Combined transabdominal devascularization

Transabdominal combined devascularization for surgical treatment of portal hypertension. This procedure is also known as combined transection of the esophagus or fundus or modified Sugiura. On the basis of the vascular disconnection around the esophagus of the cardia, the anastomosis of the fundus and the suture device were used to block the anterior and posterior wall of the fundus, and the abnormal blood flow of the portal vein in the stomach wall and esophageal wall was further blocked, and the abnormal flow was improved. Thoroughness, reducing the incidence of postoperative rebleeding. Treatment of diseases: esophageal and gastric varices and their rupture Indication Transabdominal combined devascularization is applicable to: 1. Patients with portal hypertension complicated with esophageal or gastric varices bleeding, drug and endoscopic treatment are ineffective for emergency hemostasis. 2. The patient's liver function is poor. There are pre-existing signs or symptoms of hepatic encephalopathy before surgery. The inability to tolerate shunt or shunt will aggravate the symptoms of hepatic encephalopathy. 3. Portal hypertension The hepatic lateral branch vessels have not been fully established, and there are still more hepatic blood flow to the portal vein. The shunt will aggravate liver function damage. 4. Regional portal hypertension caused by splenic vein disease. 5. Patients with rebleeding after shunt. Contraindications Patients with severe ascites or jaundice with a liver function of Child C grade portal hypertension. Preoperative preparation 1. Evaluation of liver function: Blood biochemical and prothrombin time should be measured before surgery, and Child classification should be carried out reasonably. Patients with low albumin should pay attention to the cause of blood loss or hepatocyte synthesis disorder. 2. Assessment of portal hypertension: upper digestive tract tincture and gastroscopy can detect the presence and severity of esophageal varices and further clarify the cause of bleeding. Color ultrasound, CT and MRI observation of liver morphology, size, placeholder and portal vein Vascular anatomy and blood flow, conditional indirect or direct portal venography can be used to understand portal venous anatomy, blood flow and coronary anatomy. 3. For patients with acute esophageal varices bleeding, when the drug and endoscopic treatment are ineffective, the surgery can be performed under the condition that the three-chamber two-capsule tube is pressed to stop bleeding and the vital signs are stable. Surgical procedure 1. According to the pericardial devascularization of the esophagus, the splenectomy was performed, and the blood vessels around the esophagus of the cardia were disconnected. 2. Incision of the anterior wall of the stomach, placement of the tubular anastomat 3cm above the cardia and transection of the lower part of the esophagus. The anastomosis was observed without obvious bleeding. The anterior wall of the stomach was closed with a suturing device. 3. If the fundus vein is severely varicose, the stomach wall is cut 1cm under the small curvature of the stomach 2cm under the cardia. The suture is used to suture the anterior and posterior wall of the stomach. The suture blocking line of the anterior and posterior wall should be connected at the His triangle. 4. Place the abdominal drainage under the left ankle. complication Anastomosis In the lower esophagus transection and re-synchronization, the stapler or the stomach wall is not used correctly. When the small curved side of the stomach wall is closed, the suture is not careful. The lower esophageal anastomosis or the small curved side of the stomach fistula will occur after operation. The clinical manifestations are local infections of the left axillary or left subhepatic, and severe diffuse peritonitis occurs. Once the laparoscopic drainage is required or the catheter is guided by the B-ultrasound. 2. Intra-abdominal bleeding The most common complication 24 hours after surgery was intra-abdominal hemorrhage. The main cause of bleeding is the detachment of the short vascular ligation line of the stomach and the oozing of the spleen. The clinical manifestation is that the abdominal drainage tube has a large amount of non-coagulated blood and hemorrhagic shock. If it is active bleeding, it is necessary to stop bleeding again. 3. Left axillary infection More common in 1 week after surgery. The clinical manifestations were persistent high fever, elevated white blood cells, and B-ultrasound and CT showed low-density lesions in the left axilla. Abscess puncture drainage guided by B-ultrasound should be the first treatment. 4. Postoperative bleeding Incomplete or interrupted gastric mucosal lesions can lead to early postoperative rebleeding, and can be treated with somatostatin and Losec. 5. Gastric emptying disorder In the case of devascularization, the vagus nerve trunk is damaged, and gastric emptying disorder may occur after surgery. Gastrointestinal decompression, parenteral nutrition and gastroscopic treatment can restore gastric emptying function.