PORTO-CAVAL ANASTOMOSIS (late lat. [vena] of portae portal vein + [vena] of cava vena cava; an anastomosis) — the natural or created by means of surgical intervention message between portal system and system of venas cava.
Distinguish the following anatomic P. and.: in the bottom of a gullet between veins of a stomach (system of a portal vein) and the esophageal veins (falling in unpaired and up to-luneparnuyu veins); between veins of a stomach, a spleen and a left kidney; between veins of the descending colon and the left yaichkovy (ovarian) vein; between veins of the lower third of the descending colon and veins of a renal capsule; between veins of the descending colon and a renal vein; between the lower mesenteric vein and a renal vein; between veins of the ascending colon and the right yaichkovy (ovarian) vein; between paraumbilical veins and veins of a front abdominal wall; between an upper pryamokishechny vein and average and lower pryamokishechny veins. These P. and. take part in development of roundabout blood circulation at disturbance of blood circulation in system portal vein (see).
Porto-caval anastomosis surgical, or Ekk's fistula — quickly created anastomosis of a portal vein with the lower vena cava for the purpose of pressure decrease in portal system.
A priority in P.'s imposing and. belongs to the domestic surgeon N. V. Ekk (1877) who developed operation in an experiment, having connected the distal end of a portal vein after its crossing to the lower vena cava the end sideways; at the same time the liver was completely switched off from portal blood circulation. I. P. Pavlov (1892) changed a technique of operation of Ekk, having imposed an anastomosis between a portal and lower vena cava a side sideways without crossing of a portal vein. At this option of an anastomosis only a part of blood from portal system went to the general blood stream, passing a liver that increased life expectancy of animals and reduced intoxication. In clinic Ekk's operation was for the first time executed by Vidal (M. Vidal, 1903) at the patient with cirrhosis in an ascitic stage. More wide spread occurance P.'s imposing and. got after publication a job of Bleyk-mora and the Lord (A. H. Blakemore, J. W. Lord, 1945) who reported about results of use of P. and. in a wedge, conditions. In the USSR for the first time P. and. by Ekk's technique B. V. Ognev in 1943, and then F. G. Uglov in 1950 by Pavlov's technique executed. Inokuti (To. Inokuchi) with sotr. (1970) reported about use of a gastrokavalny anastomosis with an autograft at a varicosity of a gullet or stomach. They executed gastrosu-prarenalny, gastrorenalny, hectare-strospermatikovy an anastomosis. In the USSR gastrosuprarenalny and hectare-strokavalny an anastomosis was executed by M. D. Patsiora respectively in 1963 and 1972.
P.'s imposing and. it is shown at the portal hypertensia complicated by bleeding from expanded veins of a gullet. In emergency situations, at bleeding from veins of a gullet, operation of imposing of P. and. it is accompanied by great risk.
Operation is contraindicated at active hepatitis against the background of cirrhosis, at advanced age, at the subcompensated and dekompensirovanny stages of cirrhosis.
As quick access apply a section in the ninth or tenth mezhreberye with transition to a front abdominal wall towards a navel on the right. Cut a peritoneum of a hepatoduodenal sheaf and a peritoneum over the lower vena cava to a confluence of renal veins. Allocate the general bilious channel and on a tourniquet take away it up and to the left. Otpreparovyvat a portal vein throughout 5 — 6 cm. Will mobilize the lower vena cava to a confluence of renal veins and impose on it an artery forceps in lengthwise direction, without blocking completely a gleam of a vein. In a wall of a vein cut an oval opening, diameter to-rogo corresponds to a portal vein (15 — 20 mm). On a portal vein impose two clips and cross it. The distal end of a portal vein anastomose with the lower vena cava the end sideways (fig., a). The stump of the proximal end of a portal vein is taken in. At P.'s imposing and. a side sideways on a portal vein impose an artery forceps in lengthwise direction and in its sidewall cut an oval opening of 10 in size — 15 X 6 — 8 mm. Veins pull together and anastomose (fig., b).
In the postoperative period thrombosis of an anastomosis, development is possible liver failure (see), at 18 — 25% of patients after operation encephalopathy as a result of switching off of a liver from portal blood circulation can develop. Encephalopathy is shown by disturbance of mentality — block, drowsiness, periodically arising euphoria, flashes of psychomotor excitement. Decrease in working capacity, memory, attention, a lack of coordination, an ataxic gate, trembling of hands, the heads are characteristic. Heavier display of encephalopathy — development of a soporous state.
For the prevention of encephalopathy observance of a diet with restriction or a complete elimination of meat products is recommended. The possibility of rehabilitation depends on the nature of basic process. However patients with cirrhosis quite often even in a stage of compensation of process remain restrictedly able-bodied.
According to Ungekheyr, Schuster (E. Ungeheuer, G. Schuster, 1975), Essera (G. Esser, 1976), a lethality at P. and., imposed in a planned order, reaches 10 — 13%. At the emergency imposing of P. and. at the time of the developed bleeding from veins of a gullet a lethality, according to Orlov (M. J. Orloff) with sotr. (1974), Sievert (R. Siewert, 1976), 45 — 50% make. According to Greys, Mancha, Chalmars (N. Grace, M. of Munch, T. Chalmars, 1966), a recurrence of bleedings from veins of a gullet in the remote period after a porto-caval anastomosis are observed in 2,8 — 3% of cases.
Bibliography: Atlas of peripheral nervous and venous systems, sost. A.S. Vishnevsky and A. N. Maksimenkov, M., 1949; Pavlov I. P. Complete works, t. 2, book 1, page 239, M. — JI., 1951; F. G Corners. Operation of a porto-caval anastomosis for hypertensia in system of a portal vein, Vestn, hir., t. 73, No. 2, page 61, 1953; Surgical anatomy of a stomach, under the editorship of. A. N. Mak-simenkova, D., 1972; E to N. V. K to a question of bandaging of a portal vein, Voyen. - medical zhurn., p. 130, book 11, page 1, 1877; Esser G. Chirurgisches Vorgehen bei der akuten Varicenblutung, Langenbecks Arch. klin. Chir., Bd 342, S. 181, 1976; Orloff M. J. a. o. Emergency portacaval shunt treatment for bleeding esophageal varices, Arch. Surg., v. 108, p. 293, 1974; Ungeheuer E. Schuster G. Measures and results of early therapy in acutely bleeding esophageal varices, Bull. Soc. int. Chir., t. 34, p. 169. 1975.
M. D. Patsiora; S. S. Mikhaylov (An).