Splenorenal Anastomosis Research Articles

A study of grafts in the venous system.

Only limited information is available on which to base the selection of grafts suitable for use in the venous system. Grafting techniques have been applied chiefly to the arterial system, and vein grafts have most frequently been studied from the standpoint of suitability as arterial replacements. Nevertheless, patients are seen in whom a graft to replace or bypass portions of the venous system is desirable. Clinical situations encountered include traumatic laceration of major veins, certain arteriovenous fistulae, facilitation of end-to-side portacaval and splenorenal anastomosis, resection and replacement of the superior mesenteric vein in pancreatectomy for carcinoma, benign and malignant vena caval obstruction, and suggested venous shunts to increase compensation in transposition of the great vessels. This study was undertaken to examine the fate of various types of grafts inserted in the venous system, including fresh autografts, fresh and frozen homografts, and Edwards-Tapp nylon grafts. These grafts were inserted in a

The suprarenal veins

The right suprarenal vein was single in eight subjects. In these, its average diameter was under 0.4 cm. and it joined the inferior vena cava (or anomaly) in five instances, on the average 3.6 cm. proximal to the right renal vein. In three instances the single vein joined a right hepatic vein close to the junction of the latter with the inferior vena cava. In these subjects the right hepatic vein was within 4.0 cm. of the right renal vein. In one subject there were two right veins, and in another, three, all of which joined the inferior vena cava between the lowest right hepatic vein and the right renal vein. In the subject with an anomalous inferior vena cava, the right vein joined the anomalous vein, passing to the right atrium and receiving blood from the right lobe of the liver. Venules from the capsule of the right suprarenal joined the main suprarenal vein, perirenal fat veins, the right renal vein, the right inferior phrenic vein, veins in relation to the peritoneal reflection and capsule of the bare area of the liver and to the inferior vena cava. The left suprarenal vein was single in all subjects and after receiving the left inferior phrenic vein had an average diameter of over 0.4 cm. It invariably joined the left renal vein, an average distance of 3.1 cm. from the junction of the latter with the inferior vena cava, and opposite or medial to the gonadal vein. The junction with the left inferior phrenic vein took place either close to the renal vein or within an average of 1.6 cm. distal to the renal vein. In one subject the left inferior phrenic vein did not join the suprarenal vein. The capsular veins on the left side joined the main suprarenal vein, the inferior phrenic vein, the perirenal fat vein and the renal vein or accessory renal vein, and ascending lumbar vein. The only subject displaying a raised blood pressure prior to death did not have any increase in diameter of the suprarenal vein. In one subject the inferior phrenic vein received a tributary from the splenic vein, a naturally occurring splenorenal anastomosis previously described [3].

Emergency and definitive treatment of bleeding esophageal varices.

• Bleeding esophageal varices were the cause of 93 hospital admissions during a five-year period. The vascular impediment was extrahepatic in 28, and in this group there were no deaths; there were severe hemorrhages, but in most instances a satisfactory portacaval shunt was established. The impediment was intrahepatic in 65 patients, and 32 of these died; portacaval shunts were possible only in 33. When the diagnosis of bleeding from esophageal varices is clear, tamponade by intragastric balloon has been effective; emergency suture of the varices has then been done in 20 cases through a transpleural transesophageal incision. Thereafter it has been possible to prepare the patients for some type of shunt operation. Various portacaval shunts have been established or attempted in 131 patients in 10 years, with extremely encouraging results. Splenorenal anastomosis, done in 83 cases, is feasible if the spleen has been enlarged but impossible if there has been a splenectomy. Direct portacaval anastomoses were made in 36 cases. Eleven patients with extrahepatic portal bed block and 52 with cirrhosis of the liver have resumed full-time work after the establishment of splenorenal or direct portacaval shunts.

Clinical aspects and treatment of portal hypertension

Summary1.Splenectomy, long recommended as the causal treatment of Banti Svn- drome, yields disappointing results. It remains indicated only in cases of thrombosis of the splenic vein and in the rare cases of « Banti disease ».2.Porto-caval shunt is the only rational treatment of Banti Syndrome due to portal obstruction. As portal vein is usually thrombosed spleno-renal anastomosis will be most often used. It yields better results than those obtained by direct approach on oesophagal varicose veins (ligature or cardio-oesopha- gectomy).3.Direct porto-caval anastomosis is presently the best available treatment of hemorrhages due to portal hypertension in liver cirrhosis. It does not influence cirrhotic ascitis in which portal hypertension seems less involved than imbalances of water and salt metabolism.

RESECTION OF ESOPHAGEAL VARICES

Brief considerations are made on incidence, symptomatology, endoscopic and radiologic diagnosis of esophageal varices. Mention is made of various treatments advocated. Three cases in children are described; two of them complained of liver cirrhosis and one of blocking of portal vein and chronic congestive splenomegaly; all had profuse hematemesis by varices. Splenectomy and splenorenal anastomosis were practiced without results in two cases. In view of the persistence of hematemesis, an ample thoracotomy was performed, followed by longitudinal incision of the esophagus; this brought into view the varicous columns which were then resected. The esophagus was sutured in two layers. The postoperative course was satisfactory and the esophagoscopic control done two years afterwards in two of the cases showed there has been no reproduction of varices. The third case is still under observation.

ESQUISTOSSOMOSE MANSONI

ESQUISTOSSOMOSE MANSONI

Effects of unilateral renal vein hypertension secondary to splenorenal vein anastomosis on individual kidney function

1. 1. Individual kidney clearances of inulin and p-aminohippurate and the ability of the individual kidneys to excrete sodium, chloride, potassium and water were studied before and during salt-loading in one subject nine months following splenorenal anastomosis for portal hypertension. 2. 2. Prior to salt-loading the kidney subjected to increased renal venous pressure (left) presented significant relative depressions of inulin clearance, urine flow, and sodium and chloride excretion. The depressed urine and salt excretion during this period could be explained entirely on the basis of reduced glomerular activity. 3. 3. During early salt-loading hyperemia and increased glomerular activity occurred in the right kidney, not in the left. Throughout salt-loading the relative depressions of salt and water excretion by the left kidney were significantly greater than the relative depression of glomerular function. A specific tubular effect of chronic venous congestion is postulated, manifested by increased water and salt reabsorption during salt-loading. 4. 4. The filtration fractions of both kidneys were significantly elevated and became more so during salt-loading. 5. 5. There were no significant differences in potassium excretion by the separate kidneys before and during salt-loading.

Experimental use of preserved arterial grafts in portacaval anastomoses.

IN RECENT years, through the work of such men as Whipple, Blakemore, Blalock and others,1the construction of an artificial connection between the portal and systemic venous circulations as originally described by Eck2has been accepted as a method of treatment of portal hypertension. In order to obtain a shunt of adequate size, most surgeons believe that either a direct portacaval or a splenorenal anastomosis should be performed. The type of operation utilized varies with the requirements of the specific case. This investigation concerns itself with the situation in which the indications for the construction of the fistula are present but in which neither procedure is technically possible. Previous splenectomy, for all intents and purposes, precludes the construction of a splenorenal shunt. Though attempts have been made to isolate the stump of the splenic vein after removal of the spleen, these efforts generally have been fruitless. Similarly, a

Surgical approach to upper abdomen through incision paralleling the costal margin with excision of costal cartilage opposite the fifth intercostal space

Incisions paralleling the mid-costal margin combined with a vertical incision of the linea alba, with excision of the costal cartilage opposite the fifth interspace and with a short laterally directed incision in all tissues of the fifth interspace except the skin, provide an excellent approach on the right to the common duct, portal vein and vena cava, and on the left to the cardia, abdominal esophagus, spleen and left kidney. This approach on the right is recommended in repair of a divided common duct and in portavenacaval anastomosis, and on the left in splenectomy, splenorenal anastomosis and possibly in the repair of diaphragmatic hernia. For gastric resection the midline incision from umbilicus to xiphisternum is preferred, to be supplemented by excision of the costal cartilage opposite the left fifth interspace to facilitate vagus section or high gastric resection. For simple cholecystectomy the subcostal incision paralleling the mid-costal margin to the midline and continued vertically upward through the linea alba to the xiphisternum provides improved exposure of the subhepatic area. In a difficult choledochostomy division of the costal cartilage opposite the fifth interspace may be utilized when indicated for better exposure.

Portal Hypertension: The Treatment by Splenectomy and Splenorenal Anastomosis with Preservation of the Kidney

Portal Hypertension: The Treatment by Splenectomy and Splenorenal Anastomosis with Preservation of the Kidney