Treatment of portal hypertension

Treatment. Treatment of portal hypertension depends on the underlying disease and should be comprehensive: therapeutic and surgical. The complexity principle concerns the establishment of the indications for surgery, prepare the patient for her, the choice of the method of anesthesia, the choice of method of operation, postoperative management of the patient, his further treatment and observation in the late postoperative period.
From a surgical point of view, it is important to refrain from operations, if the liver has an explicit or disguised necrotic process. Operation in these cases lead to severe liver failure often with outcomes in a coma. It is necessary to consider the speed of the disease and the degree of disturbance of liver function, recurrence of bleeding, flag-inferiority of preoperative preparation or urgentiste intervention, the severity of hypersplenism, cholangitis, mechanical jaundice and portal thrombophlebitis. Without these features can make big mistakes in the treatment of patients with portal hypertension.
Surgical treatment of portal hypertension is carried out in two very different conditions: urgent repair at the height of acute profuse esophagogastric bleeding to stop, and in a planned manner to obtain a stable decrease of portal pressure and the elimination of a number of related phenomena (ascites, hypersplenism, and others).
In acute profuse esophagogastric bleeding effective tamponade of the esophagus. For this purpose proposed probes Sengstaken, Blackmore, M. A. Topchibashov, M. D. Patsiora and other Probe is introduced on a 48, a maximum of 72 hours, after which it slowly and carefully taken, bearing in mind that the extract may cause the resumption of bleeding. Mandatory is to replace the blood loss, correction of water-electrolyte disorders. Nutrition is carried out only through the probe, not more than 150 ml of nutrient mixture at once immediately after emptying of the stomach. By removing the probe patient gradually prepared for the adoption of a dense foods. More than 72 hours to keep the probe is not possible necrosis of the esophageal wall from compression her anemizatsii.
If for any reasons described tamponade is impossible, it is justified to try to stop the bleeding tamponade biological tampon insertion using esophagoscopy. It must be made very carefully by experienced hands, because otherwise such manipulation can exacerbate bleeding. However its efficiency is not reliable.
If the attempt to stop the bleeding using conservative methods fail, without losing precious time, you should apply the operative treatment methods which varied. These include transesophageal edging varikoznorasshirennah veins oesophagus in his transabdominal and, better, transthoracic version (Boerema, 1949; Linton, Crile, 1950). However, the bleeding can be repeated as reduction portal pressure occurs. So in a few weeks (6-8) after successfully stop the bleeding, you must perform the second operation, aimed at reducing portal pressure.
Other reception stop bleeding is createfilemappinga injection in varices veins oesophagus sclerosing 66% glucose solution (Crafford, Frenchner, 1939.) This method is unsafe and unreliable as soon expand to other Vienna, may also be bleeding.
To stop bleeding some surgeons made a back mediastinotomy with tamponade mediastinum counting on down bleeding veins. The effectiveness of this proposal is not convincing.
In 1960, M. A. topchibashev and Tanner independently of each proposed cut across the stomach in the cardiac Department with its subsequent stapling after ligation of vessels in its walls, small and large gland. Similar goal pursued offer devascularization of the gastric cardia, abdominal esophagus and bandaging coronary veins of the stomach in a small gland (Henschen).
To stop the flow of blood into the veins of the esophagus Fossulte (1957) proposed to produce a gradual intersection of the esophagus ligature imposed around the esophagus and tightened over the prosthetic entered into it retrograde by the gastrotomy.
More radical surgery to combat the bleeding is gastrectomy with resection of the lower third of the esophagus or cardio-esophageal resection (Phemister, Humphrey, 1947). Although these operations is obtained separation system veins of the esophagus from the portal system or even complete removal of hazardous veins, however, because of the high morbidity these operations is not widespread received. Not to mention removing the esophagus, replacing it jejunum (Perry, Root-Miller, Varco, 1963), but this surgery in patients with profuse bleeding can probably be applied as extreme, the more so that these methods do not guarantee from recurrence of bleeding, as well as isolated bandaging of a barrel. lienalis.
Remember that in each case, portal hypertension should be selected operation on the individual account of the patient.
For this purpose you need to answer the following important questions: the degree hypertension, the reported prevalence (zoning) in the portal system, localization unit, the degree of compensation of violations of the portal blood flow, the severity of the collaterals, the tendency to bleeding, ascites, the degree of violations of the liver and intoxication, depth exchange, vitamins, hormonal, encephalographic changes in the organism, the activity of changes in the liver and kompensirovat them, the degree of hypersplenism, the presence of cholangitis, out - or intrahepatic cholestasis. Only after taking into account the entire set of these circumstances, you can make a decision about the operation. As for the problem of individualization operational manuals about portal hypertension can be given the following characteristics, and planned transactions.

Porto cavalry anastomosis really contributes to the rapid decrease of portal hypertension, reduction of the spleen and liver, improve liver functions, prevents recurrence of esophago-gastric bleeding. However, when Porto cavalino the anastomosis, especially in children, often evolves toxic encephalopathy. Therefore, should be established strict indications for this anastomosis. You need before surgery to have the data neurological, psychiatric and encephalographic research of the patient.
Apparently, direct Porto cavalry anastomosis shown at high total sub - or decompensated portal hypertension, but when satisfactory liver function without exacerbation of chronic hepatitis.
Mesenteric-cavalry anastomosis (Bogoraz - Krestovsky) or cavo-mesenteric anastomosis (operation Quierala - Clalhwarthy - Valdoni) similarly Porto cavernoma the anastomosis is only slightly slower decrease of portal hypertension, liver and spleen, improve liver function. If it fails, the choice of readings or thrombosis anastomosis is developing rapidly intoxication, ammoniate, renal and hepatic failure.
The operation is justified in sub - or asthma hypertension, prevailing in the intestinal-mesenteric area, as in intra-and extrahepatic block portal system.
Both venous anastomoses (Porto cavalry, mesenteric-cavalry) do not resolve of hypersplenism, cholangitis and mechanical jaundice. The latter require special surgical impacts.
Splenomegaly anastomosis with the removal of the spleen or without (Cooley) eliminates not only portal hypertension, but also the phenomena of hypersplenism. The imposition of this anastomosis most justified under sub - or asthma hypertension, prevailing in the gastro-lenalee zone portal system with splenomegaly and hypersplenism, but when satisfactory liver function, without exacerbation of hepatitis. Splenomegaly anastomosis, unfortunately, not always perform because of the presence of the splenic vein thrombosis, diffuse, type its branch, division of renal veins inside the kidney, muscle releases and tendon transfers trunk renal veins.
After imposition of venous anastomoses should immediately verify the effectiveness them through suboperations splenomegalia or, even better, mesenteric-pornografii. With little lower portal pressure is added or other venous anastomosis, or one of the possible organ anastomoses.
In General, we undergoing surgery overlay of one of the listed options Porto kabelnogo anastomosis results are very encouraging. However, the immediate postoperative mortality is still high and rarely reaches the figures below 20%. Apparently, in the basis of failures are underestimating human liver and disadvantages as preoperative preparation and postoperative management of patients.
Analysis of postoperative mortality shows that on the first place among the causes of death is the hepatic and renal and hepatic failure, then thrombosis anastomosis-wide system of portal vein, more rarely pneumonias, intra-abdominal hemorrhage, and full divergence abdominal wounds in relatively late days after surgery, especially if used hormone therapy.
In patients with pronounced impaired function of the liver is more suitable operation with the creation of the so-called organ anastomoses in the form omento-Reno, omento-hepato - or omento-diafragmice and vnutritorakalnah omento-cevapcici or move the spleen in the pleural cavity. Omento-organobentonite we advocate A. T. Lida, B. P. Kirillov and other Such operations tolerability easier, but they are much smaller and slower decrease of portal hypertension and prevent recurrence of bleeding. When, along with hypertensive decompensation portal blood flow and significant disorder of the liver, expressed and splenomegaly with hypersplenism, then it's reasonable to combine organohalogen with splenectomy.
In the struggle with portal hypertension some surgeons (A. N. Bakulev, Yu. A. Galushko in. A. Vinogradov, A. C. Smirnov, I. P. Shapovalov, V. Ya. Braitsev) undertook a dressing branches celiac artery (a. gastricasin., a. hepatica, a. lienalis). In 1/3 of cases of application of bandaging branches celiac artery we also observed a notable success, but with a good liver function. Bandaging a. hepatica, despite the danger of worsening of blood supply to the liver, probably, not without reason, when you are sure that arterialization of the liver is provided, already developed by collaterals.
In recent years, increasingly the statements in favour of preference before bandaging a. hepatica comm. it induced sympathectomy (denudation) per improve blood flow in the liver, promotes improvement of function of the body (Mallet-Guy in. A. Vinogradov, P. N. Napalkov, A. N. Ardamatskaya). However, our observations have shown that this operation also gives good results in case of chronic hepatitis, when not yet formed cirrhosis of the liver. The last time this operation we combine with the regional liver resection performed with the purpose of stimulation of liver tissue regeneration, with good immediate and long-term outcomes.
In addition desimasala hepatic artery, to improve arterialization of the liver proposed switching operation of the splenic artery into the portal vein of the liver. The creation of arterio-venous spleno-ombilicale anastomosis calculated, except compensation for lost volume portal blood flow, to reduce hypoxia in the liver and, thus, to improve its functions and processes of regeneration.
Splenectomy in pure form currently used very rarely. It is effective only when there is splenomegaly with hypersplenism, and portal hypertension is not high and liver function has suffered little. Otherwise, this operation is risky because of the danger of strengthening of portal hypertension and occurrence esophagogastric bleeding. Therefore, splenectomy should be supplemented or splenorenal or Salnikov organo-anastomosis.