Warren's shunt

Warren's shunt is a kind of spleno-renal venous shunt, which is mainly used to treat diseases such as portal hypertension caused by cirrhosis. Surgery can directly reduce the pressure of the portal vein, and completely transfer the portal vein into the liver circulation to the systemic circulation. The decompression effect is obvious, but the liver function damage is serious, and the incidence of hepatic encephalopathy is high. Treatment of diseases: cirrhosis of the elderly Indication Portal hypertension syndrome caused by cirrhosis Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. 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. Take the right rib incision, inward through the midline, outward to the anterior line. 2. Incision of the descending peritoneum of the duodenum, up to the duodenal ligament, descending the junction of the descending and horizontal parts, turning the duodenum forward and inward, revealing the posterior part of the pancreatic head, Lower common bile duct and inferior vena cava. 3. Cut the lateral peritoneum of the hepatoduodenal ligament, confirm the anterior wall and lateral wall of the portal vein, free and pull the common bile duct to show the portal vein. 4. Further free the posterior wall and inner wall of the portal vein, the portal vein bifurcation, down to the head of the pancreas, ligation between the common bile duct and the portal vein, and cutting off the coronary vein originating from the trunk of the portal vein. 5. The second segment of the duodenum is pulled to the left front, showing the inferior vena cava, and the anterior wall vascular sheath of the inferior vena cava is cut, up to the liver, and the right renal vein level is released. The diameter of the inferior vena cava was 2/3, and the length was about 5 cm. The branches of the two vessels were ligated and disconnected. 6. Use the Bühler clamp to block the portal vein above the duodenum, and ligature the portal vein under the left and right branches of the portal vein. The hepatic portal vein is sutured. 7. Satinsky heart ear pliers partially blocked the inferior vena cava, the free segment of the portal vein was rotated to the vena cava, and the anterior wall of the inferior vena cava was cut with a curved blood vessel under the condition of no tension, forming a slightly larger diameter than the portal vein. Oval notch. 8. End-to-side anastomosis of the portal vein and inferior vena cava with a 5-0 polyester or polypropylene thread. Firstly, the sutures of the two vessels were sutured, and then the posterior wall and anterior wall of the anastomosis were anastomosed by continuous valgus suture. Before closing the anterior wall of the anastomosis, the portal vein blocking forceps was opened to discharge the possible blood clots. Re-block and anastomosis. 9. Loosen the inferior vena cava blocking forceps and then open the portal vein blocking forceps. If there is a large gap in the anastomosis, re-block and fill the suture 1 or 2 needles; if the amount of bleeding is small, press the hot saline gauze slightly. Just fine. 10. Take a small piece of liver tissue for pathological examination, then measure the pressure of the portal vein, and place the abdominal drainage under the liver. complication 1, the cause of fever after spleen and renal venous shunt, mostly due to left iliac effusion and hemorrhage, and even underarm infection, it is important to keep the drainage tube 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 trauma and shunt after surgery and anesthesia reduce the blood supply to the liver, liver failure can often occur, 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, cirrhosis patients with postoperative ascites often intensified, mainly due to poor liver function, decreased plasma protein, decreased renal function, sodium retention and other factors, so the prevention and treatment should be addressed in these aspects.

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