splenic shunt

Splenic shunt is a kind of other shunt surgery, which is similar to spleno-renal venous shunt. It is only because the inferior vena cava is thicker and thicker than the renal vein wall, which is easy to expose and easy for surgical operation. The rate of rebleeding and hepatic encephalopathy was lower after surgery. However, when the splenic vein is too thin or has inflammation, it is difficult to perform such an operation. Treatment of diseases: portal hypertension Indication Portal hypertension, variceal bleeding, splenectomy and other symptoms. Contraindications Patients with liver function graded as Child C with portal hypertension or patients with splenic vein caliber <1 cm. Preoperative preparation 1. Give high sugar, high protein, high vitamin, low salt and low fat diet. For patients with poor appetite, appropriate parenteral and enteral nutrition support should be given, such as intravenous supplementation of GIK fluid and branched-chain amino acids to enhance nutrition and improve general condition. 2. Patients with major bleeding, if there is moderate anemia and obvious hypoproteinemia, an appropriate amount of fresh whole blood and human albumin or plasma should be intermittently infused 1 week before surgery. 3. In addition to the use of general liver protection drugs, hepatocyte growth factor, hepatocyte regenerating factor, and glucagon may be used if necessary. 4. Improve the coagulation mechanism. One week before surgery, routine intramuscular or intravenous injection of vitamin K11. For patients with prolonged prothrombin time and significantly lower platelet count, conditional preoperative injection of platelet suspension, cryoprecipitate or freshly lyophilized plasma (precursor containing various clotting factors and Fibronectin). 5. Prophylactic antibiotics. One dose should be given 30 minutes before surgery, and 1 to 2 doses should be used for intraoperative use. Antibiotics should be selected from a broad spectrum of drugs, such as aminoglycosides, cephalosporins; and anti-anaerobic drugs such as metronidazole or tinidazole. 6. Digestive tract preparation for patients with esophageal transection, preoperative 0.1% of neomycin gargle plus oral administration to clean the mouth and esophagus; clean the enema before surgery, or use magnesium sulfate powder 25 ~ 50g to warm boiled water Mix 1500ml, clean the intestines to avoid enema; place a thin and soft nasogastric tube 30 minutes before surgery. Before placing the tube, take oral liquid paraffin 30ml to lubricate the esophagus. 7. In general, catheterization should be left before surgery. Surgical procedure 1. L-shaped incision or left inferior rib incision in the left upper abdomen is helpful for finding left renal vein and spleen and kidney venous anastomosis. 2. Explore the abdominal cavity and liver and measure the pressure of the portal vein. 3. Cut the gastric spleen ligament, cut off the left ventricle of the stomach; pull the corpus to the upper right, and find, separate and ligature the splenic artery at the upper edge of the tail of the pancreas. Sharp separation of spleen colon, spleen and kidney and spleen ligament. 4. The spleen was removed, the splenic vein and its surrounding tissues were separated, the splenic artery was ligated at the upper edge of the splenic vein, and the pancreatic tail and splenic vein were blocked with Satinsky forceps. 5. Free the splenic vein on the dorsal side of the tail of the pancreas, ligation and spleen vein into the small branch vein of the pancreas, and the free splenic vein is about 3 to 4 cm. The spleen vein near the spleen was cut off and the spleen was removed. The spleen bed was sutured to stop bleeding. 6. Cut the posterior retroperitoneal fibrous adipose tissue on the surface of the renal hilum, separate it to the surface of the left renal vein, cut the vascular sheath, cut the sputum and smear the left adrenal vein, sharply separate the anterior wall of the renal vein and the upper and lower edges, free The circumference of the left renal vein is about 2/3, and the length is about 3 to 4 cm. 7. Close the splenic vein to the renal vein, block the anterior wall of the renal vein with Satinsky forceps, cut the wall larger than the diameter of the splenic vein, and use the 5-0 non-invasive suture to make the splenic vein and the renal vein end-to-side anastomosis. Close the anterior wall of the anastomosis and open the splenic vein blocking forceps to flush out possible blood clots. 8. After the anastomosis is completed, the renal vein and the splenic vein are opened, and a small amount of oozing can be stopped by hot saline gauze. 9. Stop bleeding, pressure measurement, and place abdominal drainage under the left ankle. 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.

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