J.Jpn. Surg. Soc.. 57(6): 1014-1096, 1956
宿題報告
THE PORTAL HYPERTENSION : DIAGNOSIS AND TREATMENT
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Second Department of Surgery, Nagoya University School of Medicine Hajime IMANAGA, Kichiro ISOBE |
I. DIAGNOSIS.
1. Esophageal Varices.
For the purpose of diagnostic demonstration of the esophageal varices have been performed (1) the roentgenographic demonstration of the relief of the varices, (2) esophagoscopy, and (3) roentgen visualization of the collateral venous circulations from the portal vein towards the stomach and/or esophagus. The roentgenographic demonstration of the esophageal relief has been concluded to be practically the most applicable procedure with clinically accurate results. It has been confirmed by means of serial porta-roentgenography that the esophageal varices are supplied their own blood stream neither directly by the gastric coronary vein nor by the para-esophageal veins but indirectly by the gastric coronary vein and/or the short gastric vein through the gastric submucosal venous plexes which connect with the esophageal submucosal plexes at the esophagocardiac area.
2. Roentgenographical Visualization of The Portal Venous System.
The portagraphy is diagnostically necessary for both demonstrating the exact site of pre-hepatic portal block, the tardiness of the portal venous blood flow, and the extent and distribution of portal venous collateral circulations, and determining the indication of surgical treatment. In four cases the gigantic collaterals have been found, each of which has been started from the splenic vein and emptied into the left renal vein at the retroperitoneal space : this observation suggests that the omento-nephro-rrhaphy may be more effective than Talma's operation on collateralization of the portal venous system. Success or failure of visualization of the gastric coronary vein on roentgen portagram is dominated by correlation between the procedure of porlagraphy, whether splenic or portal, and the anatomic localization of the inflow of coronary vein into the portal vein or the splenic vein. Therefore, for sufficient visualization of the vein it is likely better to take both portal and splenic portagrams. However, as it has not been rare that massive bleeding has occurred from the punctured wound of spleen after the splenic puncture for splenic portagraphy, the necessity of pre-roentgenographical arrangements for unexpected splenectomy. The safety from post-venographical complication of mesenterial thrombophlebitis owing to the used radiopaque medium has been maintained by adopting 50% Urokon which consists of 21cc of 70%-Urokon and about 9 cc of 20% glucose. When the serial portagraphy, the most adequate procedure, can not be performed in clinic, 2 sheets or more of film must be exposed for venography at least twice, 4 and 8 seconds after the beginning of injection of the radiopaque.
3. Portal Venous Pressure.
Determination of the portal venous pressure should be performed by means of direct measurement of the intra-venous blood pressure of portal venous trunk itself. In almost all patients with extremely high portal pressure, the presence of esophageal varicosities and anamnesis of hematoemesis have been revealed. In general, the portal pressure has been the higher, the portal venous collaterals has been established the more, and these collaterals have been deceptively worthless for depressing the portal pressure well enough. But, on the other hand, in 3 of 4 cases with gigantic collateral circulation, directly into the renal vein from splenic vein, the portal venous pressure has been on normal level without abnormal increase: these collaterals are surely exceptive and those cases should be named "latent portal hypertension". And, the splenic vein stenosis offers no evident increase of venous pressure of portal trunk but symptomatologically obvious splenomegaly with elevated peripheral splenic venous pressure: this case should be named "localized portal hypertension''. The normal portal venous pressure is lower than 200 mm of water according to the results obtained from 26 normal individuals.
4. Splenomegaly And Hematological Research.
The palpable spleen has been revealed always among patients with Banti's syndrome and in a few cases with extremely high portal pressure among patients with cirrhosis of the liver. The anemia has been macrocytic and hyperchromic in patients with liver failure and/or cirrhosis of the liver, and hypochromic and microcytic in those with only splenomegaly and/or Banti's syndrome. The quality and quantity of the hematological changes of the medullary blood is characteristic corresponding with the kind of diseases, whether cirrhosis of the liver or Banti's syndrome.
5. Ascitic Fluid.
The incidence of the ascites has been very high (94%) in cirrhosis of liver. For the differential diagnosis of this ascites from that of carcinomatous or tuberculous peritonitis, the estimations of the protein value, of the osmotic pressure, and of the electrolytes of ascitic fluid have been clinically valuable.
6. Liver Function.
Bromsulphalein clearance test, hippuric acid synthesis test, serum Taketa-Ara reaction, serum thymol turbidity test, urine quantitative Millon reaction, estimation of serum protein, prothrombin-vitamin K response test, and so on have help the diagnosis of the portal hypertension.
7. Dilated Superficial Veins.
Dilated superficial veins on the abdominal wall, which have been found in about 30% of all cases, are diagnostically interesting in point of their characteristics distributions and directions of blood flow in Budd-Chiari syndrome.
8. Gross Portal Circulation Time.
The gross portal circulation time, which has been stated by some researchers to be prolonged in portal hypertension, has been so uncertain in our results that this test can not be considered to be clinically applicable with in diagnostic reference.
II. TREATMENT.
1. Treatment of Esophageal Varices And Hemorrhages.
In our surgical clinic, for the purpose of treatment of the esophageal varices and hemorrhages there have been performed (1) the porta-caval anastomosis, (2) spleno-renal anastomosis, (3) splenectomy, (4) the hepatic artery and/or splenic, artery ligation, (5) omentonephro-rrhaphy (our omental wrapping of the left kidney operation), (6) transesophageal ligation of the esophageal varices, and so on. In all of them, the porta-caval anastomosis has been the most effective operation, and the spleno-renal anastomosis can never be said to have been successful in our experiences. When the patency of the portal venous trunk is confirmed, the porta-caval surgery may be put in practice before the other operations, and when the anastomotic possibility is absent in the portal trunk, the combined surgery of omento-nephrorrhaphy and direct ligation of the varices shall be done. There have been several cases that the varices hemorrhage has progressively increased after splenectomy, because post-operative thrombosis of the portal and/or splenic veins has made the mesenteric venous blood stream to flow much more into the gastric coronary vein towards the varices. This characteristic thrombosis, sitting in the portal venous trunk and splenic vein continuously and being ridden over by the mesenterio-coronary blood flow, we have named "crossing thrombosis". Therefore, man, performing the splenectomy on a patient with portal hypertension first of all, has to take the indication and consequence of this operation in to consideration and to be never thoughtless upon the postoperative thrombosis. The omento-nephro-rrhaphy (omental wrapping of the left kidney) is likely to be effective on establishing the collateralization of spleno-renal circuits. We prefer this operation simultaneously combined with ligation of gigantic collaterals to this alone.
2. Treatment of Ascites.
While it has been concluded that the mechanism of retention of ascitic fluid consists of portal venous block, liver failure, decrease of serum A/G ratio, remarkably depressed excretion of sodium and so on, the most successful treatment of ascites has been found to be the combined management of eliminating the portal block surgically and administering the electrolyte-diuretics medicinally.
3. Treatment of Hematological Disorder.
The hypersplenism, including hematological or hematopoetic disorder, depended upon the splenomegaly, has been neither cured nor improved by the porta-caval anastomosis but only the splenectomy has been effective to cure the disorder successfully. Splenectomy has to be done simultaneously together with porta-caval shunt operation or successively to the latter a few weeks later.
4. Effects of the Porta-caval Anastomosis on Patients.
The metabolic studies wich have been done on carbohydrate metabolism, vitamin metabolism, and protein metabolism, especially amino-acid metabolism, particularly trypt-ophan metabolism, in the postanastomotic course of patients, have revealed that in patients with preoperative liver failure the postoperative metabolic processes are incurably disturbed, contrary to the postoperative curable slight or negative metabolic disorder of patients without preoperative liver failure. The postoperative liver function tests and the same microscopical researches have revealed no changes in Banti's syndrome with preoperative slight or no liver failure but remarkable aggravation in cirrhosis of the liver with preop evative severe liver damage. The experimental measurement of the liver blood flow before and after the Eck fistula operation on dogs has revealed both the blood flow and the oxygen consumption of postoperative liver gradually and slightly increase. And the evidence of postoperative increase of detoxication in the lung, presumably compensating the postoperatively decreased liver detoxication, has been observed. Eck fistua animal syndrome, especially postoperative coma, has been certified to be deeply concerned in the blood ammonium concentration, which has relations with both degree and extent of liver failure and the daily intake of protein. Therefore, sufficient precaution concerning the liver repair and protein intake against these troublesome pathological syndrome must be taken throughout the patient's postoperative course.
5. Discussion on the Operative Management of the Porta-caval Anastomosis.
Our improvement of the surgical instruments, for example, a measure-clamp, a portal-clamp, or a caval-clamp, simplified approach with only the right costal margin incision avoiding combination of thoracotomy, and the other certain improvements of the operative technique has lead the operative results of success to the better. Death due to the operation has occurred immediately after the closure in a few cases, such as burdened with severe advanced liver damage or sufferinge from massive bleeding. As the adrenocortical function of the patient with portal hypertension are commonly caught in clinical reseaches, it is necessary to administer cortisone or hydrocortisone before, during and after operation continuously for the purpose of prevention of operative shock. In a half of researched cases, bacteria have been found in the parenchymal tissue of the liver : Antibiotics should be strongly applied on a patient connected with operation. The narcosis is to be done avoiding the by-effect to accelerate the liver failure.
6. Treatment of Budd-Chiari Syndrome.
Basing upon the experimental results of omento-sterno-medulopexy on dogs, we have performed this operation on one cases of hepatic vein stenosis accompanied by the inferior vena cava obstruction, the clinical result from this patient being not completely obtained yet.
(author's abstract)
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