splenorenal venous shunt

Clinical application of portal vein shunt for the treatment of portal hypertension has been nearly half a century old, it has a certain effect on reducing portal pressure and preventing esophageal varices bleeding. However, due to the complicated operation of the operation, the operation has a great influence on the hemodynamics of the portal vein, and the complications and mortality are high. Therefore, the surgical indications must be strictly controlled. The shunt can be divided into two categories: full shunt and selective shunt. The whole shunt refers to the main or main branch of the portal vein to the vena cava system, including spleno-renal shunt, portal shunt, intestinal shunt, spleen shunt Surgery. Such surgery often deprives the liver of blood flow and causes serious complications such as hepatic encephalopathy and liver atrophy. Selective shunt refers to the selective diversion of the spleen and stomach of the portal system to the vena cava system, which preserves the blood flow into the liver, which can prevent bleeding and reduce liver damage. The commonly used surgical procedures include distal spleno-renal shunt and coronary shunt. Treatment of diseases: esophageal varices and rupture of hemorrhage Indication With obvious portal hypertension, extensive esophageal and gastric varices, and severe or repeated variceal bleeding, you can seek shunt surgery as soon as possible. The timing of surgery is very important. When emergency hemorrhage, try to avoid shunt surgery. The bleeding should be stopped by conservative treatment. The general condition is better. It is better to perform surgery when the liver function is i or ii. In addition, the age is preferably under 50 years old. There are many differences in opinions on preventive diversion, and indications should be more cautious. At the same time of splenectomy, the proximal end of the splenic vein and the left anterior wall of the left renal vein were used for end-to-side anastomosis, so that the high-pressure portal vein blood flowed into the hypotensive renal vein through the anastomosis to achieve the purpose of blood pressure reduction, and also solved the problem of hypersplenism. . However, due to the small anastomosis, stenosis and thrombosis are prone to occur after surgery, and the incidence of hepatic encephalopathy is also high. In recent years, it has been replaced by selective shunt. Contraindications Patients with liver function graded as Child C with portal hypertension or patients with splenic vein caliber <1 cm. Preoperative preparation 1. Improve liver function, give high calorie, high protein, low fat, low salt diet and rich vitamins. 2. Strengthen the body's ability to resist disease, such as low plasma protein can be a small amount of fresh or plasma. 3. Correct coagulation insufficiency, intramuscular injection of vitamin k1, vitamin k3, prothrombin and hemostatic agent. 4. Apply antibiotics (neomycin, cephalosporin) two days before surgery to prevent intrahepatic infection and necrosis. 5. Bilateral renal function tests should be performed before surgery. 6. Before the condition, the spleen angiography should be performed before operation. If the venous thrombosis is suspected, the shunt can not be performed. 7. Sodium retention is unfavorable for patients with cirrhosis. Sodium intake should be restricted before surgery. Patients with cirrhosis have increased responsiveness to aldosterone. Therefore, spironolactone can be given before surgery. Surgical procedure 1. Position: supine position, the left waist is 30 ° high. 2. Incision: generally can use the left upper abdomen oblique incision, from the left 9th rib arch obliquely inward and downward, stop at the umbilicus on both horizontal fingers, try not to extend the incision through the midline, so as not to damage the varicose with a certain shunt The umbilical upper abdominal wall vein. If the spleen is huge and the exposure is difficult, the left upper abdomen l-shaped incision can be used, which is more convenient to operate. 3. Exploration: Incision of the abdominal cavity, first check carefully (including liver, spleen, kidney and spleen veins), if there is necrotic cirrhosis, extreme liver atrophy, or splenic vein, portal vein thrombosis, etc. The shunt surgery should be abandoned. If the spleen and the diaphragm are closely adhered and the effect is revealed, then the chest can be considered to facilitate the separation of the adhesion of the face and properly stop the bleeding. 4. Pressure measurement: The portal pressure is measured before the spleen is removed. Use a lower end to connect the needle to the brain pressure measuring tube, the top is connected with a section of rubber tube, the lumen is filled with normal saline, and the air is drained, then the tube is clamped, the needle is inserted into a vein of the greater omentum, and the needle is fixed. Open the hemostat of the tube at the top of the tube. After the water column in the tube is stable and stable, the value of the height of the water column plus the distance from the 0 line at the lower end of the tube to the leading edge of the lumbar vertebrae is the portal pressure. 5. Excision of the spleen: steps with splenectomy. In the process of spleen spleen, when the spleen is taken out of the abdominal cavity incision, the spleen pedicle and the tail of the pancreas are clamped about 5 to 6 cm away from the spleen with a heart-shaped pliers (satinsky), and then the spleen is removed close to the spleen. 6. Separation of the splenic vein and removal of the pancreatic tail: Due to the control of the heart ear pliers, the splenic vein is bloodless, and the splenic vein can be carefully separated from the pancreatic tail tissue, and the small branch from the pancreas is injected into the splenic vein. A ligation and cutting. If the spleen vein is too strong, try to separate at least 3cm from the trunk. For ease of anastomosis, the clamped pancreatic tail should be removed. At this time, first place the hemostasis clip (blalock forceps) on the separated spleen vein trunk, and then remove the heart ear clamp. A row of intermittent sutures was sutured at the proximal end of the 0.5 cm pancreas at the proximal end of the heart ear clamp clamp, and the distal end of the pancreatic tail was removed at the clamp, and the pancreatic duct was sutured with a wire 8-shaped. Finally, the pancreatic tail stump envelope was sutured intermittently with a silk thread. 7. Separation of the left renal vein: The assistant protects the hemostatic clip end and the tail end of the pancreatic vein with gauze and pulls it upward. The other assistant used the large deep curved groove to pull the spleen of the colon downward, and the inside of the renal sulcus was slightly below the pulsation of the renal artery. After cutting the peritoneum and pushing open the adipose tissue, the gray vein was seen. . A section of vein having a length of about 3 to 4 cm and a circumference of about 2/3 (the back wall 1/3 does not have to be separated) is separated and the outer membrane is cut off. If the spermatic vein (ovarian) vein is obstructive, it should be ligated and cut. 8. Anastomosis: Move the splenic vein to the left renal vein, clamp a heart ear clamp (or pulmonary clamp) on the anterior wall of the renal vein, and cut a fusiform wall corresponding to the diameter of the splenic vein, using a 3-0 filament. A needle pull line was opened at the leading edge of the splenic vein and the renal vein incision. The posterior wall of the anastomosis was sutured first, and the 3-0 silk thread was attached with a non-invasive needle, and after liquid paraffin was applied, the posterior wall of the anastomosis was continuously valgus sutured from the left side of the anastomosis to the right side. The needle begins to penetrate from the outside to the left in the left corner of the renal vein incision, and then penetrates from the inside to the outside in the left corner of the splenic vein, and then penetrates from the outside into the splenic vein, and penetrates through the renal vein from the inside to the outside, tightening the suture . Continuously sewed to the right corner in the same way, the stitch length and margin of the suture are each about 2 mm. Finally, the surgeon uses two fingers to gently pull in parallel, tighten the ends of the suture, and clamp the ends of the thread with a mosquito-type hemostatic forceps for temporary traction. When suturing the anterior wall, the other non-invasive needle thread is first inserted from the outside of the left spleen vein, and is pierced from the inner surface of the renal vein, and then sutured back from the renal vein to form a u-shaped suture. After knotting, the short-line head and the back-wall thread are tied, and the long-line head continues to slash the front wall continuously. When sewing to the front wall half, the hemostatic clip should be loosened once and the blood clot that may form in the splenic vein is flushed out [. Continue to complete the other half of the front wall and stitch the thread to the right end of the back wall. First relax the heart ear pliers on the wall of the renal vein, and then relax the hemostatic clip on the splenic vein. If there is a small amount of pinhole oozing, you can use the warm saline gauze to stop bleeding; if you find a large leaky hole, you need to interrupt the 1-2 stitches to stop bleeding. After the suture is completed, the portal pressure should be measured again to compare with the pre-anastomosis. 9. Drainage and suture: Carefully check the anastomosis, the tail of the pancreas and the sacral surface for oozing. In the posterior aspect of the face and the spleen fossa, there is often bleeding in the peritoneum. Any visible bleeding point should be sutured to stop bleeding. A soft rubber tube and a plastic tube of 2 to 3 mm diameter are placed under the left ankle, and a cigarette-type drainage is placed near the stump of the tail of the pancreas, and a small incision is taken from the left costal margin. Finally, the abdominal wall incision is sutured layer by layer. complication 1. The cause of fever after spleen and renal venous shunt is mostly due to effusion and hemorrhage in the left axilla, and even underarm infection, so it is very important to keep the drainage tube unobstructed and continuous negative pressure suction. On the day after surgery, kanamycin 0.5g or gentamicin 40,000 u (dissolved in 20 ml of normal saline) should be infused through the left indwelling plastic tube, and then 2 times a day for 3 to 5 days. If the body temperature does not drop in about 1 week, the antibiotic dose should be increased, or broad-spectrum antibiotics should be added. If necessary, hormone or vinic acid can be used together. If there is no infection under the armpit, the cigarette drainage should be removed 48 hours after the operation, and the hose and plastic tube should be removed after 3 to 5 days. 2. Intrahepatic portal hypertension, especially in patients with obvious cirrhosis, the blood supply to the liver is reduced after surgery and anesthesia trauma and shunt, liver failure can often occur, and should be actively prevented and treated. Within 2 to 3 days, daily infusion of 25% 25% glucose solution 1000ml. After eating, give a large amount of carbohydrate diet and rich vitamins to limit protein intake. If necessary, intravenously mix the energy mixture and the like. Do not use drugs that impair liver function. 3. After the shunt, the ammonia in the intestine is absorbed, and some or all of them are no longer decomposed into urea through the ornithine cycle of the liver, and directly enter the surrounding circulating blood, which affects the metabolism of the central nervous system and causes nervous system symptoms. Therefore, postoperative care should be taken to limit excessive protein intake. Once symptoms occur, antibiotics should be given to inhibit intestinal bacteria to reduce the production of ammonia, and give -aminobutyric acid, glutamic acid, arginine, etc., and at the same time, give magnesium sulfate and sorbitol orally for catharsis. In addition, it can also be enema or dialysis. Chinese herbal medicines (such as Angong Niuhuang Wan) have a good effect on nervous system symptoms and can be taken. The occurrence of hepatic encephalopathy is also associated with an increase in pseudoneural mediators, an increase in aryl acid and a decrease in branched chain amino acids. Therefore, dopamine, methyldopa, etc. should be administered during treatment, and amino acids with high ratio of branched chain amino acids are input. 4. Postoperative ascites is often aggravated in patients with cirrhosis, mainly due to poor liver function, decreased plasma protein, decreased renal function, and sodium retention. Therefore, prevention and treatment should be addressed in these aspects.