Portal vein and vena cava end-to-side shunt

End-to-side shunt of the portal vein and vena cava for surgical treatment of portal hypertension. End-to-end shunt of the portal vein can directly reduce the pressure of the portal vein, completely transfer the portal vein into the liver circulation, and the decompression effect is obvious, but the liver function damage is serious and the incidence of hepatic encephalopathy is high. This procedure has been Basically not used. Treatment of diseases: portal hypertension Indication 1. Intrahepatic obstructive portal hypertension complicated with esophageal and gastric varices bleeding. 2. Rebleeding after splenectomy or spleen and kidney shunt. 3. Hepatic vein distal obstruction type cloth-plus syndrome. Preoperative preparation 1. Give high sugar, high protein, high vitamin, low salt and low fat diet. For patients with poor appetite, appropriate parenteral and enteral nutrition support should be given, such as intravenous supplementation of GIK fluid and branched-chain amino acids to enhance nutrition and improve general condition. 2. Patients with major bleeding, if there is moderate anemia and obvious hypoproteinemia, an appropriate amount of fresh whole blood and human albumin or plasma should be intermittently infused 1 week before surgery. 3. Liver treatment: In addition to the use of general liver protection drugs, if necessary, hepatocyte growth factor, hepatocyte regenerating hormone, glucagon and so on. 4. Improve the coagulation mechanism. One week before surgery, routine intramuscular or intravenous injection of vitamin K11. For patients with prolonged prothrombin time and significantly lower platelet count, conditional preoperative injection of platelet suspension, cryoprecipitate or freshly lyophilized plasma (precursor containing various clotting factors and Fibronectin). 5. Prophylactic antibiotics. One dose should be given 30 minutes before surgery, and 1 to 2 doses should be used for intraoperative use. Antibiotics should be selected from a broad spectrum of drugs, such as aminoglycosides, cephalosporins; and anti-anaerobic drugs such as metronidazole or tinidazole. 6. Digestive tract preparation: patients who are intended to have esophageal transection should be given 0.1% neomycin gargle and orally before surgery. Surgical procedure 1. Take the right rib incision, inward through the midline, outward to the anterior line. 2. Incision of the descending peritoneum of the duodenum, up to the duodenal ligament, descending the junction of the descending and horizontal parts, turning the duodenum forward and inward, revealing the posterior part of the pancreatic head, Lower common bile duct and inferior vena cava. 3. Cut the lateral peritoneum of the hepatoduodenal ligament, confirm the anterior wall and lateral wall of the portal vein, free and pull the common bile duct to show the portal vein. 4. Further free the posterior wall and inner wall of the portal vein, the portal vein bifurcation, down to the head of the pancreas, ligation between the common bile duct and the portal vein, and cutting off the coronary vein originating from the trunk of the portal vein. 5. The second segment of the duodenum is pulled to the left front, showing the inferior vena cava, and the anterior wall vascular sheath of the inferior vena cava is cut, up to the liver, and the right renal vein level is released. The diameter of the inferior vena cava was 2/3, and the length was about 5 cm. The branches of the two vessels were ligated and disconnected. 6. Use the Bühler clamp to block the portal vein above the duodenum, and ligature the portal vein under the left and right branches of the portal vein. The hepatic portal vein is sutured. 7. Satinsky heart ear pliers partially blocked the inferior vena cava, the free segment of the portal vein was rotated to the vena cava, and the anterior wall of the inferior vena cava was cut with a curved blood vessel under the condition of no tension, forming a slightly larger diameter than the portal vein. Oval notch. 8. End-to-side anastomosis of the portal vein and inferior vena cava with a 5-0 polyester or polypropylene thread. Firstly, the sutures of the two vessels were sutured, and then the posterior wall and anterior wall of the anastomosis were anastomosed by continuous valgus suture. Before closing the anterior wall of the anastomosis, the portal vein blocking forceps was opened to discharge the possible blood clots. Re-block and anastomosis. 9. Loosen the inferior vena cava blocking forceps and then open the portal vein blocking forceps. If there is a large gap in the anastomosis, re-block and fill the suture 1 or 2 needles; if the amount of bleeding is small, press the hot saline gauze slightly. Just fine. 10. Take a small piece of liver tissue for pathological examination, then measure the pressure of the portal vein, and place the abdominal drainage under the liver. complication Early upper gastrointestinal bleeding The causes of early upper gastrointestinal bleeding after portal vein shunting include gastroduodenal ulcer, stress ulcer, and anastomotic thrombosis. Post-operative use of Losec to prevent and treat ulcer bleeding. Exquisite anastomosis is an important step in preventing anastomotic thrombosis. Once bleeding occurs after surgery, liver failure and hepatic encephalopathy are most likely to occur in patients with impaired liver function. 2. Hepatic encephalopathy The incidence of hepatic encephalopathy after portal shunt is high, which is related to factors such as ammonia poisoning, pseudo-neurotransmitters and amino acid imbalance after shunt. Clinical can be divided into acute and chronic disease. Once there is a prodromal symptoms of hepatic encephalopathy, it should be treated early. In addition to actively improving liver function, the following measures should be taken: 1 Remove the predisposing factors. 2 reduce the production of excess ammonia. 3 Remove the ammonia that has been produced. 4 against pseudo-neurotransmitters. 5 Correct the imbalance of amino acid metabolism. Lactulose is an important drug for the prevention and treatment of hepatic encephalopathy. 3. Liver and kidney syndrome The onset is urgent, the progress is fast, and there may be sudden oliguria or no urine. Patients with ascites, jaundice, ambition, lethargy, and even coma. In addition to vigorously protecting the liver and preventing other complications, the following measures should be taken: 1 to expand blood volume. 2 application of diuretics. 3 application of vasoactive drugs. 4 Correct water, electrolyte and acid-base imbalance. 5 hemodialysis to relieve azotemia.