer the side-to-side splenorenal shunt into a selective portosystemic shunt by laparotomy in accordance with the proposed method. During the operation, the gastrocolic ligament was dissected, the cavity of the omental sac was opened. The peritoneum was divided along the lower edge of the pancreas. The vessels of the portal system were mobilized and the lumens of the splenic (between its mouth and the anastomosis site), inferior mesenteric, left and right gastric, and right gastroepiploic veins were closed by clipping. In the postoperative period, there were ultrasound signs of a significant improvement in portal perfusion of the liver due to dilatation of the vessels of the cavernous transformation of the liver and dilatation of the intrahepatic venous vessels. Also, the level of ammonia in the blood decreased to 54 µmol/l.

Using the proposed method, 14 children with portal hypertension, a condition after splenorenal side-to-side shunting or splenosuprarenal shunting, were operated on. In all cases, the operations were successfully performed, postoperative complications, including shunt thrombosis, were not observed, and high levels of ammonia in the blood decreased or dropped to normal levels.

The undoubted advantages of the proposed method are:

• treatment and prevention of complications such as pulmonary arterial hypertension, liver failure, hyperammonemia, portosystemic encephalopathy;

• minimally invasive, simple technique.

Claims (6)

1. A method for treating complications caused by a total discharge of blood from the portal system into the inferior vena cava in children who underwent side-to-side splenorenal shunting or splenosuprenal shunting for portal hypertension, characterized in that they block the blood flow through the splenic vein on level located between the previously imposed portosystemic anastomosis and the mouth of the splenic vein. 2. The method according to p. 1, characterized in that the blocking of the blood flow through the splenic vein is performed by clipping it. 3. The method according to p. 1, characterized in that the blocking of the blood flow through the splenic vein is performed by ligating it. 4. The method according to p. 1, characterized in that laparotomy access is used. 5. The method according to claim 1, characterized in that the intervention is performed using a laparoscopic technique. 6. The method according to claim 1, characterized in that the blood flow is additionally blocked in at least one of the following veins: inferior mesenteric vein, left gastric vein, right gastric vein, right gastroepiploic vein.

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